Position statement
Ensuring safe, high quality care: managing evolving scopes of practice of all health professionals

Purpose of this document

The roles, activities and services of health professionals, also known as scope of practice, are continually changing.

This document is a point of reference to guide health professionals and privileging authorities when considering changes in health professional scope of practice.

Introduction

Numerous drivers underpin changes in scope of practice of physicians and other health professionals, including: health workforce shortages, increasing patient needs, scientific and technological discovery, personal interests and professional aspirations. These changes, which are generally supported by broadened curricula and training, are occurring within and outside of interprofessional or collaborative care models and have often improved all facets of health care. Health professionals can thus assume new scopes of practice independently or under supervision.

As the scope of practice of other health providers outside of medicine expand to encompass varying levels of clinical judgment in the diagnosis and treatment of patients, they are playing an important role in patient care and helping improve access. Jurisdictions across Canada have expanded prescribing, diagnostic and treatment privileges for various health professionals (go to the Royal College website for examples of evolving scopes and privileges). Unfortunately, not all health professions are regulated in every province and territory nor are they subject to the same provisions.

Recognizing the many benefits of evolving scopes of practice, precautions must also be in place to ensure that patient safety and wellbeing are safeguarded as all health professionals’ scopes of practice evolve. Accordingly, the Royal College believes that:

The scope of practice of all health professionals, from graduation to retirement, should be subject to the highest standards of education, and reinforced by ongoing research, inclusive consultation, and professional and regulatory oversight.

Health professionals are regulated or overseen by provincial and territorial governments and regulatory authorities, which are thus ultimately responsible for safety, competence and quality. To maintain patient safety and wellness during the uptake of new or redesigned scopes of practice of health providers, the Royal College calls on regulators and governments to respect the principles outlined below.

PRINCIPLES

Principle 1

Scope of practice should always be consistent with quality and evidence-informed specialized skills training and education of the health provider, underscored throughout the continuum of education. This includes a requirement for a rigorous accreditation process of educational programs and of continuing professional development.

Significant differences exist in the definition, scope, admissions prerequisites, and length of training between physicians and other health care professionals.

• The expanded scope of practice should be appropriate for the practitioner’s education, training and examination/evaluation requirements.
• Existing education and training should assure needed competencies to perform news skills moving forward.
• If the change in scope is an advanced skill that is tested on the entry-level licensure/entry-to-practice examination or that has to be measured after licensure/privileging has been obtained, measures should be in place to assure competence in the new technique, including the ability to deal with the consequences of treatment, services, and care such as complications.
• Measures should be in place to ensure that practitioners maintain competency in the delivery of services.

Principle 2

Research and data on population health needs, patient health outcomes, patient satisfaction and health system performance including cost effectiveness should be critical markers of evidence on the appropriateness and value of scope of practice, ensuring quality of care.

• There should be evidence establishing the population health needs to justify changes in the profession’s scope of practice.
• Research literature should be of sufficient rigour and scale, also capturing the full breadth of competencies that the professional brings to their practice, to validate scaling up of the results to the general population.
• Evaluation of changes of scope of practice should be built into appropriate provincial/territorial programs to ensure that the change is actually having the intended effect, including improved access, positive financial impact, more efficient delivery of services and quality care.
• Provinces and territories should share their experience with each other to support implementation, evaluation and ongoing provision of high quality and safe care.

Principle 3

Earnest consultations, communications and collaboration should be undertaken with key stakeholders including the physician profession and the public when significant changes to scope of practice are being considered or implemented.

• Key stakeholders including the medical profession should receive adequate notice of scope of practice reviews, with background information and evidence supporting the proposed changes, and sufficient time for feedback. Given that the expanded scope of health professionals often complement or substitute acts and services provided by physicians and surgeons who have extensive training throughout their professional lifecycle, the medical profession is able to provide informed opinions on proposed changes in the interest of the public.
• Formal collaboration is essential when implementing changes to scope of practice, in the interest of patient safety and the sound functioning of the health care system. If the broadened scope of practice of health professionals has potential for adverse outcomes for which they have not been formally trained, the practitioner should have formally established collaborations with other health professionals who have the knowledge, skills and training to deal with these complications. Changes to scopes of practice must also consider cross-impacts on other health professionals and the health system more generally.

Principle 4

Policies, regulations and practices must first and foremost be in the interest of the public and patients.

• Patients should be well informed about changes in education and credentials of the practitioner to ensure accountability and transparency. Patients, who ultimately want to move toward seamless care between health professionals and services, can provide useful insights on health care delivery and scope of practice redesign.
• Designations should clearly identify the licensure or credential held by the health professional, including physicians, and the use of titles should not overlap or resemble existing credentials of licensed or credentialed practitioners to avert confusion amongst the public and health professions.
• Regulations overseeing advertising of health professional scope of practice must clearly remove any public confusion about the qualification and certification of health professionals. Authorities responsible for such regulations should consult with the public and relevant health professions to ensure that public interests are well served.

Conclusion

All health professions have a fundamental commitment to the health and wellbeing of the patient. The principles outlined above do not reflect interests of “turf protection” or income advancement. The spirit of this position statement is focused on prioritizing patient access to care by the most competent and qualified health providers, through their training and continuing professional development. To do otherwise, patient safety may be compromised, is not cost effective and does not ensure all patients receive the quality of care they deserve.

Moving forward, we strongly encourage regulators and governments to apply a collaborative, inclusive, and transparent approach in their decision-making process about scopes of practice. We also suggest taking note of the numerous examples of successful interprofessional care models in the country that have been developed in a collaborative fashion among professions, adapting as training models evolve and utilizing the scope of a health professional’s abilities to its fullest extent, always putting patient wellbeing and safety first.

For additional information please contact — healthpolicy@royalcollege.ca

Approved by Royal College Council in June 2013
Revised and approved by Council in February 2019