This issue of ex.press offers you important new information on the following to assist you to better serve your patients as a self-regulated health professional, including:
In addition, under “Changes Affecting Registrants”, you will find news about:
You can also learn about how you can work with the College – CASLPO is recruiting for positions! Learn more about this and other key topics in this issue.
In support of marking CASLPO’s 25th Anniversary, two organizations who advocate on behalf of Ontario patients with communication disorders*, were each recognized by receiving a grant of $2500.00.
We had the pleasure of presenting the grants to the two following recipients, on June 6, 2019:
Canadian Hard of Hearing Association (CHHA), who advocate on behalf of their members to improve awareness and legislation that impacts issues for those with hearing loss. Christopher Sutton National Executive Director, and Jo DeLuzio, Board member, accepted the grant on behalf of CHHA.
Ontario Association for Families of Children with Communication Disorders (OAFCCD), who advocate on behalf of their members to improve awareness and legislation that impacts issues for families in Ontario with children that have communication disorders. Alison Morse, Provincial Coordinator and Susan Strachan, Co-Chair accepted the grant on behalf of OAFCDD.
*Recipients selected and awarded a grant met the following criteria:
Early this year, Council members were asked to put forward recommendations for professional members to receive recognition for their outstanding contributions to furthering the mission of the College.
We recently had the pleasure of honouring the service and achievements of two outstanding individuals who have helped to shape our work and influence our direction.
Presented to Bob Kroll, for dedicated and valued service as a Council member and President of Council. In recognition for outstanding contributions to furthering the mission of the college.
Bob served for a total of three terms as a professional member of Council from 2010-19. In June, 2017, Bob assumed the role of President of CASLPO Council. Bob has served on virtually every committee of Council, including the Executive. As President, Bob guided Council through ever-changing and challenging issues confronting the College but, these were exciting times as well, as the College increased its focus on patient awareness in support of Ontario’s ‘Patient First’ initiatives.
Whatever he took on, and no matter the circumstances, Bob always managed to guide Council effectively and constructively, maintaining personal and corporate standards of excellence.
Presented to Vicky Papaioannou, for dedicated and valued service as a professional member.
Vicky was honoured, as part of our 25th Anniversary recognition program. Vicky demonstrated professional excellence at all times and consistently showed a strong commitment to the public interest and the highest standards of ethical conduct as a member of Council, the Executive Committee and as President.
The important contributions Vicky has made on our many committees over the years and during her time as a Peer Assessor, and 3-year tenure as President, were formally recognized by CASLPO Council. Vicky’s knowledge base and professional insight was always sought after and impacted many Council decisions and programs over the years.
Director of Professional Conduct
By Carol Bock, Deputy Registrar
Preeya Singh, Director of Professional Conduct & General Counsel
Over the years, the College has received questions about how to apply and implement the proposed Conflict of Interest (“COI”) Regulation, 1996. Given the passage of time and the questions received, there was a recognized need to update the rules around COI to support audiologists and speech-language pathologists in daily practice.
After much consideration, on March 1, 2019 the Council approved the new COI Standards to replace the proposed COI Regulation. Consequently, the proposed Conflict of Interest Regulation, 1996, has been retired as of February 28, 2019. Here is a summary of the four new Standards:
1. Members must not provide a benefit to another person or agency, or receive a benefit, for a patient referral.
Why? Health care services and products must be recommended on the basis of patient needs and where possible must provide patient choice.
2. Members must manage/resolve unavoidable conflicts of interest appropriately.
Why? There may be situations in which an inherent conflict of interest may exist. You must recommend only those products and services which you feel are in the best interests of your patient. In addition, you must disclose and document the nature of conflict of interest to the patient.
3. Members must not enter into an employment agreement whereby they clinically supervise the person who employs them.
Why? Clinical objectivity would reasonably be compromised when you are evaluating the person who controls your employment.
4. Members must not enter into an agreement with any person or agency that limits the member’s ability to exercise their professional judgement to provide appropriate recommendations.
