The Role of Regional Health Authority Bylaws in the Expanded Authority of Health Care Practitioners
- Overview of Appointments and Privileges
Within Canada, bylaws at the local and regional levels govern the academic requirements, credentialing review process, and appointment of privileges for health professionals. There are 30 or more recognized health professions in Canada.1 This report will focus on three of these health professions: pharmacy, midwifery, and nursing. Many of these health professionals, who are overseen by these bylaws, have or will have the authority to administer or prescribe diagnostic tests and medication.
The purpose of this report is to provide information regarding local, regional, and provincial bylaws that include the processes of overseeing and governing the responsibilities of health professionals who have, or will have, the authority to administer and/or prescribe medications.
It is not intended that the findings of this Environmental Scan provide a comprehensive review of the topic. The results of this report are based on a limited literature search. This report is based on information found as of March 30, 2011.
The Regional Health Authorities’ (RHAs) bylaws enable the RHAs to oversee and manage the responsibilities and the processes that govern the academic requirements, credentialing review process, and approval of privileges. To understand how the RHA bylaws delineate the governance of these responsibilities and processes, the appointment procedure of the RHAs’ bylaws has been examined. These bylaws explain that the appointment procedure approves the initial, or reapplying, applicant’s privileges through a process that includes verifying academic requirements and credentials review. As the health authorities in different provinces use similar but distinct appointment processes, a brief overview of each appointment process is provided. This overview identifies the individuals, committees, and department heads involved in these appointment processes; the various timelines for each process; and how the processes differ between provinces.
This report will also provide a brief overview of the expansion of the scope of drug administration for health professionals. The expansion of scope is being negotiated at the provincial level, in collaboration with the credentialing colleges and associations. These college and association bylaws have been reviewed to see whether their bylaws are involved in the changes in drug administration for health professionals.
As seen in this examination of the RHAs’ bylaws in Canada, the bylaws’ processes are similar but have distinct variations between committees, in process for accepting applications, and in time frame for completing the process for an application. It is important to note that there are great variations between provinces in terms of which health professionals are covered in these regional and local bylaws:
- British Columbia bylaws include physicians, dentists, midwives, and nurse practitioners2
- Alberta bylaws include community physicians, dentists, oral and maxillofacial surgeons, and podiatrists3
- Saskatchewan bylaws include physicians, dentists, chiropractors, and midwives4
- Manitoba bylaws include physicians, dentists, midwives, psychologists, scientists, clinical assistants, and trainees5,6
- Ontario hospital bylaws include physicians, dentists, midwives, and extended class nurses7-9
- Nova Scotia bylaws include only physicians and dentists (the IWK Health Centre adds scientists)10,11
- Prince Edward Island (PEI) bylaws include physicians, dentists, and nurse practitioners12,13
- Newfoundland and Labrador’s model bylaws and Eastern Health bylaws include physicians, dentists, and chiropractors.14,15
The provinces have differences in regional health structures, with Alberta and PEI having one central RHA and Ontario having the Local Health Integration Networks and legislation that requires the hospitals to have the bylaw requirements that in other provinces are covered by the RHA bylaws.
The credentialing and medical advisory committees (MACs) have some significant variations in scope. For example, the City of London, Ontario, has a City-Wide Credentials Committee and the Fraser Health Authority has a Health Authority Medical Advisory Committee (HAMAC) Credentials and Privileges Committee;2 the District Health Authorities of Nova Scotia have one MAC for all nine District Health Authorities (while IWK Health Centre has its own MAC); PEI has a local MAC and a provincial MAC; and the other provinces have a MAC for each individual RHA.5,8-12
Newfoundland and Labrador’s model bylaws and its Eastern Health bylaw Credentials Committees are part of their MACs, as opposed to being separate bodies.14,15 Another difference pertains to whether applicants are allowed at the board meeting where the final decision on appointment and privileging is made. PEI and Saskatchewan allow the applicant to be present; Manitoba, Nova Scotia, British Columbia, Ontario, and Alberta communicate the decision of the board in writing without the applicant’s presence at a board meeting.4,6,11,12
A legislative difference is that many provinces’ bylaws are required by their Regulated Health Profession Acts, while Nova Scotia’s bylaws are found as regulations attached to the Hospital Act.11,16 Some of the bylaws cover employees, non-employees, and independent contractors working for the RHAs; this shows that RHA bylaws can guide and set provisions of work for health professionals who are employees or not direct employees of the RHAs.7,11
The only reference to the scope of drug administration is found in the Ontario hospital bylaws. These bylaws have extended the privilege to prescribe drugs to outpatients to class nurses (and midwives at the Cambridge Memorial Hospital).7-9 These bylaws, which include the privilege to prescribe, do not expand on this privilege or whether the scope of drug administration is expanding for health professionals. None of the RHAs or Ontario hospital bylaws include pharmacists as a health professional; midwives and extended class nurses or nurse practitioners are not represented in many of these regional and local bylaws.
