Optimizing Scopes of Practice REPORT English

Optimizing Scopes of Practice
New Models
of Care For a New
Health Care System
Report of the Expert Panel appointed by the Canadian Academy of Health Sciences:
Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, Mowat D, Nasmith L, Postl B, Shamian J, Sketris I. (2014)
Optimizing Scopes of Practice: New Modelsof Care For a New Health Care System
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Published 2014 by the Canadian Academy
of Health Sciences,
180 Elgin Street, Suite 1403,
Ottawa, ON, Canada K2P 2K3
Additional copies of this report are available

from the Canadian Academy of Health Sciences
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ca/e/assessments/completedprojects.php
For more information about the Canadian

Academy of Health Sciences, visit the CAHS
home page at: http://www.cahs-acss.ca/
Suggested citation: Nelson, S., Turnbull, J.,

Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D.,
Mowat, D., Nasmith, L., Postl, B., Shamian, J.,
Sketris I. (2014) Optimizing Scopes of Practice:
New Models for a New Health Care System.
Canadian Academy of Health Sciences.
Ottawa, Ontario.
Letter from the President
of the Canadian Academy
of Health Sciences
On behalf of the Canadian Academy of Health Sciences (CAHS), I am pleased to
present this Assessment: Optimizing Scopes of Practice: New Models of Care
for a New Health Care System. The Assessment had its origins in the CAHS Forum
of September 2011, which focused on the future of Canada’s health care system.
Deliberations after the Forum led to a realization of the importance of scopes of
practice to innovation in Canada’s health care system.
I wish to extend the sincere gratitude of the CAHS Every CAHS Assessment requires the financial
to the co-chairs, Jeff Turnbull, University of Ottawa, sponsorship of visionary organizations. This
and Sioban Nelson, University of Toronto, and to the Assessment was supported by a large number
distinguished members of the Expert Panel. This of organizations, which generously contributed
publication is the culmination of their 24 months of anywhere from $5,000 to $50,000. The CAHS is
careful review of the evidence and development profoundly grateful to each of these sponsoring
of innovative recommendations. I wish also to thank organizations. They are acknowledged in the
Ivy Bourgeault, University of Ottawa, Scientific Director introductory pages of this report.
of the Canadian Health Human Resources Network, The leadership of the CAHS brings this Assessment
for vital contributions to this Assessment. to the attention of the Canadian public, confident
Appreciation is due also to Dale Dauphinee, McGill that it will be of substantial value in national efforts
University, Past-Chair of the CAHS’s Standing Committee to strengthen and sustain the health care system
on Assessments, for the guidance that he and his so highly valued by all Canadians.
dedicated committee provided for this Assessment
from its earliest phases to its successful conclusion.
I wish to extend a sincere “thank you” to Carol Herbert,
Western University, who provided critical oversight
of the process as it neared conclusion. I wish also to
acknowledge Tom Marrie, Past President of CAHS,
for his leadership in building the early momentum
John A. Cairns, MD, FRCPC, FCAHS
and securing sponsors for this Assessment.
President (2013–2015),
Canadian Academy of Health Sciences
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The Canadian Academy
of Health Sciences
The Canadian Academy of Health Sciences (CAHS) provides “scientific advice for a
healthy Canada” (Canadian Academy of Health Sciences, 2009, p. 1). It is a non-profit
charitable organization, initiated in 2004 to work in partnership with the Royal Society
of Canada and the Canadian Academy of Engineering. Collectively these three bodies
comprise the founding three-member Council of Canadian Academies. The Canadian
Institute of Academic Medicine played a leadership role in developing the Canadian
Academy of Health Sciences, ensuring the inclusion of the broad range of other
health science disciplines.
The Canadian Academy of Health Sciences is modeled appointed by the Canadian Academy of Health
on the Institute of Medicine in the United States and Sciences and undergoes extensive evaluation by
provides timely, informed, and unbiased Assessments external reviewers who remain anonymous to the
of urgent issues affecting the health of Canadians. The Panel until the study is released. Final approval for
process of the Canadian Academy of Health Sciences’ release and publication of an Academy report rests
work is designed to ensure appropriate expertise, only with the Board of the Canadian Academy of
integration of the best science, and avoidance of the Health Sciences.
bias and conflict of interest that frequently confound The Canadian Academy of Health Sciences is composed
solutions to difficult problems in the health sector. of elected Fellows from diverse disciplines both within
The Academy’s Assessments provide an objective and external to the health sector. It is both an honorific
weighing of the available scientific evidence at arm’s membership organization and a policy research
length from political considerations and with a focus organization. The Fellows are elected to the Academy
on the public interest. by a rigorous peer review process that recognizes
Assessment sponsors have input into framing the study demonstrated leadership, creativity, distinctive
question; however, they cannot influence the outcomes competencies, and a commitment to advance
of an Assessment or the contents of a report. Each academic health sciences.
Academy Assessment is prepared by an Expert Panel
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Expert Panel Members Legal Consultant
This Expert Panel represents a diverse range of Nola M. Ries, University of Alberta and University
expertise and perspectives, exemplifying the of Newcastle (Australia)
reputation of the Canadian Academy of Health Biographies of the Expert Panel members, Project
Sciences for objectivity, integrity, and competence: Team, Legal Consultant and CAHS liaison are in
Sioban Nelson (co-chair), University of Toronto Appendix 4*. All members volunteered their time
Jeff Turnbull (co-chair), Ottawa Hospital and expertise to address this critical issue and were
required to declare in writing any potential conflicts
Lesley Bainbridge, University of British Columbia of interest. These are available for review on request.
Timothy Caulfield, University of Alberta
Gilles Hudon, former Director of Health Policy and
Professional Development, Federation of Medical External Reviewers
Specialists of Quebec
External reviewers provided candid and constructive
Dennis Kendel, former Registrar of the College comments to assist the Canadian Academy of Health
of Physicians and Surgeons of Saskatchewan Sciences in ensuring that this report meets its stan-
David Mowat, Medical Officer of Health for dards for objectivity, evidence, and responsiveness
Peel Region, Ontario to the study charge. The external reviewers were:
Louise Nasmith, University of British Columbia Dr. J. Lloyd Michener, Professor and Chairman,
Department of Community and Family Medicine, and
Brian Postl, University of Manitoba
Clinical Professor, School of Nursing, Duke University
Judith Shamian, International Council
Dr. Nancy Edwards, Professor, School of Nursing and
of Nurses, Ontario
Institute of Population Health, University of Ottawa,
Ingrid Sketris, Dalhousie University Scientific Director of the Institute of Population and
Public Health, CIHR
Dr. Julie Fairman, Nightingale Professor of Nursing
Project Team: Canadian and Director of the Barbara Bates Center for the Study
Health Human Resources of the History of Nursing, School of Nursing, University
of Pennsylvania
Network (CHHRN) Dr. Richard Reznick, Dean, Faculty of Health Sciences,
Ivy Lynn Bourgeault, Scientific Director of CHHRN, Queen’s University
University of Ottawa
Gillian Mulvale, McMaster University
Katelyn Merritt, Project Manager, CHHRN,
Biographies of the Expert Panel members, Project
Team, Legal Consultant and CAHS liaison are in
Appendix 4*. All members volunteered their time
and expertise to address this critical issue and were
required to declare in writing any potential conflicts
of interest. These are available for review on request.
* All appendices are available solely on the CAHS website: http://www.cahs-acss.ca/completed-projects/
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Acknowledgements
MAJOR SPONSOR
Government of Ontario, Ministry of Health
and Long-Term Care
SPONSORS
Alberta Health Services
Government of Alberta
Canadian Nurses Association
Royal College of Physicians and Surgeons of Canada
Ontario Neurotrauma Foundation
Institute for Health System Transformation
and Sustainability
Saskatchewan Health Research Foundation
Canadian Medical Association
CONTRIBUTORS
Alberta Innovates
Manitoba Health Research Council
Nova Scotia Health Research Foundation
Dalhousie University
University of Manitoba
McGill University
University of Saskatchewan
University of Toronto
Association of Faculties of Medicine of Canada

Canadian Association of Occupational Therapists
Capital District Health Authority
McMaster University
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Preface: A
Message from
the Co-Chairs
Over the last decade, it has become increasingly clear that our health care system in Canada
is underperforming relative to investment. This has led to widespread calls for change and
the recognition that a new health care system must be built upon collaborative care models,
where the right professional provides the highest quality of care in the right setting and at
the right time based upon the needs of the individual patient. Determining the optimal scopes
of practice of these health care providers will be an essential element in leading health care
transformation for the future. Unfortunately, the systems in place for determining and
regulating scopes of practice have done more to preserve the status quo than promote
change. As a result the Canadian Academy of Health Sciences commissioned a report towards
the end of 2012 to address the following question: What are the scopes of practice that will
be most effective to support innovative models of care for a transformed health care system
to serve all Canadians?
We were honoured to be named as co-chairs of a The report concludes with specific recommendations
distinguished Expert Panel, which spent the next to those key stakeholders who are required to make
18 months addressing this question. We were fortunate this transformation a reality.
to partner with the Canadian Health Human Resources As co-chairs, we would like to take this opportunity
Network (CHHRN) which, through its extensive knowl- to thank the members of the Expert Panel for their
edge base and network, completed an exhaustive unlimited energy and expertise. We would also like to
scoping review and conducted focused interviews highlight the importance of those individuals who gave
with opinion leaders in the field. freely of their time as key informants and reviewers.
During this process we recognized the importance of This report would not have been possible without
non-regulated and informal health providers as well Ivy Bourgeault and the team at CHHRN, especially
as the need to consider health promotion strategies the tireless Katelyn Merritt. We thank them for their
in any comprehensive plan for health care reform. remarkable efforts. Finally, we would also like to
However, this review focuses primarily upon regulated thank the Academy for trusting us with such an
health professions and their contribution in supporting important task.
collaborative models of care and transforming our We hope that this report will be the beginning of
health care system. a process of thoughtful discussion and debate that
The report calls for a new approach towards determin- must at all times put the future of the health care
ing scopes of practice based upon community need. system and the welfare of our patients and
This approach would empower the collaborative communities first and foremost.
practice team to determine the relative responsibilities
of the different practitioners and the team would be
held accountable through an accreditation process Sioban Nelson Jeff Turnbull
within a professional regulatory environment.
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Table of Contents
THE CANADIAN ACADEMY OF 3. KEY FINDINGS.................................................................................31

HEALTH SCIENCES...................................................................................2
A. Micro (Practice) Level Interventions..................... 32
Executive Summary........................................................................8 B. Meso (Institution) Level Interventions................. 39
INTRODUCTION......................................................................................15 C. Macro (Structure) Level:
Overview of the Scope.................................................. 17 Educational Interventions......................................46
Outline of the Assessment Report............................ 18 D. Macro (Structure) Level:
1. WHY FOCUS ON SCOPES OF PRACTICE?.......... 19
Economic Interventions.......................................... 49
What is the problem we are trying to address?...... 19 E. Macro (Structure) Level:

Legal and Regulatory Interventions.....................54
Rationale for Investigating Scopes of Practice........ 19
Summary of the Key Findings...................................... 59
The Various Meanings of Scope of Practice............... 20
Research Gaps................................................................ 62
The Politics of Scopes of Practice..............................23
4. RECOMMENDATIONS...............................................................63
Conceptual Framework................................................. 25
Reference ................................................................................................66
2. METHODOLOGICAL APPROACH.................................27
References Cited............................................................66
Overview of the Scoping Review Process................. 28
References − Published Literature............................. 69
Overview of the Key Informant Interviews............... 30
References − Grey Literature...................................... 74
APPENDICES................................................................................................76
List of Case Studies, Figures, Tables, and Appendices
Case Studies Case Study 4: Integration of Electronic Medical

Records, Sault Ste. Marie Group
Case Study 1: Expanded Scope of Practice,
Health Centre, Ontario..............................40
Physiotherapist Triage Model..................34
Case Study 5: Integrated Evaluation and Monitoring,
Case Study 2: Shared Care Model, Hamilton
Taber Family Care Clinic, Alberta............. 42
Family Health Team–Mental Health
Program (HFHT-MHP), Ontario................ 36 Case Study 6: Scalability of Innovations,
Collaborative Emergency Centres (CECs),
Case Study 3: Nurse-led Model, 1 Quick Care
Nova Scotia................................................... 61
Clinics, Manitoba......................................... 37
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Figures Appendices
Figure 1: The Triple Aim Model.......................................... 16 Appendix 1: List of Acronyms.......................................... 76
Figure 2: The Relationship between Scopes
of Practice and Models of Care.......................23 Appendices – Appendix 1 is included with the bound
Figure 3: Conceptual Framework..................................... 25 version of this report. All additional appendices are
available on the CAHS website:
Figure 4: Overview of Key Informant http://www.cahs-acss.ca/completed-projects/
Interview Participants........................................30
Figure 5: Overview of the Number of Citations
of Practice-Level Interventions from Appendix 2: Original Prospectus
the Literature....................................................... 32 Appendix 3: Glossary of Terms
Figure 6: Number of Citations of Type of Intervention Appendix 4: Biographies of Assessment Team
Studied in Intervention Literature.................. 39
Appendix 5: Screening Guidelines
Appendix 6: Health Care Professions Included
Tables Appendix 7: Search Strategy
Table 1: Barriers and Enablers at the Micro,
Appendix 8: List of Organizations Targeted
Meso and Macro Levels........................................60
for Grey Literature Search
Table 2: High-level Strategies for Optimal
Appendix 9: Literature Flowchart0
Scopes of Practice.................................................64
Appendix 10: Literature Extraction Tool
Table 3: Detailed Strategies, Recommendations
by Stakeholders......................................................64 Appendix 11: List of Key Informants
Appendix 12: Ethics Approval from the
Appendix 13: Letter of Information and Consent
Form for Key Informant Interviews
Appendix 14: Semi-Structured Key Informant
Interview Guide
Appendix 15: NVIVO Coding Scheme
Appendix 16: Overview of the Scopes of Practice
Interventions Literature
Appendix 17: Types of Funding Mechanisms
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Executive Summary
Recent shifts in the socio-demographic and epidemiologic contexts in which both scopes of practice and models
profile of Canadians, transformations in technology, and of care are embedded. In response to the challenge of
the ongoing concern over the return on investment of providing high-quality and accessible care, the scopes
health care dollars have led to a wide recognition of the of practice of some health care professionals, such
need for health care system transformation. Efforts to as pharmacists and nurse practitioners, have been
both preserve and improve upon the successful elements extended and new professions and roles, such as
of the Canadian health care system continue to be pharmacy technicians and health navigators, have
insufficient to meet the evolving health care needs been developed in several jurisdictions across Canada.
of all Canadians. The various elements of the current In some cases, however, these roles have been intro-
system were largely created to respond to acute, episodic duced without full articulation of how these new roles
care provided in hospitals and most often by individual will be integrated into existing service delivery models
physicians. Over the decades, these elements have or how they will impact the scopes of practice of
become enshrined in legislative, regulatory, and financial existing health professions. Beyond extending scopes
schemes that challenge adaptation to shifts in population of practice for some health care professions, optimiza-
health care needs. Health care organizations and person- tion of existing scopes of practice must be determined
nel seeking innovative solutions must often work around in alignment with the models of care in which they
these barriers in order to optimize resources and improve function. The misalignment of Health Human Resources
quality of care. These models typically remain localized capacities with the need to provide health care services
and lack the structures or systematic supports that relevant to population demands is a global issue for
would enable broader scalability. This Assessment directly which we are seeking a Canadian solution.
addresses the optimal scope of practice of health care
providers through an examination of these issues and
calls for system-wide transformation that builds upon Objectives and Research
ongoing quality improvement initiatives to better meet
patient, community, and population needs. Question
With health care professionals at the frontline of service The objectives of this Assessment were to conduct a
delivery, an examination of the utilization of health review of the evidence regarding the optimization of
human resources (HHR) is required. This endeavour health care professional scopes of practice, drawing
includes an investigation of the tasks and responsibilities upon the Canadian Academy of Health Sciences’
outlined within each health profession (referred to as network of scientists, professional leaders, and health
scopes of practice); the configurations in which health care professionals to provide an expert analysis. Led
professionals interact (referred to as models of care); by an Expert Panel and its two chairs, this Assessment
and the educational, legal, regulatory, and economic
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also represented the first time the Canadian Academy The conceptual framework, which was developed as
of Health Sciences (CAHS) had partnered with a part of the Assessment process, guided the data
knowledge exchange network in the relevant field, collection and analysis and is shown below. Briefly, it
the Canadian Health Human Resources Network maps out where we are—describing the insufficiencies
(CHHRN), which took the lead as the Project Team. of the present health care system—and where we want
CHHRN provided not only content expertise but also to be—highlighting the Expert Panel’s vision statement
access to an extensive national and international and target outcome indicators for patients, health care
network of scholars and Health Human Resources professionals, and the health care system. Depicted in
innovators. The charge developed by the Academy the middle of the framework is a model of how we can
and assigned to the Expert Panel in partnership with get there—focusing on various levels of structural
CHHRN was to address the following question: inputs that influence the optimization of health care
professional scopes of practice and supportive models
of care.
What are the scopes of practice that will be
Our explicit focus was to synthesize ways through
most effective to support innovative models which the reconfigurations of scopes of practice and
of care for a transformed health care system models of care, especially in a collaborative care
to serve all Canadians? environment, have the potential to initiate transforma-
tion of the health care system in order to better meet
patient, community, and population needs.
Approach
Using the Health Council of Canada’s Triple Aim Plus,
that comprises better health, better care, and better
value presented through a health equity lens, the
Project Team undertook a systematic process to
identify promising approaches related to the optimi
zation of health care professional scopes of practice.
There were three elements to the data collection
and synthesis: (1) a scoping review to systematically
map out the existing literature relevant to scopes of
practice from both published and unpublished sources,
(2) 50 key informant interviews to augment findings
from the literature, and (3) Expert Panel meetings to
discuss the state of the evidence and implications for
Health Human Resources planning and policy decision
making. This report reflects the consensus of the
Expert Panel members, which was developed over a
series of in-person and teleconference deliberations
over an 18-month period.
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Conceptual Framework:
Scopes of practice that support innovative models of care that better address population health needs a
nd a transformed
Health Care System
WHERE WE ARE HOW WE CAN GET THERE WHERE WE WANT TO BE

Current Canadian Health A transformed health care
Care System characterized Evaluation & system characterized by:
Performance
by insufficiencies around:
Measurement • A move from supply to need
• Accessibility – particularly focused (needs determine
for marginalized and models to scopes)
disadvantaged populations • A move from professional
• Care provided outside to patient focused
of business hours • A move from isolated, siloed
• Wait times professionals to teams based
Enablers and on non-conventional and
• Health promotion including
conventional providers
patient involvement and strategies for
self-management circumventing • A move away from historic
long term credential SoP to
• Appropriate use of health care barriers towards
a model of team defined tasks
providers and resources innovative models to meet population needs;
• Chronic care management of care optimizing team allocates resources and
• Mental health care scopes of practice responsibilities (task certification
process to ensure competency)
• Elderly and end-of-life care
M • Individual regulation to
• Fiscal effectiveness IC
M RO combined/team accreditation
and sustainability ES IN P U TS
M O • Performance monitoring and
AC IN P evaluation that is aligned with
RO U TS
these principles
IN
PUT
S • Funding groups rather than
individuals (not necessarily
health outcomes – process
outcomes, reduction to ER)
MACRO INPUTS – Structure Level MESO INPUTS – Institution Level MICRO INPUTS – Practice Level
Education & Training Context • Governance • Team composition
• Education needs/requirements • Labour/CQI Processes • Team vision
• Assessment/standards/competencies • Unionization • Degree of hierarchy
Economic Context • Technology form & content • Professional cultures
• Funding • Provider supply & retention • Communication
• Financing • Geography • infrastructure
• Remuneration
Legal & Regulatory Context
• Legislation/Form of regulation
• Registration requirements
• Provider accountability
List of insufficiencies from: Nosmith L., Bailem P., Baxter R., Bergman H., Colin-Thomé D., Herbert C., Keating N., Lessard R., Lyons R., McMurchy D., Ratner P.,
Rosenbaum P., Tamblyn R., Wagner E., & Zimmerman B. (2010). Transforming core for Canadians with chronic health conditions: Put people first, expect the best,
manage for results. Ottawa, ON, Canada: Canadian Academy of Health Sciences.
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Findings (institution), and macro (structure) levels based on the
interventions assessed for quality improvement. In the
Recognizing the variability of both communities and table below, we depict the fluidity of key barriers that
practice circumstances and the need to support models can provide an opportunity to become key enablers for
of collaborative care, the Expert Panel felt that a new optimizing scopes of practice and supporting innovative
approach towards determining and assigning scopes of models of care through modification or circumvention
practice was required. This strategy, one that is focused of structure or function.
on the patient and is flexible and accountable, would Over the course of this Assessment, we identified an
ensure that the right provider gives the best care in the emerging consensus that optimizing scopes of practice
most appropriate location. Critically, the model proposes paired with supporting evolving models of shared care
that the health care team or institution be held account- can provide a multidimensional approach to shift the
able for assigning appropriate and optimal scopes of health care system from one that is characteristically
practice within a regulated structure. siloed to one that is collaborative and patient-focused.
The findings from the scoping review and key informant
interviews were organized into micro (practice), meso
Barriers And Enablers:

Optimal Scopes Of Practice Within Collaborative Care Arrangements
At The Macro, Meso, And Micro Levels
BARRIERS ENABLERS
ealth care professional

H • E
ducating professionals and courts on changes to legislation that recognize the
accountability/liability concerns principles of shared care models
Educational needs/requirements • Establishing practicums and residencies that foster inter-professional competencies
that inhibit professionals working
MACRO
• Post-licensure credentialing for continued competency development over the course

to full or optimal scope
of a career
R igid legislation/regulations • E
xpanding adoption of more flexible legislative frameworks that can be interpreted
at the local setting
ayment models that do not support
P • A lternative funding (e.g., bundled or mixed payment schemes) to include all health
changes in scopes of practice care professionals and to be aligned with desired outcomes
ommunication across
C • I mplementation and upkeep of electronic medical records essential for all respective
multiple care settings health care professionals (and for patients themselves) to have timely access to the
most up-to-date information on treatment and status
Professional protectionism • R
epresentation of the interests of professions in the context of collaborative care
MESO
arrangements and inter-professional standards/overlapping scopes of practice

Accountability • B
roader application of collaborative performance measures and an overall quality
assurance framework through involvement of accrediting bodies
Availability of evidence • S
ystematic monitoring and evaluation (with specific focus on inputs and outputs) to
estimate cost incurred for introducing change and the long-term return on investments
Professional hierarchies • C
hange management team: a designated role for managing changes in scopes of
practice and models of care
Professional cultures (lack • C
ontinuing professional development to cultivate team thinking and develop levels
of trust and role clarity; job of trust around relative competencies
protectionism, turf wars,
• T
eam vision: to reinforce that the ultimate goal is the improved well-being of the patient;
task escalation)
MICRO
who provides the care is secondary to the quality and accessibility of services provided
Communication among health • I nstilling group mentality: internalization of shared responsibility across health
care professionals care professions
• Scheduling of regular meetings for health care team members to consult on
appropriate care strategies and problem-solving strategies; integrating information
communication technologies
• C
o-location to have different types of health care professionals and services
functioning in a shared space
* T he summary box above has been informed by data collected from both the scoping literature review and the key informant interviews.
The points presented were selected based on emerging themes and discussions among the Expert Panel members.
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Recommendations health care professional’s competence and secondly, an
accountability model embedded within collaborative
The recommendations provide a blueprint for action health care practice through a proposed accreditation
that will lead to the creation of more flexible environ- structure that ensures all members are working to
ments to enable the scalability of promising initiatives their optimal scopes of practice in order to better meet
around optimal scopes of practice and innovative patient, community, and population health needs.
models of care. Beyond the issue of transforming To enable this transformation, the recommendations
barriers into enablers, our analysis of scopes of practice are directed at the multiple constituencies that define,
innovations revealed that a common characteristic of fund, oversee, and regulate scopes of practice. Priority
innovation is that it circumvents largely macro-level actions are set out under each recommendation.
structural barriers. This finding supported our focus
on the broader context of health professional scopes
A. The Federal Government: Provide leadership
of practice that may be better able to address patient,
and support to encourage the expansion of
community, and population health needs. We are calling
collaborative care models and the evolution
for the implementation of an integrative structural
of scopes of practice.
framework that supports the optimization of health care
professional scopes of practice and innovative models
Priority Actions
of care. At the same time, we recognize the unique skills
and abilities specific to different professions as critical • A1. Convene a national summit of all stakeholders to
to best practice in collaborative care models. Rather discuss a coordinated and prioritized plan of action
than recommending changes to the scopes of practice based on the recommendations in this document.
of individual health care professions, we are proposing • A2. Develop an infrastructure that provides
an evidence-based approach characterized by arm’s- length evidence and evaluation of the health
three overarching elements: workforce with both HHR planning and deployment
• The approach is supportive of innovative through optimal scopes of practice as its mandate.
models of care. • A3. Earmark research funds to address gaps in
• The approach is flexible in order to respond to the literature, particularly those at the meso and
the varying needs of patients and communities. macro levels.
• The approach is accountable to the public and • A4. Develop a national framework for guidelines
to funders. and quality standards for optimal, expanded,
and overlapping scopes of practice.
This approach recognizes the importance of collaboration
• A5. Promote best practices and facilitate
among health care professionals as a central feature
subsequent scale-up and sustainability of
of the future of the health care delivery system. This
initiatives across the country.
level of collaboration requires shared responsibility at
the practice and institution levels with accountability • A6. Support the development and ongoing
for the quality of services provided, based on the needs implementation of umbrella health professional
of the respective communities. Entry-level scopes of regulatory legislation across provinces
practice should arise from pre-licensure professional and territories.
training and then expanded scopes of practice should
arise from supplemental training in special competencies B. Provincial/Territorial Governments: Take the
and be formally recognized. We are proposing two levels lead to create systems of funding, financing, and
of accountability that are interrelated and articulated: remuneration that enable collaborative models
firstly, a regulatory model that ensures the individual of care that align with patient outcomes.
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Priority Actions • D3. Expand accreditation to additional levels of
health care service provision to include collaborative
• B1. Adopt alternative funding structures to support
care models.
collaborative practice among professionals within
and across settings.
• B2. Initiate a review of professional and union E. Pre-licensure and Continuing Professional
collective agreements to examine their impact on Education Providers: Accelerate the ongoing
flexibility in health professional scopes of practice. development of pre-and post-licensure education
practices that foster collaborative care and reflect
• B3. Ensure accountability for collaborative, the changing nature of required competencies.
patient-oriented care through accreditation.
• B4. Develop mechanisms that support a move to Priority Actions
team- or institution-based liability coverage. • E1. Mandate and embed interprofessional,
• B5. Support system-wide adoption of information competency-based education across the profes-
technologies that foster optimal scopes of practice. sions so that interprofessionalism is an essential
competency (rather than an additional competency).
C. Regulatory Bodies: Take the lead to align regulations • E2. Develop certificates for advanced collaborative
in order to enable respective professionals to better practice competencies.
meet population health needs within collaborative • E3. Develop mechanisms to support widespread
care models, particularly in cases of overlapping and engagement in lifelong learning to build and
expanded scopes of practice. enhance collaborative care competencies.
Priority Actions
F. Professional Associations and Unions: Take
• C1. Work collaboratively with professional certification the lead in supporting collaborative care practice
bodies to create national standards and competency models as meeting the needs of the individual
frameworks that recognize training and recertification in professions represented and recognizing that
areas of overlapping and changing scopes of practice. this is the context in which most members work
• C2. Recognize certificates for advanced competencies or will work.
that enable expanded scopes of practice.
Priority Action
D. Accrediting Bodies: In partnership with Quality • F1. Contribute to the establishment of evidence-
Councils wherever possible, take the lead in informed guidelines for collaborative care models
establishing an accountability model through the in which their members participate.
accreditation and performance measurement of
Although these recommended actions are provided
collaborative care arrangements at the commu-
in itemized format, their implementation cannot
nity, primary care, and institution levels.
occur in isolation. There is an interactive and iterative
relationship between each recommendation and its
Priority Actions
development that is based on a common vision of
• D1. Build on existing standardized performance “where we want to be” to be implemented over time.
metrics for collaborative care models.
• D2. Build on existing metrics to inform lifelong
learning and collaborative competency development
for practitioners at pre- and post-licensure.
— 13 —

Conclusion collaborative care arrangements. This is best afforded
through the alignment of education, regulation, and
Increased flexibility around scopes of practice and models funding models to optimize health professional scopes
of care is required to meet the changing population health of practice. It is this collaborative practice model that
needs and the diversity represented in communities across must have the flexibility to best utilize the scopes of
Canada. To determine optimal scopes of practice, clearly practice of team members within an accountable and
defined roles and tasks are best delineated at the local regulated environment in the context of patient,
practice level relative to community needs and resources. community, and population health care needs.
Enabling greater flexibility requires an approach that takes In summary, the proposed recommendations provide a
into consideration changes over the course of a health blueprint for action to align optimal scopes of practice
professional’s career, including skills development, with innovative models of care through educational,
certification processes, skills mix, and professional legal, regulatory, economic, and evaluative structures.
interests. For such changes to be adopted and scaled Consideration and adoption of the recommendations
up over time, there needs to be both a systematic, will require time and cooperation from all stakeholders.
evidence-based approach to furthering individual- and The ultimate goal is for the transformation of scopes of
team-level accountability and a new balance between practice and models of care to enable the future health
regulated individual practice and the accreditation of care system to best meet the needs of Canadians.
— 14 —

Introduction
In the fall of 2011, the Canadian Academy of Health Sciences (CAHS)1 accepted a prospectus
to undertake a major Assessment of the current configurations of health care professionals,
their respective scopes of practice, and their relationship to Canada’s health care system
(see Appendix 2*).
Scopes of practice 2—the activities performed by a health innovative models of care, interviewed an array of
care professional—have emerged as a critical point in Canadian and international experts in the field, and at
policy discussions around health care transformation. key junctures, worked closely with the Co-Chairs and
The goal of this Assessment was to conduct a review of the Expert Panel about these ongoing findings. In the
the scientific evidence regarding the optimization of remainder of this report, we will use we to refer to the
health care professional scopes of practice, drawing combination of the Project Team, the CAHS Co-Chairs,
upon the Academy’s network of scientists, professional and the Expert Panel.
leaders, and health care providers to provide an expert From an initial scan of the literature and following the
analysis. This Assessment, under the responsibility of first Expert Panel meeting (and later confirmed by the
an Expert Panel and its Co-Chairs, also represented the key informant interviews), it was clear that answering
first time the CAHS has partnered with a knowledge the question as it was posed would be a challenging
exchange network; the Canadian Health Human Resources undertaking. We were confronted with ambiguity around
Network (CHHRN) took the lead as the Project Team. the relationship between scopes of practice and models
CHHRN not only provided content expertise but access of care. This raised the following question: Are certain
to an extensive national and international network scopes of practice required to support innovative models
of scholars and health human resource innovators. of care or are certain models of care required to optimize
The charge developed by the Academy and assigned scopes of practice?
to the Expert Panel in partnership with CHHRN was
to address the following question: Recognizing that we could not assert a linear relationship
between scopes of practice and models of care, we
considered the possibilities of their interdependent
What are the scopes of practice that will be nature and we interpreted the research question from
most effective to support innovative models both directions.
of care for a transformed health care system To do so, first we built upon the current consensus
to serve all Canadians? among policymakers and clinicians alike that scopes of
practice and models of care should be designed primarily
to meet patient and population needs rather than the
To systematically approach the question, the Project Team vested interests of the health care workforce. This was
examined the literature on health care professional scopes particularly relevant in the context of chronic disease
of practice to see how these could be optimized through management, where the 2010 CAHS report on chronic
1 See Appendix 1 for List of Acronyms.

2 See Appendix 3* for Glossary of Terms.
— 15 —

care (Nasmith et al., 2010) set out the key elements of the issues and perspectives relating to enablers and
an integrated health care system: barriers to health care transformation, with reference
• having primary care practices that are responsible to health human resource capacities.
for a defined population;
Figure 1: The Triple Aim Model
• being person-focused (and family or friend [adapted3]
caregiver-focused);
• providing comprehensive services through
interprofessional teams;
• linking with other sectors in health and social care; and
• being accountable for outcomes.
ACCESSIBLE
Taking these elements from this earlier work as a starting
point, we looked for configurations and approaches to
scopes of practice that demonstrated innovation through
(a) transcending or further optimizing traditional scopes PATIENT-
of practice, (b) involving more collaborative practice ORIENTED
environments, and/or (c) increasing patient and family
engagement. A core principle that emerged from the
literature was the necessity of institutional flexibility to AFFORDABLE QUALITY
reflect the changing needs of individuals, communities,
and the broader population over time. We searched
for integrative structural contexts that support rather + EQUITY
than hinder the development and proliferation of
innovative and flexible models of care that optimize
health professional scopes of practice.
Second, we adhered to the Triple Aim philosophy of The Necessity and Timeliness
better health, better care, better value, developed
by the Institute for Health Care Improvement (IHI,2012) of an Assessment of Scopes
(see Figure 1). Better health refers to health promotion of Practice
strategies and improving accessibility and therefore
improved health outcomes at population levels; better The need to inform health human resource (HHR) policy
care refers to improving the quality of care and overall and planning with the best available evidence around
patient experience; and better value refers to improv- promising models of care that better optimize health
ing the affordability and controlling the per capita cost professional scopes of practice to ensure that patient,
of care on a system level. More recently, the Health community, and population needs are met is becoming
Council of Canada (HCC) has added the principle of increasingly important. With health care professionals
equity to the framework; it is defined as “the absence at the frontline of service delivery, a system-wide exam-
of systematic disparities in health between social groups ination of the configurations of health care professions
who have different levels of underlying social advantage/ and respective scopes of practice, relevant to the current
disadvantage.” This principle was added to ensure that epidemiologic, socio-demographic, and technological
improvements made affect all Canadians. The literature landscape, is needed to inform the next steps towards
review and key informant interviews focused on the transforming the Canadian health care system.
question of scopes of practice and models of care along
the four axes presented in Figure 1. It then maps out
3 Visual representation was adapted from the original model developed by the Institute for Health Care Improvement (2012); outlined in the Health Care
Innovation Working Group’s Report and augmented with the Health Council of Canada’s report Better health, better care, better value for all: Refocusing
health care reform in Canada (2013).
— 16 —

The A Framework for Collaborative Pan-Canadian Health A second feature of the Assessment has been to
Human Resources Planning (2007) highlighted that investigate strategies with the potential for scalability
“Canada’s ability to provide access to high quality, in order to build upon previous successes. Information
effective, patient-centred and safe health services around ways of moving beyond pilot phases for broader
depends on the right mix of health care professionals and more sustainable adoption was primarily drawn
with the right skills in the right place at the right time” from key informants. Although we did not systemati-
(p. 28). The Council of the Federation advanced this cally evaluate the literature that focused on the process
perspective by identifying the issue of scopes of practice of implementing or scaling up scopes of practice
in January, 2012, as one of the three priority areas of the (an important issue for follow-up), these data were
Health Care Innovation Working Group. Specifically, the used to inform the recommendations, which are
Working Group focused on “Team-based Health Care targeted at government, regulatory, professional, and
Delivery Models that encourage all health care profes- education stakeholders at regional, provincial, territo-
sionals to work to their full professional capacity to better rial, and federal levels, including research-funding
meet patient and population needs in a safe, competent, organizations like the Canadian Institutes of Health
and cost effective manner” (p.4). Research (CIHR).
The Council’s interest in scopes of practice was threefold.
It identified scopes of practice as integral to:
• advancing pressing issues around chronic disease
Overview of the Scope of
prevention and management, seniors’ care, and rural this Assessment
and remote health care delivery;
We recognize that population-based equity issues—
• developing strategies to scale up leading practices and
referred to as social determinants of health—are
innovative models of care across the country; and
fundamental to improving the overall health of
• improving outcomes for patients through better access Canadians across social strata. For pragmatic
and more effective and efficient models of care. purposes, however, we have confined this Assessment
to an examination of the health care system as a start-
Health care transformation is at the heart of these
ing point for health system transformation. Improving
discussions and prioritizes the optimization of health
the health of all Canadians will, by necessity, involve
professional scopes of practice that systematically
multiple measures that fall outside the structures of
support health care innovations.
the health care sector, such as access to clean water,
One feature of this Assessment has been to examine suitable housing, education, food security.
the evidence around changes to scopes of practice and
This Assessment also selectively focuses on the scopes
traditional models of care that focus on better responding
of practice of regulated health care professionals providing
to community needs and tackling the issues of accessibility,
predominantly public services and does not explicitly
quality, equity, and financial sustainability. We looked for
examine scopes of practice of unregulated and informal
examples of needs-based approaches that often refor-
care providers, such as family members and personal
mulated traditional models of care. Our explicit focus
support workers. We recognize that informal care provid-
was on ways to transform the health care system
ers are and will continue to be essential components to
through the reconfigurations of scopes of practice
an effective health care system. Regulated health care
and models of care that are informed by patient,
professions were targeted in this Assessment as they
community, or population needs.
tend to dominate discussions around fragmented
service provision and siloed models of care.
— 17 —

Specific parameters for the scope of this Assessment are outlined in the summary points below.4
WHAT THIS ASSESSMENT DOES WHAT THIS ASSESSMENT DOES NOT ADDRESS
(but recognizes as important)
1. Addresses areas for improvement within the health care Social determinants of health—health factors outside of the
system that relate to scopes of practice health care system, such as education, housing, social capital.
2. Analyzes strategies for designing patient-oriented care Interventions related specifically to health promotion and more
models and aligned configurations of health care professional broadly to public health.
scopes of practice
3. Outlines trends in changes to scopes of practice of regulated Informal and unregulated caregivers
health care professionals, offering services predominantly in
the public sector 5
4. Identifies key elements—at the micro, meso, and macro A process-based analysis of how best to scale up promising
levels— that are necessary to create changes in the practice interventions and models of care (separate analysis of this
setting that relate to scopes of practice, including both enablers body of literature is required)
and barriers to introducing such elements (see Figure 3)
5. Assesses articles that reported on at least one of the Cost-effective analysis

following outcomes: quality of care, effectiveness, patient
satisfaction, safety, comprehensiveness, continuity of care,
compliance, job satisfaction, work burden, intercollegiate
relations, role development, competence, collaboration,
accessibility, cost-related outcomes, efficiency, equity
6. Provides a mapping out of the existing literature relevant Methodological analyses of individual studies as required
to scopes of practice, identifying key gaps and areas of by a systematic review
saturation, thereby fulfilling the definition and explicit
purpose of a scoping review (Arksey and O’Malley, 2005)
7. Offers recommendations, predominantly at the macro and Micro-level recommendations, given the prominence of existing
meso levels, to be acted upon by respective stakeholders examples paired with challenges around applicability for
at national, provincial/territorial, and organizational levels context-specific needs
Outline of the the scoping review and complementary key informant

interviews. In Section 3, we highlight the key findings
Assessment Report in the sections that follow the conceptual framework
(see Figure 3), beginning with the micro (practice) level
In Section 1, we begin our analysis by reviewing the inputs, followed by the meso (institution) level inputs,
present state of the health care system and the pivotal and finally the macro (structure) level inputs (educa-
place that scopes of practice occupy in service delivery tional, economic, and legislative). In the last section,
approaches. We then introduce our orienting conceptual we present key recommendations and strategies for
model for the Assessment (see Figure 3). In Section 2, we next steps informed by these inputs.
describe the methodological approach taken, involving
4 See Appendix 5* for Screening Guidelines used in scoping literature review.