Why? Agreements that prohibit you from making recommendations that involve products or services that are beyond what the employer offers would compromise your professional judgement.
The new Standards were written to simplify and clarify the definitions, such as benefit and referrals. The language used is also intended to simplify the guidance around COI. Simplified language provides for more effective application to a variety of situations. We also know from the overwhelmingly positive consultation feedback from registrants that the Standards successfully speak to both Audiologists and Speech-Language Pathologists. It is expected that the new Standards will support audiologists and speech-language pathologists in safeguarding the trust patients place in professionals.
To watch the recent e-Forum discussing the new Standards, please click here.
You may not know it, but the College depends on you, our registrants, to help us do our job. That's why we have many registrants currently fulfilling many exciting roles. We want to encourage you to apply for these roles, too. In fact, the phrase, “the more the merrier”, reflects CASLPO’s approach when looking for people who can support our work to protect the public because “more” really means more diversity of viewpoints, experience and knowledge.
Although we have always had registrants serving many roles, including Non-Council Members, Peer Assessors, Focus Group Participants and Peer Coaches, we are seeing a growing interest from our registrants in giving back to the profession. In addition, we have recently developed a few new roles!
But don’t rely on our view, instead consider your peers’ views. When we asked registrants, who already work with the College, “What are the benefits?”, here’s what they told us:
By Brian O'Riordan, Registrar
On July 31, 2019, the Commissioner of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System, Justice Eillen Gillese, released her final report into the crimes of former nurse Elizabeth Wettlaufer in the murder of eight patients in her care in southwestern Ontario.
The report contained a large number of recommendations directed at the Ministry of Health, the College of Nurses of Ontario, long-term care homes and the Coroner’s office.
While the report does not contain any recommendations targeted directly at other regulatory health professional Colleges, there is much for Colleges to learn in terms of their own policies and procedures relating to the public safety of patients. CASLPO in the coming months will be reviewing carefully many of our own internal operations, to enhance our support to employers and registrants particularly in the area of mandatory reporting obligations by employers in the case of the termination of a registrant’s employment or, if they believe a registrant in their employ is incompetent or incapacitated. As well, we will be educating registrants further on their obligations for reporting to the College in the interest of patient safety. All Colleges will be focusing the attention of registrants on the possibility of intentional harm to patients being committed by health care providers and the phenomenon of health care provider serial killers.
CASLPO will be providing in the coming months, additional important educational materials to registrants, employers and others relating to the topics above.
We must together have “zero tolerance” for harm to patients, and must work in partnership to ensure that the public is provided at all times with safe and quality health care.
Learn more about Mandatory Reporting – Employers and Facilities.
For practice advice questions, visit the resource section on CASLPO’s website.
Director of Professional Practice and Quality Assurance
Advisor, Professional Practice and Quality Assurance
Alexandra Carling Ph.D.
Director of Professional Practice and Quality Assurance
Advisor, Professional Practice and Quality Assurance
Every time you have a consent conversation with a patient, you are, in fact, doing a capacity evaluation. In the consent conversation you are determining if the patient understands your assessment or treatment plan, the risks, benefits and alternatives. You are also determining if they appreciate the consequences of their decision to consent or refuse to consent. If you determine that the patient has capacity to consent to your assessment or treatment, and has consented, then you can proceed with your plan of care. Most consent conversations are straightforward when your patients have capacity.
These FAQs are directed towards more challenging aspects of evaluating capacity to consent to treatment such as fluctuating capacity, disagreement with your findings, patient refusal, age of consent, clarification between capacity evaluators and capacity assessors, as well as some tips on how to support communication and hearing barriers for decision making when needed.
These answers to the FAQs supplement the e-forum on Evaluating Capacity to Consent.
In the Health Care Consent Act 1996 (HCCA), capacity to consent to treatment is not determined by age. It is determined by the following:
4 (1) A person is capable with respect to a treatment, admission to or confining in a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment, admission, confining or personal assistance service, as the case may be, and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision. 2017, c. 25, Sched. 5, s. 56.