In Ontario, the RHAs are the Local Health Integration Networks (LHINs); the LHINs’ bylaws pertain only to the governance of the 14 LHIN boards and not to the credentialing, appointing, and granting of privileges to health professionals.17-20 Legislatively, it is the hospitals that are given the mandate to have bylaws to appoint and grant privileges through the Ontario Public Hospital Act. These bylaws are mandated by Regulation 965 of the Public Hospital Act, which states that both the assessment of new appointments and their credentials must be delineated in individual hospitals’ bylaws.21 The Ontario Hospital Association has developed prototype bylaws as a guide to assist hospitals in their bylaw development.22 The Ontario hospital bylaws enable the hospitals to oversee and manage the responsibilities and processes they use to govern the appointment process, which includes verification of academic requirements, credentialing review, and approval of privileges. See Appendix A for details of Ontario hospital bylaws for the Cambridge Memorial Hospital, London Health Services, and Hamilton Health Services.
British Columbia has six regional health authorities, one of them being the Provincial Health Services Authority (PHSA).23 The PHSA is involved in the credentialing and privileging process of medical, dental, and midwifery staff. In a 2005 Consolidated Constitution, the PHSA outlined bylaws affirming that the PHSA board will “promulgate medical staff bylaws…of medical, dental and midwifery staff and [they] shall be bound by…these bylaws.”24 The PHSA has medical staff bylaws that show PHSA’s medical affairs are “responsible for coordinating the credentialing and privileging process in all medical, dental, midwifery…appointments to the PHSA.”25
It has been noted that PHSA bylaws are consistent with other regional health bylaws, in that they do not provide the credentialing itself but coordinate the process of verifying credentials in order to complete the privileging process.
The 2010 Fraser Health Authority (FHA) Medical Staff Bylaws cover physicians, dentists, midwives, and nurse practitioners. These bylaws show that the FHA has a HAMAC and a HAMAC Credentials and Privileges Committee. The process of appointment, credentialing, and privileging is laid out below. The applicant must make a complete application. The Chief Executive Officer (CEO) will receive and refer the completed application to the Credentials and Privileges Committee, which will investigate the application and report within 60 days to the HAMAC; the HAMAC will forward its recommendations regarding the application to the board. The board will make a decision and notify both the applicant and the medical staff within 120 days of the application’s receipt by the CEO. Unlike most bylaws of regional health authorities, the FHA bylaws address the privileges of the members of the FHA medical staff at length. These privileges are to practice according to their health profession in the facilities and programs of the FHA. The privileges “describe the extent of clinical practice of an individual Member based on the Member’s credentials, competence, performance and professional suitability” and describe the “extent and scope of the permitted clinical practice of a Member.”2 The Interior Health Authority 2004 Medical Staff Bylaws are similar regarding appointment process, having the same time allocations and committees as the FHA.26
In Saskatchewan, the RHAs are mandated by the Minister of Health to make their bylaws available to the public; the Minister of Health has provided RHA and medical staff bylaw models.28-30 The model bylaws are from 2010 and include midwives and nurse practitioners. However, the 2008 RHA bylaws of the Saskatoon RHA include only midwives as health professionals, along with physicians, dentists, and chiropractors.
The 2008 bylaws detail the appointment and privileging process. Similar to Ontario Hospital bylaws, the Saskatoon bylaws outline the applicant’s requirements for appointment application; midwives have to provide registration or proof of eligibility to be registered with the Saskatchewan College of Midwives. Upon completing the application, the applicant sends it to the senior medical officer. The senior medical officer, if it is in his/her opinion that the applicant meets the required criteria, will send the completed application to the Credentials Committee for consideration and recommendation. The Credentials Committee will evaluate the application and the information submitted, consider the advice of the department or program head, and possibly interview the applicant. The Credentials Committee will make a recommendation to the Practitioner Advisory Committee to accept, accept on modified conditions, or reject the application. With these recommendations, the Practitioner Advisory Committee will recommend to the Saskatoon RHA board to either accept or reject the application. At least 14 days before the board meeting, the applicant will be notified in writing and can come to the meeting, thus having the right to appear personally in front of the board. The board will make the final decision in the appointment process.
