New Scope of Practice, Authorized Acts and Standards of Practice for MRTs in Ontario

1. New Scope of Practice, Authorized Acts and Standards of Practicefor MRTs in Ontario September 2011 Workshops Presented by: Linda Gough, M.R.T.(R.), Registrar

2. Objectives • Scope of Practice • Authorized Acts • Standards of Practice • Other changes to legislation that will affect the practice of MRTs Discuss and review the changes to the regulatory framework for the practice of MRTs in Ontario

3. Good News! September 1, 2011: • amendments to MRT Act came into force • new scope of practice statement • new authorized acts • revised Standards of Practice

4. College of Medical Radiation Technologists of Ontario (CMRTO) • Regulatory (licensing) body for MRTs in Ontario • It regulates the activities of the MRT according to the Regulated Health Professions Act (RHPA) and the Medical Radiation Technology (MRT) Act • Mandatory registration for MRTs to practise in Ontario • Protects the public interest byensuring that MRTs are qualified to practise and are practising professionally

5. CMRTO Council David Price, M.R.T.(R.), (President) Donna D. Lewis, M.R.T.(T.), (Vice-President) Bronwen Baylis, M.R.T.(R.) Patrice Burke, Public Member Anthony (Tony) Carroll, Public Member Mary Ann Ginty, M.R.T.(R.) Robert Kamen, M.R.T.(N.) Claudina Di Zio (Dina) Longo, M.R.T.(R.) Elnora Magboo, Public Member Hal McGonigal, Public Member Caron Murray, M.R.T.(M.R.), M.R.T.(R.) Cathryne Palmer, M.R.T.(T.) Amin Saab, Public Member Ghulam Sajan, Public Member Tarlok Singh, Public Member

6. Differences between CMRTO and OAMRT CMRTO or “College” OAMRT professional association for MRTs in Ontario voluntary organization of professional members acts in the interest of members and profession provides member services: PD, advocacy, benefits • regulatory body for MRTs in Ontario • established in provincial law • regulates the profession in the public interest • sets and enforces the standards of the profession

7. Regulated Health Professions Act • Umbrella legislation for the regulation of 22 health professions in Ontario • Defines 13 “controlled acts” • Sets out the common regulatory requirements: registration, complaints and discipline, quality assurance • Each of the 21 regulated health profession colleges (soon to be 26) has its own profession specific Act under the RHPA which sets out its scope of practice and its authorized acts

8. Medical Radiation Technology Act MRT Act sets out: • Scope of practice statement • Authorized acts for MRTs • Additional requirements for performance of authorized acts MRT Act has been in place since December 31, 1993 First amendments September 1, 2011

9. Scope of Practice under RHPA Under the Regulated Health Professions Act, the scope of practice consists of 2 components: • Scope of practice statement • Authorization to perform some or all of the 13 controlled acts defined under RHPA

10. Scope of Practice Statement General statement describing what the profession does and the methods it uses. Serves as a frame of reference for: • Establishing standards of practice for the profession • Deciding whether or not to perform authorized acts • Establishing entry to practice requirements • Establishing course content for educational programs

11. Scope of Practice Statement • A profession does not have the exclusive right to provide services within its scope of practice • No one profession is granted an exclusive license to practice • There is no prohibition againstan unregulated practitioner performing services within a regulated profession’s scope of practice

12. Controlled Acts and Authorized Acts Controlled Act: 13 procedures listed in the RHPA that are deemed to pose risk of physical harm if performed by unqualified persons Authorized Act: A controlled act, or portion of a controlled act, that is authorized for a specific profession to perform under its health profession Act

13. Controlled Acts and Authorized Acts • Only a member of a regulated health profession who is authorized under the member’s specific legislation (or a person to whom a controlled act is delegated) may perform a controlled act • MRTs are authorized to perform 5 controlled acts (previously 4) under the MRT Act

14. Controlled Acts A ‘controlled act’ is any one of the following done with respect to an individual: • Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis

15. …Controlled Acts • Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth including the scaling of teeth • Setting or casting a fracture of a bone or a dislocation of a joint • Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust • Administering a substance by injection or inhalation

16. …..Controlled Acts • Putting an instrument, hand or finger; • beyond the external ear canal • beyond the point in the nasal passages where they normally narrow • beyond the larynx • beyond the opening of the urethra • beyond the labia majora • beyond the anal verge, or • into an artificial opening into the body

17. …..Controlled Acts • Applying or ordering the application of a form of energy prescribed by the regulations under this Act • Prescribing, dispensing, selling or compounding a drug as defined in clause 113(1)(d) of the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept • Prescribing or dispensing for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers

18. …..Controlled Acts • Prescribing a hearing aid for a hearing impaired person • Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning • Managing labour or conducting the delivery of a baby • Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response

19. Authorizing Mechanisms to Perform Controlled Acts Defined in RHPA • Authorized Acts – authority under MRT Act • Delegation– delegation from health carepractitioner who is authorizedto perform controlled act • Exemptions – authority to perform controlled act under exemption in RHPA regulation e.g. electromagnetism for MRI

20. Previous MRT Scope of Practice Statement “The practice of medical radiation technology is the use of ionizing radiation and other prescribed forms of energy to produce diagnostic images and tests, the evaluation of the technical sufficiency of the images and tests, and the therapeutic application of ionizing radiation” Ontario Regulation 226/03 “1. Electromagnetism is a prescribed form of energy for the purposes of section 3 of the Act”

21. Previous MRT Authorized Acts 1. Taking blood samples from veins 2. Administering substances by injection or inhalation 3. Administering contrast media through or into the rectum or an artificial opening into the body 4. Tattooing MRTs need an order from a physician in order to perform an authorized act.