5 See Appendix 6* for included regulated health care professions.
— 18 —

1. Why Focus On
Scopes Of Practice?
What is the problem we after-hours care. This 2010 report also identified a
number of key insufficiencies related to the quality and
are trying to address? comprehensiveness of the current health care system,
including poor availability and quality of mental health
care and addictions services, chronic care management,
The transformation of a health care care of the elderly in the home, long-term care, end-of-life
system that is failing to address changing care, and effective health promotion. These insufficiencies
highlight the need to change the system in which health
population health needs care services are delivered. With health care professionals
at the frontline of health care delivery, transformation
The Canadian health care system falls short of achieving within the health care system directly implicates health
the Triple Aim of better health, better care, and better care professionals’ scopes of practice. Meaningful change
value (see Figure 1), particularly from a health equity requires an examination of the optimal use of health
perspective. Population health research suggests that human resources, a questioning of traditional hierarchies,
stresses on the Canadian health care system will con- and an understanding of how to create the best condi-
tinue to grow as prevalence rates of chronic illnesses tions for health care professionals to deliver accessible,
increase, the population ages (driving up health care high-quality care over time for all Canadians.
demands and diminishing HHR supply), and technolog-
ical and pharmaceutical innovations drive up relative
costs, particularly within a tight economic climate. But
change would be necessary even if economics did not
Rationale for Investigating
warrant it. Our current health care model is failing to Scopes of Practice
provide optimal care to marginalized and vulnerable
One of the key problems in the way health care is
populations (e.g., aboriginal, new immigrant, transient,
delivered in Canada today is that health professional
homeless, and elderly populations) that are more likely
scopes of practice and associated models of care tend to
to experience compounding ailments (e.g., mental and/
be organized on the basis of tradition and politics rather
or chronic illness) while at the same time facing multiple
than in relation to the evidence of how best to meet
barriers (e.g., language, social capital, and/or geography)
contemporary population health needs (Tomblin Murphy
to accessing care.
and MacKenzie, 2013). That is, scopes of practice tend to
Within public discourse around the Canadian health care reflect a time when health care was focused on acute,
system, one of the most commonly reported complaints episodic care. Over the decades of the evolution of our
concerns the issue of timely access to high-quality services. current health care system, these scopes of practice have
Data from a comparison of international surveys suggests become enshrined into legislation, solidified by funding
that compared with respondents from the other countries models, and made sacrosanct by labour contracts in
examined (the United States, the United Kingdom, spite of changes in epidemiologic and socio-demographic
Australia), Canadians reported waiting longer at almost trends, as well as technological advances that have
every point of the care journey (Duckett and Kempton, increased organizational and clinical capacities. The result
2012).The CAHS report on chronic care that was released has been a myriad of professional silos across Canada,
in 2010 (Nasmith et al.) also noted insufficiencies around varying from jurisdiction to jurisdiction. Consequently,
access and long wait times, particularly for marginalized we have come to live with a health care system that
and disadvantaged populations and non-emergent may prohibit individual health care professionals from
— 19 —

performing much-needed tasks (diagnosis, prescribing, • A lack of standardization of scopes, professional
suturing, medication administration, referral, medication titles and licensure criteria for the same
dispensing, etc.) because of a complex system of legal and profession across jurisdictions;
historical legacies. These legacies have left Canadians
with structures for organizing, preparing, and regulating • Inconsistency in scopes of practice, i.e. the need
professional practice and models of care that are no to expand existing scopes, and a resistance of
longer fit for purpose, fail to put the patient experi- working beyond existing scopes;
ence foremost, and ignore the context of technological • The inconsistency of scope determination
advances. Simply put, health and health care needs have between regulatory bodies, employers and
changed, yet corresponding scopes of practice, and
actual clinical practice; and
to a certain extent models of care, have not changed.
The result is a health care system that is not well aligned • The requirements of clarity of scopes, the
with present population health needs and at the same appropriate determination and optimization
time is systemically resistant to fundamental reform. of skill mix, and the potential liability issues
While the current institutionalization of scopes of due to new models of delivery and collaborative
practice has shielded the system from radical reform, practice. (Health Council of Canada, 2005, p. 1)
there has been incremental change across micro, meso,
and macro levels. In fact over the past several decades This gap analysis supports the undertaking of this
there have been multiple innovations involving a series Assessment to bring health human resource planning
of adjustments to scopes of practice in specific areas. to the forefront of high-level policy discussions, thereby
These have included the development of new roles, promoting health care transformation.
such as patient navigators and pharmacy technicians,
and the expansion of scopes of practice for professions
such as nurse practitioners and pharmacists to address The Various Meanings of
specific populations with higher needs or access issues.
As reflected in the CAHS report on chronic care, there
Scope of Practice6
is optimism around the increased capacities these One of the challenges in the field of scopes of practice
innovations could provide: is the lack of clarity and consistency in the use of this
term and its related vocabulary. In 2005, the HCC called
The potential to expand the scope of practice for for a review of general definitions and position papers
other health professions has been suggested as relating to scopes of practice. This review describes the
a way to reduce pressure on the system and to nature of ambiguity around defining scopes of practice
provide more opportunities for person-focused and outlines the variety of stakeholders involved:
care. (Nasmith et al., 2010, p. 23)
While the term scope of practice is sometimes
But unless designed to be integrated into health system used in health care research, government policy
transformation at the outset, many of these changes documents, and professional position papers,
to health professional scopes of practice and models of no consistent definition was found. These docu-
care end up coexisting in parallel to mainstream practice. ments more commonly refer to roles, functions,
Reflecting on the potential for alterations in health care tasks and activities, professional competencies,
professional scopes of practice to help transform the
standards of practice, entry to practice, registra-
system, the HCC convened a national summit on HHR
tion requirements, the practice of medicine
in 2005. The gap analysis commissioned for the summit
(nursing, pharmacy, etc.), domains of practice,
revealed the following set of limitations:
scope of employment, or scope of enactment.
(Baranek, 2005)
6 See Appendix 3* for Glossary of Terms.

— 20 —

The challenges highlighted in the HCC review were A health care professional’s scope of practice is the
reflected throughout the data collection process of product of a number of processes that are overseen
this Assessment. Depending on the profession, the by various stakeholder organizations at the provincial,
jurisdiction, the structural context (i.e., education and territorial, or federal levels. These organizations include
training, economic, legal and regulatory), the term “ministries of health and education, regulatory bodies,
scopes of practice can encompass a range of profes- professional associations, credentialing bodies, educa-
sional parameters. Here we explain the working tional bodies, and employers” (HCC, 2005, p. 4). Under
definition used throughout this Assessment. the auspices of these multiple overseeing bodies,
Scope of practice (SoP)—the activities performed pre-licensure education, as well as additional training
by a health care professional—encompasses and practice, varies by jurisdiction.Beyond the legal and
multiple dimensions. regulatory dimensions of this issue, at a practical level
scopes of practice outline the actual demarcation of
particular tasks to ensure patient safety. The control of
A profession’s scope of practice encompasses
certain tasks, as well as the authority to delegate them,
the activities its practitioners are educated and
reflects historical legacies around contestations of
authorized to perform. The overall scope of scopes of practice.
practice for the profession sets the outer limits
In the literature, the term health care roles is
of practice for all practitioners. The actual scope
sometimes used to describe the services a health care
of practice of individual practitioners is influenced
professional is able to actually perform by virtue of
by the settings in which they practice, the require-
setting; available physical, technological, and human
ments of the employer and the needs of their resources; staff mix; competencies; patient, community,
patients or clients. Although it can be difficult or population demand; and so forth. These determi-
to define precisely, scope of practice is important nants of scopes of practice constitute the social or
because it is the base from which governing practical parameters of scopes of practice. For the
bodies prepare standards of practice, educational purposes of this Assessment and clarity of language,
institutions prepare curricula, and employers we will use the term scope of practice to encompass the
prepare job descriptions. (Canadian Nurses activities a health care professional is able to perform
Association, 2014) and then identify its legal, social, and/or practical
dimensions. (The term role is reserved for situations
From a legal perspective, scopes of practice have where a new position is created altogether.)
been defined as the health care services a regulated Paralleling these distinctions, the review of health
health care professional is formally authorized to professional scopes of practice undertaken by the
perform by virtue of professional license, registration, Health Professions Regulatory Advisory Council
or certification (College of Registered Nurses of British (HPRAC) in Ontario extrapolated the following layers
Columbia, 2013). The primary intent of legislation from a number of sources:
around scopes of practice is to protect public safety.
• How professionals are defined—who can call themselves
The term is also used by regulatory bodies to define
a member of the profession;
the procedures, actions, and processes within the
remit of a registered individual professional. The scopes • What professionals are trained to do;
of practice employed are then theoretically limited • What professionals are authorized to do by legislation;
to the skills for which the health care professional
• What professionals actually do;
has received education, supervised practice, clinical
experience, and demonstrated competence. • How a professional does what he/she does; [and]
• What others expect a profession can do (i.e. delegation).
(HPRAC, 2007, p. 2–3)
— 21 —

At the forefront of the discussion around evolving contexts may, in fact, work against the creation of a
scopes of practice is whether or not the scope of more efficient, cost-effective health care system.
practice of some health care professions should be Alternatively, working to optimal scope means achieving
expanded, contracted, or left as historically determined. the most effective configuration of professional roles
As was noted in the Canadian Medical Association (CMA) as determined by other health care professionals’ rela-
report Roles of Physicians and Scope of Medical Practice: tive competencies. This means that in some settings,
Future Prospects and Challenges (2000), “The scope of physicians, for example, may not work to their full
a profession must be based on patient needs, and be scope of practice, but restrict their scope of practice
supported by the educational preparation of the prac- to their unique high-level skills in order to facilitate the
titioners and demonstrated competence. … A change optimal contribution of other allied health professional
in the scope of practice of any profession should be team members. Assuming competencies are satis-
permitted if it enhances patient care.” (p.14) factory, professionals such as nurse practitioners or
Expanded scopes of practice occur in the practice medical assistants may increase accessibility of services
setting when health care professionals take on a wider and be less costly to the overall health care system if
range of tasks that would be considered outside their enabled to practice designated tasks in an integrated,
traditional scopes of practice. This may involve the collaborative approach. In this Assessment, we focus
process of task-shifting, or delegation of tasks (i.e., on approaches that optimize scopes of practice as an
use of medical directives), from the responsibility of enabler for health care transformation.
one health care professional or group to another. This
can be from a more expensive health care provider
to a less expensive health care provider (theoretically
The Relationship between Scopes of
improving accessibility and affordability), but it could Practice and Models of Care
also reflect the more appropriate utilization of the The term model of care is used to broadly describe the
unique skills of different health care professionals. way health care services are designed and delivered.
An increasingly common example of a scope of practice Without providing a comprehensive typology around
that is being expanded in some jurisdictions across models of care, this Assessment prioritizes innovative
Canada is pharmacists’ ability to prescribe a limited models of care with some degree of integration7 across
range of prescription drugs. sectors, professions, settings, and complementary
Similarly in recent years, new roles that tend to be scopes of practice in order to counteract the traditionally
specific to a setting or institution and have not been fragmented and siloed organization of health care
adopted across multiple jurisdictions have come into services. (See Figure 2)
effect. Examples of new positions emerging in Canada How innovative models of care relate to optimal scopes of
include pharmacy technicians and patient navigators. practice is a relationship that needs to be understood
Such positions therefore imply negotiation around their as being complex and reciprocal rather than linear and
associated scopes of practice relative to the scopes causal. Modifications to one will have implications for
of practice of existing health care personnel. the other. Innovative models for health care delivery
A final note about terminology is the distinction typically optimize HHR through, for example, decreasing
between full scope and optimal scope. Full scope reliance on independent physicians while increasing the
denotes health care professionals practicing the full role of non-physician health care professionals (in some
range of skills for which they have been trained and are cases, the focus is on decreasing the reliance on nurses).
competent to perform. The ultimate goal of enabling At the same time, new health care professions with
full scopes of practice is to create better-resourced overlapping scopes of practice are changing health
teams to provide more accessible and patient-oriented care delivery. These evolutions within the health care
care. With this end in mind, the principle of all health system need to be reflected in both the parameters
care professionals practising to their full scope in all of scopes of practice and the ways in which models
of care are organized.
7 Integrated care can be defined as “holistic, population-based, person-centred approach to addressing the multiple needs of individuals with complex
conditions who frequently suffer gaps in services, disjointed care, and suboptimal quality” (Kodner, 2012a in ECCO 2012).
— 22 —

Health care professionals need to be prepared and
enabled to work at the top of their scope through
The Politics of Scopes
appropriate education and training, and, if authorized of Practice
by government legislation to act with standards, limits,
and conditions outlined by the respective regulatory Beyond the need for clarity of terminology related to
colleges or associations (depending on the province or scopes of practice, it is also important to highlight its
territory). These formal parameters of scopes of prac- political nature. While recognizing that health care pro-
tice are then subject to the particular model of care and fessionals have the best intentions for their individual
associated practice-setting factors. Such determining patients, the field of scopes of practice itself has indeed
factors include, but are not limited to, the configuration been politicized as a proxy for professional advance-
and skills mix of health care professionals, changing ment—focusing on the demarcation of tasks rather
competencies over time, collaborative organization than on population needs and system-level efficiency.
and management, interprofessional relations, available Additionally, perceptions of higher status or pay result
resources, patient needs, remuneration mechanisms, in a jostling for positions, which in effect can distort
institutional bylaws, technology, communication, and the relation between health human resource supply
patient record systems. and health care demand (e.g., generalization versus
Figure 2: The Relationship between Scopes of Practice and Models of Care
How do Models of Care relate to Scopes of Practice?

Innovative models for health care delivery are typically seeking to optimize health human resources through decreasing reliance on
independent physician services while increasing the role of non-physician health care professionals. Changes to the organization of
health care need be reflected in the legislative, regulatory, educational, and training parameters of the respective scopes of practice.
Innovative
Models of Care
(ie. supporting respective
scopes of practice through
service design, remuneration,
technological infrastructure,
Patient/ accreditation …)
Improved
Community/
Outcomes
Population at patient, population,
Health Needs, professional, and system
in conjunction with levels; (for affordable,
evidence-based best accessible, equitable,
practices and ongoing Optimal Scopes and quality care)
evaluation, to drive:
of Practice
(ie. expansion or contraction of
roles or responsibilities for health
care professionals; in alignment
with legislation, regulations,
education, and training, …)
How do Scopes of Practice relate to Models of Care?

Expanding scopes of practice (ie. pharmacists’ ability to prescribe), overlapping scopes of practice (ie. nurse
practitioners working with family physicians), and new roles (ie. associated with technological innovations),
necessitate modifications to the design and delivery of health care services.
— 23 —

specialization or rural/remote versus urban). This uneven challenges posed by legislation and related regulatory
distribution of health services based upon professionals’ frameworks, labour contracts, the organization of
competing claims is a result of the reality that service professional education and training programs, concerns
provision is organized along health care professional about quality and safety, funding models, and tradition.
lines. A clear indication of the problem with this situ- In this report, we highlight six Canadian case studies as
ation is that during times of health worker shortage examples of health care innovations where correspond-
within particular cadres there is much more flexibility in ing changes to scopes of practice have been implemented8.
expanding and overlapping scopes of practice, whereas Together these examples depict the limited extent to
in times of surplus, there is much more rigidity. This which they are integrated into the broader health care
is particularly salient in rural and remote areas where system and macro-level structures; rather than integra-
shortages of health workers are endemic and scopes tion, the majority of health care innovations reviewed in
of practice must accommodate accordingly. this report describe parallel operations or actual circum-
Given the persistence of professional legacies that vention of these macro-level struThanksctures. The
entrench the traditional organization of models of care recommendation scheme tries to address this directly
along predefined scopes of practice, it is not surprising by identifying the actions that would help create a more
that we have limited understanding of whether we have flexible environment, which in turn would enable the
the right configuration of professionals with appropriate scalability of promising initiatives around optimal scopes
skills and scopes of practice to meet the current and of practice and innovative models of care.
future needs of all Canadian. To date, there has been
no comprehensive analysis of the knowledge and skills Overarching Principles that
required to meet changing population health needs
and whether the range of knowledge and skills is
Guided the Assessment
present in the current Canadian health workforce. The following set of principles guided the work of the
Assessment team and reflects the kind of transforma-
As a society, we need answers to the questions around
tional shift in our thinking:
scopes of practice and models of care, specifically
whether expanding the scopes of practice of some • Scopes of practice and associated models of care
health care professionals or introducing new roles or must be informed by and designed for patient/
scopes of practice would provide solutions to improve community/population needs.
health outcomes at patient, professional, and system • Health care practice must involve some level of
levels. Alternatively, it is not known if some health care integrated collaborative mentality; the coordinated
professionals should reduce their participation in some and internalized sense of group responsibility for
care areas. We opted to focus this Assessment on the a patient’s well-being is essential for the effective
societal structures that could better address patient, provision of patient-oriented care.
community, and population health needs rather than
• The determination of who does what task in health
on the specific scopes of practice of individual profes-
care is fundamentally a dynamic issue that must be
sions; it was felt that this focus would have the greatest
adapted to different settings and over time to reflect
potential for health care transformation.
epidemiologic, socio-demographic, and technological
There have been a number of promising initiatives that needs and changes.
have shifted traditional scopes of practice and models
• The contextual (educational, economic, legal) systems
of care to optimize health human resources and improve
that define scopes of practice need to be aligned with
health outcomes. Across Canada the scaling up of these
these principles and complementary models of care.
innovations appears to have been met with a myriad of
8 These six case studies were identified through complementary work undertaken on behalf of the Canadian Health Human Resources Network in
partnership with the Health Council of Canada. The inclusion criteria for these case studies differ slightly from those outlined in the screening
guidelines for this Assessment but were selected based on their ability to depict the relationship between models of care and scopes of practice.
More innovative practices of this nature can be found on the Health Innovations Portal website http://innovation.healthcouncilcanada.ca/.
— 24 —

Conceptual Framework address. It ends with where we want to be: our vision
statement and the target outcome indicators for patients,
Figure 3 outlines the conceptual framework that the health care system, and health care professionals
informed this study. It begins with where we are: the themselves. In the middle of the framework is a model
identification of the insufficiencies of the present health of how we can get there: the identification of inputs that
care system that attention to scopes of practice could influence the optimization of health care professional
scopes of practice and supportive models of care.
Figure 3: Conceptual Framework

Scopes of practice that support innovative models of care that better address population health needs a
nd a transformed
Health Care System
WHERE WE ARE HOW WE CAN GET THERE WHERE WE WANT TO BE

Current Canadian Health A transformed health care
Care System characterized Evaluation & system characterized by:
Performance
by insufficiencies around:
Measurement • A move from supply to need
• Accessibility – particularly focused (needs determine
for marginalized and models to scopes)
disadvantaged populations • A move from professional
• Care provided outside to patient focused
of business hours • A move from isolated, siloed
• Wait times professionals to teams based
Enablers and on non-conventional and
• Health promotion including
conventional providers
patient involvement and strategies for
self-management circumventing • A move away from historic
long term credential SoP to
• Appropriate use of health care barriers towards
a model of team defined tasks
providers and resources innovative models to meet population needs;
• Chronic care management of care optimizing team allocates resources and
• Mental health care scopes of practice responsibilities (task certification
process to ensure competency)
• Elderly and end-of-life care
M • Individual regulation to
• Fiscal effectiveness IC
M RO combined/team accreditation
and sustainability ES IN P U TS
M O • Performance monitoring and
AC IN P evaluation that is aligned with
RO U TS
these principles
IN
PUT
S • Funding groups rather than
individuals (not necessarily
health outcomes – process
outcomes, reduction to ER)
MACRO INPUTS – Structure Level MESO INPUTS – Institution Level MICRO INPUTS – Practice Level
Education & Training Context • Governance • Team composition
• Education needs/requirements • Labour/CQI Processes • Team vision
• Assessment/standards/competencies • Unionization • Degree of hierarchy
Economic Context • Technology form & content • Professional cultures
• Funding • Provider supply & retention • Communication
• Financing • Geography • infrastructure
• Remuneration
Legal & Regulatory Context
• Legislation/Form of regulation
• Registration requirements
• Provider accountability
List of insufficiencies from: Nosmith L., Bailem P., Baxter R., Bergman H., Colin-Thomé D., Herbert C., Keating N., Lessard R., Lyons R., McMurchy D., Ratner P.,
Rosenbaum P., Tamblyn R., Wagner E., & Zimmerman B. (2010). Transforming core for Canadians with chronic health conditions: Put people first, expect the best,
manage for results. Ottawa, ON, Canada: Canadian Academy of Health Sciences.
— 25 —

The framework borrows and expands upon the The conceptual framework highlights how interventions
conceptual model created from a series of studies on that alter or optimize scopes of practice must address
interprofessional teams and publications by Bourgeault multiple layers of inputs—from the macro (structural)
and Mulvale (2006; Mulvaleand Bourgeault, 2007). level to the meso (institution) level to the micro
The concentric circles embody the various levels of (practice) level.
inputs that acknowledge the complex, dynamic, and At the macro (structure) level, we highlight legal and
interdependent elements of the health care system. regulatory, education and training, economic, and
The framework builds on the statement framed in political factors. At the meso (institution) level, we tease
the CAHS report on chronic care: apart institutional, technological, and community
factors. At the micro (practice) level, the factors of team
It is important to recognize that health care composition and professional cultures are highlighted.
in Canada is a complex adaptive system,
These elements are neither exhaustive nor mutually
achieved not from one central control mech-
exclusive. It is important to note that scopes of practice
anism, but rather functioning and changing interventions cannot be implemented or assessed in
through a complex network of federal, pro- isolation. This acknowledges the underlying context of
vincial, territorial, regional, and municipal any intervention as a complex adaptive system that
policies and structures, research, and other exemplifies our organization of health care services.
evidence about improving practice, shared
learning across professions and other groups,
organizational frameworks, and on-the-ground
adaptations. Complex systems, such as in
health care, change, evolve, and grow through
multiple parallel or divergent initiatives,
responses, and changes. (Nasmith et al.,
2010, p. 40)
— 26 —

2. Methodological
Approach
The Academy appointed Jeff Turnbull, Chief of Staff at The Ottawa Hospital, and
Sioban Nelson, Vice-Provost of Academic Programs and Professor of Nursing at the
University of Toronto, as the Co-Chairs of this Assessment. The Academy then appointed
an Expert Panel comprised of members with unique and interdisciplinary expertise
(see Appendix 4* for biographies).
Through the Co-Chairs, the Academy then partnered • Key informant interviews10 (n=50) were conducted
with the pan-Canadian Health Human Resources to augment the insights (and gaps) from the scoping
Network (CHHRN), led by Ivy Lynn Bourgeault, CIHR/ review around a range of issues, including patient
Health Canada Research Chair in Health Human experiences, highlighting cases of complex needs
Resource Policy; Katelyn Merritt at CHHRN; and Gillian where individuals must navigate across multiple
Mulvale, Assistant Professor of Health Economics at levels of the health care system; innovative models
McMaster University, to undertake the research to that may not be formally documented; and a more
inform this Assessment. The methodological approach in-depth consideration of process, and contextual
of the Assessment encompassed two key components: factors, and forces impacting upon implementation,
• A scoping review9 was selected as the most scale-up, and sustainability.
appropriate form of literature review to map out After the data were collected from the literature and
the existing literature relevant to scopes of practice, key informants, the Expert Panel members, over the
thereby identifying areas of knowledge saturation course of four meetings, produced a comprehensive
and knowledge gaps where more research is required. Assessment that addresses the research question of
The relevant literature was captured from both identifying approaches to scopes of practice that will be
published and unpublished sources in Canada, as most effective to support innovative models of care for a
well as reviews from the United States, the United transformed health care system to serve all Canadians.
Kingdom, and Australia. A literature extraction tool
was generated to systematically extract information During the later drafting stages, the document under-
on the key enablers and barriers to change, and to went formal internal and external reviews as a standard
report on context, processes, and outcomes at the requirement of CAHS. A total of five internal reviews
patient, professional, and system levels. and four external reviews were completed and through
a further series of teleconferences and face-to-face
meetings the Expert Panel revised the document.
We provide more descriptive details of the scoping
review and key informant interview components on
the next page (28).
9 See Appendices 6–10* for more details behind the Scoping Review.
10 See Appendix 11* for the List of Key Informants.
— 27 —

