Standard for Professional Practice: Performing Controlled Acts and Other Restricted Activities

How Consultation Feedback Was Incorporated into Final Standards

The College approved the Standard: Performing Controlled Acts and Other Restricted Activities and it came into effect on June 29, 2016. All physiotherapists are expected to review and implement the final Standard into their practice.

We would like to thank everyone who submitted their feedback and contributed to this policy review.

Below is an overview of the comments received and Council’s rationale for incorporating changes and approving the finaconsultations.collegept.org/feedback.phpl Standard.

More than 88% of respondents felt the Standard provided clear guidance on how physiotherapists should: perform controlled acts, accept the delegation of controlled acts and delegate controlled acts.

A significant number of people—about 20%—were concerned about patient safety.

Concerns

Allowing physiotherapists to learn how to perform controlled acts through informal learning methods might put patients at risk.

Council considered the issue and concluded that public protection is maintained as long as the informal learning programs meet the same safeguards as formal learning programs by including theory, practice and evaluation.

The requirement to tell patients what statutory authority physiotherapists are using to perform delegated controlled acts may be confusing for patients.

After considering this feedback, Council agreed. Council amended the requirement so that physiotherapists who perform controlled acts under delegation should tell patients which caregiver delegated the act.

Physiotherapists who perform controlled acts under delegation or who delegate controlled acts should be required to roster.

Council considered this and felt it was beyond the scope of this Standard and was more closely related to the informed consent requirements when controlled acts are performed. No changes were made at this time.

Physiotherapist should not be permitted to delegate controlled acts like communicating a diagnosis, pelvic floor interventions and spinal manipulation because these activities are too risky to patients and contain elements of assessment.

Council agreed that there were substantial risks associated with these activities. Based on this feedback, Council amended the Standard to forbid PTs from delegating communicating a diagnosis, performing pelvic floor assessments and interventions and spinal manipulation. All aspects of acupuncture (including removing needles) will continue to be prohibited from being delegated as was the case in the past.

Input

Many respondents wondered why acupuncture was treated differently and could not be delegated.

The simple answer to this somewhat complicated question is that the authority that permits physiotherapists to perform acupuncture is different from the authority for all the other controlled acts.

Physiotherapists can perform acupuncture because of a government regulation that exempts them from the normal restrictions on performing acupuncture. Since this exemption does not apply to people that they could delegate to, acupuncture cannot be delegated. 

Some people believed that the Standard was not clear about whether controlled acts performed by a physiotherapist have to be within scope.

This lack of clarity was identified and addressed by rewording the Standard. The hope is that it is now clear that any controlled act performed by a physiotherapist must be within scope.

Others suggested that PTs should be permitted to perform controlled acts beyond their scope if these acts were delegated to them.

Council considered this suggestion and noted that the scope of physiotherapy is broad. They concluded that any activity that a physiotherapist performs while acting as a physiotherapist, including performing a controlled act under delegation, must be within the physiotherapy scope of practice.

A number of people indicated that it was not clear whether the written instructions for managing adverse outcomes were intended for patients or for physiotherapists.

This lack of clarity was identified and corrected by rewording the Standard. The hope is that it is now clear that physiotherapists are required to have written instructions indicating how they will manage reasonably foreseeable adverse outcomes.

Some respondents suggested that the Standard needed additional information.

Council decided that rather than make the Standard longer and more complex by adding details, the Standard will contain links to explanation, definitions and resources as needed.

Consultation

The College is holding a public consultation on the Standard: Performing Controlled Acts and Other Restricted Activities. Gathering feedback and comments from the public, the profession, and other interested groups helps the College to develop Standards and policies that best support the College’s work in protecting the public interest.

All feedback is appreciated—both what you think works well and what you think does not work well. Please note your comments submitted online will be published anonymously and you are welcome to read what others have said by clicking the button that says Interested in Reading What Others Said?—Read Their Comments Here

Note: The existing Standard for the Performance of Authorized ActivitiesLink opens in a new window includes performance expectations for physiotherapists to order diagnostic tests. At this time, the relevant legislation has not been enacted so references to diagnostics were removed from the proposed Standard. When regulations to permit physiotherapists to order diagnostic tests are enacted, the College will publish these expectations to ensure that both physiotherapists and patients are aware of the relevant Standards.