These bylaws govern the responsibilities of the practitioner staff; responsibilities are to the RHA and include provision of quality care and services that focus on satisfying the need of the patient and meeting standards of licensing bodies and national clinical societies that include “competence, accessibility, acceptability, effectiveness, appropriateness, efficiency, affordability and safety.” The practitioner is also responsible for promoting evidenced-based clinical practice and mission fulfillment of the RHA according to its strategic plan.4
In Manitoba, the RHAs are mandated by the Regional Health Authorities Act31 to have bylaws. This report refers to the 2000 Brandon RHA bylaws and the 2005 Winnipeg RHA bylaws, as they were the only bylaws that were accessible.
The 2000 Parkland Regional Health Authority Bylaws were found online but not through the RHA website, making it difficult to ascertain if these bylaws are still in effect or if they have been superseded by more current bylaws. Of these three bylaws, the Parkland RHA bylaw refers only to board governance;32 the Brandon RHA and Winnipeg RHA bylaws make reference to the appointment and privileging of medical staff. These bylaws include physicians, dentists, scientists, and midwives; nurses and pharmacists are not mentioned. The Brandon RHA bylaw has a MAC that assists the RHA in the appointment process for its medical staff. The procedure for accepting a new applicant as a staff member is similar to but not as detailed as the Saskatoon RHA bylaw. The applicant must complete and submit the application to the CEO or designate, who will forward it to the Credentials Committee; in 30 days, this committee will contact references and the credentialing college, interview the applicant, and forward its recommendations to the MAC. Within 60 days, the MAC will recommend to the Board to accept the application, accept the application with modified terms, or reject the application. The Brandon RHA bylaws detail the midwives’ privileges by referring them to the established standards of the College of Midwives of Manitoba.5
The 2005 Winnipeg RHA bylaws, like the FHA, has a Medical Affairs Office to coordinate the applicant’s appointment and privileging process. They also have a Medical Executive Committee (MEC), which is similar to the medical advisory committees of other provinces’ RHAs. The Winnipeg RHA has a Selection Committee that has 45 days to investigate the application and interview the applicant. The Selection Committee then sends its recommendation to the Clinical Program Appointments Committee, which has 45 days to investigate and forward its written recommendation to the MEC. The MEC has 30 days to review and produce a written recommendation to the board. The board will consider the recommendations and application and will decide to grant, not grant, or grant with modifications the application.6
In Nova Scotia, very few current bylaws for the individual district health authorities were found; a bylaw from 2001, for the Annapolis Valley District Health Authority,33 and bylaws from 2004, for the Capital Health District Authority, were found.34 The most current bylaws, for the district health authorities, are found in the Nova Scotia provincial government regulations and have been in effect since 2007.35 These bylaws are regulations of the Hospitals Act, R.S.N.S. 1989, c. 208.11 The regulations of the Nova Scotia Hospital Act include these three bylaws:
• District Health Authorities Medical Staff (Disciplinary) Bylaws, N.S. Reg. 289/2007
• Medical, Dental and Scientific Staff Bylaws (Credentialing/Disciplinary) for the IWK Health Centre, N.S. Reg. 306/2007
• Medical, Dental and Scientific Staff Bylaws (General) for the IWK Health Centre, N.S. Reg. 305/200710
The District Health Authorities Medical Staff (Disciplinary) Bylaws include instructions on the process of appointment, credentialing, and approval of privileges, but do not encompass health professionals other than physicians and dentists. The processes are similar to other provinces’ RHA bylaws. The medical staff applicant applies to the CEO or delegate, providing proof of registration with the credentialing college and having malpractice insurance. Within four days, the CEO gives the application to the District Chief of Staff who, with the District Department Chief, determines whether the health professional is needed; the two district chiefs write and forward a written report on the application to the CEO within 60 days. If a position is open, the application is sent to the Chair of the Credentials Committee. The Credentials Committee will do the necessary investigations, including having a discussion with the applicant, and will forward its written recommendation within 60 days, with the application and recommendations, to the Chair of the District MAC. If the recommendation of the Credentials Committee is in agreement with the application, then the District MAC will review the documentation, provide a written recommendation, and forward it to the board. The board considers the District MAC’s recommendation and makes a decision that is final and is to be communicated to the applicant and District Department Chief within 10 days of the decision. These bylaws also mention a Privileges Review Committee (PRC), which is used to mediate reappointments when the party is in disagreement or mutually decides to refer it to the PRC; or if the District MAC refers it to the PRC, the PRC will come to a proposed agreement for the two parties.
