Direction and Control of a Medical Practice
Your medical practice
Reason for amending the standard: Outside of a hospital setting, a medical practice comprises more than patient care – it’s also all the professional and administrative activities that support that care. By amending the standard, the College wants to ensure both individual and team-based practices have the greatest opportunity for success and provide the highest standard of care possible.
The amendment proposes to:
- promote high quality care by ensuring quality improvement and quality assurance are part of every practice,
- reinforce the responsibility of each physician, while also recognizing the importance of medical leadership in developing high-functioning teams,
- support the College’s new Group Practice Review program, which works with clinics to achieve excellence in team-based care, and
- ensure the College is aware of new practices, changes to practice location and services that require College regulation.
The draft amendment also incorporates the physician’s responsibility to make sure anyone entering the practice is aware of the qualifications of all care providers working in the practice setting (from Practice in Association, to be rescinded).
Deadline to provide feedback is December 1, 2017.
This standard gives physicians the authority to lead and be in direct control over all of the things that make a high quality practice and ensure good outcomes for patients.Dr. Karen Mazurek, Deputy Registrar
Do you agree with the proposed changes or have concerns? How would they affect your practice?
Consultation 013 is now closed
The profession, stakeholders, other organizations and public members were invited to provide feedback from October 2-December 1, 2017. Council will consider non-nominal feedback when approving final amendments to the standard at its May 2018 meeting.
All feedback is subject to the College’s Privacy Statement. The College reviews all comments before publication to ensure there is no offensive language, personal attacks or unsubstantiated allegations.
If you have any questions or require further assistance, please contact Chantelle.Dick@cpsa.ab.ca
In discussions with the physicians that partner with Lifemark Health in Alberta, we have reviewed the consultation document available from the CPSA titled “Direction and Control of a Medical Practice”. Lifemark Health fully agrees with the principles of autonomous control and responsibility amongst all of the regulated health professionals that we work with, including physicians. What is needed however from this standards of practice document is more clarity around the limits of the medical practice and what can be expected of physicians when working within complex interdisciplinary practices.
Health care delivery within private practice environments continues to evolve towards interdisciplinary care, similar to that of public practice hospitals and government facilities. As such it is unclear as to why physicians practicing in public or private practice environments would have differing responsibilities and authority within these various practices.
Additionally, in clinical practices with multiple professionals who are both regulated and non-regulated, it is inherent that we clearly delineate the extent to which a physician’s responsibility reaches. When referring to another regulated health care provider, we would assume that a physician is not responsible for the care provided by that provider. Is this reflected within the CPSA’s practice standard? Additionally, when a physician’s role is determining whether a patient is medically fit to proceed with treatment, how responsible is that physician for the treatment provided? In interdisciplinary practices where multiple regulated professionals are working together in a matrix management structure, it is likely that these professionals share responsibility for clinical decisions in many cases. How is this taken into account within the practice standards of the CPSA?
Questions such as these that depend on the definition of the medical practice are areas where further clarity would help direct physician practices and strengthen their relationships with the rest of the interdisciplinary team.
Direction and Control of a Medical Practice
1) A regulated member must maintain full direction and control of his/her medical practice in any setting outside of a hospital or facility operated by government or a provincial health authority, including but not limited to:
You must absolutely get rid of "but not limited to..." This altogether too convenient expression, which lawyers love to stick in documents, weakens every standard in which it appears. It is pathognomonic of laziness, or the inability of the College to clarify its ideas. It indicates to me that the College really does not have a clear idea of what it is regulating and therefore throws this omnibus phrase "but not limited to..." to cover all possible eventualities. It is the literary equivalent of "etc., etc., etc..." Get rid of it! Think. Draft. Legislate. But do not legislate with the word "etcetera," not if you want respect. In fact, the use of this expression merely indicates to the rest of us that you have a bunch of lazy lawyers working for you. Not good lawyers, but lazy ones for sure.
"But not limited to" is a legislative cancer.
Graham Hunter MD
In regards to the component...
"In a multi-physician setting, one regulated member must be designated as the medical lead responsible for representing the clinic in interactions with the College"...can you provide some details as to what issues this physician might deal with (i.e.-complaints about the cleanliness of the clinic, complaints about staff, etc.). I feel that more clarification is required.