Standard

Performing Controlled Acts and Other Restricted Activities

1. Physiotherapists must have legal authority to perform a controlled act/legally restricted health care intervention.

2. Every controlled act performed by a physiotherapist must be within the scope of practice of physiotherapy.

3. In order to perform a controlled act, physiotherapists must assume the responsibility for the decision to offer the act and the actual performance of it.

4. When requested to do so by the College, physiotherapists must be able to demonstrate that they have successfully completed formal or informal training for the controlled acts they perform.

5. Formal or informal training for controlled acts must contain at least the following three components:

   1. Learning the indications, contraindications, adverse outcomes and risks associated with the performance of the activity,
   2. Practicing the technical performance of the controlled act under the supervision of a person who is authorized to perform it, and
   3. Evaluation of both the knowledge and practical components that demonstrate their ability to safely and competently perform the controlled act.

6. Physiotherapists who perform controlled acts must be able to manage the reasonably foreseeable adverse outcomes associated with the performance of the act.

7. Upon request by the College, physiotherapists must be able to demonstrate that:

   1. they have the knowledge, skills and judgement required to safely and competently perform the controlled act(s) they offer,
   2. they know what to do if performing a controlled act results in an adverse outcome, and
   3. they have written instructions describing what to do if performing a controlled act results in an adverse outcome.

8. To perform controlled acts, physiotherapists must be listed on the relevant College roster(s) of members who are permitted to perform that controlled act. The only exceptions to the requirement to roster are:

   1. when the controlled act performed is the communication of a diagnosis identifying a disease, a physical disorder or dysfunction as the cause of a person’s symptoms, or
   2. when physiotherapists perform controlled acts under the authority of a delegation from another health professional.

9. Physiotherapists who perform controlled acts that may impact the care their patients are receiving from other health care professionals must provide relevant and timely information to these caregivers.

10. Physiotherapists must only accept the delegation of a controlled act when the following conditions are met:

    1. They have provided the delegating professional with the information needed for that person to meet the professional obligations for delegation that may have been established by his or her college,
    2. The delegating professional has provided the following information:
       1. the controlled act being delegated,
       2. the circumstances when physiotherapists can perform the controlled act,
       3. the limits on the delegation, and
       4. the patient or a class of patients to whom the delegation applies.
    3. They believe the delegating professional:
       1. can perform the authorized activity safely, competently and ethically,
       2. has the legal authority to delegate, and
       3. has delegated the authority according to his or her professional obligations.

11. Physiotherapists who perform controlled acts under delegation must tell patients the authority they are using to perform the act.

12. Physiotherapists who have been delegated the authority to perform a controlled act must not delegate it to anyone else.

13. Physiotherapists must not delegate any component of the controlled act of performing acupuncture.

14. Physiotherapists may delegate the controlled acts they are authorized to perform when the following conditions are met:

    1. They assume the responsibility for the decision to delegate the act.
    2. They have the knowledge, skills and judgement required to perform the controlled act safely, competently and ethically.
    3. They have determined that the controlled act is within the scope of practice of physiotherapy.
    4. They have determined that the person receiving the delegation has:
       1. the knowledge, skills and judgment to perform the delegated act safely, competently and ethically,
       2. the ability to manage the reasonably foreseeable adverse outcomes associated with the performance of the act.
    5. They have confirmed that the person receiving the delegation has a set of written instructions indicating what should be done if performing the controlled act results in an adverse outcome.
    6. They have confirmed that the person receiving the delegation knows that the authority cannot be delegated to anyone else.
    7. They have provided the person receiving the delegation with the following information:
       1. the controlled act being delegated,
       2. the circumstances when the person can perform the controlled act,
       3. the limits on the delegation, and
       4. the patient or a class of patients to whom the delegation applies.
    8. They have documented how they have met the delegation requirements.