Overview of the Scoping to target for searching. Sources included health human
resources organizations in Canada, the United States,
Review Process the United Kingdom, and Australia as well as organi-
zations with a global focus (see Appendix 8*). Within
A scoping review was selected as the most appropriate Canada, the Canadian Electronic Library and the CHHRN
form of literature analysis given the limited understanding Library produced the majority of the relevant grey liter-
around scopes of practice of health care professionals ature; provincial and territorial government websites
across Canada. It was intended that this review would yielded few results, with the vast majority of results
provide a preliminary mapping of the existing evidence coming from Ontario.
around optimizing health care professional scopes of prac-
In the second phase, identified databases/sources/
tice and innovative models of care in order to identify key
websites were searched using the following terms that
lessons learned as well as key knowledge gaps. It should
were derived from the peer-reviewed literature search
be noted that while rigorous systematic research methods
and were validated by our research librarian: “inter-
were applied to retrieve and analyze the literature, the
professional,” “interdisciplinary,” “multidisciplinary,†”
selection criteria for this Assessment included an exam-
“collaborative,†” “job satisfaction,” “organizational model,”
ination of the evaluation components of each study, which
“model of care,” “model,” “scope of practice,” “professional
scoping reviews do not typically include (Arksey, 2005).
role,” “delegate,†” “task-shifting,” “reform,†” “change,†”
and “transform†” († for truncated variations). Depending
Search Strategy on the source, search tools, databases and websites
were determined based on respective systematic search
1. Published Literature capacities. For less-populated grey sources (i.e., typically
with fewer than 2000 unique items), comprehensive
The following databases were searched with a core searches were conducted through title and abstract
search strategy (for Medline) (see Appendix 7*), which screening. The number of articles identified during the
was then modified for each subsequent database second-phase search was recorded by source. For a
accordingly (Embase, PsycInfo, Healthstar, CINAHL, summary of the output from the search strategy and
ERIC, and Sociological Abstracts). Together, these data- screening, please refer to Appendix 9* for a detailed
bases provide a comprehensive source to search all breakdown by source.
published literature from the medical, health sciences,
education, economic, and sociological domains. Output
items were restricted by year, language, and geography Screening, Extraction and Analysis
to produce articles from 2000 onwards, published in After collecting all potentially relevant literature, we
either English or French, and based in Canada only. conducted title and abstract screening to determine
Given the breadth of the topic, output from the primary potentially eligible articles. As outlined in the screening
search was substantive (2344 articles identified before guidelines (see Appendix 5*), articles were included if
removing duplicate results). A secondary search was run they addressed at least one of the three following areas:
to identify reviews from the United States, the United (1) regulated health care profession as listed, (2) roles
Kingdom, and Australia. The same search terms and and scopes of practice, and (3) change mechanisms
language parameters were used except that the year relating to innovative health care models (e.g.,interpro-
was restricted to2008 onwards, considering that reviews fessionalism, task-shifting, collaborative care models,
would capture research predating this year (1728 reviews and expanding scopes of practice, as well as the
identified before removing duplicate results). inclusion of information regarding the evaluative
methodology used in the study).
2. Grey Literature Title and abstract screening of the literature was
A systematic search of the grey literature was conducted performed by a team of five analysts. Discrepancies
employing a three-phase strategy. In the first phase, were discussed among the analysts for final decision.
the research team, co-chairs, and Expert Panel mem- Full-text screening was conducted concurrently with
bers identified sources of high-quality grey literature the literature extraction process (described below).
— 28 —

Articles that included an evaluative component and to identify reports and updates on health professions
reported on at least one of the patient, professional, regulatory reform. Court decisions were identified using
or system-level outcomes as listed in the screening combinations of search terms: “health care,” “negligence,”
guidelines were identified to be of primary interest. “team,” “interdisciplinary care,” “interprofessional collabo-
A total of 96 published articles and 29 grey literature ration,” and “scope of practice”. Decisions were reviewed
items for a total of 125 sources were fully extracted for relevance and illustrative cases were selected.
and synthesized in this report. Complete references Scholarly articles and grey literature were identified
are provided in the References section. using online databases (PubMed, Google Scholar, Index
We then developed a Literature Extraction Tool (see to Legal Periodicals, Index to Canadian Legal Literature)
Appendix 10*) in order to provide a level of standard- that use combinations of terms: “health profession,”
ization for the extraction of data from these literatures. “regulation,” “scope of practice,” “interdisciplinary care,”
This tool was informed by the conceptual framework and “interprofessional collaboration”. The draft report
(see Figure 3). The extractions of the individual analysts was distributed to ten legal academics and practitioners
were discussed regularly so that a standardized approach for expert feedback.
was maintained. An end-of-extraction analysis and
review were also undertaken and some extractions Limitations
revised accordingly. Extractions from each analyst
Due to the nature of the research question and the
were then collated and analyzed to provide descriptive
volume of relevant literature produced, selective
and thematic summaries. This enabled the creation
inclusion was required. Articles included for analysis
of key descriptive tabular summaries of the columns
were prioritized based on their inclusion of a change
of extracted data. The data within the completed
mechanism relating to scopes of practice, an evaluative
extraction tool were sorted according to the three key
methodology, and reported outcomes and impact.
inputs: education and training, economic, and legal and
It is important to reiterate that because this was a
regulatory, as outlined in the conceptual framework.
scoping review, individual methodological qualities
Literature summaries were augmented with extractions
of the included articles were not assessed. This would
from the key informant interviews (discussed more fully
be an important next step on the research agenda.
below) and with the deliberations of the Expert Panel.
An extraction tool was developed to facilitate the
3. Legal and Regulatory Literature/Documents systematic approach of retrieving the usable data
from the literature. Given that five research analysts
After consulting with various legal librarians and were involved at this stage, there was room for incon-
conducting a partial extraction process, it was clear sistencies in data reporting. Throughout the review
that information regarding the legal and regulatory process we conducted several check-ins to reconcile
aspects of scopes of practice was sparse with existing potential discrepancies.
search methods. We then commissioned a separate,
yet integrated, process to access this literature by A challenge for extractions and analysis was the lack of
working with a legal expert who specializes in health clarity in the literature around terminology with respect
law and health care professional scopes of practice to scopes of practice and professional roles. Terms
(see Appendix 4* for biography of Nola Ries). The such as “task-shifting,” “delegation,” and “substituted
legal consultant performed a more targeted search acts” are inconsistently defined in the literature. There
to synthesize all relevant regulatory, legal, and case is also wide variance in the terminology used outside
law documentation. of Canada to describe the skills profile and regulated
scope of health professionals, and terms such as “skills-
For this process, the Canadian Legal Information mix,” “skills-dose,” and “skills-laddering” are commonly
Institute (CanLII) website (www.canlii.org) was used and inconsistently used. This heterogeneity creates
to search for relevant legislation and court decisions. challenges for the examination of scopes of practice,
Health professions statutes and regulations were particularly with respect to the meanings associated
identified for each province and territory. Provincial and with new or expanded roles.
territorial health ministry websites were also searched
— 29 —

During the screening process, identified articles that The list of key informants was generated from a variety
met the inclusion criteria, but may not have reported of sources, including the scoping review, and a snowball
on the outcomes outlined, were identified. These articles sampling strategy where key informants suggested other
were grouped as either process-based, if they described key persons. The intention of the sampling strategy was
innovations and mechanisms for implementation, or to represent the diversity of the health care domains and
context-based, if they described the evolution of a role regions in Canada and stratify by respective involvement
or particular education and training, economic, or legal (i.e., expert or stakeholder). The recruitment strategy
and regulatory contexts.11 followed a clockwise approach noted in the diagram.
Participants were recruited by email and provided with
an e-letter of information and a consent form for the
Overview of the Key study (see Appendix 12*).
Informant Interviews Using a series of semi-structured interview guides

tailored to the area of expertise of the key informant,
To augment the knowledge gaps that we anticipated interviews were conducted by phone by members of
would remain after conducting the scoping review, we the project team (Ivy Lynn Bourgeault, Gillian Mulvale,
conducted 50 key informant interviews. Ethics approval or Katelyn Merritt), digitally recorded, transcribed
for these interviews was secured by the University verbatim, and coded for thematic analysis using NVivo
of Ottawa (see Appendix 12*). The approach to the qualitative analysis software (see Appendix 14* for
identification and selection of the key informants was the standard interview guide and Appendix 15* for
purposive, starting with national and international health the coding scheme). The structure of the interview
workforce experts, scope of practice innovators, and guide and the subsequent coding scheme followed the
government policymakers at the local/regional, provincial, thematic areas identified in the conceptual framework
and federal levels, and continuing with representatives and the literature extraction tool for consistency of
of professional stakeholders and patient/community integrating the findings in this Assessment. Because
groups (see Figure 4). the literature was dominated by the micro-level inputs,
the content of the key informant interviews tended to
Figure 4: Overview of Key Informant emphasize the meso- and macro-level inputs. Many of
Interview Participants the interviews were loosely structured conversations
allowing for maximal exploration of issues not presently
1. 2. under consideration. Due to time limitations, we had to
strategically select the most relevant questions for the
HEALTH SCOPE OF
WORKFORCE PRACTICE individual key informant based on his or her particular
EXPERTS (18) INNOVATORS (7)
area of expertise.
SUMMARY OF KEY
INFORMANTS
5. [N=50] 3.
PATIENT/ GOVERNMENT
COMMUNITY POLICYMAKERS (7)
GROUPS (5)
4.
PROFESSIONAL
STAKEHOLDERS (13)
11 It is suggested that these articles undergo separate investigation to provide additional background to the intervention-oriented analysis included
in this Assessment.
— 30 —

3. Key Findings
Overall, we found that the scopes of practice intervention excluded some of the international reviews in
literature focused largely on particular. We also recognized that a significant
• descriptive studies with an emphasis on proportion of innovations-based literature was
survey methods; missed by limiting international sources to the
United Kingdom, the United States, and Australia.
• primary, tertiary, and then chronic care, including However, for the purposes of this study, it was
the overlap between these levels; necessary to define limits and consider health
• the professions of nursing, medicine, and pharmacy; care systems and structures most comparable
and relevant to the Canadian context.
• the practice-level change mechanisms; and
• health care professional outcomes, followed by There were few comprehensive studies that report
patient outcomes and then system-level outcomes, on outcomes that can serve as a framework for guiding
most of which were reported positively.12 the redesign of future health professional scopes of
practice. The key informant interviews and Expert Panel
We found general biases and research limitations debates propelled the discussion from what is currently
to affect the following areas: known in the literature to a recommendation scheme
• There was a particularly strong reporting bias to guide the process of better defining those scopes
towards positive outcomes with relatively little of practice that will be most effective to support innovative
discussion around lack of or no change after an models of care for a transformed health care system to
intervention had been introduced. This was found serve all Canadians.
equally across published and grey literatures. It is We present our findings first by the micro-level inputs,
also important to consider that the work of many followed by the meso-level inputs and then the macro-
HHR projects may not be documented, as scholarly level inputs in the education and training, economic, and
output may not have been a priority for the project legal and regulatory contexts (see Figure 3). In general,
team; rather, efforts were concentrated on local a focus on the micro level dominates the literature—
implementation and sustaining the innovation covering nearly half of the articles extracted. The next
without needing to document or promote it for a largest category of articles covers educational interven-
wider audience (Evans, Schneider and Barer, 2010). tions with a minority discussing the macro-level factors
• The findings from the literature were quite modest, of economic and regulatory/liability issues. We identify
which is perhaps reflective of the generally conser- at each of these levels: key features, reported out-
vative nature of the publication and research funding comes, and any enablers or barriers associated with
associated with the innovation. Related to this, the intervention. The information gathered from the
there was very little research retrieved on health key informants is then presented, and used to draw out
equity and addressing issues of disproportionate points of consistency with the literature and also fill in
accessibility for particularly marginalized or vulner- gaps not addressed in the literature. Summary boxes
able populations, such as immigrant, aboriginal, are presented at the end of each section, which are
or homeless populations. informed by both the data drawn from the literature
and key informants, and synthesized after the Expert
• Language and geographical biases are important
Panel meetings. In the last section, these summaries
to consider given that the inclusion criteria was for
are used to inform the recommendations.
English and French papers only, which may have
12 Additional graphs describing the overview of the literature are provided in Appendix 16*
* All appendices are available solely on the CAHS website: http://www.cahs-acss.ca/completed-projects/.
— 31 —

A. Micro (Practice) Collaborative or team-based care: Two or more
health care professionals of different professional
Level Interventions backgrounds working together to meet patient needs.
Expanded scopes of practice: When health care
In 2010, The World Health Organization (WHO) recognized
providers take on a wider range of tasks in the practice
“interprofessional collaboration in education and practice
setting that would be considered outside of their
as an innovative strategy that will play an important role
traditional scopes of practice.
in mitigating the global health workforce crisis” (WHO,
Framework for Action on Interprofessional Education and New roles: Roles that have been introduced into the
Collaborative Practice, p.7). The literature captured in this health care system within recent years that have not
scoping review is consistent with this statement, demon- been adopted across jurisdictions and may not yet
strating the degree of attention towards interprofessional be formally regulated.
collaborative care models as one promising strategy to Competence-based development: Interventions
improve quality of care. Among the 125 sources identi- designed around improving the skills of health care
fied in the scoping review, there were 58 that involved professionals to improve quality of care.
an interprofessional, collaborative, team-based change
mechanism. Classification for these models was guided Task-shifting: When a health care task is assigned to
by the WHO’s definition of collaborative practice: “multiple another health care professional to use professional
health workers from different professional backgrounds resources at the highest possible level within the
provide comprehensive services by working with patients, regulatory framework of delegated acts.
their families, caregivers and communities to deliver the Skills mix: The mix of skills both across professions
highest quality of care across settings” (2010, p.7). Along and within professions in a given setting.
with collaborative or team-based change mechanisms, From the literature, key features associated with
other approaches to intervention at the practice level successful interprofessional, collaborative,
are depicted in Figure 5 and described below. or team-based care models include
Figure 5: Overview of the Number • Regular communication protocols, such as daily

of Citations of Practice-Level meetings or patient-specific consultations (Aziz,
Interventions from the Literature13 2005; Carter, 2009; Eiser, 2008; Kates, 2002;
60
Health Systems and Workforce Research Unit, 2011;
Howard, 2003; Lalonde, 2011; Sargeant, 2011;
Tomblin Murphy, 2010; Tomblin Murphy, 2012;
50 Zwarenstein, 2009)
• Designated management team or coordinator role
40 (Eiser, 2008; Kates, 2002; Kilner, 2010; Kisely, 2006;
Moe, 2010; Tomblin Murphy, 2010; Tomblin Murphy,
30
2012; Trojan, 2009; Santé Québec, 2012)
• Sense of shared responsibility; shared decision making
(Bonin, 2012; Buckley, 2009; Irvine Doran, 2002; Isetts,
20
2012; Health Systems and Workforce Research Unit,
2011); role clarification (D’Amour, 2008)
10
• Collaborative care competence development
(Boulet, 2008; Charles, 2011; Dumont, 2010;
0 Gagliardi, 2007; Gaines, 2008; Health Council of
Canada, 2009; Johnston, 2000; Kenaszchuk, 2012;
ix
ng
tic s
d
s
ca ive/
ac pe
le
m
e
e
fti
re
as
ro
pr co
lls
ed at
Laprise, 2012; MacDonald, 2008;Reeves, 2009;

hi
-b
ew
of d s
as or
i
-s
Sk
e
nc
sk
-b lab
N
e
Suter, 2008; Suter, 2010; Wheeler, 2011)

nd
Ta
te
am ol
pe
pa
te C
m
Ex
Co
• Integrated evaluation (Health Council of Canada,

2009; MacPhee, 2012; Zwarenstein, 2009)
13 Categories are not mutually exclusive.
— 32 —

Barriers to interprofessional collaborative care Added to these Canadian-focused articles, there were
models were related to the following: two systematic reviews drawing from international
• Professional cultures, including role uncertainty settings that focused on practice-level interventions
(Doran, 2009; Howard, 2003) and reported inconclusive outcomes:
• Intercollegiate respect or trust in relative competencies • Zwarenstein et al. (2009) included five studies that
(Aziz, 2005; Besner, 2011; D’Amour, 2008; Farrell, 2008) examined the effect of interprofessional practice-based
interventions on patient satisfaction and health care
• Job protectionism (Kilner, 2010; Lalonde, 2011) processes; findings on effectiveness and efficiency
• Physical space or organizational slack (Health Council were inconclusive.
of Canada-ON, 2009; Kates, 2002; Trojan, 2009) • Kilner et al. (2010) examined 14 studies of the role
• Appropriate compensation (Blash, 2011; Tomblin of teamwork and communication in the emergency
Murphy, 2010) department; studies demonstrated high levels of
staff satisfaction but provided moderate evidence
In addition to the sources discussing interprofessional that the introduction of multidisciplinary teams to
collaborative care models, there were 47 articles that the emergency department improved access.
referred to expanded scopes of practice, which
tended to come from the perspective of a given health And one meta-analysis in this category reported
care profession rather than from the perspective of an significantly positive health outcomes:
interprofessional health care team. Articles involving • Carter et al. (2009) reviewed 37 studies of team-based
expanded scopes of practice referred to pharmacy, nurs- care interventions for hypertension where nurses
ing, or physiotherapy professions exclusively. There were and/or pharmacists were integrated into the primary
12 sources that described new roles, which included care setting; studies showed significant reductions
patient navigators, clinical associates, mental health in systolic blood pressure.
liaisons, physician assistants, and other roles associated
with technological innovations. Seven sources included Overall, interventions involving collaborative care models,
task-shifting models where there was some form of expanding scopes of practice, new roles, task-shifting,
routine delegation involved, typically from a physician and skills mix configurations were consistently asso-
to another (less-expensive) health care professional. ciated with positive outcomes. The majority of these
All of these practice-level interventions had implications outcomes were reported at the professional level,
on both the scopes of practice of the health care pro- describing increased collaboration and job satisfaction;
fessionals involved as well as the model of care through the latter of which was correlated with decreased work-
which the services were delivered. load among physicians and a greater sense of influence
The enabler most commonly reported under over the patient’s well-being among non-physicians
expanding scopes of practice or new roles (Lalonde, 2011). Several sources reported increased
was in reference to intercollegiate respect and under- patient satisfaction, commonly attributed to health
standing of respective roles among other health care care professionals with an expanded scope of prac-
professionals (Browne, 2012; Farrell, 2008; Higuchi, tice or a new role being able to spend more time with
2006; Jensen, 2004). Interestingly, this was also the the patient as compared to usual care where visits
most commonly reported barrier associated with with physicians or specialists are often described by
expanding scopes of practice and new roles patients as rushed and/or less frequent (Bonsall, 2008;
(Bryant, 2007; Farrell, 2008; Hoskins, 2011; Howard, Dumont, 2009; Parrish, 2009).
2003; Irvine, 2000; Musclow, 2002). Additionally, With respect to economic considerations, while a number
appropriate remuneration systems and fiscal constraint of studies did present evidence around cost-effectiveness,
(Canadian Health Infoway, 2013; Bonsall, 2008; Lalonde, in general the findings remain inconclusive. It is important
2008; Salgado, 2012), as well as concerns around liability to acknowledge that any interpretation of cost-effectiveness
(Bonsall, 2008; Hooker, 2010) were also noted. must recognize that decision makers may have different
objectives that sometimes align, but may also compete
— 33 —

when introducing an intervention. For some, the expectation would be a lower cost-effectiveness ratio
objective of the scopes of practice intervention is and an intervention that would be cheaper to deliver
primarily to improve the effectiveness of a service than standard care. For scopes of practice interventions,
in terms of a particular outcome (e.g., patient health policymakers must consider the relative weight given
status, interprofessional collaboration. In these situations, to objectives of cost control and service improvement
the intervention may be more costly, but it is consid- in their particular context, including the time horizon
ered worthwhile relative to the associated outcomes. over which they would like to achieve these objectives.
In other cases, the objective of the scopes of practice This underscores the importance of interpreting cost-
intervention may be to achieve cost savings for a current effectiveness ratios relative to a specified alternative
(or potentially improved) level of effectiveness; here the and set of objectives.
Case Study 1: Expanded Scope of Practice
Physiotherapist Triage Model
Model of Care: In this model, physiotherapists are involved in the consultation process to determine
appropriate care pathways for patients presenting with musculoskeletal disorders. This is different from
usual care models where the orthopaedic surgeon performs all musculoskeletal-related consultations,
which are becoming a growing health care demand with the aging population and prevalence of obesity.
The physiotherapist triage model is designed to reduce consultation wait times, reduce the number of
unnecessary surgeries, and improve system-level cost-effectiveness by transferring initial Assessment
responsibilities from a higher-cost professional to a lower-cost professional. This model has been explored
sporadically throughout the country (most notably in Alberta, Ontario, and Quebec) since the late 1990s.
Implications for Scopes of Practice:

• In one particular case in Quebec, the advanced practice physiotherapists are responsible for formulating
a diagnosis, triaging potential surgical candidates, ordering imaging or laboratory tests, and prescribing
medication for patients with musculoskeletal disorders.
• General musculoskeletal consultations conducted by physiotherapists include spinal injuries, joint pain
(particularly knees and hips), and post-osteo-operative services.
• Scope and workload of orthopaedic surgeons previously providing these services is consequently shifted.
• Additional training is required for advanced practice physiotherapists.
Enablers:
• Community-/institution-based support
• Professional collaboration between orthopaedic surgeons and physiotherapists
• Competency-based education initiatives
Take-Away Evidence is promising around treatment concordance between physiotherapists and orthopaedic
surgeons. Physiotherapists tend to spend more time with patients, which may be related to the increased
patient satisfaction levels reported.
Desmeules, F., Toliopoulos, P., Roy, J-S., Woodhouse, L., Lacelle, M., Leroux, M., Girard, S., Feldman, D., Fernandes, J. (2013). Validation of an advanced
practice physiotherapy model of care in an orthopaedic outpatient clinic. BMC Musculoskeletal Disorders, 14:162.
Bath, B., Grona, S., Janze, B. (2012).A Spinal Triage Programme Delivered by Physiotherapists in Collaboration with Orthopaedic Surgeons.
Physiotherapy Canada., 64(4): 356-366.
— 34 —

Key Informant Interviews “If I had one piece of advice, it’s really
During key informant interviews, we were careful to to build up capable management and
inquire about innovative models of care and modifications leadership structures, from the team all
to scopes of practice without leading key informants in the way up through the senior level leaders,
a particular direction. Consistent with the literature,
interprofessional collaborative care models emerged
that include both physicians and other
as the most common change mechanism. A number health team workers working collaboratively,
of key features were raised: or leaders working collaboratively. I don’t
• The benefits of collaboration for patients and health think you’re going to get that far without
care professionals are increasingly recognized. having that leadership and management.”
Some examples of different types of collaborative care

“In terms of the innovative models, I mean
models were highlighted.
it is so crystal clear that we have to have
functionally integrated multidisciplinary
Shared Care: “So that is where instead of…
teams of the right providers giving the right
I mean what typically happens in health care,
service at the right time in the right place.
or what often happens, …is when a patient
And the composition of those teams really
is referred to a specialist, it can happen
will depend on the needs of the population.”
that that specialist takes over their primary
“So all health care professionals believe care as well, which is a very great misuse
yes, collaborative care is important to of the specialist’s expertise... so this is the
provide better health outcomes (or patient opposite. This is the idea of the specialist
outcomes)but also can improve efficiency supporting the primary care physician to
and all these other benefits that we know provide a better level, a better quality of
[interprofessional care] teams can provide.” care by helping that clinician tease out
some diagnostic issues or provide help with
• A clear understanding of the roles and competencies managing medications, that kind of thing,
of each of the professionals in the health care team or conducting in-services with the doctor,
is necessary for effective team collaboration.
the health care team, the nurses, etc.”
“Understanding each other, respecting each

other, appreciating what each other can do.”
• Team leadership is of critical importance and this

role does not necessarily need to be held by the
physician on an interprofessional team.
— 35 —

Case Study 2: Shared Care Model
Hamilton Family Health Team–Mental Health Program (HFHT–MHP), Ontario
Model of Care: Since 1994, HFHT–MHP has integrated mental health counsellors and psychiatrists into
primary care settings. Reaching over 80 family practice clinics, this shared care model addresses issues of
poor accessibility and availability of mental health services. Its practice structure is unique in its specialized
referral system, where psychiatrists see new cases and select follow-ups, review cases with other medical
staff, and provide educational support, and physicians can refer patients directly to counsellors who are
available onsite. After initial intake, patients can continue seeing a counsellor on an intermittent basis
without needing to make an appointment with a physician or a psychiatrist.

• Responsibilities of shared care between psychiatrists, physicians, and counsellors depending on patient
needs are facilitated through communication sessions and an open referral system.
• A designated program coordinator is needed to manage clinic operations, human resource processes,
monitoring, and evaluation.
Enablers:
• Blended capitation payment system
• Regular, structured communication processes between health care professionals
• Central coordinating team
• Active involvement of family physicians
• Strong support network for counsellors (workshops and direct access to health services)
Take-Away: This program has demonstrated improved health outcomes for patients, with better coordination
of care, reduced wait times, less stigmatization for persons seeking service, and high satisfaction reported
among participating health care professionals and patients. This model of care is considered to be highly
transferable to other settings.
Kates, N., Crusstolo, A.M., Farrar, S., Nikolaou, L. (2002) Counsellors in Primary Care: Benefits and Lessons Learned. Canadian Journal of Psychiatry, 47(9): 6.
Website: http://hamiltonfht.ca/i-am-a-patient/mental-health
Nurse-Led Primary Care: “And in the care for this patient... That requires them
nurse practitioner-led clinic, regardless to articulate what were the needs of
of how many patients you had rostered, the community and how would a team
you started off with a pre-built team of individuals better serve the needs
of interprofessional workers that were of the community.”
designed to figure out how to extend
— 36 —

Case Study 3: Nurse-Led Model
1. Quick Care Clinics, Manitoba
Model of Care: The Quick Care Clinics in Manitoba are designed to meet low-complexity, primary health
care needs, thereby addressing unnecessary visits to the emergency room, duplicated diagnostics/testing/
imaging, and shortages around availability of family physicians. The Quick Care Clinics operate as nurse-led
care models, meaning that there is no physician located on site; rather, patient visits are shared between
registered nurses and nurse practitioners. Basic services include treating eye infections, rashes, sprains,
etc.; prescribing birth control; and administering immunizations. The clinics provide extended-hour options
by delivering services during weekends, evenings, and holidays. Steinbach Quick Care Clinic was the first of
four clinics to open in Manitoba in 2012.

• Socio-cultural changes associated with level of authority for advanced practice nurses
• Coordinated care with family physicians; streamlined referral system for more complex needs
• Education and training designed for nurses working without physicians alongside.
Enablers:
• Electronic medical record system established from the beginning
• Coordination with Regional Health Authority
• Block funding
• Centralized clinic locations for improved accessibility
• Support from the broader provincial agenda to increase access to family physicians by 2015
Take-Away: In order to match health human resource supply with population health needs, educational
programming needs to be aligned with current service delivery models.
Source: personal communications.
In terms of barriers to introducing practice-level “So in hospitals, the biggest barrier for
changes, each key informant presented competing, or
[collaborative care] right now ... is that
rather multiplicative, challenges (related to his or her
area of work and expertise); these focused largely on physicians are by far and away the
economic issues but also acknowledged the role of cheapest labour for us to bring in because
liability, regulation, and employment contracts. they just bill OHIP [the Ontario Health
Insurance Plan] … The challenge is the
“[T]hat is probably the biggest barrier to billing. It’s not the legislation that allows
change—is changing how people do things access, it’s the billing.”
after having done it one way for so long.”
“It’s always an issue with the physicians,
because traditionally…a physician is always
the ultimate bearer of the liability.”
— 37 —

“The biggest thing they could do is to align Overall, the critical barriers raised by key informants
that had an impact on the practice-level configurations
the incentives so they make sense.”
of health care professionals and their scopes of practice
“So we have some processes that are now crossed micro, meso, and macro levels. This reinforces
the complexity of the interaction of multi-level inputs and
built into our union contract that really their potential to serve as both enablers and barriers (see
undermine the ability to move people to full Figure 3, Conceptual Framework, and Table 1, Barriers
scope of practice if they’re doing anything and Enablers at the Micro, Meso, and Macro Levels). The
other than an RN role.” barriers ranged over legislation, certification, liability, edu-
cation and training, transition to practice, turf protection,
colleges, associations, unions, cohesive vision, leadership,
Depending on the context and framing, and as shown monitoring, evaluation, information technology, profes-
from the summary of the literature findings, some of sional cultures, tradition, and sustainable programming.
these barriers were also viewed as enablers. These areas were all raised in the literature (Blash,
2011; Doran, 2009) with the exception of unions, which
“And so those models of legislation have the were largely perceived as being impediments to change
(unions are discussed further in the next section).
ability to either enable change in practice or
present a huge barrier to change in practice.”
Summary (A): MICRO (PRACTICE) LEVEL INTERVENTIONS

Key feature: Collaborative care models are widely accepted as essential characteristics of innovative
models of care and support changes to scope of practice in order to improve health care delivery. Commonly
linked to collaborative care models are expanded scopes of practice of some health care professionals and
the development of new roles altogether, both of which require a renegotiation of responsibilities, implying
task-shifting or delegation.
Outcomes: The associated outcomes with these interventions were consistently positive, particularly for
reports on both provider and patient satisfaction. There is little evidence around system-level outcomes
and more systematic research would be required to determine any kind of causational effect.
Enablers:
• Regular communication and space for collaborative work practices
• Designated team leadership and management
• Awareness of respective professional roles
Barriers:
• Professional cultures and traditional hierarchies
• Unions and professional protectionism
• Remuneration systems that create disincentives
* T he summary box above has been informed by data collected from both the scoping literature review and the key informant interviews. The points presented
were selected based on emerging themes and discussions among the Expert Panel members. Together, the summary boxes from all levels of findings are used
to inform the Recommendations.
— 38 —

In the next section, we turn to the less-studied
meso-level and macro-level interventions. In terms
B. Meso (Institution)
of processes to enable change to scopes of practice Level Interventions
and models of care, educational interventions (macro
level) were most commonly studied (n=43), at both Institution-level, or organization-level, inputs described
the pre-licensure and post-licensure phases, as in the literature included interventions involving specific
compared to institutional interventions (meso level) reference to communication systems, electronic medical
(n=31), legal-/regulatory interventions (macro level) or health record systems14, accreditation, and perfor-
(n=8), and economic interventions (macro level) (n=7) mance monitoring and evaluation. Most notable of the
(see Figure 6 below). 125 sources were 9 articles that described the integration
of technological innovations, including electronic health
Figure 6: Number of Citations records, and 17 that described integrated performance
of Type of Intervention Studied monitoring and evaluation. While many articles sup-
in Intervention Literature ported the rhetoric around the need for patient-oriented
50 care, only 3 sources in this review actually articulated
how they were able to enact patient integration.
Examples of studies describing promising institution-level
40 technological innovations included
• the sharing of laboratory results available through
networked computer programs (Lalonde, 2008) and
30
• the integration of nurse-led telemedicine, which
reported mixed outcomes and highlighted the
20 need for aligned structures, such as appropriate
remuneration models (Carter, 2012).
10
Interventions that included some form of integrated
performance monitoring and evaluation assessed
• the measure of the composition and mix of skills of a
0 health care team, the level of perceived interprofes-
Institutional Education Economic Legal/regulatory sional team collaboration, and daily activities among
interprofessional team members (Lineker, 2009;
Latimer, 2009; Orchard, 2012; Eiser, 2008; Lundon,
2009; Legault, 2012). The integration of performance
monitoring and evaluation was not linked to impact
on outcomes but was considered an important
process element in practice change.
One of the included studies that examined a patient

engagement model found that
• patient focus groups were a helpful tool to inform
different kinds of health care delivery models during
design stages; evaluation of the study showed
improved health outcomes for patients when
compared across performance benchmarks
for diabetes management (Isetts, 2012).
14 Note that in the literature and interviews, the terms electronic medical records and electronic health records are often not distinguished from one another.
Electronic medical records are considered to be a replacement for physicians’ charts, notably for the purposes of tracking diagnoses and treatment;
whereas electronic health records are considered to encompass all types of health records across settings and providers (Canada Health Infoway, 2011).
Ideally a person would have one electronic health record for all health-related histories and care. Throughout this Assessment, we use electronic health
records most commonly, but refer to electronic medical records to appropriately reference specific interventions
— 39 —

Case Study 4: Integration of Electronic Medical Records
Sault Ste. Marie Group Health Centre, Ontario
Model of Care: Originally established in 1962, the Group Health Centre has evolved into an interdisciplinary
ambulatory heath care organization, now serving over 70,000 residents of Sault Ste. Marie and Algoma
District (95% of the population). This innovative model of care addresses issues around accessibility and
comprehensiveness of primary care service delivery through the provision of same-day care as well as
longer-term chronic care support. There are diagnostic services and laboratory facilities on site that are
also used by other primary and secondary care services. The most distinctive feature of this model is the
use of EPIC—a large-scale electronic medical record system where each patient has a single record. This
allows for different types of health care professionals to access patient data as needed, make real-time
referrals to specialists, generate treatment plans based on algorithms, and aggregate data for population-
level monitoring and evaluation. This system also enables patient engagement through the accessibility of an
online patient portal.

• A range of health care professionals are located onsite, including doctors, nurses, nurse educators,
physiotherapists, optometrists, kinesiologists, dietitians, and lab technicians, which facilitates collaborative
practice styles throughout the organization.
Enablers:
• Alternative payment structure
• Support from the Ontario Ministry of Health and Long-Term Care
• Electronic medical record system
• Ongoing monitoring and evaluation
Take-Away: The Sault Ste. Marie Group Health Centre has the largest primary care electronic medical
record system in Canada. The system-level improvements made in continuity, integration, and comprehen-
siveness of care and associated patient health outcomes are largely attributed to the capacity of this
electronic infrastructure.
Sault Ste. Marie Group Health Centre: Big Success in a Small Community. Government of Ontario.
Shaw, N., Ward, A. (2011) Case Study: A look into the Group Health Centre’s Electronic Medical Record Procurement Process
Website: http://www.ghc.on.ca/
— 40 —

There was one scoping review (Canada Health Infoway, A second scoping review focused on examining the
2013) that assessed the impact of technological innovation current status and estimated impact of telehealth
of electronic medical records across Canada, which by services across Canada (Gartner, 2011). New clinical
association, also involved performance monitoring and services provided through telehealth initiatives included
evaluation, and even patient engagement. Electronic telepsychiatry, telecrisis, telestroke, teleophthalmology,
medical records were found to be efficient through the teledermatology, teleoncology, telehomecare, and
substitution of time-consuming administrative tasks telemonitoring (live videoconferencing and “store
such as chart pulling, managing lab results, schedul- and forward solutions” for the transmission of images
ing, billing, clinical documentation, and order entry. On or video to a specialist clinician for interpretation).
patient-and system-level outcomes, the findings showed These new services enabled expanded programming
that electronic medical records were considered to be capabilities such as scheduling, knowledge sharing,
an enabler for improving quality of care by increasing and interprofessional communications. Most impor-
communication among health care professionals, ensur- tantly, the new approaches to service delivery were
ing appropriateness of diagnostic tests, improving the found to improve timeliness and accessibility of care.
monitoring for chronic disease management, increasing Improved outcomes were described by the capacity to
patient satisfaction, supporting the continuity of care, offer better support for chronic disease management,
and integrating with web-based patient engagement enable improved coordination of care across settings,
models. The primary barrier noted in reference to the improve equitable accessibility to specialized clinical
implementation of electronic medical records was services, particularly for patients in rural and aboriginal
hesitation, particularly among clinicians, in regard to settings, and contain escalating and unnecessary costs
the relative return on investment relative to the time to the health care system and patients. Despite tele-
and cost of implementation and upkeep. This hesitation health services being identified as a catalyst for leading
was reinforced by the lack of available evidence show- other innovative practices, the largest barrier to their
ing the direct cost benefits; however, authors indicated broader adoption was noted as the lack of existing or
the importance of having realistic expectations around consistent electronic health record systems into which
the timelines for return on investment, recognizing that these services could be integrated. This reiterates the
it could take several years to see any major impact on intent of the conceptual framework—that none of the
function let alone patient outcomes. The integration of interventions considered in this scoping review can be
electronic medical records or electronic health records assessed in isolation.
has a direct organizational impact on scopes of practice
as it enables health care professionals (and in some
cases, patients themselves) to share patient information
more easily, particularly across health care settings.
— 41 —

Case Study 5: Integrated Evaluation and Monitoring
Taber Family Care Clinic, Alberta
Model of Care: Established in 1999 in Taber, Alberta, the Taber Clinic was designed to address issues of
accessibility to primary care services. Through a team-based model of care, the family clinic is able to link
over 16,000 patients to a health care professional. Key features enabling the broader capacities of this clinic
include improved patient intake processes so that the data collected at each point of care can be used to
inform appropriate care pathways and health care professional allocation. This patient data collection also
enables the generation of algorithms for screening depending on patient profiles as well as aggregate
comparisons of clinic functioning to population health benchmarks.

• Dieticians, physicians, diabetes educators, asthma teams, public health nurses, and nurse practitioners
operate under one roof to create a centralized patient information network.
• Medical office assistant plays a key role working directly with the physician, taking standard patient metrics.
Enablers:
• Block funding for closed population
• Integration with Chinook Primary Care Network
• Electronic medical record system for both patient information sharing and communication between providers
• Ongoing monitoring and evaluation
Take-Away: The effective provision of primary care services in Taber has had a positive impact on relative
health services, reducing unnecessary or preventable visits to the emergency department and acute care
services. There are possibilities for expansion to include public health, homecare, mental health, addictions,
and family and community services.
Tholl, B., Grimes, K. (2012). Strengthening Primary Health Care in Alberta through Family Care Clinics: From concept to reality. Part One: Issue Brief.
Website: http://www.chinookprimarycarenetwork.ab.ca/clinics/clinic.php?view=19
Overall, from the literature, it is clear that information been able to involve patients in the provision of their
technologies such as the establishment of electronic own health care, such as the development of online
medical record systems and telehealth services are patient portals where patients can directly access their
becoming more common in health care delivery. Such own health records. These examples are depicted at
information technologies have direct implications on the meso (institution) level. The important piece lacking
scopes of practice as they enable expanded scopes of across these information technology innovations is
practice through improved communication systems standardization within and across regions. This frag-
(e.g., when pharmacists can take on greater responsibil- mentation has implications for continuity of care,
ities for patients through more direct communication particularly for patients travelling between rural and
with family physicians);new scopes of practice through urban settings. Professional turnover also affected
the delivery of altogether new services (e.g., teleoncol- the sustainability of innovations.
ogy) and the associated competencies required; and Institutional features that were not discussed from this
effective collaboration in cases of overlapping scopes of data source include institutional accreditation and the
practice (e.g., sharing patient data across providers and role of institutional and financial incentives.
settings). In some cases, these technologies have also
— 42 —

Key Informant Interviews move across different parts of the system,
In the key informant interviews, we inquired about where things fall through the cracks, and
institution-level inputs in order to facilitate innovative start solving problems in an integrated
models of care and optimal scopes of practice. The role manner. So I think it actually comes more
of technology was commonly discussed among key
informants, noting that if done well it can be supportive,
to a sense of stewardship and some form
but new barriers can surface if the technology is not of accountability, which probably includes
integrated with other structural enablers or designed some kind of performance management or
with input from the users across settings. at least performance monitoring.”
“You know, a lot of health care organizations “And I think the literature is pretty clear—when
have spent a lot of money on creating you do public reporting, it doesn’t necessarily
electronic medical records, electronic health change a lot of [patients’] behaviour but it
records. And certainly individual hospitals does change the behaviour of the health care
went their own way. So there are huge, huge professionals knowing that what is happening
questions of interoperability. But most of the will be reported publicly.”
resources spent on these systems went to,
The impact of accreditation and performance management
you know, closed proprietary programs.” systems, however, is often challenged by the measurability
of selected outcomes, particularly within shorter reporting
Beyond the issue of the effective implementation of time frames. This challenge speaks to the importance of
technology, there was also an acknowledgement that if distinguishing between short- and long-term impact
unchecked, advances in technology can also lead to a relative to initial investments.
consequent proliferation of roles or scopes of practice
that also need to be coordinated.
“One of the things that happens is that
there’s a real problem if things are not easily
“I think that new technology in that way
measurable; they get lost in the shuffle …
can sometimes create a front-end demand
There’s also some real places where it won’t
for a new type of worker that can’t be met
do what you want it to do … We found that
by a current role or training a current role
things like transitions and the systems of
and enhancing that role.”
care, they just vanish on most of the matrix,
because first they’re hard to measure, and
Performance monitoring and evaluation were
raised positively by a number of key informants regard-
secondly, people don’t control them as well.”
ing quality, safety, and efficacy.
This point is consistent with the argument in the CAHS
report on chronic care, which emphasized that “a culture
“Using accountability or performance of accountability is needed in which … all health profes-
measurement, or even [electronic health sions recognize the importance of measuring their
record] investment, all of those other things performance, compare their performance to their
that you can do to make the system on peers’, and change their behaviour. However, … [this
requires] having access to the right data, being able to
a management level actually look like analyse and compare between health care profession-
more of a system where you can look als and the right outcomes, and ultimately changing
at what happens to patients when they practice” (Nasmith et al., 2010,p. 31).
— 43 —

