The Expanding Role of Nurse Practitioners (RN(EC)s) in Ontario
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1 The Expanding Role of Nurse Practitioners (RN(EC)s) in Ontario Joshua Liswood Jesstina McFadden DISCLAIMER This Coffee Talk presentation is provided as an information service and is not meant to be taken as legal opinion or advice. Please do not act on the information provided in this presentation without seeking specific legal advice. Miller Thomson LLP, 2011 All Rights Reserved. All Intellectual Property Rights including copyright in this presentation are owned by Miller Thomson LLP. This presentation may be reproduced and distributed in its current state. Any other form of reproduction or distribution requires the prior written consent of Miller Thomson LLP which may be requested at
2 Privileges for NPs (Everything you wanted to know but were afraid to ask)
3 Overview 1. Legislative Roots 2. Common Law Obligations 3. The Decision to Appoint 4. Credentialing and Appointment Issues
4 Public Hospitals Act Board Powers s.36 - Appointment and privileges limited to physicians Medical Advisory Committee s. 35 Recommendations re: appointment and reappointment limited to physicians s. 37 Other duties as assigned by Act or Board
5 Regulation 965 under the PHA s. 11(1) No person shall be admitted to a hospital as a patient except: (a.1) on the order or under the authority of a registered nurse in the extended class who is a member of the extended class nursing staff; (July 1 st, 2012) s. 11(3) No person shall be registered in a hospital as an out-patient except: (a) on the order or under the authority of a member of the medical staff, midwifery staff or extended class nursing staff
6 Extended Class Nursing Staff Defined at section 1 of Regulation 965 as those NPs in a hospital who are: Employed by the hospital and are authorized to diagnose, prescribe for or treat out-patients or in-patients in the hospital; or Who are not employed by the hospital and to whom the Board has granted privileges to diagnose, prescribe for or treat outpatients or in-patients in the hospital. NP staff previously only permitted to diagnose, prescribe for or treat out-patients
7 Common Law Obligations Board has duty to appointment [physicians] that Meet the needs of the community Effectively utilize the resources of the hospital Are skilled & experience Will work as an effective member of the healthcare team (collaborative, respectful, ensure patient and staff safety)
8 To Credential or not to Credential Need for service Right of access required Scope of practice independently definable Quality and review Funding Appointment vs employment
9 Credentialing Issues Credentialing criteria Credentialing process (not prescribed by statute) Discipline and appeal
10 Appointment Foundation for Appointment & Re-Appointment Competency and quality of care Professional human resource need and resource availability Collegiality Team work Interpersonal behaviors Compliance with rules
11 Expanding the Role of NPs in Hospitals
12 Overview 1. Impetus for Change 2. Legislative Amendments 3. Considerations for Implementation
13 HPRAC Review re: Scope of Practice for NPs Initiated at request of Ontario Minister of Health HPRAC Report (2008): NP practice constrained through restrictive provisions built into law and regulation Expansion of NP scope of practice and changes to regulatory system are in the public interest Provided detailed and specific recommendations re: regulatory and legislative changes Bill 179 (Regulated Health Professions Statute Law Amendment Act)
14 Medical Directives Historical reliance on physician delegation via medical directive to expand NP scope of practice Band-aid solution with some challenges: Complex documents usually requiring time to draft In hospital or other multi-disciplinary setting, all authorizing physicians must agree Processes for implementation can be cumbersome
15 Expansion of NP Care Scope of practice expanded to permit NPs to: Set or cast fracture, dislocation (Oct 1/11); Apply forms of energy prescribed by regulation (pending); Dispense/sell/compound/prescribe drugs within scope of practice (Oct 1/11) Removal of lists of drugs NPs can prescribe RNs and RPNs authorized to implement order by NPs for performance of controlled act (Oct 1/11) Opportunities created for expanded role of NPs in hospitals
16 Expansion of NP Care Significant legislative amendments affecting hospital care provided by NPs Contingent on NP having appropriate relationship with hospital (employment, privileges, contractual) Subject to authorization by hospital/board Individual NP professional scope of practice and competencies
17 1. Attending Hospital In-Patients NPs employed or privileged by hospital permitted to independently attend in-patients (July 1/11) Previously restricted to out-patients Orders for treatment/diagnostic procedures (s. 24) Incidental amendments to Reg 965 regarding completion and authentication of medical records for examination, treatment, reports by NPs for in-patients (s. 19)
18 2. Laboratory Tests Removal of restrictions on lab tests NPs can order Lists under Laboratory and Specimen Collection Centre Licensing Act (July 1/11); and Nursing Act (Oct 1/11) Lab tests are insured services when ordered by NPs in hospitals or independent health facilities (Jun 3/11) Health Insurance Act Reg 552
19 3. Medical Certificates of Death For patient who dies in a hospital, attending NP can: Complete medical certificate of death under Vital Statistics Act (VSA) Complete Form 1 (certificate of death) under PHA (July 1/11) VSA - authority subject to legislated restrictions: Must have had primary responsibility for patient during last illness; and During last illness: Death was expected, Documented diagnosis of terminal illness made by qualified medical practitioner; Predictable pattern of decline; No unexpected events/complications (Reg 965, s. 17; VSA Reg 1094, s. 35)
20 4. Discharge of Hospital In-patients Authorized to write discharge orders for patients who are no longer in need of treatment in the hospital and communicate order to patient In capacity as attending NP Where designated by attending physician, midwife, dentist (oral and maxillofacial surgeon) or NP (Reg 965 s.16)
21 5. Admit Hospital In-Patients As of July 1, 2012, NP staff be able to admit hospital inpatients on the order or under authority of NP staff Currently able to register out-patients on order/authority of NP staff Must be clinically necessary to admit as in-patient Incidental amendments regarding notification re: dangerous or infectious patient (Reg 965 s.11, s.14)
22 Other Upcoming Changes Removal of current restrictions on types of X- rays NPs can order Will be able to order x-ray and CT scan as appropriate for patient care Amendments to Healing Arts Radiation Protection Act (HARP) pending proclamation
23 Considerations for Change Opportunities, not requirements Roles/responsibilities of NPs subject to hospital authorization Implications for delivery of hospital care NPs scope of practice and competencies Existing patient care model(s), organizational structure and staffing Governance, policy, HR and risk frameworks
24 Thank You! Joshua Liswood Jesstina McFadden
25 Added experience. Added clarity. Added value. Follow us...
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