Nova Scotia also has the IWK Health Centre, a health centre for the birth and care of children, which is mentioned in relation to the nine District Health Authorities.36 The Medical, Dental and Scientific Staff Bylaws (General) for the IWK Health Centre deal with the governance of its board and the responsibilities of the leadership of IWK Health Centre and board.11 The IWK Health Centre Medical, Dental and Scientific Staff Bylaws (Credentialing/Disciplinary) do not include health practitioners outside of physicians, dentists, and scientists; these bylaws oversee the credentialing, appointment, and disciplinary processes.37
The bylaws show that the IWK Health Centre has its own Credentials Committee, PRC, and MAC. The bylaws for the IWK Health Centre specify that the CEO will investigate if there is a need and resources for additional staff; from this investigation, the CEO will make a decision to allow or not allow the potential applicant to apply. The CEO’s decision is final and, if the answer is negative, it will be communicated to the applicant and the process of appointment will end. If the answer is positive, the individual will be given the application package. Five days from receipt of the completed application, the CEO will give the application to the Vice-President Medicine, who has five days to give the application to the Credentials Committee. The Credentials Committee then has 45 days to investigate the application and applicant before sending its recommendation to the MAC. The MAC has 25 days to make its recommendation and inform the appropriate Department Chief of the recommendation (to accept, change, or have at variance). If it is at variance, the PRC will, within five days, receive the MAC’s recommendation and have 20 days to review the matter. The decision of the PRC will be final. Once the appointment is obtained, the reception of privileges is also obtained, as per the bylaws and the terms of their appointment.37
Newfoundland and Labrador
In Newfoundland and Labrador, model bylaws were created in 2007 to help the RHAs create their own bylaws; the Newfoundland RHAs were established in 2006.38 The model bylaws suggest that the Vice-President Medical Services receive the applicant’s application (the applicant having 60 days to fulfill the application’s requirements), review the application, and, if complete, send the application to the Credentials Committee of the MAC. The Credentials Committee will do its investigations and then report to the MAC. The MAC is also called the Local MAC in these model bylaws. The Local MAC recommendation is sent to the Vice-President Medical Services who, if the recommendation is positive, sends the application and recommendations, with his or her own additional comments, to the CEO. The CEO, in consultation with the Vice-President Medical Services, will make the final decision. Within 30 days this decision will be communicated in writing to the applicant, the MAC, and the Vice-President Medical Services.14,15
These draft bylaws have been used to create, in 2009, the Eastern Health Integrated Health Authority’s Eastern Health Bylaws Respecting Medical Staff. These bylaws are virtually identical to the model bylaws, except that the “Local MAC” in the Eastern Health bylaws appears to be the main committee involved in the appointment process. The Eastern Health bylaws have an additional step, in that the Vice-President of Medical Services forwards the application to the relevant clinical chief and discipline chair (where applicable), who will send the completed application to the Credentials Committee. In the Eastern Health bylaws, it is the Vice-President of Medical Services who decides, without the CEO’s involvement, whether the application fails and has 90 days to report the decision to the applicant. The rest of the appointment process of the 2009 bylaws matches the model bylaws.14,15
In New Brunswick, there are currently interim bylaws in place for the two RHAs.39 These bylaws relate to the credentialing and granting privileges of physicians, dentists, and affiliated scientists.