Each individual physician will directly be responsible for complaints about the healthcare that they provide and those directly under their supervision (i.e.-an elective medical student, personal MOA instead of a shared clinic MOA). If a complaint is made regarding a PCN nurse, for example, the physician who that PCN nurse works for should respond to the complaint as the medical lead is not responsible for overseeing their performance.
As others have noted, this draft Standard implies that every individual physician CAN have "full direction and control" over his/her medical practice, when the reality is that most physicians work in group practices. As one member of a group, it's impossible to have full control over the issues affecting all members, like compliance with laws, overseeing staff, billing, advertising, quality improvement - essentially everything except item (a) "patient care provided". If the goal is to ensure physician practices are not managed by non-physicians, that should be explicitly addressed. Otherwise, this Standard will be impossible to implement for everyone except solo practitioners. Trying to re-jig it to account for all the numerous ways in which group practices are structured will be equally impossible I think. Perhaps taking another look at whatever the underlying reason for instituting such a Standard was in the first place would be wise.
Item (g) makes sense, although it might be hard for docs moving to a new building to remember this point buried in the Standards, in the midst of everything else they're thinking about at that stage.
Item (h) seems reasonable superficially, but thinking about how to implement it raises lots of questions:
1) what exactly is a professional "standing" and "designation"?
2) how does one encapsulate "scope of practice" in font that can be read without a microscope?
3) where exactly does this information get posted - there is currently no more room on walls covered with "information"?
4) is trying to spell out this information, somewhere, more likely to illuminate patients and/or the public, or confuse them?
5) how do I describe the "unregulated standing" of my Medical Office Assistant (MOA)? "This person is unregulated" might be humorous, but probably (hopefully) not enlightening. Or perhaps "This person is unregulated, there is no one to control them"?
6) how do patients know which persons have which qualifications? You'd need name tags for sure, because registered nurses and MOAs are indistinguishable (unless the RN wears a stethoscope). The nurse's name-tag to include "Jane Doe; Registered Nurse (RN, registered, disciplined in 2005 for [redacted], in good standing, dues paid up); able to measure blood pressures, draw blood (as in take it from your vein, not art class), ask you questions about your personal life, poke your tummy or any other part of you, weigh babies, poke babies (with fingers or needles), give babies medicine (by mouth or rectum), and many other skills too numerous to list here", and the identically-dressed MOA's name-tag to include "Jackie Doe, unregulated". Because without name-tags, patients won't be able to tell who's the regulated and who's the unregulated one, and hence who to trust with their baby.
Lastly, as I'm way too tired, and I'm sure the above will land me in trouble, I would suggest clarifying paragraph 2 to read "In a multi-physician setting, one [physician] must be designated as the [contact person for] the clinic in interactions with the College". Otherwise no one in their right mind will sign up to be responsible for everything about a clinic, which they may or may not have any control over whatsoever, when dealing with the College. It defies the laws of reason.
I am wondering about H 1 how are we supposed to explain to the patients what a Registered Nurse does if she works in my clinic. ? a sign< a one page document or just verbal information not really clear. To the general public most would not know what the difference is between a RN a LPN or a MOA?? some specific wording would be helpful we in the professions know what they mean but need simple version
As with other respondents - I am unsure about the 'medical lead' designation. I feel Dr Todd Leaman has absolutely put my concerns into words.
The revisions were a bit difficult to understand but I am concerned about a regulated member having to be responsible for the staff in the clinic. I know that in my clinic, I am an associate, and I do not have any say on the staff hired or their function in the clinic. I have actually had significant concern about some of the hired staff and brought that up with the partners (owners) of the clinic who do not take my advice so I am concerned about being responsible for staff that I cannot have any control over. Ultimately, in my situation, this may lead to me leaving the practice unfortunately but in the event of another physician who has similar circumstances, I would not want them to be liable for something they have no control over.
I am uncertain regarding this statement: "In a multi-physician setting, one regulated member must be designated as the medical lead responsible for representing the clinic in interactions with the College" I share office space and staff with 2 other psychiatrists, but we do not share patients: must we designate one of us to represent the office, when we do not function as a clinic?