Two accrediting bodies that were highlighted in the key “When you measure and give feedback
informant interviews were the Association of Faculties of
to people in a non-threatening way,
Medicine of Canada (AFMC) and Accreditation Canada—
one largely for education and one for practice. The they will get better.”
AFMC covers 17 Faculties of Medicine for undergrad-
uate medical education through the Committee on Institutionalized forms of patient-oriented care were
Accreditation of Canadian Medical Schools in Canada noted as promising.
and the Liaison Committee on Medical Education in
the United States. It also has developed the Interim
Accreditation Review Process for continuous quality “Patients can cut through a lot of the… Well,
improvement and the Accreditation of Interprofessional they can make their demands known. They
Health Education (AIPHE). Accreditation Canada, which can make their perspectives known. And in
focuses more on accreditation of practice, is certified some cases, can break the logjam sometimes.
under the International Society for Quality in Health Care
and reaches beyond medicine, working with health care
So I would say that a more formal way of
organizations that elect to undergo the accreditation involving patients, patient groups, patient
process. It was suggested that these are two primary organizations in the development of policy
organizations to target for greater pan-Canadian impact and in the development of services would be
on quality assurance.
a very good step in improving the quality and
Despite the optimism around the impact or potential
the safety of health care.”
impact of accreditation, it also has its caveats.
However, there was concern in regards to the ambiguity

“Now, the problem with accreditation is, of around the term patient-oriented care—how it is defined
course, it begins to set up boundaries that and measured.
are defined by scopes of practice … And once
you have accreditation and legislation linking “But nobody has a good definition of it or a
together, you can see how difficult it is to good understanding of what patient-centred
begin to break those walls down.” care means.”
Linking performance measurement to economic tools

“So if we’re saying we’re doing patient-centred
was cautioned by a number of our key informants. care, it has to be around the patient. And
The preference was to deploy these tools in a manner we’re not measuring things from the patient.
of constructive criticism. And how do we know that what we’re doing
is what we want to achieve?”
“Because these are driven, creative, massively
capable people (that’s how they got to the jobs Another institution-level factor discussed by the key
that they’re in), they’re internally motivated. informants that did not emerge from the literature was
the role unions play in determining scopes of practice.
What you need to do is find a way to capture
When it was mentioned, unions were often identified as
that internal motivation and drive it towards challenging to the evolution of scopes of practice, which
the outcomes you want to see produced.” could be seen as being based on their traditional hierar-
chies and their inherent profession-protective nature.
— 44 —

“Most of them are busy protecting what Meso (institution) level areas that were emphasized
more often in the key informant interviews, and less
they have rather than demanding creativity,
so in the literature, included the role of institution-
innovation and a better future. And all of based accreditation and performance management.
that has to change. People have to quit Interestingly, there was little suggestion about the
protecting and locking into place the status linking of incentives to accreditation processes such
quo as if somehow it’s the right answer as the pay-for-performance model that is becoming
increasingly present in health care organizations in
because it’s not the right answer.” Canada. Unions were also recognized as key actors
to involve in the discussion in regard to increasing
“So both the protect-and-defence stance of flexibilities around scopes of practice and models
unions and the protect-and-defence stance of care. Successful mechanisms for engagement
of regulatory people is just freezing in time were not articulated.
what we have today with more and more
strict limits on the ability to innovate and
create change, and improve.”
Summary (B): MESO INSTITUTIONAL LEVEL INTERVENTIONS

Key features:
• Technological infrastructures such as electronic medical record systems and telehealth services are becoming
increasingly common to provide solutions around collaborative care models and accessibility of services
• Accreditation and performance management provide mechanisms to hold health care teams and institutions
responsible for delivering high quality care
Outcomes:
• Electronic medical records are associated with increasing efficiency though the substitution of time
consuming administrative tasks and mitigating duplicated services; and improving quality of care
through better record keeping and collaborative capacity building
• Expanded services through telehealth models have been found to increase general accessibility of care
• While considered necessary for quality assurance and patient safety, the impact of accreditation processes
and performance management is not well documented
Enablers:
• Electronic health records are viewed as an essential infrastructural element to enabling collaborative
care models
• Remuneration models that match the institutional changes (ie. developing appropriate billing mechanisms
for nurses providing telehealth services)
Barriers:
• Resistance among health care professionals to shift from traditional modes of operation to new communication
and organizational systems
• In some cases, union contracts and internal interests
were selected based on emerging themes and discussions among the Expert Panel members. Together, the summary boxes from alllevels of findings are used
— 45 —

C. Macro (Structure) Level: are less inclined to select interprofessional coursework
may be more effective than applying a one-size-fits-all
Educational Interventions approach (Kenaszchuk, 2012).
While most studies indicate broadly positive effects of
Educational programming for health care professionals
interprofessional education, particularly on the degree
has the potential to support the evolution of scopes of
of collaboration among health care professionals, one
practice on a macro level through the systematic devel-
paper to highlight is a recently updated Cochrane sys-
opment and implementation of modified curricula and
tematic review by Reeves et al. (2013), which examines
competencies to reflect different practice styles and
15 different interprofessional education intervention
changing epidemiologic trends. A number of studies
studies. Seven of these studies indicated positive
cited (42 out of the 125 sources) report on educational
correlations in the following areas: “quality of diabetes
interventions, which consistently refer to interprofes-
care, emergency department culture, and patient satis-
sional education initiatives as a focus for preparing the
faction; collaborative team behaviour and reduction of
incoming health care workforce and/or continuing the
clinical error rates for emergency department teams;
professional development of the existing health care
and improved outcomes related to collaborative team
workforce for collaborative care models. It is important
behaviour in operating rooms; management of care
to note that based on the content of the literature, inter-
delivered in cases of domestic violence; and mental
professional education initiatives are used more-or-less
health practitioner competencies related to the deliv-
interchangeably with broader educational interventions
ery of patient care” (p. 2). The remaining studies either
for this section.
reported mixed outcomes or that the interventions had
Of the interprofessional education interventions, the no impact on either professional practice or patient
majority (n=29) focused on the post-licensure stages, care. The reviewers concluded that although overall
assessing the impact of workshops and continuing results indicate some positive outcomes, the effective-
education and professional development programs. ness of interprofessional education and what it entails
These studies highlighted how interprofessional remains unclear.
education can
Helpful recommendations to move forward with
• be helpful in reshaping attitudes and understanding continuing interprofessional education, suggested by
of other health care professional roles (Eiser, 2008) Silver et al. (2009), include the development of desig-
• enhance communication skills to increase engage- nated faculty for interprofessional education, which
ment in new models of care (Sargeant, 2011); and would involve “careful needs Assessment, application
of a systems approach [micro/meso/macro] to iden-
• occur through an e-learning platform whereby new
tifying the target audience of learners, incorporation
knowledge and skills can be obtained and trans-
of principles of effective learning, multimodal teach-
ferred to the workplace (MacDonald, 2008).
ing methods, incorporation of interprofessional
Less common (n=13) were interventions reported at the education-based curriculum and an outcomes-based
pre-licensure education and training levels. Different curriculum design” (p. 176).
views were presented around the degree of integration Arising out of the literature was the need for continuity
into existing programs, such that mandatory exposure and commitment throughout the change process, from
to a team-based practice before students have formed pre-licensure phases on to advanced career stages.
strong professional identities provides an opportune These findings were consistent with needs and subse-
time to positively shape attitudes towards collaborative quent recommendations outlined in the World Health
practice. In this particular case, students were exposed Organization’s Framework for Action on Interprofessional
to collaborative care practice while working with older Education and Collaborative Practice (2010). From the
patients with complex multi-morbidities, which also included studies, there was particular focus on the point
showed efficacy in breaking down apprehensions of transition from the pre-licensure education setting
around working with this demographic (Basran, 2012). into the workplace. Specific issues were raised about the
Alternatively, another study indicated that interprofes- culture shock experienced by recent graduates when,
sional education and training that target students who despite their intention of practising collaboratively they
— 46 —

were confronted by the realities of traditional, siloed strategy development together. So how do
care models. Some of the key barriers that were identi-
we know that what is being taught in the
fied in the literature included concerns over professional
competence, public acceptance, role uncertainty, pro- faculty or education setting is palatable to
tection of jobs, and professional autonomy. Factors that the employers? How do we know that they’re
could be either barriers or enablers depended on the going to be able to actually put into practice
practice context. For example, poor communication was what the educators are teaching?”
seen as a barrier in some cases whereas good commu-
nication was noted as an enabler in others. Similarly, lack
of organizational management was seen as a barrier Another key informant lamented about the amount of
whereas presence of designated change management time it will take for new graduates trained in pre-licensure
was seen as an enabler. Other enablers included the interprofessional education to change the system.
existence of dedicated mentors for clinical staff, support-
ive organizational leadership, the existence of resources “If we only focus on the pre-licensure
and available evidence to draw upon.
education system, it’s going to take an entire
Overall, from the literature on educational interventions,
generation because you’re not focusing on
it is generally understood that interprofessional education
at either the pre- or post-licensure stage is considered the people who are in the workforce already,
an essential element to improving the way health care is who are actually the vast majority. I mean
delivered for current and future patient populations. For 90% of the current health care professionals
professional level outcomes, there is positive correlational
are working, not in training. Proportionately,
evidence between interprofessional education interven-
tions and improved collaborative competencies as well as there are only a small number of people in
greater respect and understanding for other health care training. So when you talk about education,
team members; however, the impact of these interven- you can’t just say, oh well, let’s get the next
tions on patient and system outcomes remains unclear. generation of nursing students; (a) it takes
too long and (b) they won’t have the role
Key Informant Interviews model they need. We need to focus on
The findings from key informant interviews resonate change for all health care professionals
with the literature. Similarly, the informants raised at all stages of the career.”
important issues in regards to the disconnection
between the education and practice contexts.
Nearly all key informants who discussed issues around
the alignment of the education system felt interprofes-
“So I think one of the things we need to sional education may be a necessary intervention,
include, and I do, is link the education but in and of itself is insufficient.
system with the service delivery system,
because whether or not you change the “But when you have a majority of people in
scope of practice or not, and their legislation the practice setting who are influencing the
and regulation, you fundamentally need practice behaviours of the new graduates,
to teach people to function differently.” they will always just adopt the behaviours
of the dominant group, which is the current
“And you know that in Canada, we still
practitioners. So if we do not invest in
have educators and employers who don’t
continuing education or on-site learning or
understand each other’s world. They don’t
redevelopment of the current practitioners,
do any joint planning. They don’t do any
we’re never going to change the system.”
— 47 —

Others commented on the importance of the modes And that’s not what continuing means when it
and structure through which continuing professional
comes to interprofessional. It’s about learning
development initiatives are delivered.
and practising all the time interprofessionally.”
“So a lot of people, they never come to the The concept of lifelong learning emerged more prominently
face-to-face training events. They tend to do in the key informant interviews and discussions with the
all their [continuing professional development] Expert Panel members than it did in the literature; there
online and through webinars and things. So was a fundamental appreciation that there will be con-
stant change in professional competencies and scopes
they don’t get the benefit of that joint sharing
of practice relative to changing professional interests,
of knowledge and joint learning.” competencies of other health care professionals, and
population needs. These changes over one’s profes-
“So I’m always a bit careful about continuing sional career need to be reflected in the way in which
education versus life-long learning, because education and credentialing is delivered and recognized
if you talk to surgery, for example, about at post-licensure levels. There was little discussion
continuing education, they’ll say how many around the establishment of feedback loops between
accreditation criteria and educational programming.
[continuing education] credits do I get?
Summary (C): MACRO (STRUCTURE) LEVEL:

EDUCATIONAL INTERVENTIONS
Key features: Interprofessional education—when two or more professionals learn with, from, and about
each other—at either the pre- or post-licensure stage is considered an essential element to improving the
way health care is delivered for current and future patient populations.
Outcomes: There is positive correlational evidence between interprofessional education interventions and
improved collaborative competencies as well as greater respect and understanding for other health care
team members; the impact of these interventions on patient and system- level outcomes remains unclear.
Enablers:
• Dedicated mentors, leaders, and resources to continue the development and promotion of
interprofessional education
• Evidence demonstrating positive effects of interventions
Barriers:
• Lack of communication between pre-licensure training institutions and the practice setting regarding
composition of human resource supply and appropriate competence development
• Lack of continuity for interprofessional education from the classroom to aligned residency/practicum
trainings to practice settings
were selected based on emerging themes and discussions among the Expert Panel members. Together, the summary boxes from all levels of findings are used
— 48 —

D. Macro (Structure) Level: • A primary health care team (comprised of an addiction
counsellor, a community nutritionist, administrative
Economic Interventions staff, management team, mental health workers,
psychiatrists, nurses, nurse practitioners, physicians,
Economic interventions were identified in the literature social workers, and community volunteers) was able
if they described a modification to either funding (how to pay its allied health care professionals through the
funds are allocated to health care organizations or successful acquisition of extra funds from private
institutions) or remuneration approaches (how health partnerships, respiratory/ambulatory care services,
care organizations or institutions pay their health care and Public Health (HCC-Nova Scotia, 2009).
personnel), either directly by the government authority
• With the expanded scope of practice of pharmacists,
(province or territory in Canada) or indirectly through
an additional billing mechanism was introduced in
allocations from the government authority to a regional
which the changes in prescribing practices the phar-
structure, which in turn allocates the funding to a
macists’ baseline dispensing fees were augmented by
health care organization15. These modifications were
new adaptation fees to reflect their new role of offering
considered relevant if they were introduced in associ-
prescription services (Marra, 2012). (This model could
ation with a change in professional scopes of practice,
also be considered as a financial incentive to improve
such as pharmacists taking on extra clinical tasks and
drug management among pharmacists.)
therefore incurring more demanding workloads, or
a model of care redesign, such as the introduction • The development of an anticipatory and preventative
of public health nurses in the primary care setting. care team, in which family physicians were remuner-
Consistent with the examination of other micro-, meso-, ated through a capitation system and all other
and macro-level interventions, this section focuses on health care professionals (notably, nurse practitioners
economic inputs (e.g., funding allocation mechanisms and pharmacists) were salaried (Legault, 2012).
and billing processes) rather than economic outputs • Similarly, a mental health care team of family
(e.g., cost-effectiveness). When changes are made to physicians, counsellors, and psychiatrists working
how funds flow from the government authority to the in a primary care setting were paid through a
provider (e.g., a provincial government paying physicians capitation system (through the Alternate Payments
directly through fee-for-service in association with the Branch of the Ontario Ministry of Health and Long-
provincial public health insurance plan) in order to Term Care and additional program funding for mental
support changes in scopes of practice, this would be health and nutrition services) (Kates, 2002).
considered a direct macro-level intervention that has
an impact on delivery at the micro level. Of the five sources cited, the economic interventions
Of the 125 articles, only five provided explanations of described challenges predominantly around lack of
the way changes to remuneration models were intro- uptake, sustainability, and administrative support
duced in the practice setting. In general, they did not (Marra, 2012; HCC-Nova Scotia, 2009).
provide details of the macro and meso funding struc- For enablers, the included economic interventions
tures within which these changes were made. For the were made possible through the concurrent applica-
purposes of this review, these were labeled as economic tions of other micro, meso, and macro inputs. Several
interventions and are briefly summarized here: examples follow:
• An alternate payment system of block funding16 • Prerequisites for the implementation of the intensive
was introduced alongside the development of a multidisciplinary neonatal care model with its alternate
multidisciplinary neonatal resuscitation team. This block funding included supportive provincial regula-
payment system contrasts to the traditional fee-for- tions, hospital bylaws, unit policies, staff training,
service model and was considered an enabling staff recruitment, communication strategies, and
input for the involvement of other non-physician re-evaluation of professional roles (Aziz, 2005).
professionals (Aziz, 2005).
15 See Appendix 17* for Types of Funding Mechanisms.

16 Annual budgets negotiated for a group of physicians, usually associated with an academic medical centre (CIHI, 2005; p.ii).
— 49 —

• In Nova Scotia, political support from the provincial Key Informant Interviews
government helped to enable the payment of all
The key informant interviews addressed the barriers
health care team members (HCC-Nova Scotia, 2009).
and enablers that a range of economic factors play in
• Determining the appropriate incremental pay of optimizing scopes of practice and enabling innovative
pharmacists’ prescription services in British Columbia models of care. They point out that public financing
required obtaining accurate information to calculate under the Canada Health Act18 focuses on physician
the incremental labour and investment costs in and hospital services, but not the rest of health care
addition to establishing the legal changes in scopes delivery. The result is that payment is tied to particular
of practice (Marra, 2012). health care professional types (e.g., physicians) or to
• Realistic time frames needed to be set for the certain settings (e.g., hospitals) but not to others and
transition to new scopes of practice and pay this can get in the way of collaboration across profes-
systems, the adaptation of personnel, and the sions and service delivery settings.
capturing of associated outcomes (Legault, 2010).
• The involvement of mental health care professionals “I find this question that you’re posing to be
as part of the central coordinating team was consid-
about the most frustrating in all of Canadian
ered essential to be responsible for problem solving
around appropriate resource allocation (Kates, 2002). health care policy. We have all of the tools
available to us, with one exception, and that
The only economic intervention that also reported on
is that if I were to do anything, it would be
cost outcomes was the additional billing mechanism
for the expanded scope of practice of pharmacists. to move physicians inside the tent [i.e., to
This intervention was reported as being more costly include them in the same funding envelope
than the usual care, yet was considered to be valuable as other health professionals] ….and that to
for improving patient health outcomes and promoting me is the thing that absolutely has to change
efficiencies in the system (Marra, 2012). This point reit-
erates the importance around defining cost-effectiveness
before anything else can happen.”
and also looking to return-on-investment analyses17
“This inhibits the ability to optimize scopes of
to deconstruct the short- and long-term impacts.
The remaining articles in this section reported on practice and maybe cheaper for the hospital,
the correlation between supportive economic struc- but ends up costing more when viewed from
tures and improvements in health human resource the broader budget of total public spending
efficiency and collaboration.
on health care.”
Overall, alternative remuneration schemes were
considered to be enablers to support expanded scopes
When the funding for physicians is through direct
of practice and collaborative care models but were
fee-for-service payment, the lack of public financing
dependent upon the alignment with other organiza-
for health professions other than physicians is a major
tional and technological inputs. More specifically, all
barrier to collaboration.
of the alternative models of payment captured in the
literature involved shifts away from the traditional
fee-for-service model for physician services.
17 To guide Assessments using a return-on-investment framework, the Canadian Academy of Health Sciences released the report Making an Impact: A
Preferred Framework and Indicators to Measure Returns on Investment in Health Research (Panel on Return on Investment in Health Research) in 2009 and
since then, the Institute on Governance drew upon this in its preparation of The Return on Investment in Team: Return on investment analysis framework,
indicators and data for interprofessional care and interprofessional education in health in 2013 that is most relevant to collaborative models and changing
scopes of practice (Nason).
18 The Canada Health Act, adopted in 1984, specifies the federal government standards to which provincial and territorial health insurance programs must
conform in order to receive transfer payments for all insured persons. The five principles of terms are(1) public administration—health care insurance
plan is administered and operated on a non-profit basis; (2) comprehensiveness—coverage of all insured health services; (3) universality—100% of
insured persons receiving insured health services are covered; (4) portability—insured persons will be covered outside of home province or territory;
and (5) accessibility—“provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either
directly or indirectly [all that are subject to conditions]” (Manore, 2005).
— 50 —

“With fee-for-service, the fee is only paid population, responsibility for a set population,
if the service is provided by a physician. and responsibility for the continuum of care.”
Even a well-intentioned practice won’t hire
an allied health care professional to do Key informants noted that there is a need to have a set
the work because it’s a cost to the practice budget in a closed system; population expectations
about quality and need should be explicit and then
with no associated revenue stream.” funding provided to allow practices to experiment
and evolve the system over time. This approach will
“So we’ve expanded scopes of practice
enhance innovation.
for a number of them. We’ve created new
professions in some cases. And we have
“To the degree you get integrated funding, well,
no way to pay for them.”
then the discussion around scopes and roles
Consistent with the literature, there was general consensus
becomes that much more easily handled.”
among the key informants around the need to move away
from exclusive fee-for-service structures. Other emerging payment models include bundled
payments that cover the care provided across settings.
Work is being done on this in Ontario, Alberta, and the
“Changing to non-fee-for-service physician United States.
payment is a necessary (but insufficient)
condition for allowing greater substitution “If you think about surgical models that
of care by or greater collaboration with are innovating in Alberta, we’ve seen a few
other professions. If the practice is funded that are using physician extenders and
through capitation, salary, or global more coordinated intake … And the main
funding, they are provided with money to innovation there seems to be that you’ve got
meet the needs of the population and will alternative payment, that it isn’t so linked to
hire the appropriate mix of health care who’s doing each particular step of the care
professionals to do so.” pathway. They’re paying more from entry
to exit through the entire pathway.”
There was general consensus across key informants,
with some cautionary caveats, that approaches to
alternative funding for optimizing scopes of practice Even more radical was the recommendation to consider
and fostering collaboration typically involve a closed funding that is not tied to a particular provider or setting
system where a health care organization is responsible but to the population needs.
for the care of an entire population.
“Start thinking about recommendations
“I think that the best evidence out there for of payments for services that people need
success, if you’re talking about innovative rather than services provided by a particular
practices and use of [health human resources] group in a particular place…physicians
efficiently, it’s the closed systems that have and centres leveraging private sources of
any hope of doing it. And I’m thinking here funding which tend to be less specific about
about Group Health Cooperative and Kaiser who provides the service and what for. Like
and the Veterans Association, to some degree. think of the most generic form of a flexible
So it’s the places that… again, it’s this defined spending account.”
— 51 —