Prince Edward Island
PEI has one RHA called Health PEI, which recently published its 2011 Medical Staff Bylaws. These bylaws have appointment procedures that begin with the applicant’s completed application being given to the Executive Director of Medical Affairs, who will forward it to the appropriate Department or Program Head for evaluation. The Department or Program Head then sends it to the Local MAC, which makes its recommendation and sends the application back to the Executive Director of Medical Affairs. The Executive Director then sends it to the Provincial MAC, which will give its recommendation to the board. The applicant will be informed in writing of the board’s meeting, where the application will be discussed; the applicant is allowed to be present at this meeting. The board makes a decision, which is sent to the applicant within 30 days.12,13
Provincial legislated Acts are used to change the scope of drug administration within Canada. This section of the report will briefly examine recent legislated changes for the scope of drug administration, and which colleges and associations are involved in creating these changes. In Ontario, the Ontario government passed Bill 179 (May 2009),40 which is now an official Act, the Regulated Health Professions Statute Law Amendment Act, 2009, and governs drug administration practices.16,41 The Ontario Ministry of Health and Long-Term Care has affirmed that this Act will allow specified health professionals to provide more services and changes to the rules for drug administration for nurse practitioners, pharmacists, and midwives. The Ontario Ministry of Health and Long-Term Care also affirms that this Act removes the restrictions on which drugs nurse practitioners can “prescribe, dispense, compound and sell.”42 This Act is significant as it will affect who in the RHAs is responsible for drug administration; this can affect the RHA bylaws that govern the appointing of these health professionals. The credentialing colleges or associations are often directly involved in the process of making legislative changes in Health Acts within the individual provinces.43 A clear example of this is the Midwifery Regulatory Bylaws, which are published by the government of Saskatchewan but are authored and certified by the Saskatchewan College of Midwifery.44
For midwives, their regulator is often the credentialing College of Midwives for the province.45 The national Canadian Association of Midwives affirms that “Midwifery regulators in some provinces are currently engaged in scope of practice reviews to amend drug schedules and expand on the authorized acts that midwives may perform.”45 A scan of the bylaws of the midwifery colleges found that these bylaws do not speak to the expansion of scope in drug administration for midwives.44,46-49 The Ontario College of Midwives has information on the expansion of scope of drug administration outside of its bylaws.50 The Midwifery Regulatory Council of Nova Scotia has provided guidelines for prescribing, ordering, and administering drugs, but does not have bylaws regarding drug administration.51
For pharmacists, there are recent legislative changes that will have a direct impact on the creation of future bylaws. In 2009, the British Columbia Health Services announced that pharmacists are now able to renew prescriptions, change the dosage, or substitute drugs “where appropriate.”52 The legislation that supports this change is the Health Professions (Regulatory Reform) Amendment Act, 2008.52
The Alberta (provincial) Health and Wellness department is increasing the scope of pharmacists to be able to counsel patients and other health care providers on optimum drug therapy.53 New legislative changes to Saskatchewan’s Pharmacy Act, slated to be in force by summer 2011, will be expanding the scope of pharmacists in the province.54 The Saskatchewan government has announced that as of March 2011, pharmacists can extend refills on medications and provide emergency supplies of prescribed medicine.43 These changes will affect the bylaws pertaining to the drug administration scope within Saskatchewan. These bylaws include amendments to the Saskatchewan College of Pharmacists' bylaws that will authorize pharmacists to extend refills on existing prescriptions, provide emergency supplies of prescriptions, and “in the near future to prescribe certain medications for minor ailments.”55 In Manitoba, Bill 41 came into effect in 2010, as the Pharmaceutical Act.56 This Act permits “qualified pharmacists to prescribe and administer certain medications, to order certain laboratory tests, and to obtain qualifications of specialty practice.”57,58 The bylaws of the Ontario College of Pharmacists pertained only to the governance of the college and the code of conduct.59,60 However, the Ontario College of Pharmacists has information on the recent changes in the Ontario government regarding the expansion of the scope of drug administration. The Ontario College of Pharmacists affirms that it is its regulations that have become legislated under both the Drug and Pharmacies Regulation Act and the Pharmacy Act (advertising). Pharmacists who practice in accredited pharmacies can now refill existing prescriptions “under specified conditions without further authorization from a prescriber, excluding those for narcotic or controlled drugs.”61Nurse practitioners
For nurse practitioners, there are reports on the expansion of the scope of drug administration,62,63 but Canadian nursing college bylaws for Ontario, British Columbia, and Alberta do not reference this expansion.64-66
The authority of health practitioners, especially midwives, pharmacists, and nurse practitioners, is being expanded through the efforts of the credentialing colleges and professional associations. These colleges and associations are directly involved in the legislative regulation processes for the expanded authority of drug administration for health care practitioners in the RHAs in Canada. The bylaws of the RHAs will be affected by these changes, as more health professionals will need to be covered by these bylaws. Examples of this have been noted in Ontario and British Columbia bylaws that include midwives and extended nurse practitioners, the Manitoba and Saskatchewan bylaws that include midwives, and in the Prince Edward Island bylaws that include nurse practitioners. The appointment process to credential and grant privileges will then incorporate an expanded authority of drug administration that is given to a larger group of health professionals, as opposed to the authority for drug administration being limited to physicians and surgeons.