22. MRT Scope of Practice Review On April 7, 2008, the CMRTO and the OAMRT received a letter from the Health Professions Regulatory Advisory Council (HPRAC) identifying that there will be a review of certain professions’ scopes of practice, including MRTs, to: • Identify barriers to interprofessional collaboration (IPC) • Allow MRTs to work to their maximum competence • Promote IPC

23. …MRT Scope of Practice Review CMRTO and OAMRT formed a working group to provide advice on submission comprised of: • CMRTO Council and Committee members • OAMRT representatives • Practising MRTs in all 4 specialties from a varietyof practice settings • Managers • Educators

24. Consultations with Stakeholders • CMRTO staff conducted interviews of MRTs, educators, managers, radiologists and radiation oncologists regarding MRTs’ practice • CMRTO and OAMRT consulted with stakeholders including: CAMRT, provincial regulators and associations, Ontario Hospital Association, Ontario Medical Association, regulatory bodies and associations of other health professions (physicians, nurses, respiratory therapists, physiotherapists), radiology managers, radiologists, educational institutions, and Ontario government

25. What we heard from MRTs • Safe application of ionizing radiation and electromagnetism to patients undergoing imaging and therapeutic procedures • 3D computed tomography, nuclear medicine, magnetic resonance, radiation therapy planning • Digital imaging and treatment planning • Hybrid imaging: PET/CT, SPECT/CT, image-guided radiation therapy, image-guided interventional radiology, CT/MRI • Increased use of contrast media – MRTs are routinely administering intravenous contrast

26. Problems with Previous Scope of Practice • Scope of practice statement did not include the application of electromagnetism for MRI • Authorized acts are interpreted differently by different professions • Didn’t reflect current practice • MRTs required delegation of controlled acts not authorized to us in order to perform routine procedures

27. Requested for Change in Scope of Practice and Authorized Acts for MRTs Requested change to the scope of practice statement and the authorized acts for MRTs in the CMRTO/OAMRT joint submission address the following: • Updated scope of practice and authorized acts to reflect current practice • MRTs’ ability to practise to full extent of current competence • Interprofessional collaboration and patient centered care

28. MRT Scope of Practice Amendments Dec 2009: Regulated Health Professions Statute Law Amendment Act passed, includes amendments to MRT Act March 2010: September 1, 2011 announced as date changes came into effect May 2010: Registrar gave workshops to MRTs around the provinceOct 2010 – June 2011: Revised Standards of Practice developed and approved by CMRTO Council Sept 1, 2011: New Scope of Practice, Authorized Acts and Standards of Practice came into effect

29. New Scope of Practice StatementEffective September 1, 2011 The practice of medical radiation technology is the use of ionizing radiation, electromagnetism and other prescribed forms of energy for the purposes of diagnostic and therapeutic procedures, the evaluation of images and data relating to the procedures and the assessment of the individual before, during and after the procedures.

30. Principles Behind the Wording of theNew Scope of Practice Statement The practice of medical radiation technology is the use of ionizing radiation, electromagnetism and other prescribed forms of energy… • Electromagnetism now included in the scope of practice statement rather than being an add on through regulation • Increases transparency to public and provides role clarity • Keeps door open to add other forms of energy through regulation in the future

31. … Principles Behind the Wording of the New Scope of Practice Statement … for the purposes of diagnostic and therapeutic procedures, … • New technologies and innovative procedures are performed by MRTs in all of the specialties (e.g. image-guided therapies, hybrid technology) • New scope of practice statement eliminates the previous separation between diagnostic imaging and radiation therapy

32. … Principles Behind the Wording of the New Scope of Practice Statement … the evaluation of images and data related to the procedures … • This is what MRTs told us that they are doing – the previous wording of “evaluation of the technical sufficiency of the images and tests” was too narrow • MRTs are assessing the image, making decisions and implementing medical directives or making adjustments based on their observations • The radiologist remains responsible for providing a final written report, an interpretation or a diagnosis

33. … Principles Behind the Wording of the New Scope of Practice Statement … and the assessment of an individual before, during and after the procedures. • Screening the patient for contraindications prior to performing the procedure is an essential component to ensure the safety of the patient • The interpreting physician, radiologist or oncologist is not present for most procedures • MRT is alone with the patient most of the time

