Working with Ontario PAs: Establishing PA Medical Directives
To ensure that PAs can practice at the top of their scope and contribute effectively to the healthcare team, it is crucial for employers to establish clear and comprehensive medical directives.
Medical directives are used in Ontario*, and can play a crucial role in allowing PAs to practice with indirect supervision by providing a framework that outlines their authorized scope of practice and level of autonomy.
We will explore the importance of medical directives for PAs and provide a practical guide for employers seeking to establish these directives in Ontario.
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*Note: In Canada, this is in reference to PAs in Ontario. Please consult CAPA to see if medical directives are required in other jurisdictions.
I. Medical Directives in Ontario
a) What is a Medical Directive?
A medical directive, also known as a clinical directive or a practice directive, is a document that outlines the specific tasks, procedures, and clinical activities that healthcare professionals, such as Physician Assistants (PAs), RNs, RTs and paramedics, are authorized to perform within their scope of practice.
It serves as a framework that guides their practice and defines the boundaries within which they can autonomously make decisions and provide patient care.
b) Medical Directives should be periodically updated
Medical directives are dynamic documents that may be reviewed, updated, and revised periodically to reflect changes in healthcare practices, regulatory guidelines, and the evolving scope of practice for PAs.
They serve as a critical tool in supporting PAs to practice within their authorized scope, provide quality care, and contribute to the overall healthcare team.
c) Who develops medical directives for PAs?
PA Medical directives are typically developed for PAs working in a practice, or department, or hospital-wide.
Medical directives can vary between departments, institutions, and specialties and are customized according to how the PA practices in their specific setting.
For example, not all Orthopaedic Surgery PAs across Ontario would have the same medical directives. PAs that focus primarily in inpatient Orthopaedic PAs would be different from PAs who focus primarily in clinic, on-call and assist in the operating room.
The stakeholders that may be involved in developing medical directives:
Physician Assistant: The PA actively participates in the development of their medical directives. They contribute their knowledge, skills, and understanding of their scope of practice to ensure that the directives accurately reflect their capabilities and the activities they are authorized to perform.
Supervising Physician(s): The supervising physician plays a crucial role in the creation of medical directives for PAs. They provide oversight and guidance to the PA, collaborate in defining the scope of practice, and contribute their expertise to ensure that the directives align with the standards of care and regulatory requirements.
Relevant Hospital departments, committees (if applicable): This may be applicable if this is the first PA/first set of medical directives being introduced into a hospital. Clinical Director of Patient Services, Pharmaceuticals and Therapeutics (P&T), Medical Affairs, Chief of Staff, Chief of Department
The Canadian Association of Physician Assistants (CAPA), advocates for the interests and professional development of PAs. They may provide resources, best practice guidelines for implementing medical directives. There are guidelines, outlines and templates of medical directives. CAPA does not develop customized medical directives for
d) How general or specific should PA medical directives be?
Medical directives should strike a balance between providing specific guidance and allowing flexibility within the PA's scope of practice. They should be detailed enough to outline the authorized activities and interventions, while also allowing room for professional judgment and adaptation to individual patient needs.
While medical directives should provide specific guidance, it is important to acknowledge that they cannot account for every possible clinical scenario. Very specific directives can be very limiting, and impede PA efficiency and delivery of patient care.
We recommend keeping medical directives broad instead of specific. For example, instead of listing individual medications list classes of medications or groups together by disease processes.
An example would be to say you can prescribe Sulfonylureas (class of medication) instead of Diamicron (specific medication) or even better, all antihypoglyemic medications (by disease process). This ensures directives don’t need to be updated every time a new medication comes on the market
Medical directives should empower PAs to exercise their judgment and adapt their practice within the authorized scope to provide safe and effective care to their patients.
II. How do Medical Directives Impact PA practice?
Effective medical directives allow PAs to practice at the top of their scope of practice by providing:
Clarity in scope of practice: Medical directives provide clear guidance on tasks, procedures, responsibilities that PAs are authorized to perform. This eliminates ambiguity and promotes efficient use of their skills and knowledge.
Enhanced workflow: Medical directives establish protocols and guidelines of roles and responsibilities to reduce delays and ensure smooth patient care transitions.
Autonomy and decision making: PAs are not independent practitioners, but can practice autonomously through indirect supervision through use of effective medical directives. PAs exercise their clinical judgment within their authorized scope of practice. This autonomy enables PAs to make timely decisions, respond to patient needs promptly, and contribute to efficient care delivery.
Seamless Supervision: Medical directives outline the parameters for collaboration and consultation between PAs and supervising physicians. This ensures that PAs have access to guidance and support when needed, minimizing delays in decision-making and promoting efficient patient management.
Facilitating Collaboration: Medical directives also serve as a means to promote effective collaboration between PAs and other members of the healthcare team. These directives outline the roles, responsibilities, and communication channels between PAs and supervising physicians or other healthcare professionals. Clear medical directives facilitate seamless coordination, teamwork, and communication, ultimately leading to improved patient care outcomes.
III. Sample Outline of a PA Medical Directive
Here is a general outline that can serve as a starting point for creating a PA medical directive.
Medical Directive for PAs in [specialty]
a) Medical Directive Info
Program: [department]
Medical Directive Title:
Medical Directive Number:
Approval Date: [insert date]
Next Review Date: [insert date]
Applies to: [PA names, supervising MDs]
b) Order or Delegated Procedure:
Insert description of the delegated order or treatment (e.g. prescribing medications, first assist in the operating room, performing in-office procedures, etc.). This is the explanation of actiities, procedures and/or tasks the PA is authorized to perform.
Provide additional background information (e.g. delegation of controlled acts)
c) Authorized Professionals
PAs who are working in the division of [department] who are certified under the Physician Assistant Certification Council of Canada (PACCC) or the National Certification Council of Physician Assistants (NCCPA), and have successfully completed an accredited PA program
The PA works under the supervision of a registered physician.
Authorized by:
[insert appropriate councils and committees]
d) Indications:
This medical directive applies to [insert patient deogramophic] referred to admitted to [insert service name]
If applicable, you can add other clinical indications
e) Contraindications
[insert contraindications (e.g. consent was not obtained)]
f) Description of Process
Describe the process or mechanism that the PA will implement this medical directive.
Guidelines for seeking consultation or collaboration with the supervising physician or other health care providers (e.g. pharmacist)
g) Communication and Required Documentation
This outlines how the PA will document the implementation of the medical directive in the patient’s health record.
Communication protocols for regular collaboration and consultation with the supervising physician
h) Appendices (optional)
Sample forms for documentation or reporting
Reference materials, guidelines, or protocols supporting the medical directive
You can also attach documents, tables, images (e.g. an example prescription of what a medication prescribed by a PA would look like).
i) References
Can include references such as:
Canadian Association of Physician Assistants, Scope of Practice and National Competency Profile, 2009
College of Physicians and Surgeons of Ontario (2004). Policy#4-03: Delegation of Controlled Acts. Toronto, Ontario: Author.
Regulated Health Professions Act, 1991
j) Approvals:
Physician Approvals: should include supervising physicians (name, program, signature and dates) that PAs will be working with
Administrative Approvals (if applicable): more applicable to hospital settings, but this includes directors/managers of surgical services, interprofessoinal practice, pharmacy and therapeutics committee, pharmacy, lab and diagnostic imaging and patient care services.
Final notes
Understanding the importance of medical directives, tailoring them to the PA's scope of practice, and addressing legal and ethical considerations are essential in supporting the PA's practice and promoting collaborative healthcare.