Some key informants also noted the limitation of “There’s an additional complication which is
independent economic interventions that are not
one size doesn’t fit all. And one of the things
accompanied with coordinated inputs.
I didn’t see as much in the write-up was the
difference between different types of patients,
“Do not assume that you can change the
that some patients are much sicker and need
way health care is delivered by changing
a lot more care. Other patients don’t. And the
the financial incentives that face individual
model that will work for a relatively healthy
health care professional groups. So you
population may not be the same as the
know,[general practitioner]incentives and
model that will work for a sick population.”
incentives for chronic care management and
so on, it doesn’t change anything about the “Money is an extrinsic driver. Doing a good
fundamental structure of the system and job, having pride in your work, wanting to
the ways that the health care professionals produce something better today than you
and different organizations are expected to produced yesterday, that’s intrinsic drive
interact with each other. Individual financial and motivation. And it turns out that all the
incentives will not change the basic structure research and every industry that’s ever looked
or organization of your health care system.” at this, the places that are really successful
and drive outstanding performance over time,
There was some discussion of linking financial incentives figure out how to tap into people’s pride and
to performance measures as one component to health intrinsic drivers. And as soon as you start to
care quality improvement.
try to put in place, you know, checklists that
add up to certain scores that then get you
“The biggest thing they could do is to align bonuses, or you withhold pay you’re trying
the incentives so they make sense. So that to meet the requirements to get the money
people are not being asked to do something to which you think you are already deserving.
or to make a change that isn’t supported by And that de-professionalizes people.”
the financial and professional remunerations
and perks that are out there.” “The money is crazy. And it incentivizes
people to just do one thing each visit. It
Specific strategies for performance-based incentives creates lots of different subgroups that are
(including the pay-for-performance model) were not separate from each other. It discourages
discussed in depth; however, there was concern around
integration, coordination, and team work.
the impact on existing health inequities and the creation
of perverse incentives.
And it is increasingly becoming more and
more extrinsically driven in how it manages
its money and its incentives.”
“But I think one of the things that you’ve got
to be careful about is this gaming business…
You started getting incentives for treating
diabetics and every margin person got
classified as a diabetic. I mean most of the
places that have played with this have found
that it gets gamed. ”
— 52 —

From the key informant interviews, there were parallels area, theoretically enabling greater flexibility to meet
with the literature around the focus on funding and remu- specific population needs. There was a considerable
neration and, in particular, the ways in which separate level of concern around external economic incentives
modes of payment for physicians from other health being used to drive quality improvement initiatives due
care professionals often directly inhibit the optimization to other consequences of cost escalation and what the
of scopes of practice and innovative models of care. informants referred to as cream skimming; more discus-
This appeared to be the case even when other changes sion focused on how to build other incentives into the
were made at legal and regulatory levels. ways in which health care providers are paid.
Areas that were not discussed in the literature included Ultimately, there is no one perfect economic model
suggestions of ways to think outside the box in terms of that emerged from our research as each one must be
funding schemes. The ideas of integrated funding and adapted to the particular needs of a community or
bundled payments were raised favourably as they do population (i.e., some models that work for a relatively
not limit resources to a particular health care profes- healthy population may not be appropriate for patients
sion or place but rather enable support for health care with multiple, chronic conditions). Moreover, economic
professionals across care settings. There was also sug- factors are only part of the solution; they alone are
gestion for closed-system funding, where a lump sum is not enough to change the structure of delivery in
provided to care for patients within an entire catchment the health care system.
Summary (D): MACRO (STRUCTURE) LEVEL:

ECONOMIC INTERVENTIONS
Key features: Alternative remuneration schemes were considered to be an essential component to support
the optimization of scopes of practice and innovative models of care. In line with this, there was consensus
around the need to move away from the traditional fee-for-service model in particular.
Outcomes:
• Positive correlation between supportive economic structures and improvements in health human
resource efficiency and collaboration
• Limited correlational evidence between changes to economic structural inputs and the impact on cost at
a system level
• Role and impact of external financial incentives unclear
Enablers:
• Bundled payments for all health care professions across settings
• Closed system for targeted population (rather than tied to provider)
• Alignment with other organizational and technological inputs, including broader provincial or territorial
support
Barriers:
• Lack of sustainability beyond project-based funding terms
• Lack of administrative support to manage system changes
were selected based on emerging themes and discussions among the Expert Panel Members. Together, the summary boxes from all levels of findings are used
— 53 —

E. Macro (Structure) Level: interventions, Hooker et al. (2012) highlights that “there
are four major elements of malpractice risk for doctors
Legal and Regulatory who supervise a physician assistant: (1) lack of adequate
Interventions supervision, (2) untimely referral to a consultant or the

physician assistant’s failure to use a consultant, (3) failure
One of the most commonly cited barriers (or perceived of a physician assistant to make the correct diagnosis of
barriers) to altering scopes of practice of health care pro- a patient’s condition, and (4) inadequate examination of
fessionals is at the legal and regulatory level; that is, how a patient by a physician assistant. A twenty-year analysis
do governing bodies ensure the safety of the patient and validated that physician assistants do not increase liabil-
the responsibility of the health care professional when ity and in fact may even lower the liability of a medical
scopes of practice change, scopes of practice overlap, practice” (p. 75–76).
and/or there is general role or competence uncertainty
among health care professionals? It is interesting, there- Analysis of Case Law and Regulatory
fore, that of the 125 articles extracted, none explicitly
evaluated legal or regulatory interventions; that is, if
Models across Canada
any legal or regulatory measure was described in an As noted in the methodology section, we commissioned
article, it was presented not as an intervention but as a targeted analysis of legislation affecting scope of practice
a contextual factor alongside organizational changes. as well as legal liability issues through case law. Highlighted
One possible explanation of this gap in the literature below are the key insights garnered from this analysis.
is the nature of the regulatory complex adaptive system,
a system which makes the linear thinking of intervention
and outcome less applicable to the legal context.
Legislation Affecting Scopes of Practice
and Collaborative Models of Care
Of the 125 articles, there were eight studies that described
how the context of legal and regulatory changes formed An important trend in health care profession regulation
the backdrop for their analysis of the impacts of other in Canada is the move toward a common legislative
interventions involved (e.g., Marra, 2012; Parrish, 2009). framework for health care professions regulated in
Of these eight studies, four focused on changes at the each province or territory. This move to umbrella leg-
legislative level, two at the provincial regulatory level, one islation alters scope of practice statements to provide
at the regional regulatory level, and one at the institu- non-exclusive descriptions of each regulated profes-
tional regulatory level. One reoccurring theme was the sion’s activities and may include overlapping or shared
importance of legislative ability to enable expanded roles, scopes. Restricted or controlled practices remain but
such as advanced practice nurses and pharmacists. are only in the case of narrowly defined, higher-risk
activities. Umbrella legislation with more flexible scopes
The articles that did address outcomes of regulatory
of practice provides a possible foundation for collab-
interventions (e.g., recent regulatory changes to phar-
orative models of care. The regulatory frameworks,
macy prescribing) highlighted that although there were
and the practice cultures they influence, are “one of
some more immediate implications for professional
the determinants of the shift to a culture of interpro-
practice, such as determining appropriate remunera-
fessional regulation” (Lahey and Currie, 2005, p.198).
tion for new tasks, it was too soon to indicate what the
Health professions statutes in some provinces state
impact would be on patients and the broader public
that a regulatory college has a duty to collaborate inter-
(e.g., Marra, 2012). In a scoping review of physician assis-
professionally with other professions and to promote
tants in the U.S., which involved past legal and regulatory
collaborative practice among regulated professionals.
— 54 —

From Legal Frameworks to Health obligation to provide appropriate care. A breach of the
duty of care occurs when a health care professional falls
Profession Practice: Issues to Consider below a reasonable standard of care. The law requires
• Changes to statutory instruments alone will not a health care professional to meet the standard of
transform the traditional hierarchies and silos of “a prudent and diligent” health care professional of the
health care practice. Legislation sets out broad same profession.21 A court determines the standard of
principles but they are interpreted by health organi- care and whether it was met in a specific case based on
zations and professionals who may have vested and expert evidence. Expert evidence is provided through
conflicting interests. the oral or written evidence of persons who are pre-
• Disputes over professional turf are a barrier to sented and accepted as experts to the court for the
change, particularly if health profession leaders focus purpose of the litigation.
on “[scope of] practice disputes and turf protection
rather than the exploration of collaborative and
Legal Liability Issues, Collaborative
interdisciplinary approaches.” ( Jansen, 2008, p.222)
Care, and Working to Optimal Scope
• While health care professions statutes may be
reformed to promote professions working to broader Collaborative models of care, often in team-based
scopes in collaborative models, older statutes may structures, demand reliance on all health care pro-
structure health care environments in ways that fessionals working to their appropriate scope and
work against this modern approach (e.g., older rules standard. Courts recognize that health care profes-
that require physician orders for certain health care sionals must be able to rely on other professionals to
procedures, while new statutes authorize nurses to discharge their duties at an acceptable standard: “The
perform more actions without physician orders).19 health care system in Canada mandates that these pro-
fessionals work as a team with each individual having a
role in the provision of care to a [patient]. Each person
Legal Liability Issues, Interprofessional must carry out their role within their appropriate stan-
Collaboration, and Working to Full dard of care and each of these professionals is entitled
to rely upon (and must rely upon) the others to fulfill
Scope of Practice
their respective individual responsibilities.” 22
The general principles of negligence in the health care
Impact of a team structure: The team structure
context are well settled in Canadian law. To succeed with
adopted in a health care setting may be relevant to
a negligence claim, a patient must establish the following
the interpretation of the standard of care expected
elements: (1) the health care provider20 owed the patient
of a health care professional. For example, a hospital
a duty of care; (2) the health care professional breached
policy may require one professional to be designated
that duty of care; (3) the patient experienced harm; and
the “Most Responsible Practitioner”—a role that carries
(4) the health care provider’s breach of the duty caused
additional duties, but does not mean that the person
the patient’s harm (Picard and Robertson, 2007).
will necessarily be held liable for the conduct of his or
Once the health care professional-patient relationship her colleagues who were working as a team to deliver
is established, the health care professional has a legal care to the patient.23
19 See e.g. S. Regan et al., Policy Analysis of Interprofessional Collaborative Requirements under Bill 171 and Bill 179: Final Report (February 2013).
20 Note that depending on the country, different terms are used to describe a health worker that provides care to a patient. For clarity of terminology used
internationally, we use health care professional throughout this Assessment; however, in Canadian legal documents, the term health care provider is used
most prominently. For this legal and regulatory section, these two terms are used interchangeably, as relative to the Canadian context.
21 terNeuzen v. Korn, [1995] 3 SCR 674 at para. 33. See also Crits v. Sylvester, [1956] O.R. 132 (C.A.) at 143; aff’d [1956] S.C.R. 991.
22 Bauer v. Seager et. al.,2000 MBQB 113.
23 For discussion, see e.g. Manary v. Dr. Martin Strban, et al., 2011 ONSC 176, para 37.
— 55 —

Delegation and liability: Delegation of tasks by a • Canadian legal precedent does not support holding
regulated health care professional to another person a health care professional to a standard that is
may raise issues about who bears responsibility, partic- applicable to a different health care professional
ularly if the person asked to carry out a task performs group where that practitioner has acted reasonably
it at a substandard level. It is important to distinguish within that practitioner’s own legal scope.
between situations involving statutory rules about • In some cases, risks of increased liability in collaborative
delegation and situations where practitioners work col- care models maybe a result of “courts misallocating
laboratively and their scopes of practice enable shared accountability among members of interprofessional
responsibility for some tasks. Reasonable reliance on teams (sometimes to doctors and sometimes to
a colleague to carry out a task that the colleague is others), largely due to continuing reliance on tradi-
qualified and legally permitted to perform should not tional understandings of the allocation of work and
attract liability.24 A health care professional governed responsibility among health care professionals”
by specific statutory rules concerning delegation must (Lahey and Currie, 2005).
not delegate tasks in contravention of a rule.25
“Ultimate responsibility”: In a collaborative context,
or more specifically a team context, some health care
Key Informant Interviews
professionals, particularly medical doctors, express The key informant interviews largely focused on the
concern about being “ultimately responsible” for the barriers that legislation places on creating more optimal
actions of other professionals. Canadian law does not and flexible scopes of practice rather than any facilitat-
support the notion that based on statutory scope of ing capacities. This was particularly the case where
practice alone, a doctor should be legally liable for the there are separate authorities for each profession.
acts of other regulated professions (with the exception of
situations described above where a doctor has specific
legal obligations as an employer) (Kielley, 1997).
“What those regulations essentially do …
[are]… basically freeze in place what we have
Professional liability insurance: Legislation, practice
guidelines, and professional policy statements all address today because it doesn’t allow for innovation,
requirements for regulated health practitioners to carry creativity, redefining roles, re-creating ways
adequate professional liability insurance. Such insurance people relate to each other for systems of
provides protection for practitioners and patients when
care over time.”
situations of negligence arise.
In summary, what is known from the literature about
There was also concern expressed over the unfulfilled
the legal and regulatory context of scopes of practice
promise of umbrella legislation.
interventions is as follows:
• Many provinces and territories have, or are
moving toward, a common legislative framework “I think it’s a mechanism that has not been
for health professions. Umbrella legislation with exploited … because as soon as we got the
more flexible scopes of practice provides a Act done, all of these little Colleges then settled
possible foundation for collaborative care
in comfortably and said, okay, we’re now
models but in and of itself is insufficient.
covered by the umbrella. But there’s no cross-
chat between them. So they’re just there.”
24 Kielley v. General Hospital Corp (1997) 150 Nfld & PEIR 163; Percy v. Kieser, (2005)54 Alta LR (4th) 329.
25 Roberts v. College of Dental Surgeons (British Columbia) 1997 BCJ 1125.
— 56 —

“Legislation and regulation, like I said, is much
There was a clear link made between liability and concern
over harm issues and typical regulatory responses.
harder to change. It doesn’t mean it shouldn’t
be tackled but it is a more difficult nut to crack
“Statistics come out that show all the ways in with fewer opportunities and longer timelines.
which we do lots of harm and how health care I think what people need to do is spend more
systems really can be dangerous places, and time thinking how they work within the current
the mistakes that are made. And so in reaction, legislation and regulation but in new ways…
political folks and regulatory folks want to there is significant opportunity within existing
do things to try to make things safer. And legislation and regulation.”
so they restrict. You know, this category of
people can do this, they cannot do this, they These last statements are consistent with many of the
cannot do this, they cannot do this. And we innovations we studied and are highlighted in the case
find it to be mostly terribly negative in that studies; small-scale models, usually with closed popula-
tion groups, were able to enact changes through working
you have regulations starting to determine
around legislative or regulatory barriers rather than
what your care team looks like rather than waiting for the desired, hospitable environments to be
skills, abilities, and functions driving what created. So as to better enable the development and
your care team could look like and do.” scale-up of these types of innovations, legislation ought
to create the conditions for the optimization of and
“I think one of the most common false flexibility around scopes of practice. We address this
barriers is issues of liability.” directly in the recommendations.
Patient safety was also raised as a way to align visionary
goals across regulatory bodies. If appropriate evidence
Rather than waiting for legislation or regulation to
is available to support an alignment, (e.g., shared care
change, other key informants discussed methods
models that enhance patient outcomes without com-
for circumventing the barriers to increased flexibility
promising safety standards), then this evidence could
around scopes of practice.
be used as a tool to promote the movement towards
collaborative self-regulation (Conference Board of
“You know, show me quality outcomes and Canada, 2007; Institute of Medicine, 2001; Taskforce
lack of harm at a system level and then let on Health Care Workforce Regulation, 1995).
me control inside the system what we do in From the key informant interviews and Expert Panel
terms of roles and responsibilities and how discussions alike, the legal and regulatory constructs
around scopes of practice were commonly considered to
we organize to deliver the goods.” be inhibiting areas for advancing the flexibility of profes-
sional roles. From the legal analysis presented above,
“What I think we need to realize is that there’s
there is a fair level of optimism for the way in which health
often a workaround, and there’s often capacity law is beginning to shift in response to the challenges of
within the existing regulation and legislation contemporary practice. The adoption of delegated tasks
that has not been optimized. Yes. I mean I and umbrella legislation in some jurisdictions provides
examples of ways in which overlapping scopes of practice
think …we need to work harder to recognize
are being increasingly recognized as enabling some of
the benefits within the current legislation.” the required flexibility to meet community and popula-
tion needs. Moreover, some existing case law reveals
that courts are beginning to interpret standards of care,
scopes of practice, and liability in ways that demonstrate
an understanding of the goals of collaborative care and
expanded scopes of practice.
— 57 —

Summary (E): MACRO (STRUCTURE) LEVEL:
LEGAL REGULATORY INTERVENTIONS
Key features: Trends from the literature show movements towards more flexible environments for
innovative models of care and optimizing scopes of practice through the formal recognition that health
care professionals are no longer working in silos.
Outcomes:
• It is unclear how changes to legislation and regulation that are designed to increase flexibility around
scopes of practice and models of care compare to initiatives that circumvent the system.
• The impact of greater flexibility around scopes of practice is dependent upon the alignment with other
educational and economic inputs.
Enablers:
• Umbrella legislation that allows for non-exclusive descriptions of each regulated profession’s activities,
creating flexibility around overlapping scopes of practice
• Health professions statutes that promote collaboration across regulated professions
(present in some provinces)
• Identification of patient safety as a common goal across regulatory bodies
• Communication within and between regulatory colleges
Barriers:
• Disputes over professional turf
• Older statutes that continue to prioritize physician orders without recognition of other qualified
professionals or overlapping scopes of practice
• Professional concerns over liability in group settings
• Protective interests of regulatory colleges
* T he summary box above has been informed by data collected from both the scoping literature review, additional legal analysis, and the key informant interviews.
The points presented were selected based on emerging themes and discussions among the Expert Panel Members. Together, the summary boxes from all levels of
findings are used to inform the Recommendations.
— 58 —

Summary of the At the Macro (Structure) Level:
Education and Training Context
Key Findings
We found the following:
It is clear that the literature on scopes of practice
• Interprofessional education has been shown to
focuses more on micro-level interventions than meso-
improve competencies and collaboration among
and macro-level interventions, a finding that it is not
health care professionals working in interprofessional
dissimilar to the literature on health services and policy
settings, but few studies have linked interprofessional
research more generally. While there are important
education to patient or system outcomes.
lessons for the micro level to draw from the literature,
it was strategically important for us to focus on some • Interprofessional education must extend beyond
of the fundamental meso- and macro-level factors in the classroom and entry to practice level so that
the key informant interviews and the Expert Panel continuing professional development programs
discussions. Below are the key findings across these reflect the associated with changes in population
different sources of evidence. needs, best practices, and professional competencies
and interests over time.
• Scopes of practice should be defined by patient
At the Micro (Practice) Level needs and the composition of the health care team,
We found the following: which ought to feed directly into reforming pre-
• Collaboration is widely accepted as an essential and post-licensure education programs around
element to improving health care delivery and has competence-based requirements.
been shown to improve patient satisfaction and • There is a gap in the literature addressing the impact
increase job satisfaction among health care profes- of certification for health care professionals and
sionals through shared workload and a positive accreditation specific to changing scopes of practice;
impact on patient well-being. this could be a key strategy for enabling a more
• Key enablers to support collaborative care models dynamic and structured process that takes into
for optimizing scopes of practice include (a) ensuring account the skills and competencies required by
that all health care professionals are aware of education systems (supply) and the needs of a
the roles of their fellow health care professionals, population and practice setting (demand).
(b) employing a designated person to oversee the
change management processes and/or be respon-
sible for the management of the health care team At the Macro (Structure) Level:
and overall care coordination, (c) institutionalizing Economic Context
regular communication structures, and (d) provid-
ing a shared space for different types of health care
professionals to physically work in the same location. • Payment of physicians (predominantly under fee-
for-service systems) separate from other health care
professionals (who are paid through hospitals or
At the Meso (Institution) Level other health care service groups) creates disincentives
for collaborative approaches to care that optimize
scopes of practice.
• Successful innovative models integrate information
• Other promising alternatives to traditional
communication technologies and electronic health
fee-for-service models include integrated funding
record systems.
models that are not tied to particular health care
• Accreditation of performance measurement and professionals or settings. This might involve bundled
evaluation could play an important role in quality payments across the continuum of care or funding
improvement and accountability. services for an entire population as a closed system,
• Alignment among all stakeholders at all levels is and/or combinations of other non-financial incentives,
required, particularly to bring the professional associ- such as professional development opportunities,
ations and unions into discussions around how best to reward performance.
to meet patient, community, and population needs.
— 59 —