If the parent as the Substitute Decision Maker has provided consent for their child’s assessment or treatment, you do not need to have a consent conversation with the child. However, depending on the maturity of the child, you will include them in therapy activity choices to maximise participation.
If you believe that the child/youth can understand the assessment or treatment plan and can appreciate the consequences of their decision to participate, then you would obtain consent from the child/youth.
Question: In a school setting does a capacity review need to be initiated if I find the student to be capable of consenting but the parent doesn’t feel that their child has capacity to consent?
Answer: Capacity to consent to treatment is not determined by age rather by the person’s ability to understand and appreciate the consequences of their decision regarding the proposed treatment. If the student understands and appreciates why you are assessing or treating, including the nature, risks, benefits, consequences and alternatives of the services, then they have capacity to consent (refer to the Consent Tool for suggestions on what to discuss in the consent conversation).
Explain to the parents how the legislation defines capacity and share your evidence of the student’s capacity to consent, that they understand and appreciate. Be sensitive and respectful about the parents’ concerns regarding their child, but if you have the evidence that the child has capacity to consent or refuse consent, you should trust your professional judgement. If the issue remains contentious, consult colleagues or your manager, if you have one. Finally, you can call the Consent and Capacity Board for advice.
Question: Are there any resources on assessing consent/capacity with children?
Answer: If you decide to evaluate a child’s or youth’s capacity to consent, adapt your conversation to their level of understanding. Use the same strategies and resources as you would for your intervention (repetition, picture supports, key words, large font, verifying the information is understood). Document your findings including evidence of the child’s ability to understand and appreciate in detail in the patient/student record.
The Child, Youth and Family Services Act 2017 (CYFSA) states that every child and young person receiving services under this act has the following rights:
-To be engaged through an honest and respectful dialogue about how and why decisions affecting them are made and to have their views given due weight, in accordance with their age and maturity.
-To be informed, in language suitable to their understanding, of their rights.
CYFSA Part II, ss. 3(2) and (5)
a) I am concerned about a parent’s capacity to provide consent on behalf of their child. The child would clearly benefit from speech therapy. How do I deal with this situation?
b) Can you request a review of capacity to consent when the parent has cognitive delays?
Answer: The parent is the child’s substitute decision maker and, as such, must meet the following criteria:
In the instance where the parent has cognitive delays, if they can understand the information regarding the treatment decision and appreciate the likely results of making the decision, then they have capacity to consent on behalf of their child. It is your responsibility to assist them to understand the information and appreciate the consequences of their decision. If they do not understand and appreciate, even with your assistance, they do not have capacity to consent and you must seek out another SDM.
Parents will not always agree to audiology or SLP services, even when their child needs them. Parents as SDMs have the right to decline proposed services. If you have concerns about a parent’s capacity to consent on behalf of their child (the ability to understand and appreciate), then document your findings in detail and contact the Consent and Capacity Board for advice.
If you suspect neglect of the child, then consider making a mandatory report to Children’s Aid (Family and Children’s Services).
Question: I work in a hospital and the healthcare team is concerned about some patients’ capacity to consent to treatment and admission to long-term care because the patient’s capacity fluctuates according to the time of day you converse with them. What do we do in this situation?
Answer: You would find the best time for the patient when they are at their most alert, responsive and capable of participating in a consent conversation where you are determining if they have capacity. Check in with your team for updates on the patient’s medical status and ability to participate in consenting to treatment and intervention.
Remember, it is your responsibility to determine capacity, it’s not the patient’s responsibility to demonstrate capacity. You may need to return later when the responsiveness of the patient has improved.
If deterioration in the patient’s decision making is more permanent, then you may need to re-evaluate capacity to consent to treatment and/or admission to long-term care. You may need to consult with the patient’s substitute decision maker at this point. If the patient has a communication barrier, advocate to be involved with the capacity evaluation for admission to long-term care.
Question: I have a patient that I have determined has capacity regarding my proposed treatment and wants to replace her lost hearing aid. (such as Mrs. Kumar in the e-Forum). What do I do when a family member calls and says she is unable to understand decisions and they want to cancel the order?