34. New Authorized ActsEffective September 1, 2011 In the course of engaging in the practice of medical radiation technology, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration to perform the following: • Administering substances by injection or inhalation(no change) • Tracheal suctioning of a tracheostomy

35. …..New Authorized Acts • Administering contrast media, or putting an instrument, hand or finger, • Beyond the opening of the urethra • Beyond the labia majora • Beyond the anal verge, or • Into an artificial opening of the body • Performing a procedure on tissue below the dermis • Applying a prescribed form of energy

36. Principles Behind the New Authorized Acts 2. Tracheal suctioning of a tracheostomy • MRTs were previously performing the controlled act of putting an instrument beyond the larynxunder delegation • MRTs have knowledge, skill and judgment to perform this controlled act

37. ….Principles Behind the New Authorized Acts 3. Administering contrast media, or putting an instrument, hand or finger : • Beyond the opening of the urethra • Beyond the labia majora • MRTs were previously performing these controlled actsunder delegation • MRTs have knowledge, skill and judgment to performthese controlled acts

38. ….Principles Behind the New Authorized Acts 3. Administering contrast media, or putting an instrument, hand or finger: • beyond the anal verge, or • into an artificial opening into the body • This is an expansion of the previous authorized act of “administering contrast media through or into the rectum or an artificial opening into the body” • Clarifies that the procedure performed by MRTs routinely includes the insertion of the rectal tube • Includes other procedures, e.g. transrectal ultrasound for brachytherapy of the prostate

39. ….Principles Behind the New Authorized Acts 4. Performing a procedure on tissue below the dermis • Clarifies that “administering a substance by injection” includes performing the venipuncture. Clarification needed when MRTs are functioning within interprofessional care teams • MRTs’ previous authorized acts of “taking blood samples from veins” and “tattooing” are subsets of this controlled act

40. ….Principles Behind the New Authorized Acts 5. Applying a prescribed form of energy • MRTs are exempted from this controlled act for the purposes of applying electromagnetism for MRI, under the Controlled Acts regulation, made under the RHPA • Clarifies current regulatory regime to authorize the controlled act to MRTs under the MRT Act, and improves transparency to the public and other health professionals • Does not include the application of ionizing radiation

41. RHPA: Forms of Energy Regulation Controlled Act # 7 under RHPA: “Applying or ordering the application of a form of energy prescribed by the regulations under this Act” Forms of energy for Controlled Act # 7 as defined in Regulation 107/96: • Electricity (for 10 purposes set out in regulation) • Electromagnetism for MRI • Soundwaves fori) diagnostic ultrasound, orii) lithotripsy

42. Authority for MRTs to Apply Electromagnetism for MRI Ont. Reg. 107/96 – Controlled Acts – Made under RHPA Forms of Energy - Exemptions 3.1 “A member of CMRTO is exempt from 27(1) of the Act for the purpose of applying electromagnetism if the application is ordered by a member of CPSO, and ” ….. (other conditions)

43. Wait a Minute….. • MRTs are still required to have an order from a physician in order to perform an authorized act • MRTs still need to have the knowledge, skills and judgement to perform the procedure safely, effectively and ethically, given the circumstances in the situation • Application of ionizing radiation still subject to the provisions set out under the Healing Arts Radiation Protection (HARP) Act

44. The Evolution of the Practice ofthe Profession MRTs have demonstrated their competence to practise in the new scope of practice through: • Safe Practice (CMRTO Essential Competencies, QA) • Education (part of entry to practice programs) • Testing (part of CAMRT certification exam)

45. …The Evolution of the Practice ofthe Profession Changes will: • provide clarity to the public and other health care practitioners • improve efficiency by maximizing the use of MRTs within interprofessional care settings • improve patient access to state of the art diagnostic and therapeutic procedures • update legislative framework to reflect current practice of MRTs

46. Standards of Practice:for the profession, by the profession Standards of Practice: • based on the values of a profession and developed by profession (College) • are an essential component of self-regulation • are a framework which describes the knowledge, skill and judgment required to practise the profession safely • demonstrate to the public, government and other stakeholders that a profession can regulate itself in the public interest

47. CMRTO Standards of Practice Object of the College set out in RHPA: “to develop, establish and maintain programs and standards of practice to assure the quality of practice of the profession”

48. CMRTO Standards of Practice Previous standards comprised of • Essential Competencies • Comprehensive Guidelines • Addendum to the Comprehensive Guidelines

49. CMRTO Standards of Practice • MRTs : sets out minimum standards of professional practice for MRTs in Ontario • Managers: developing policies and procedures, and making decisions about the practice of MRTs • Educators: developing curriculum and providing appropriate instruction • Public: assessing quality of care provided by MRTs

50. CMRTO Standards of Practice Standards are the foundation for all College’s legislated functions including: • Registration (entry to practice) • QA (continued competence) • Complaints and discipline (enforcement) “Failing to maintain the standards of practice of the profession” is an act of professional misconduct under the RHPA (CMRTO Professional Misconduct Regulation)