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15. Eastern Health Bylaws Respecting Medical Staff [Internet]. St. John's, NL: NLMA Newfoundland and Labrador Medical Association; 2009. [cited 2011 Mar 30]. Available from: http://www.nlma.nf.ca/documents/medical_staff_bylaws/medical_staff_bylaws_5.pdf
16. An act to amend various acts related to regulated health professions and certain other acts [Internet]. Toronto: Queen's Printer of Ontario; 2009 Dec. [cited 2011 Mar 30]. Available from: http://www.e-laws.gov.on.ca/html/source/statutes/english/2009/elaws_src_s09026_e.htm
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35. District health authorities medical staff (disciplinary) by-laws [Internet]. Halifax: Province of Nova Scotia; 2007 May 1. [cited 2011 Mar 30]. Available from: http://www.gov.ns.ca/just/regulations/regs/HA-DHAbylaws.htm
36. [Internet]. Halifax: Province of Nova Scotia. Nova Scotia District Health Authorities; 2010 Oct 13 [cited 2011 Mar 30]. Available from: http://www.gov.ns.ca/health/about/dha.asp
37. Province of Nova Scotia. Medical, dental and scientific staff bylaws (credentialing/disciplinary) for the IWK Health Centre, N.S. Reg. 306/2007 [Internet]. Ottawa: Canadian Legal Information Institute; 2007 Jun 12. [cited 2011 Mar 30]. Available from: http://www.canlii.org/en/ns/laws/regu/ns-reg-306-2007/latest/ns-reg-306-2007.html
38. Statutes of Newfoundland and Labrador 2006 [Internet].2006 May 26. Chapter R-7.1: An act respecting the delivery of health and community services and the establishment of regional health authorities. [cited 2011 Mar 30]. Available from: http://www.assembly.nl.ca/legislation/sr/annualstatutes/2006/r07-1.c06.htm
39. Regional health authority interim bylaws [Internet]. Bathurst, NB: Vitalité Health Network; 2008. [cited 2011 Mar 30]. Available from: http://www.santevitalitehealth.ca/pdf/Reglements_RRSA_EN.pdf
40. Bill 179 An act to amend various acts related to regulated health professions and certain other acts [Internet]. In: Legislative Assembly of Ontario Parliament 39: 1 (2007-11-28 – 2010-03-04). Toronto: The Legislative Assembly of Ontario; 2009 [cited 2011 Mar 31]. Available from: http://www.ontla.on.ca/bills/bills-files/39_Parliament/Session1/b179.pdf .
41. An act to amend the regulated health professions act, 1991 [Internet]. In: Statutes of Ontario. Toronto: Legislative Assembly of Ontario; 2009 [cited 2011 Mar 31]. Available from: http://www.ontla.on.ca/bills/bills-files/39_Parliament/Session1/b141ra.pdf Chapter 6 Statutes of Ontario, 2009.
42. Ministry of Health and Long-Term Care. New law increases access to health care: health care worker bill gets legislative green light [Internet]. Toronto: Queen's Printer for Ontario; 2009 Dec 1. [cited 2011 Mar 31]. Available from: http://www.health.gov.on.ca/en/news/release/2009/dec/nr_20091201.pdf
43. Estevan Mercury [Internet]. Estevan, SK: Glacier Media; 31/03/2011. Gov't announces pharmacy changes; 2011 Mar 15 [cited 2011 Mar 31]. Available from: http://www.estevanmercury.ca/article/20110315/ESTMERCURY0101/110309874/-1/ESTMERCURY/
44. Saskatchewan College of Midwifery. The Midwifery Regulatory Bylaws [Internet]. Regina, SK: Queen's Printer of Saskatchewan; 2008 Apr 4. [cited 2011 Mar 31]. Available from: http://www.qp.gov.sk.ca/documents/bylaws/SCM/April4,2008.pdf
45. Midwifery regulation in Canada [Internet]. Montreal: Canadian Association of Midwives; 2010. [cited 2011 Mar 31]. Available from: http://www.canadianmidwives.org/DATA/DOCUMENT/FACT_SHEET_Regulation_updatedApril2010.pdf Canadian Association of Midwives Fact Sheet updated April 2010.
