Safety of care
The new reality: Expanding scopes of practice
An article for physicians by physicians
Originally published March 2010
It used to be physicians made all the decisions about their patients. As a result, there was rarely any question about who was ultimately responsible for patient care. This is no longer the case.
Today's reality is that physicians are increasingly working with—and relying on—other health care professionals when treating patients. Evolving models for health care delivery mean that other health professionals are playing an increasingly significant and valuable role in the care of patients.
Interprofessional (collaborative) care brings with it many benefits, including giving patients greater access to a range of skills and knowledge. Expanding the scope of care of each member of the team improves access.
In an interprofessional model, every member of the care team is accountable for the care he or she provides and may also be held accountable for his or her role in the outcomes. As a result, each professional owes a separate duty to the patient within his or her scope of practice. There is an established legal precedent that confirms health professionals are not to be held directly liable for the acts of others. However, as interprofessional practices often involve multiple encounters, events and conditions treated by multiple health professionals over a period of many years, it is often not straightforward to determine individual responsibility for outcomes.
As one response to the shortage of physicians, governments continue to expand the scopes of practice of other health professions. Depending on the province or territory, scopes of practice have increased for such professionals as pharmacists, nurse practitioners, nurses, chiropractors, dentists, respiratory therapists, dieticians, naturopaths, midwives and physiotherapists. It is becoming more common for a pharmacist to prescribe medications or give injections, for a nurse practitioner to order tests or to treat fractures, or for a nurse to suture a wound or to manage labour in hospital. These are actions that were once, but are no longer, the sole domain of physicians.
Communication—More than just an exchange of information
As collaboration and the scope of practice for health professionals increase, so do the likelihood and the possible negative consequences of miscommunication. Effective, clear and timely communications are essential.
Communication in an interprofessional health care setting means more than relaying messages. It means:
- Clearly delineating roles and responsibility of each team member (under a formal agreement, as appropriate) based on his or her scope of practice and the individual's knowledge, skill and ability.
- Clarifying one's role and the role of other team members in the interprofessional relationship.
- Understanding how health care decisions will be made, and who is responsible and therefore accountable for health care delivery decisions.
- Having systems and processes in place to ensure communications are timely and effective.
- Clarifying how the team will manage patient expectations and respond to patient concerns.
- Establishing who is responsible for ordering tests and for following up.
- Providing clear instructions to the patient regarding the need for follow up.
- Communicating to the patient who is responsible for what care. It is important that patients understand the team roles and a physician's place in it.
The potential for overlapping responsibilities that result from expanded scopes of practice heightens the need for mutual understanding between physicians and other health professions.
Importance of adequate liability protection
With the evolving models of care and increasing scopes of practice also comes an increasingly important requirement that all health professions have adequate liability protection. This requirement is particularly necessary given the legal principle1 that permits a plaintiff to recover the full amount of damages from one defendant where two or more defendants are considered to be jointly at fault for the harm caused the patient. Further, a member of the health care team may be held financially responsible for the damages caused to a plaintiff by the fault of another health care provider who is employed2 by the first team member. All members of the health care team must be confident that responsibility and accountability for the patient's care will be shared appropriately among team members or with independent health care professionals.
When physicians work with independent health care professionals, it is generally understood that each professional owes a separate duty to the patient with respect to matters falling within each individual's scope of practice. In those circumstances, the physician can typically rely on the duty owed by that health care professional and will generally not be held liable for wrongdoing on the part of the allied health care professional.
For example, a physician who was not notified by a pharmacist of a change to a prescribed treatment should not be responsible for any injuries the patient may suffer due to the modification. However, a physician may be exposed to liability where he or she becomes aware of an erroneous prescribing decision made by the pharmacist but fails to take action to prevent harm to the patient.
Given a number of professions are assuming responsibilities that were previously performed solely by others (usually physicians), CMPA members should:
- Become familiar with the scope of practice, qualifications, experience and training of the other health care providers involved in the care of their patient. This will require a determination as to whether the health care provider is regulated or unregulated, and whether legislation specifically sets out the health care provider's scope of practice.
- Establish a mutual understanding of the responsibilities and expectations for communication between the physician and the other health professionals, particularly for actions where scopes of practice overlap.
- Have confidence that each health care provider in the team has adequate liability protection/insurance to protect themselves and the patients they treat.
Health professionals need to know other health professionals with whom they work have adequate medical liability protection so that, should a patient suffer harm, neither is held financially responsible for negligent acts or omissions of the other.
It is likely governments will continue to further expand the scopes of practice of health professionals. The CMPA is committed both to working with stakeholders to support the evolution of interprofessional care and to identifying and reducing risks associated with it. Within the context of expanded scopes of practice, the CMPA continues to emphasize two key requirements: clear, effective and timely communications (particularly between physicians and other health professions) and adequate liability protection for all providers.
- When a court finds more than one defendant negligent or civilly liable, the court will assess the amount of damages (often expressed as a percentage of the total damage award) to be paid by each defendant. Defendants can be jointly and severally liable for the damages awarded. This means the plaintiff may recover full compensation from any one of the negligent defendants, even though one defendant may be paying for more than his or her proportionate share of the damages. That defendant may then seek contribution from the other negligent defendant(s).
- If an employee is found negligent or has committed a fault, the court may order damages be paid by the employer, pursuant to the doctrine of vicarious liability. This legal doctrine provides that an employer, who may be an individual or an institution, will generally be held financially responsible for the negligence or fault of its employees. An employment relationship must have existed at the time for the incident and the defendant employee must have been sued for work done within the scope of his or her employment.