Professional Discipline Display slide. Board Member Training Introduction to Regulatory Governance Council on Licensure, Enforcement and Regulation

Session Introduction Display slide. Explain that we will first review the session learning objectives and session structure.

Learning Objectives Upon completion of the session, you will be able to: Understand the difference between disciplinary issues and fitness to practice issues Define the enforcement procedures in place for professional discipline Identify the options available to board members regarding professional discipline Display slide. Explain the learning objectives on the screen. Ask if there are any questions.

Learning Objectives Upon completion of the session, you will be able to: Understand the need for a strong enforcement process Identify and consider the unintentional consequences of professional discipline on the practitioner Describe processes for dealing with practitioner incapacity Discuss issues of openness and transparency in professional discipline and fitness to practice Display slide. Explain the learning objectives on the screen. Ask if there are any questions.

Professional Discipline and Fitness to Practice Session Map Professional Discipline and Fitness to Practice The Enforcement Process Receiving and Sharing Information Disciplinary Sanctions Practitioner Misconduct Session Review Display slide. Explain that this session is divided into six lessons. These lessons are: The Enforcement Process Elements of a Strong Enforcement Process Receiving and Sharing Information Disciplinary Sanctions Practitioner Misconduct Session Review Ask if there are any questions.

The Enforcement Process Display slide. Explain in this lesson we will review the enforcement process, and characteristics of a strong enforcement process.

Introduction Public access and perception Board’s responsibilities Understand board policies and procedures Display slide. Explain The operation of disciplinary processes is often the most visible role that regulators undertake. How complaints are handled, particularly those from consumers, has a significant impact on the public’s perception of the regulatory process and public confidence in the profession concerned. When concerns are raised about a regulated practitioner’s conduct, competence or fitness to practise, regulatory agencies must ensure that they apply fair, transparent and timely processes in addressing those concerns.   Disciplinary activity often accounts for the largest share of a regulator’s budget and Board members need to ensure that there are sufficient reserves available to enable this important part of their regulatory mandate to be delivered. They also need to ensure that those directly involved in administering the disciplinary process receive appropriate training and have access to legal counsel. The exact nature of the processes used by regulatory agencies does vary and it is important that Board members are aware of and comply with the specific requirements which apply in their jurisdiction. However, those processes are typically based upon quasi-judicial procedures which share many broad similarities

The Enforcement Process Intake Assessment Investigation Review Resolution Final Orders Compliance Display slide. Explain The regulatory enforcement process can be regarded as consisting of seven steps, as follows: Intake Assessment Investigation Review Resolution Final Orders Compliance In this lesson we will review the components of each of these steps, and their importance to you as a board member, your practitioners, and the public.

Intake Complaint received and acknowledged Assessment Investigation Review Resolution Final Orders Compliance Complaint received and acknowledged This is often the only contact public has with regulatory agency Notification sent to practitioner File set up File status tracking mechanisms Display slide. Explain Receiving and acknowledging complaints; setting up files and initiating complaint tracking. This is often the only point at which a consumer makes contact with a regulatory agency and the handling of telephone calls and correspondence at this stage has a real impact on the public’s perception of the regulator.

Assessment Initial screening of complaint Determine jurisdiction Intake Assessment Investigation Review Resolution Final Orders Compliance Initial screening of complaint Determine jurisdiction Assess risk to public and interim measures Assess issues for possible alternative resolution mechanisms Display slide. Explain Screening complaints; applying the agency’s ‘standard of acceptance’; determining jurisdiction and the form of response that is appropriate for the complaint. In cases where an immediate public risk is perceived the regulator may have statutory powers to impose some form of immediate suspension of registration

Investigation Assign complaint to investigator or investigative team Intake Assessment Investigation Review Resolution Final Orders Compliance Assign complaint to investigator or investigative team Evidence gathering Interviews Identify, obtain, and review relevant documentation Investigation report Display slide. Explain Assigning an individual or team to gather evidence and produce an investigation report. In some jurisdictions this work is undertaken by Board members or prosecutors rather than by investigators.