46. College of Midwives of Ontario by-laws [Internet]. Toronto: College of Midwives of Ontario; 2010. [cited 2011 Mar 31]. Available from: http://www.cmo.on.ca/member_area/documents/J01-CMOBy-laws_June2010_revMAY2010.pdf June 2009 revised May 2010.
47. Bylaws for College of Midwives of British Columbia [Internet]. Vancouver: College of Midwives of British Columbia; 2006 Mar 2. [cited 2011 Mar 31]. Available from: http://www.cmbc.bc.ca/pdf.shtml?Registrants-Handbook-04-02-Bylaws-of-the-CMBC-Complete Date approved by the board: December 16, 1996 Consolidated: April 3, 1997 Amended effective: March 2, 2006.
48. College of Midwives of Manitoba by-law no. 1 [Internet]. Winnipeg Manitoba: College of Midwives of Manitoba; 2000 Dec. [cited 2011 Mar 31]. Available from: http://www.midwives.mb.ca/docs/cmm-by-laws-2011.pdf December 2000 as amended January 28, 2010.
49. Midwifery administrative bylaws [Internet]. Regina, SK: Saskatchewan College of Midwives; 2007 May 10. [cited 2011 Mar 31]. Available from: http://www.saskmidwives.ca/assets/File/midwives_admin_bylaws.pdf
50. Frequently asked questions: about the midwifery designated drugs regulation (O.Reg. 884/93) [Internet]. Toronto: College of Midwives of Ontario; [cited 2011 Mar 31]. Available from: http://www.cmo.on.ca/member_area/documents/FrequentlyAskedQuestions-MidwiferyDesignatedDrugsRegulation.pdf
51. Guidelines for prescribing, ordering and administering drugs [Internet].Midwifery regulatory council of Nova Scotia; 2009 Apr 8. [cited 2011 Mar 31]. Available from: http://mrcns.ca/images/uploads/Guidelines_for_prescribing_ordering_and_administerng_drugs17-4-09.pdf
52. BC Ministry of Health Services. News release: most routine prescriptions now easier to renew [Internet].Ministry of Health Services; 2009 Jan 1. [cited 2011 Mar 31]. Available from: http://www.bcpharmacists.org/library/A-About_Us/A-8_Key_Initiatives/MOH-News_Release-2008HSERV0120-001939.pdf
53. Alberta Pharmaceutical Strategy [Internet]. Edmonton, AB: Alberta Health and Wellness; [cited 2011 Mar 31]. Available from: http://www.health.alberta.ca/initiatives/pharmaceutical-strategy.html
54. CBC News [Internet]. 2011. Toronto: Canadian Broadcasting Corporation. Sask. pharmacists to get dose of prescribing power; 2010 Mar 3 [cited 2011 Mar 31]. Available from: http://www.cbc.ca/news/canada/saskatchewan/story/2010/03/03/sk-pharmacists-powers-expanded.html
55. News release - improving access to health care by enhancing pharmacists' prescribing authority [Internet].Government of Saskatchewan; 2011 Mar 2. [cited 2011 Mar 31]. Available from: http://www.mypharmacistknows.com/site/wp-content/uploads/2011/03/March-2nd-News-Release.pdf
56. Legislative Assembly of Manitoba. Pharmaceutical Act, C.C.S.M. c. P60 [Internet]. In: Ottawa: Canadian Legal Information Institute (CanLII); [cited 2011 Mar 31]. Available from: http://www.canlii.org/en/mb/laws/stat/ccsm-c-p60/latest/ccsm-c-p60.html Current version in force since 17 Jun 2010; website last updated 25 Mar 2011.