Answer: You may want to start by exploring with the family member why they want to cancel the hearing aid order. However, if you were satisfied that the patient had capacity at the time of the assessment and understood and appreciated the likely results of making the health care decision such as ordering a new hearing aid, then you should share your determination of capacity to the family. In your discussions you may want to explain why a replacement hearing aid would be beneficial. If the family reports a significant change in the patient’s functioning, you may want to re-evaluate her capacity to consent to the hearing aid purchase.
Question: Can you elaborate more on evaluating the appreciation of consequences of decision for swallowing assessments and treatment? I am especially interested when patients have a communication barrier.
Answer: With respect to treatment decisions, you can determine that a person is able to appreciate the consequences of their decision as long as they are able to:
1. Realistically evaluate their current condition or situation.
“I’ve had a stroke and now I can’t swallow properly”
2. Apply relevant information to their own circumstances.
“I am choking on my food and it keeps getting stuck in my throat”
3. Weigh risks and benefits of the available options
“Pureed and soft and moist foods are easier to swallow and will reduce my coughing and choking. It will help if I take smaller bites and sips”.
4. Demonstrate that they have considered the consequences of their choice.
“I understand that if I eat hard, tough, chewy, dry food like toast or steak, it might go down the wrong way making me cough, choke, and may lead to a chest infection or pneumonia.”
As audiologists and SLPs, you have a unique and specialised training in communication. When evaluating capacity, you are going to provide your patient with every opportunity to use their most effective mode of communication, and consider any type of sensory loss (hearing, vision, speech etc.) or additional confounding issues such as fatigue, alertness, medical condition, delirium, mental health concerns.
When determining if a patient can appreciate the reasonably foreseeable consequences of a decision, it is important to verify the information they communicate. Ask questions which require a positive answer, then verify with a question requiring a negative response.
Selecting and writing key words, using simple language and avoiding jargon, hearing amplification, visual magnifiers, drawing and picture supports (Boardmaker, visual schedules, Aphasia Institute ParticiPics, Communication Aid to Capacity Evaluation (CACE), alphabet boards, communication boards), repetition and rephrasing, writing key information, forced picture or word choices suited to their level of understanding, communicating step 1, step 2, step 3 commands.
Give the patient time to respond, encourage/model pointing to forced choice picture or word answers, include ‘other’ as an option for unique information, use interactive drawing, rating scales, gesture, yes/no/not sure response sheet, written choices, etc.
Question: What do you do when the patient is not capable, and you can’t contact the SDM? Are there situations where consent doesn’t need to be obtained?
Answer: If you have determined the patient is lacking in capacity to provide consent, and the highest ranking SDM is not available, you must refer to the next individual on the hierarchy of substitute decision makers:
It is very rare that SLP or audiology services would be considered an emergency especially if there are non-oral alternatives for administering medication. According to the HCCA, (s.25(1)) a situation can be considered an emergency if:
“…the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk, if the treatment is not administered promptly, of sustaining serious bodily harm.”
Consult with the health care team to determine if it is an emergency situation. If you decide that it is, and you are going to proceed without consent, you must document your reasons in the patient record including the reasons for the emergency, risk to the patient if the intervention was not provided, and how the patient does not understand or appreciate and your efforts to find a substitute decision maker.
Question: What happens when a patient repeatedly refuses to have an audiology or speech language assessment?
Answer: If a patient refuses to be assessed, it is not grounds for determining they are incapable. If the patient has the ability to understand the information needed to make the health care decision and appreciates the likely consequences of making the decision, then that is their right to refuse an assessment. Be sure to document your capacity evaluation and their refusal.
Question: What kind of questions would be included in a capacity evaluation?
Answer: That would depend on what the patient is consenting to. You would complete a treatment decision analysis, that is consider all of the significant components of the decision. Develop questions to determine if they understand those components and appreciate the consequences of their decision. Refer to the Consent Tool on the CASLPO website for suggestions in different areas of practice.