I am glad to answer questions on behalf of Clinic Managers working within Alberta
as someone who has been caught up in a debacle of medical practice mismanagement, here are my thoughts.
the debacle i refer to is the company that now goes by the name [redacted]. this company has NEVER been physician owned, managed or run. [redacted] when i tried giving them Medical Direction as the only physician in the outfit willing and able to do so, the management response written in an email was "[redacted] off". (yes, those very words, i'll send the email any time you want). they subsequently fired me, which because of the methadone clinic mayhem which ensued, a patient died from an overdose.
the problem with this kind of non-physician owned clinic there is NO recourse by the College to address deficiencies in patient care since the owners are outside of the scope of control by the College. the short recommendation here is that no medical facility should be allowed to operate anywhere in the province without being under the FULL managerial control and ownership by physicians. no physician control, no operation, period. non-physicians do not have the ethical commitment to patients that we do, the primary interest is the $$$$, patients be damned.
furthermore, it turns out that under the original ownership, my billing number was used to defraud Alberta Health to the tune of thousands upon thousands of dollars, which i was never aware of, since the company never ever gave me the AH payment sheets. me the fool for trusting and thinking i was dealing with honest folk.
one VERY CONCRETE thing which should be enshrined in any practice management thing is that physicians MUST ALWAYS be given a copy of their billing reconciliation stuff so they KNOW how much is being billed if they are letting a third party bill and collect their payments, and giving them a stipend, as was my case. it should be written in stone that Alberta Health send to each physician who has billings submitted either by themselves or a third party using their billing number, be sent a printout of the Statement of Assessments for each and every payment made.
when i found out how things were going, i called AH to get my statements, and was told they would NOT send them to me, i would have to talk to the manager of the clinic. i had to take legal action to get copies of my statements from AH. i recently spoke with a colleague in one of the [redacted] clinics and he is having difficulties with the management getting his billing reconciliation sheets from them, as in all likelihood, things are not on the square regarding his billings from head office of [redacted]. i told him to contact AH directly and wished him well.
i have decided to retire at the end of this year, so frankly i don't actually care anymore about any of this stuff, i'm done. i feel the College has really let me down regarding what i've been dealing with over the [redacted] debacle. i submit these suggestions as a parting gift to those who may follow in my footsteps, that if these necessary changes are implemented, no one else will have to suffer through the same kind of crap i've had to deal with in my final year of practice.
respectfully submitted, Glenn Kowalsky, MD
should you wish any further clarification regarding my comments, i would be more than happy to discuss things further.
I would like to see if something could be added. This comes from personal experience with a very unprofessional doctor who took over my practice in 2002. I would like to propose that a doctor who takes over another doctors' practice must keep the original phone number for 6-12 months. When I transferred my practice, I had carefully written letters to all my patients. The week after he took over, he changed the phone number. Those patients who had moved and didn't receive my letter thought I had skipped town when they called and the number was disconnected ONE WEEK AFTER I LEFT. Please don't let this happen to another doctor who works had to transfer care. It destroys our efforts at providing continuity. Thanks.
I agree with your recommendations
1) I wonder if there is ambiguity around partnerships vs. shared practices?
2) It is not clear to me how the guidelines apply to itinerant physicians and if they are responsible to ensure the practices they cover are in compliance?
This standard does not address physicians who work in multidisciplinary settings for non profit organizations providing medical services. Examples would be the Boyle McCauley Health Centre or CASA. Although the physician has control over the medical care provided the other staff are hired by, supervised by and their roles and responsibilities determined by the organization or CEO of the organization. An alteration to the standard to address these circumstances in the same way that hospitals and other government run organizations are managed would be useful.
The designation of a medical lead seems somewhat vague and confusing. If individual associate physicians within a practice are solely responsible for the direction and control of their practices, how would another physician in that group be able to "represent" them if that other physician is independent? Does the medical lead become liable or responsible in any way for the actions of other physicians in the group? I think before this policy is implemented, the responsibilities (and potential liabilities) of the medical lead need to be more explicitly clarified.
Need to ensure that fax number is also updated if changed. This prevents privacy breeches when a fax number changes and then the information gets sent to a wrong fax number (perhaps taken by a non health care professional).
Need to define multiphysician practice. Some are group in that they share patients and others are individuals in that they do NOT share patients. If they do not share patients then a single provider may leave the practice or move. The responsibility to the college should be from the individual care provider and not the group. If the entire group moves then one person could inform for the group (whether they share patients or don't) as long as it is clear who is moving. It can get very complicated.