57. Hospital pharmacists support bill 41 [Internet]. Winnipeg, MB: Canadian Society of Hospital Pharmacists, Manitoba Branch; 2006 Nov 3. [cited 2011 Mar 31]. Available from: http://www.cshp.ca/dms/dmsView/1_Manitoba%27s-Hospital-Pharmacists-Support-Bill-41-Branch-Ltr.pdf
58. Bill 41 - regulations pharmacist prescribing position statement [Internet]. Winnipeg: Manitoba Society of Pharmacists; 2008 Dec 9. [cited 2011 Mar 31]. Available from: http://www.msp.mb.ca/PDF/PS-PharmacistsPrescribing.pdf
59. Ontario College of Pharmacists - by-law no. 2: a by-law relating generally to the conduct of the affairs of the Ontario College of Pharmacists [Internet]. Toronto: Ontario College of Pharmacists; 2010 Dec. [cited 2011 Mar 31]. Available from: http://www.ocpinfo.com/Client/ocp/OCPHome.nsf/object/By_Law_2/$file/By-Law_No2_2010.pdf
60. Schedule A - code of ethics for members of the Ontario College of Pharmacists [Internet]. Toronto: Ontario College of Pharmacists; [cited 2011 Mar 31]. Available from: http://www.ocpinfo.com/Client/ocp/OCPHome.nsf/object/Sched_A_B/$file/Schedule+A+-+B.pdf Effective: December 2006.
61. Advisory notice - to all members/pharmacy operators - new regulation under the drpa [Internet]. Toronto: Ontario College of Pharmacists; 2011 Mar 15. [cited 2011 Mar 31]. Available from: http://www.ocpinfo.com/client/ocp/OCPHome.nsf/web/Notice+-+new_dpra_reg
62. A report to the Minister of Health and Long-Term Care on the review of the scope of practice for registered nurses in the extended class. Toronto: Health Professions Regulatory Advisory Council (HPRAC); 2008. [cited 2011 Mar 31]. Available from: http://www.hprac.org/en/reports/resources/HPRACExtendedClassNurseReportENGMar08.pdf
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Appendix A: Hospital Bylaws in Ontario
Cambridge Memorial Hospital, Ontario
The 2010 Cambridge Memorial Hospital Bylaws professional staff designation includes midwives and extended class nurses; pharmacists are not mentioned. To begin the appointment process of a new professional staff member, the individual applying for a position at the hospital must provide:
- A certificate of registration and a certificate/letter of professional conduct or letter of standing from either the College of Midwives of Ontario or the College of Nurses of Ontario
- Signed consent form for the credentialing college to provide any reports on the individual
- Report from last hospital they practiced or were trained in
- Recital and description of any complaints or reports regarding discipline or professional misconduct
- Evidence of individual liability insurance
- Consent to a criminal record check.
This list for the application package has been found to be a standard requirement in all the bylaws for the appointment process of all regional health authorities (RHAs) and will not be repeated in this report.
The Cambridge Memorial Hospital Bylaws state that the Credentials Committee reviews and makes written recommendations to the hospital’s Medical Advisory Committee (MAC). The MAC reviews the individual’s application and report from the Credentials Committee and makes its recommendation, within 60 days of the receipt of the application, to the CEO or president of the hospital. The board makes the final recommendation based on the Credential Committee and MAC reports. The Cambridge Memorial Hospital Bylaws specify the privileges for physicians, dentists, and midwives. In Section 1.1 (y), the extended class nurses are granted the privileges to “diagnose, prescribe for or treat out-patients.”7
London Health Services, Ontario
The 2010 London Health Services bylaws stipulate a city-wide credentialing committee. Its procedure for appointing professional staff is as follows. The CEO or delegate, upon receipt of the application, will refer the application to the Chief of the Department, who will make a recommendation to the City-Wide Credentials Committee. The City-Wide Credentials Committee investigates the application, qualifications, and experience of the applicant. It will write a report to the hospital MAC with the recommendation of the Department Chief; the MAC will review the application according to sections 2.02 and 2.03 of its bylaw. The MAC will then write its report for the London Health Services Board.8 In the London Health Science Centre and 2009 Hamilton Health Services bylaws, the extended class nursing staff is “authorized to prescribe for…out-patients in the Hospital.”8,9 The same bylaws delineate the necessity of midwifery staff to have current and valid registration with the College of Midwives of Ontario. The Cambridge Memorial Hospital Bylaws allow both the midwifery staff and extended class nursing staff to “prescribe for…outpatients” and state that midwives need to be “a member in good standing” with the College of Midwives of Ontario.7 To be registered with the college that provides the credentials (which a credentialing committee reviews) demonstrates that the academic requirements are also met, as registering with the college is only possible if the academic requirements have been completed. The academic requirements are thus covered in each bylaw by verifying the credentials that are provided by the individual health profession’s college.
Cite as: Roosien, E and Morrison, A. The Role of Regional Health Authority Bylaws in the Expanded Authority of Health Care Practitioners [Environmental Scan issue 29]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2010.
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