Review Determine the disposition of the complaint Intake Assessment Investigation Review Resolution Final Orders Compliance Determine the disposition of the complaint Investigation/screening committee Complaints without merit are closed Complaints with merit move forward Display slide. Explain Determining the disposition of investigated complaints. At this stage a decision will be taken on prosecutorial viability or some other measure of whether there is ‘case to answer’. Complaints without merit will be closed and a level of action will be determined for those which merit further consideration.

Resolution Confidential / Informal Resolutions Intake Assessment Investigation Review Resolution Final Orders Compliance Confidential / Informal Resolutions Before the screening committee Written/oral cautions Irrevocable undertaking Remediation Display slide. Explain Hearing or otherwise deciding the case. This may be some form of informal process (such as a stipulated agreement or undertaking) or may involve formal resolution at a hearing before the Board, a tribunal or administrative law judge. Instructor Note: This topic is continued on the next slide.

Resolution Public / Formal Resolutions Intake Assessment Investigation Review Resolution Final Orders Compliance Public / Formal Resolutions Consent orders / agreed statements of fact Contested hearings Discipline hearing before a committee or panel Similar to a trial Display slide. Explain Hearing or otherwise deciding the case. This may involve formal resolution at a hearings before the Board, a tribunal or administrative law judge. Instructor Note: This topic is continued from the previous slide.

Final Orders The Discipline Panel adjudicates by: Intake Assessment Investigation Review Resolution Final Orders Compliance The Discipline Panel adjudicates by: Determining the facts based on the evidence Making findings Ordering sanctions Producing written decisions Decisions and orders can be appealed Display slide. Explain Disposing of the case, including imposing an appropriate sanction. The resolution process will establish facts based upon the evidence, apply the relevant law and, depending upon the legislative language, reach conclusions as to ‘liability’ or ‘guilt’. The person or body that conducted the hearing will often also make the final order. However, in some jurisdictions the findings in the case may be referred back to the Board or a committee which then makes the final order (either as to guilt and sanction or only on sanction).

Compliance The board must monitor compliance with sanctions Intake Assessment Investigation Review Resolution Final Orders Compliance The board must monitor compliance with sanctions Sanction orders may include consequences of non- compliance Display slide. Explain Following up on final orders to ensure that they are being obeyed. Ensuring a high degree of compliance is an important part of maintaining public confidence in the regulatory process.

A Strong Enforcement Process: Is well-published Is based on a well-organized, open, and transparent process Operates in a timely manner Avoids appearances of institutional bias Defines misconduct, incompetence, and other offences clearly Maintains internal consistency Display slide. Explain Characteristics of a Strong Enforcement Process There are six common elements to a strong enforcement process. Boards should: Publicize their existence and role in handling consumer complaints. Options include: Toll-free complaint lines Consumer-friendly websites Distribution of information brochures Posting ‘how to complain’ notices in all registered practitioners' premises Advertising Speeches and other stakeholder outreach by board members Coordination of publicity and information with consumer groups Develop well-organized complaint handling processes With clear guidelines on how to log complaints, who receives notification of the complaint, and within what period of time. Set appropriate timescales For notices, the review of investigations and other key steps in the complaint handling process and adhere to them. Timescales and deadlines should be set out in legislation or clear policy statements. Observe due process By separating the investigation, prosecution and decision-making processes. Where Board members participate directly in the disciplinary process they should not be involved in more than one of these three steps. Specify the basis on which disciplinary action may be taken Such as misconduct or unethical behavior. So far as possible, the basis on which action can be taken and any definitions of the terms used should be set out in the regulatory agency’s governing legislation or regulations. Consider how to maintain consistency in relation to charges and sanctions So that the principle of fairness is observed. Set guidelines which enable consistent charging and sanction decisions to be made and which also allow for deviation where there are aggravating or mitigating circumstances that make it appropriate and can be explained.

Receiving and Sharing Information Display slide. Explain This lesson will cover the requirements and best practices of sharing and receiving information across and within jurisdictions, and agencies.