Question: With respect to capacity for admission to Long Term Care (LTC), I was always under the impression that it could only be done by a trained capacity assessor and SLPs and audiologists do not qualify to be assessors (as opposed to capacity evaluators). Can you clarify?
Answer: There is a difference between capacity evaluators and capacity assessors. Under the HCCA (s. 2(1)) all SLPs and audiologists are considered to be capacity “evaluators” for healthcare decisions, admission to LTC, support services in the home and confinement. If the patient is living with a communication or hearing barrier, you may be the most appropriate health care professional to conduct a capacity evaluation for admission to LTC. You can carry out the evaluation on your own or with another healthcare professional.
SLPs and audiologists are not on the Ministry of the Attorney General’s list for capacity assessors for personal care and property (finances). As per the Ministry of the Attorney General, capacity assessors need to have completed the capacity assessor course under the Substitute Decisions Act, 1992.
As a construct, to ‘understand’ refers to a person’s cognitive abilities to factually grasp and retain information. To the extent that a person must demonstrate understanding through communication, the ability to express oneself (verbally or through symbols or gestures) is also implied. (Capacity Assessment Office, Ministry of the Attorney General of Ontario)
The ‘appreciate’ standard attempts to capture the evaluative nature of capable decision making and reflects the attachment of personal meaning to the facts of a given situation. (Capacity Assessment Office, Ministry of the Attorney General of Ontario)
Audiology Advisor and Manager of Mentorship
Audiology Advisor and Manager of Mentorship
The College is pleased to announce the successful launch of a new online Mentorship Self-Assessment Tool (MSAT) for use by CASLPO initial registrants and their mentors. The MSAT is required for all mentorship periods that began on or after June 3rd,2019.
The MSAT is already being used by over 60 mentees and mentors!
Here is what one mentee had to say:
“My mentor and I have explored the MSAT online, it’s pretty cool! I’ll begin loading some goals in the next few days…”
On September 11, 2019, CASLPO offered a one-hour training webinar for mentors called “A Conversation About Consistency.” This webinar aimed to:
Attendees of this webinar were asked to complete a survey regarding their mentor training needs.
The feedback that we receive from this survey will assist us as we develop future training sessions to meet the needs of our mentors. If you are a mentor or are thinking about becoming a mentor, we want to hear from you! This survey will take less than 3 minutes to complete.
Alexandra Carling Ph.D.
Director of Professional Practice and Quality Assurance
Research shows that ‘in the moment’ education and remediation is the most effective catalyst for change regarding the registrant’s knowledge, behaviour and activities.
Given that the College and peer assessors have always viewed the peer assessment process as collaborative and educational, it has been a natural evolution to take full advantage of teachable moments.
In the past, when finding a registrant needing work to meet a standard, the peer assessor would discuss general improvement strategies. However, each and every indicator that was not met was brought to the Quality Assurance Committee (QAC) for their input. The committee’s requirements were communicated to the registrant, who then had to provide further evidence of meeting the standards. This was time consuming and did not capitalize on ‘in the moment learning’ for less serious issues.
The QAC has initiated an On-Site Remediation process for the 2019 peer assessment process. If registrants are found to need work to meet a standard, and meet the criteria below, they are given the opportunity to work with the peer assessor, at the site visit, to develop a plan to ensure that the standard is met.
When the remediation plan has been completed and the peer assessor has reviewed the new evidence, the peer assessor writes a summary for the QAC stating that the registrant meets the standard. The QAC will not receive registrant-specific on-site remediation reports, unless the process is unsuccessful.
The QAC and staff will track aggregate data regarding the professions, indicators needing work to meet the standard and the key components of the remediation plan on a bi-annual basis. This data is used to develop further resources for our registrants. The information will also be added to the Quality Assurance section of CASLPO’s Annual Report.
In summary, On-Site Remediation allows for quick, effective remediation of many less serious matters. More complex or serious concerns, or those that are not successfully remediated on-site, will be brought to the QAC for their determination.
