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The Silver Threads Among Standards of Practice, Essential Competencies and Ethics

The Silver Threads Among Standards of Practice, Essential Competencies and Ethics. Presenters: Tina Langlois – College of Medical Radiation Technologists of Ontario Sharon Saberton – College of Medical Radiation Technologists of Ontario Chris Ward – Ward Health Strategies, Ontario.

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The Silver Threads Among Standards of Practice, Essential Competencies and Ethics

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  1. The Silver Threads Among Standards of Practice, Essential Competencies and Ethics Presenters: Tina Langlois – College of Medical Radiation Technologists of Ontario Sharon Saberton – College of Medical Radiation Technologists of Ontario Chris Ward – Ward Health Strategies, Ontario Presented at the 2005 CLEAR Annual Conference September 15 - 2:30-3:30 p.m Phoenix, Arizona

  2. Agenda • Enforcement Issues Related To Standards Of Practice, Essential Competencies And Codes of Ethics • A Case Study • Point Of View From A Member Of The Public • Questions & Discussion Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  3. The Silver Threads Among Standards of Practice, Essential Competencies and Ethics Enforcement Issues Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  4. Enforcement • Cornerstone of professional regulation • Public protection • Public expectation • Transparency • Accountability Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  5. What is Enforceable? • Depends on your jurisdiction and the relevant enforcement statute • Licensure model • Certification model • Regulation model Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  6. What is Enforceable - Ontario? • Regulated Health Professions Act (RHPA) • Professional misconduct, incompetence & incapacity defined • Professional misconduct regulation • Standards of practice • Essential competencies Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  7. What About… • Codes of Ethics • Guidelines • Policies • Practice advisories • Position statements Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  8. Issues • Public expectations • Managing the gap between expectation & reality • Rules vs. tools • If it is not enforceable • Why have it? • Who is it for? Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  9. Public Member - Perspective Health professional regulation plays a critical role in both consumer protection and consumer confidence. Intense publicity over medical errors and the adverse effects of new treatments undermines public confidence in the competency of practitioners and the quality of health care delivery. The interests of consumers and health professionals alike are best served by transparent and effective enforcement of professional standards. For consumers litigation is the blunt alternative to timely, transparent and effective self regulation. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  10. Solution The silver threads • Links to enforceability • Links between levels • Standards of Practice • Essential Competencies • Codes of Ethics • Others • Transparency • Fairness to professionals and public Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  11. Standards of Practice • Expectations of practice • Minimum requirements • Defines what needs to be done • Not all breaches result in enforcement action • Needs to be stated to be enforceable Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  12. Public Member - Perspective Public Expectations • The public expects: • That they will be heard • That they will be kept informed • That appropriate action is taken promptly and in a timely manner • In most cases, simply for an acknowledgement or apology and an assurance that it won’t happen again Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  13. Public Member - Perspective • Standards of Practice • Assure public safety • Assure that health professionals work in patients’ best interest • Assure access to appropriate treatments Increased government intervention in professional regulatory reform intervention is usually precipitated by the failure of self-regulation to protect the public : Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  14. Public Member - Perspective New Zealand: Report of the Cervical Cancer Inquiry: • Numerous women diagnosed with cervical carcinoma in situ had, without their knowledge or consent, been part of a research trial at New Zealand’s leading women’s hospital. The research entailed withholding conventional treatment to study the natural course of the disease, when the prevailing view was that carcinoma in situ was a precancerous condition. 40 women eventually developed invasive cancer • The report recommended the development of a code of patients’ rights, the appointment of a health ombudsman to investigate patients’ complaints, publicly funded patient advocates and the creation of research ethics committees. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  15. Public Member - Perspective UK: • Quality Assurance (QA) initiatives in England may have initially come as a response to scandals in the health care system. • These included the Harold Shipman case, in which a physician apparently murdered over 400 patients over a period of years. • The National Clinical Assessment Authority (NCAA) and The National Patient Safety Agency (NPSA) were established to prevent such future scandals. • The role of the NCAA, however, goes well beyond eliminating criminals or disciplining those who do not comply with professional standards. • Responsibilities of the NCAA also include the safety aspects of hospital design, cleanliness and food, ensures research is carried out safely, etc. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  16. Standards of Practice - Examples Law Society of Upper Canada • Standard • Honesty and Candour “When advising clients, a lawyer shall be honest and candid” Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  17. Standards of Practice • Linked to professional practice & enforcement mechanisms • Silver thread • Applications • Quality Assurance • Complaints • Discipline • More silver threads Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  18. Essential Competencies • Standards in action • Application to practice – task oriented • Define how well things must be done • In Ontario • Not enforceable on their own • Enforceable through the standards • Another silver thread Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  19. Essential Competencies - Examples Honesty & Candour The lawyer’s duty to the client who seeks legal advice is to give the client a competent opinion based on a sufficient knowledge of the relevant facts, an adequate consideration of the applicable law, and the lawyer’s own experience and expertise. The advice must be open and undisguised and must clearly disclose what the lawyer honestly thinks about the merits and probable results. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  20. Essential Competencies • Linked to standards which are linked to enforcement mechanisms • Silver thread • Applications • Education • Registration • Quality Assurance • Complaints & Discipline • More silver threads Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  21. Codes of Ethics • Reflect values & beliefs of the profession • Aspirational • Promotional • Reflect existing law • Not always enforceable & often not meant to be • Members only • No enforcement mechanisms Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  22. Public Member - Perspective New Zealand Canada United States England Australia Complaints & Discipline • Many models exist: does Canada have the best one? Patients’ Complaint Continuum: Most Patient Centered Least Patient Centered Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  23. Public Member - Perspective Complaints & Discipline: • “NZ/Aus/UK Model” is characterized by: • A centralized complaints handling system • Attempts are made to be flexible and accommodating to patient needs • Focus on less formal complaint resolution • A patient-centered approach and • The use of complaints to attempt to make health system-wide changes • Use of Patient advocates Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  24. Public Member - Perspective Complaints & Discipline: • Advantages of this model include: • Patients remain involved and apprised of all proceedings • Less litigation and less bureaucracy (a less litigious culture may mean less ‘defensive medicine’) • Allows for consistency among professional disciplines • Allows decision makers to track trends and areas for improvement • An emphasis on learning from the complaints received, in order to help improve health care delivery and to make system-wide improvements. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  25. Public Member - Perspective Complaints & Discipline: • The US provides a more litigious model and consumers are encouraged to hire a lawyer during the complaints process • The regulatory colleges have a duty to ensure that complaints and disciplinary actions are carried out appropriately, as consumers do have options. And in the U.S. the option that is most often manifested is litigation. • It is estimated that medical liability costs add $60 billion to $108 billion to the total cost of health care each year Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  26. Public Member - Perspective Does better self regulation contribute to less litigation? Health Affairs, Volume 24, Issue 4, 2005 Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  27. Public Member - Perspective Physicians who recommend more invasive procedures than they believe are medically necessary 54% Physicians who refer patients to specialists more often than they believe is medically necessary 74% Physicians who order more tests than they believe are medically necessary 79% Can effective professional regulation reduce litigation AND improve the quality of care? Source: Fear of Litigation Study, Harris Interactive, 04. 11. 2002. Mauli, J, et al. A System Approach to Improve Error Reporting, Journal of Health Care Information Management, Vol. 16, No. 1. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  28. Code of Ethics • Ontario • RHPA – one of the objects of health colleges • To develop, establish and maintain standards of professional ethics for the members • However • Ethics do not form part of the definition of professional misconduct or incompetence • Interesting tension • If you develop it you should be able to enforce it Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  29. Codes of Ethics - Examples “Under all is the land. Upon its wise utilization and widely allocated ownership depend the survival and growth of free institutions and of our utilization.” Canadian Real Estate Association (values and beliefs) Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  30. …Codes of Ethics - Examples “Foster an environment.” “Support the society.” Canadian Society of Association Executives (unenforceable language) Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  31. …Codes of Ethics - Examples “Provide service with dignity and respect to all people regardless of race, national or ethnic origin, colour, gender, sexual orientation, religious affiliation, age, type of illness or mental or physical challenge.” Canadian Association of Medical Radiation Technologists (duplicates existing law) Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  32. Codes of Ethics • Where are the silver threads? • Should regulators have codes of ethics if they are not enforceable? • Who are codes of ethics for? • Do codes of ethics create unrealistic public expectations? Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  33. The Silver Threads Among Standards Of Practice, Essential Competencies And Ethics A Case Study The College of Medical Radiation Technologists of Ontario (CMRTO) Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  34. A Case Study - CMRTO • The CMRTO is the governing body for medical radiation technologists (MRTs) in Ontario, Canada • The College carries out three main regulatory functions set out in the Regulated Health Professions Act (RHPA) Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  35. CMRTO – 3 Main Regulatory Functions • It sets requirements for entry to the profession and registers practitioners. These requirements assure that individuals have met certain standards before practising medical radiation technology in the province. • It establishes and monitors standards of practice for MRTs, which guide MRTs, employers, educators and the public about acceptable practice and behaviour. • It investigates complaints about the practice and conduct of MRTs and enforces the standards of practice. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  36. Standards of Practice – The Heart of the CMRTO’s Mission Statement: • “The mission of the College of Medical Radiation Technologists of Ontario is to serve and protect the people of Ontario through self-regulation of the profession.” • One of the ways the College meets its mission statement is by establishing and enforcing Standards of Practice for MRTs. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  37. …Standards of Practice – The Heart of the CMRTO’s Mission Statement: Essential Competencies Comprehensive Guidelines for acting in accordance with the Regulated Health Professions Act Scope of Practice/Controlled Acts Model Addendum to the Comprehensive Guidelines The Standards of Practice are composed of Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  38. Purpose of the Standards of Practice: The Standards of Practice assist MRTs in understanding the College’s expectations with respect to the professional practice of medical radiation technology. They • help managers in making appropriate decisions regarding management of the practice of MRTs and in developing suitable policies and procedures • assist educators in developing curriculum and in providing appropriate instruction • assist the public in assessing quality of care Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  39. The Silver Thread • The Standards of Practice link enforcement and transparency. • The Standards of Practice serve the College in all areas where criteria for professional performance are needed in making decisions. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  40. …The Silver Thread They are used • to make determinations regarding professional misconduct, incompetence or incapacity by the: • Complaints Committee • Discipline Committee • Fitness to Practise Committee • for other College processes such as ascertaining entry-level requirements for registration • for evaluation of Quality Assurance records in the Quality Assurance Program Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  41. Code of Ethics for Members of the CMRTO • The Code of Ethics is a set of principles that delineates responsible conduct and the ethical and moral behaviour of members of the CMRTO. • It has as its foremost goal the welfare and protection of patients and the public Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  42. … Code of Ethics for Members of the CMRTO • The Code of Ethics is intended to help MRTs choose the right, fair, good and just action. • Each MRT is personally responsible for behaving according to the ethical principles set down in the Code. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  43. Public Member – Perspective • Observation: • Remarkable similarity between the CMRTO Standards of Practice, Essential Competencies and Code of Ethics Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  44. Ethical Principles: Responsibility to Patients - MRTs act in the best interests of their patients by: Indicators - Upholding the principle of informed consent including the right of the patient, or the patient’s substitute decision maker, to refuse service Competency: Relationship with Patients - Medical radiation technology is a health care profession that has patient care as its main concern. Indicators - Carry out examinations or treatment only with the informed consent of the patient, or the patient’s substitute decision maker Public Member - PerspectiveExamples: Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  45. Public Member – Perspective • Observation: • The Standard of Practice/Essential Competencies are clearly reflected in the Code of Ethics. • Is this, then, the Silver Thread? If so, it has a tight knot. • Why does the CMRTO have a Code of Ethics? Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  46. Public Member – Perspective • Code of Ethics is set out in the objects of the RHPA. • Council Composition is made up of • Public members appointed by Lieutenant Governor of the Province • Elected members of the profession elected by MRTs. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  47. Beware the Slippery Knot in the Silver Thread Ethical Principles: • Responsibility to the Public – MRTs act to ensure the trust and respect of the public by: Indicators - • Maintaining high standards of professional conduct, competence and appearance; • Providing only those services for which they are qualified by education, training or experience; • Not making false, misleading or deceptive statements, orally or in writing; and • Advancing and supporting health promotion and research Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  48. Public Member – Perspective • Does this mean that a member of the public might make a complaint against an MRT with respect to the MRT’s appearance or lack of involvement in research? Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  49. Applying Ethical Principles • A member of the public can lodge a complaint about any part of their treatment provided by an MRT. However, the Complaints Committee has received special training respecting the application of ethical principles. • Questions addressed by the Complaints Committee when reviewing such a complaint include: • Is there a risk of harm to the public regarding this complaint? • Is there an issue of incompetence, incapacity or professional misconduct respecting this complaint? • Is the complaint frivolous or vexatious? Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

  50. …Applying Ethical Principles • It is probable that the answer to the foregoing questions would be “No”. • The complaint would likely be dismissed. Reason: • “Appearance and advancing research” are aspirational principles and not essential competencies or standards of practice of the profession. • Aspirational principles such as these are not and should not be enforceable by a regulatory college. Presented at the 2005 CLEAR Annual Conference September 15 – 2:30-3:30 p.m. Phoenix, Arizona

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