Seek to Receive Information Disciplinary action which: Significantly limits a practitioner’s scope of practice or practice privileges Leads to suspension or expulsion from an organization Concerns about practitioner’s: Competence or ability to perform professional services Unethical behavior Violation of professional standards Possible chemical abuse Display slide. Explain Sharing information with other regulators, professional associations, insurers and the employers or users of the services provided by registered practitioners is a valuable public protection safeguard. In many jurisdictions the sharing of information is a legal requirement but even in those where it is not, Boards should seek to ensure that they receive information from others about: any disciplinary action which significantly limits a practitioner’s scope of practice, practice privileges or leads to their suspension or expulsion from an organization; concerns about the practitioners’ competence or ability to perform professional services, unethical behavior, violation of professional standards or possible chemical abuse

Things a Board Should Consider Requiring insurers to report settlements against registered practitioners over a specified amount Requiring practitioners to inform board of concerns about another practitioner Ensuring notice of any sanctions imposed are circulated to relevant regulatory agencies in other jurisdictions Display slide. Explain Where they have the power to do so, Boards should also consider: Requiring insurers to report all settlements involving a registered practitioner which exceed a specified sum; Requiring all registered practitioners to inform them of concerns about other registered practitioners; Ensuring that notice of any sanctions they impose are circulated to relevant regulatory agencies in other jurisdictions.

Disciplinary Sanctions Display slide. Explain in this lesson we will discuss the principles and objectives of disciplinary sanctions, aggravating and mitigating circumstances pertaining to disciplinary sanctions, and the types of disciplinary sanctions available to regulatory authorities.

Principles and Objectives Protect the public Maintain confidence in the board Deterrence General Specific Rehabilitation Display slide. Explain the key principles and objectives of any board as it pertains to disciplinary sanctions are: Protect the public Maintain confidence in the board Deterrence General Specific Rehabilitation

Aggravating and Mitigating Circumstances Seriousness of the conduct Prior discipline history Single event vs. pattern of conduct Harm to specific individuals Misleading the board/agency Cooperation with the investigation Insight / Remorse Display slide. Explain that there are aggravating and mitigating circumstances to take into consideration when determining the type and severity of disciplinary sanctions. Discuss how the circumstances displayed on this slide could affect the type and severity of sanctions you would consider as a board member of a regulatory authority.

Types of Disciplinary Sanctions Revocation of registration Suspension from practice Probation or other form of restriction of practice Denial of reinstatement or renewal Restitution order Mandatory substance abuse testing or submission to mental or physical evaluation Censure and reprimand or a caution Administrative fine or monetary penalty Display slide. Explain The disciplinary sanctions available to boards vary significantly from jurisdiction to jurisdiction and often a board’s governing legislation only provides a limited number of options. The sanctions which may be available include: Revocation of registration; Suspension from practice for a fixed period or until specified conditions are met; Probation or some other form of restriction on practice, which may include, limitations on practice, supervision requirements or satisfactory completion of remedial activity; Denial of reinstatement or renewal of registration; Restitution order, requiring the refund of fees and costs to a consumer; Mandatory substance testing or submission to some other form of mental or physical evaluation; Censure and reprimand or a caution; Administrative fine or monetary penalty.

Practitioner Misconduct Display slide. Explain in this lesson we will discuss the implications of professional misconduct, and mental, physical, and chemical impairment or practitioners.

Practitioner Misconduct Physical harm or abuse of a client Failure to maintain accurate records Failure to maintain standards of practice Code of conduct violations Fraud or falsifying of records Improper advertising Practice while intoxicated or mentally impaired Display slide. Explain that practitioner misconduct is one of the most common forms of violations that regulatory boards face and may include the examples provided on this slide. Ask if any of the attendees have had experience with complaints of any of the examples provided. Ask if they have examples of other types of practitioner misconduct.