Director of Professional Practice and Quality Assurance
Good news! Registrants have responded well to our new engagement initiative of offering to come to your place of work to discuss information and your issues. This year we will be visiting organizations in Sarnia, Hamilton, Toronto and Ottawa and providing an e-Forum to registrants in London.
If you can assure 20 registrants or more will attend, we will come in person, if less than 20 attend we will join by webinar. For information on this new program click here.
Our two annual pre-arranged CASLPO Forums (one in the north and one in the south of the province) will take place in St Catharines on September 19th and Kenora on October 29th. We look forward to meeting you in person.
Missed one of our e-Forums? You can watch the recording and review the presentation slides on the website. Click here to see e-forums you may have missed and what e-forums are coming up.
Director of Professional Conduct & General Counsel
Under the Regulated Health Professions Act, 1991, the Patient Relations Committee is required to have a program which includes measures for preventing and dealing with sexual abuse of patients. The program is outlined in the College’s Sexual Abuse Prevention Program (“Program”) and is accompanied by the Position Statement on Professional Relationships and Boundaries. This Program provides important information and guidance to Committees tasked with investigating and adjudicating cases of sexual abuse.
The Program and Position Statement have undergone a comprehensive review to bring it in line with recent legislative changes. The review has also sought to simplify the information contained so that it can be more accessible to the public and to audiologists and speech-language pathologists. The review has brought forward some important changes which include:
1. New definition of “patient” for the purposes of sexual abuse.
As of May 1, 2018, sexual abuse includes engaging in a sexual relationship with a patient during the treatment relationship and/or within one year of the treatment relationship ending. The new patient definition is reflected in both the Program and the Position Statement.
2. Enhanced Discipline Rules of Procedure
In August 2017, the College’s Discipline Committee revised its Rules of Procedure (English and French available online) in light of a recommendation made in the “To Zero: Independent Report of the Minister’s Task Force on the Prevention of Sexual Abuse of Patients” (2015). The Task Force recommended increased protections to vulnerable witnesses testifying in sexual abuse cases. This protection is now contained in Rule 11, which presumes that it is an appropriate case for orders respecting support persons for vulnerable witnesses, testifying with screens or devices or by close circuit television, or preventing an accused AUD or SLP from cross-examining a vulnerable witness directly and appointing an alternative to cross-examine the witness.
3. Access for Funding for Therapy
Following amendments created by the Protecting Patients Act, 2017, the eligibility for funding has now changed. Previously, a patient who had been sexually abused could only access funding for therapy after a panel of the Discipline Committee had made a finding of sexual abuse. Now, any patient who comes forward to raise a complaint of sexual abuse, or if the Registrar initiates an investigation regarding concerns that a AUD or SLP has sexually abused a patient, that patient has the right to access funding for therapy. (It should be noted that this change comes with the specific provisions that access for funding does not amount to a finding of guilt.)
The changes to funding are set out in the Program and policy and are now available on the website (here).
4. List of Community Resources for Survivors
The Program also includes a new Appendix which lists organizations in the Community that can provide support to survivors of sexual abuse. While the list is not meant to be an exhaustive one, it provides access to various supports which survivors may find beneficial.
5. Enhancements to the Public Register
As discussed in the last edition of ex.press, the Protecting Patients Act, 2017 included new requirements for posting information on the public register. These requirements are in conjunction with the revisions Council made to its bylaws in 2015. Changes include the posting of information respecting:
It is hoped that these changes will give the public more information to help them make informed decisions about their health care.
The Program and Position Statement form an important cornerstone in the College’s strategy for preventing sexual abuse. It is intended to give AUDs and SLPs guidance respecting CASLPO's position of zero tolerance of sexual abuse. It is expected that all AUDs and SLPs are familiar with both the Program and Position Statement. Should there ever be concerns that a patient has been or is being sexually abused, AUDs and SLPs must report this information to the College immediately. Public protection is the responsibility of not only the College, but of every registrant trusted to provide honest and safe health care to the public of Ontario.
To review the Program and Position Statement, in either English or French, please refer to the College’s Sexual Abuse Prevention Program page: here.