• Outcome-based funding, as opposed to activity-based • Many provinces and territories have, or are
funding, is becoming more common in some juris- moving towards, a common legislative framework
dictions; however, there remains concern around for health professions. Umbrella legislation enables
perverse incentives that create a cream-skimming greater flexibility for expanded and overlapping
effect in which healthier persons receive better care scopes of practice.
than sicker populations, as well as issues related to
defining valid and reliable outcome measures. We summarize below in Table 1 the perceived barriers
and how, with the right action plan, they can become
enablers for optimizing scopes of practice and support-
At the Macro (Structure) Level: ing innovative models of care. Given the fluidity of these
elements, the table uses a micro, meso, and macro
Legal and Regulatory Context lens todescribe how the identified barriers provide an
We found the following: opportunity to become enablers through modification
• Based on case law review, there may be or circumvention of structure or function.
disproportionate concern around the extent
to which liability impedes collaborative practice.
Table 1: Barriers And Enablers:

Optimal Scopes Of Practice Within Collaborative Care Arrangements
At The Macro, Meso, And Micro Levels
BARRIERS ENABLERS
ealth care professional

H • E
ducating professionals and courts on changes to legislation that recognize the
accountability/liability concerns principles of shared care models
Educational needs/requirements • Establishing practicums and residencies that foster inter-professional competencies
that inhibit professionals working
MACRO
• Post-licensure credentialing for continued competency development over the course

to full or optimal scope
of a career
R igid legislation/regulations • E
xpanding adoption of more flexible legislative frameworks that can be interpreted
at the local setting
ayment models that do not support
P • A lternative funding (e.g., bundled or mixed payment schemes) to include all health
changes in scopes of practice care professionals and to be aligned with desired outcomes
ommunication across
C • I mplementation and upkeep of electronic medical records essential for all respective
multiple care settings health care professionals (and for patients themselves) to have timely access to the
most up-to-date information on treatment and status
Professional protectionism • R
epresentation of the interests of professions in the context of collaborative care
MESO
arrangements and inter-professional standards/overlapping scopes of practice

Accountability • B
roader application of collaborative performance measures and an overall quality
assurance framework through involvement of accrediting bodies
Availability of evidence • S
ystematic monitoring and evaluation (with specific focus on inputs and outputs) to
estimate cost incurred for introducing change and the long-term return on investments
Professional hierarchies • C
hange management team: a designated role for managing changes in scopes of
practice and models of care
Professional cultures (lack • C
ontinuing professional development to cultivate team thinking and develop levels
of trust and role clarity; job of trust around relative competencies
protectionism, turf wars,
• T
eam vision: to reinforce that the ultimate goal is the improved well-being of the patient;
task escalation)
MICRO
who provides the care is secondary to the quality and accessibility of services provided
Communication among health • I nstilling group mentality: internalization of shared responsibility across health
care professionals care professions
• Scheduling of regular meetings for health care team members to consult on
appropriate care strategies and problem-solving strategies; integrating information
communication technologies
• C
o-location to have different types of health care professionals and services
functioning in a shared space
* T he summary box above has been informed by data collected from both the scoping literature review and the key informant interviews.
The points presented were selected based on emerging themes and discussions among the Expert Panel members.
— 60 —

Beyond the issue of transforming barriers into enablers, potential and actual improvements” (Evans, Schneider
our analysis of key scopes of practice innovations revealed and Barer, 2010, p. 1). Similarly, David Blumenthal, President
that a common characteristic is that they circumvent of the Commonwealth Fund, argued that “we cannot build
largely macro-level structural barriers. This finding health care reform on the backs of heroes,” referring to
supported our focus at the outset on the broader the early innovators who demonstrate excellence within
context of health professional scopes of practice that a context that generally impedes it. What is missing across
may be able to better address patient, community, these examples of innovation, whether they are captured
and population health needs. Thus, one must do more in the literature or not, is a structural context that will
than just shine the light on these scopes of practice support the scaling up of the innovations across the
innovations. Others have noted that “despite the fact country into mainstream health care. (see Case Study 6
that there are points of light scattered throughout the for an example).
system, a large implementation gap persists between
Case Study 6: Scalability of Innovations
Collaborative Emergency Centres (CECs), Nova Scotia
Model of Care: As part of Nova Scotia’s Better Care Sooner plan, the first CEC opened in Parrsboro in July 2011.
Now there is a total of eight CECs across the province with expansions underway within Nova Scotia as well
as Saskatchewan and Prince Edward Island.
This innovative model of care works to expand access to primary health care services. Health care teams
are comprised of physicians, nurse practitioners, registered nurses, and paramedics. The practice structure
is unique in its ability to provide same- or next-day medical appointments for urgent cases, extended hours
and expanded services, such as registered nurse telehealth services, and 24/7 access to emergency care.

• By matching care services with patient needs rather than health care provider availability, greater
coordination of roles and communication processes are required among all health care team members.
Enablers:
• Support from provincial government funding
• Political endorsement, consistent with broader provincial priorities (Ross, 2010; Better Care Sooner:
The plan to improve emergency care. Government of Nova Scotia.)
• Upgraded infrastructure (i.e., communication systems, medical equipment, exam tables, and waiting areas)
Take-Away: The introduction of telehealth services has been a key feature for addressing physician
shortages, particularly in rural around areas. Over the phone, nurses are able to provide support and
education around appropriate next steps for seeking care, in effect, decreasing the number of unnecessary
formal care visits, primarily to emergency departments.
Hayden, J., Babineau, J., Killian, L., Martin-Misener, R., Carter, A., Jensen, J., Zygmunt, A. (2012) Collaborative Emergency Centres: Rapid Knowledge Synthesis.
Nova Scotia Health Research Foundation; Nova Scotia Cochrane Resource Centre.
— 61 —

Research Gaps
Although we were able to identify some robust findings from this scoping review, it also revealed some significant
research gaps. If these gaps were systematically researched, stronger evidence could be provided to policymakers
and stakeholders. These are highlighted below in the Key Research Gaps text box.
KEY RESEARCH GAPS

At the micro level, we need to know more about
• cost-benefit analyses and return on investment relative to different types of practice-level models of care and
scopes of practice; and
• the direct impact of changes in practice on patient outcomes through more methodologically rigorous examination.
At the meso level, we need to know more about

• the ways technological interventions support the optimizing of scopes of practice and innovative models of care
and their longitudinal impacts on communication efficacy, cost-effectiveness, accessibility, and quality of
transitions of care; and
• effective approaches for evaluation and accreditation to determine what type of practice-level performance
measures provide the most appropriate indicators around optimizing scopes of practice.
At the macro level, we need to know more about

• procedural inputs for introducing educational interventions that optimize scopes of practice at pre- and
post-licensure education stages;
• the impact of alternative remuneration systems on socio-economics, the health sector, and human resources; and
• the long-term impact of different types of legislative frameworks on optimal and flexible scopes of practice.
Overall, we found an emerging consensus that the to meet the needs of their unique communities and in
optimization of health professional scopes of practice the financial alignment of resources, tasks, and out-
in alignment with innovative models of care provides a comes available to the team. Individual practitioners
promising health human resource strategy to shift the will need to be certified and regulated, but with an
health care system towards the delivery of collabora- emphasis on skills development, so that team members
tive, patient-oriented care. In this approach to care, the can perform tasks for which they have taken defined
collaborative vision is patient-focused and unified and training and are certified. Equally, there will need to be
supported by supported by communication and con- recognition that many of the essential tasks required
tinuing professional development. A critical element of for comprehensive patient-oriented care do not need
the model is the combination of accountability for the to be performed by health care professionals; patients,
individual and the collaborative team and a correspond- their families, personal support workers, navigators,
ing balance between self-regulation and accreditation counsellors, educators, and patient advocates must
of collaborative care arrangements. Clearly defined all play an important role.
roles need to be delineated within the team according To move towards the goal of optimizing scopes of
to service need and the range of abilities, training, and practice as a strategy to improving health care and
experience of team members. The fundamental prin- system effectiveness, we present here a set of recom-
ciple at play is that scopes of practice are aligned with mendations to guide the actions of decision makers,
collaborative care arrangements to achieve the team’s health care planners, and health care professionals.
collective goals and targets. This approach will require
flexibility in the roles and scopes of practice of providers
— 62 —

4. Recommendations
The Expert Panel identified six principal parties that would have to act in cooperation to
facilitate the changes required to optimize scopes of practice in order to achieve the goal
of a transformed health care system. We suggest an integrated scheme of general strategies
and specific recommendations for each of the principal parties (see Tables 2 and 3 below).
The recommendations identify actions that will lead to the creation of more flexible environ-
ments to enable the scalability of promising initiatives around optimal scopes of practice and
innovative models of care. In general, the recommendations emerging from this Assessment
call for respective stakeholders to implement the necessary structures to support health
care teams, institutions, and regional jurisdictions in a shift from the current siloed, provider-
centric care systems to collaborative and responsive patient-oriented care systems. While
the conceptual framework and the different sources of data synthesized in this Assessment
acknowledge the multi-level inputs, the recommendations explicitly focus on the macro-level/
structure-level changes to guide transformation in a systematic but flexible, visionary way
where patient and population needs drive models of care that better utilize a range
of scopes of practice.
The recommendations have been constructed to Therefore, the recommendations are intended to
set the foundation for an integrative framework or • build on pre-existing efforts where they exist and
blueprint that recognizes (a) in many jurisdictions, pioneer changes where they have not yet been made;
investments aligned with the strategies presented are
already underway; (b) no one recommendation will be • be interpreted synergistically across disciplines,
sufficient to initiate and sustain transformation in and jurisdictions, and agencies;
of itself; (c) these changes, let alone their measureable • imply both immediate and long-term actions; and
impact, will not occur over night; and (d) these recom-
• reflect that their application is iterative and will
mendations must be applied within the context of a
require adaptation over time.
complex system.
Table 2 presents the six key high-level strategy areas
that we detail in Table 3 specifically with reference to
the key stakeholder groups who need to take these
recommendations forward.
— 63 —

Table 2: High-Level Strategies for Optimal Scopes of Practice
A. B. C. D. E. F.
Provide leadership Create systems of Align regulatory Establish account- Accelerate the Provide leadership
and support to funding, financing, bodies to enable ability through development of pre- in supporting
encourage the remuneration, and professionals accreditation and and post-licensure collaborative care
evidence-based evaluation that are to practice performance mea- education practices practice arrange-
expansion of aligned with patient collaboratively surement systems, that foster collabo- ments as being in
collaborative care outcomes and with overlapping including the mon- rative practice and the best interest of
models and enable collaborative scopes of practice. itoring of return on reflect the changing the individual pro-
evolution of models of care. investment, at team nature of required fessions represented
scopes of practice. or institution levels. competencies. and recognizing
this is the context
in which most
members work.
Table 3: Detailed Strategies and Recommendations to Responsible Parties
PRINCIPAL OTHER
RESPONSIBLE STAKEHOLDERS/
PARTY STRATEGY RECOMMENDATIONS PARTNERS
Provide leadership and 1. Host a national summit to bring all the stakeholders • Canadian Institutes
A. support to encourage the together to develop a plan of action on scopes for Health Research
Federal evidence-based expan- of practice.
• Health Canada
Government sion of collaborative care
2. Develop an arm’s length evidence infrastructure
models and evolution • Federal-Provincial/
(i.e., pan-Canadian health workforce policy and
of scopes of practice. Territorial Committee
planning organization).
for Health Workforce
3. Earmark research funds to address evidence gaps
• Canadian Institute for
in the literature.
Health Information
4. Develop a national set of guidelines and quality
• Patient groups
standards for overlapping scopes of practice.
5. Promote best practices and facilitate subsequent
scale-up and sustainability of initiatives across
the country.
6. Support the development and continued implemen-
tation of umbrella health professional regulatory
legislation across provinces and territories.
Create systems of 1. Adopt alternative financing structures to cover all • Local Health
B. funding, financing, health care professionals across settings and sectors. Integration Networks
Provincial/ remuneration, and eval- and Regional Health
2. Initiate a review of professional and union collective
Territorial uation that are aligned Authorities
agreements to examine their impact on health
Governments with patient outcomes
professional scopes of practice and develop policy • Health care
and enable collaborative
recommendations to guide collective bargaining in institutions
models of care.
the health care sector.
3. Ensure accountability for collaborative, patient-
oriented care through accreditation.
4. Develop mechanisms that support a move to team-
or institution-based liability coverage.
5. Support system-wide adoption of information
technologies that foster optimal scopes of practice.
Align regulatory bodies 1. Work with national certifying bodies to create • National
C. to enable professionals national standards and competence frameworks that certifying bodies
Regulatory to practise collaboratively recognize training and recertification processes in
• Pan-Canadian
Colleges with overlapping scopes areas of overlapping and changing scopes of practice.
regulatory federa-
of practice.
2. Recognize certificates for interprofessional practice tions and consortia
competencies that enable expanded scopes of
• Education bodies
practice, informed by the National Interprofessional
Competency Framework and the work of the
Canadian Interprofessional Health Collaborative.
— 64 —

PRINCIPAL OTHER
RESPONSIBLE STAKEHOLDERS/
PARTY STRATEGY RECOMMENDATIONS PARTNERS
Establish accountability 1. Work with national certifying bodies to create • Professional

D. through accreditation and national standards and competence frameworks that regulatory bodies
Accrediting performance measure- recognize training and recertification processes in
• Professional
Bodies and ment systems, including areas of overlapping and changing scopes of practice.
associations
Quality Councils the monitoring of return
2. Build on existing standardized performance metrics and unions
on investment, at team or
for collaborative care models.
institution levels. • Accreditation Canada
3. Build on existing metrics to inform lifelong learning
• Patient groups
and collaborative competency development for
(Patient Voices
practitioners at pre- and post-licensure.
Network)
4. Expand accreditation to additional levels of health
• Canadian Patient
care service provision to include collaborative care
Safety Institute
models. Mandate accreditation for all health care
service provision organizations
Accelerate the 1. Mandate and embed interprofessional, competency- • Canadian

E. development of based education across the professions so that Interprofessional
Pre-Licensure pre-and post-licensure interprofessionalism is an essential competency Health Collaborative
and Continuing education practices (rather than something additional or above
• Accreditation of
Professional that foster collabora- baseline competencies).
Interprofessional
Education Bodies tive practice and reflect
2. Develop certificates for advanced collaborative Health Education
the changing nature of
practice competencies.
required competencies. • Regulatory bodies
3. Support lifelong learning to build and enhance
collaborative care competencies.
Provide leadership in 1. Contribute to the establishment of evidence-informed • Regulatory bodies

F. supporting collaborative guidelines for collaborative care models in which
• Health care
Professional care practice arrange- members participate.
employers
Associations and ments as being in the best
Unions interest of the individual • Federal, provincial
professions represented and territorial
and recognizing this is governments
the context in which most
members work.
Fundamentally, we are recommending the optimization The above recommendations provide a blueprint for
of health professional scopes of practice to enable action to support the leadership and generate the
collaborative responsibility for shared care that meets champions required to transform health care practice
patient, community, and population health needs. This and improve outcomes across the health care system.
strategy will ensure that the right provider gives the
best care, and the health care team or institution is
accountable for assigning appropriate and optimal
scopes of practice within a regulated structure.
***
In conclusion, this Assessment presents a compelling to inform decision making. The current epidemiologic
case, based upon key informants and published evidence, trends and demand for a transformation of the health
for a paradigm shift in optimizing scopes of practice and care system provide an opportunity for Canada to
in the way health care is delivered in Canada. This shift is become a global leader in supporting health care inno-
one that moves patient needs to the forefront of health vation through the optimization of scopes of practice.
care planning; aligns educational, economic, legal, and We are confident that the recommendations presented
regulatory inputs with desired outputs; rewards health in this Assessment provide a comprehensive approach
care teams and institutions for improved processes to initiate this shift to ultimately improve the health care
and outcomes while also holding them accountable delivery for all Canadians.
for sub-optimal performance; and prioritizes evidence
— 65 —

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Appendices
Appendix 1: List of Acronyms

AFMC Association of Faculties GP General Practitioner
of Medicine of Canada HCC Health Council of Canada
AIPHE Accreditation of Interprofessional HHR Health Human Resources
Health Education
HPRAC Health care professional Regulatory
CAHS Canadian Academy of Health Sciences Advisory Committee
CAHSPR Canadian Association for Health Services ICTs Information Communication Technologies
and Policy Research
IPC Interprofessional Collaboration
CEHL Canadian Electronic Health Library
IPE Interprofessional Education
CFNU Canadian Federation of Nurses Unions
LPN Licensed Practical Nurse
CHHRN Canadian Health Human Resources Network
MOHLTC Ministry of Health and Long-term Care
CHSRF Canadian Health Services
Research Foundation MRT Medical Radiation Technologist
CIHI Canadian Institute of Health Information NP Nurse Practitioner
CIHR Canadian Institutes for Health Research OECD Organization for Economic Co-operation
and Development
CINAHL Cumulative Index to Nursing
and Allied Health PA Physician Assistant
CMA Canadian Medical Association RN Registered Nurse
CNA Canadian Nurses Association RNAO Registered Nurses’ Association of Ontario
CPD Continuing Professional Development RPN Registered Psychiatric Nurse
CPSO College of Physicians and Surgeons Ontario SoP Scopes of Practice
ERIC Educational Resources Education Center
Appendices – All additional appendices are available on the CAHS website

http://www.cahs-acss.ca/completed-projects/
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* All appendices are available solely on the CAHS website: http://www.cahs-acss.ca/completed-projects/

Association of Faculties of Medicine of Canada

THE CANADIAN ACADEMY OF 3. KEY FINDINGS.................................................................................31

What is the problem we are trying to address?...... 19 E. Macro (Structure) Level:

List of Case Studies, Figures, Tables, and Appendices

Case Studies Case Study 4: Integration of Electronic Medical

WHERE WE ARE HOW WE CAN GET THERE WHERE WE WANT TO BE

Barriers And Enablers:

 ealth care professional

• Post-licensure credentialing for continued competency development over the course

arrangements and inter-professional standards/overlapping scopes of practice

1 See Appendix 1 for List of Acronyms.

5. Assesses articles that reported on at least one of the Cost-effective analysis

Outline of the the scoping review and complementary key informant

4 See Appendix 5* for Screening Guidelines used in scoping literature review.

6 See Appendix 3* for Glossary of Terms.

Figure 2: The Relationship between Scopes of Practice and Models of Care

How do Models of Care relate to Scopes of Practice?

How do Scopes of Practice relate to Models of Care?

Figure 3: Conceptual Framework

WHERE WE ARE HOW WE CAN GET THERE WHERE WE WANT TO BE

* All appendices are available solely on the CAHS website: http://www.cahs-acss.ca/completed-projects/

* All appendices are available solely on the CAHS website: http://www.cahs-acss.ca/completed-projects/

Informant Interviews Using a series of semi-structured interview guides

Figure 5: Overview of the Number • Regular communication protocols, such as daily

Laprise, 2012; MacDonald, 2008;Reeves, 2009;

Suter, 2008; Suter, 2010; Wheeler, 2011)

• Integrated evaluation (Health Council of Canada,

13 Categories are not mutually exclusive.

Case Study 1: Expanded Scope of Practice

Physiotherapist Triage Model

Implications for Scopes of Practice:

Some examples of different types of collaborative care

“Understanding each other, respecting each

• Team leadership is of critical importance and this

Hamilton Family Health Team–Mental Health Program (HFHT–MHP), Ontario

Implications for Scopes of Practice:

1. Quick Care Clinics, Manitoba

Implications for Scopes of Practice:

Source: personal communications.

Summary (A): MICRO (PRACTICE) LEVEL INTERVENTIONS

One of the included studies that examined a patient

Sault Ste. Marie Group Health Centre, Ontario

Implications for Scopes of Practice:

Taber Family Care Clinic, Alberta

Implications for Scopes of Practice:

However, there was concern in regards to the ambiguity

Linking performance measurement to economic tools

Summary (B): MESO INSTITUTIONAL LEVEL INTERVENTIONS

Summary (C): MACRO (STRUCTURE) LEVEL:

15 See Appendix 17* for Types of Funding Mechanisms.

Summary (D): MACRO (STRUCTURE) LEVEL:

Interventions supervision, (2) untimely referral to a consultant or the

Table 1: Barriers And Enablers:

 ealth care professional

• Post-licensure credentialing for continued competency development over the course

ealth care professional

• Post-licensure credentialing for continued competency development over the course

ealth care professional

• Post-licensure credentialing for continued competency development over the course