Mental, Physical or Chemical Impairments Mental and physical impairments: Can affect a professional’s ability to practice properly Evaluations of licensee’s state to ensure board has all needed information Chemical impairment is one of the most common disciplinary issues Use, misuse, abuse, dependency Recognizing where someone is in the continuum can help determine degree of harm to public Display slide. Explain Practitioners may be referred to a Board on grounds of mental or physical impairment, which may be affecting their ability to practice competently and putting clients at risk. It is important that, where the Board has the power to do so, the practitioner is required to undergo appropriate mental and/or physical evaluations to ensure that the Board has complete information on which to make a decision. Chemical Impairment   The process of substance impairment typically progresses along a continuum from use, to misuse, to abuse, to dependency. Each of these stages indicates an increased degree of dependence. Legitimate drug use can also lead to misuse or abuse, but does not inevitably result in dependence. Regulatory authorities frequently hear cases at points along the continuum from misuse through dependence and will rarely have jurisdiction over the legitimate use of legal substances. For that reason a regulatory authority should take particular care in determining whether a practitioner’s drug use is for legitimate reasons and whether it affect their ability to perform professional duties. The complexity of impairment is such that clients may at times be at different kinds of risk from a practitioner in the "misuse and abuse" portion of the continuum, whose behaviour may be more erratic than those who are dependent but who may have built up tolerance and react more predictably to the drugs they are using. In all cases clients are at risk and intervention may be needed in order to protect the public. As those recovering from chemical dependence are prone to relapse, close monitoring of practitioners at this stage is also advisable as a public safety measure.

Session Review Display slide.   Say “We have completely reviewed all topics within the Professional Discipline session of the Board Member Training – Introduction to Regulatory Governance course. We will now review the key concepts of this session.”

Session Review Employ fair, transparent, and timely processes Provide for informal resolution options where appropriate Give specific training for board members involved in discipline proceedings Display slide. Review the points made on the slide. Explain Board members must ensure that their organization has fair, transparent and timely processes for addressing professional discipline issues.  Formal processes for investigation, information management, hearings and sanctions must be established and followed.  For those directly involved in the discipline process adequate training is critical and an understanding of the types of practitioner misconduct will also assist them in their deliberations.

Learning Objectives Review You should now be able to: Understand the difference between disciplinary issues and fitness to practice issues Define the enforcement procedures in place for professional discipline Identify the options available to board members regarding professional discipline Display slide.   Review the learning objectives. Ask if there are any questions regarding the objectives displayed.

Learning Objectives Review You should now be able to: Understand the need for a strong enforcement process Identify and consider the unintentional consequences of professional discipline on the practitioner Describe processes for dealing with practitioner incapacity Discuss issues of openness and transparency in professional discipline and fitness to practice Display slide.   Review the learning objectives. Ask if there are any questions regarding the objectives displayed.

Practical Exercise Display slide. Explain the Scenario During a narcotics record audit, it is found that a nurse has been diverting medications from patients for more than a year; using a number of techniques to obtain and hoard medications for personal use, including marking narcotics as "wasted," and also forging other nurses' signatures on narcotic sign-off sheets. When confronted by the employer, the nurse claims to have had serious injury last year, and pain killers were prescribed by a doctor. The doctor refuses to continue the prescription and this person claims that without drugs, the pain is too severe to provide proper patient care. Even on pain medication, the nurse’s performance has otherwise been stellar, with no patient issues. Though the nurse has agreed to enter a drug treatment program, to protect itself, the hospital has reported this incident to your Board. What if any action should be taken by the Board? What variables must be considered? Since the nurse has already agreed to treatment, is this still a board problem? Review the points of consideration for the scenario: The answers to these questions will lie with the specific process and remedies that are instituted by the Board and jurisdiction in question (and in this particular incidence, an examination of any laws that might be in effect). Is the process in accordance with the “legislation” governing the regulation of the profession? Is the incident related to practitioner conduct or fitness to practice? Is a fair, transparent and timely process followed? Instructor Note: Try to draw the class into a discussion about the points listed above, rather than lecture to them. You may choose to break the class into groups, or continue as a class depending on class size. Advise the group(s) to answer the questions provided in their workbooks. Once complete, you may review the answers as a class if the exercise was completed in small groups.

? Questions Display slide.   Ask if there are any final questions before completing the session.