2.1 Minutes of the Council meeting of September 22, Business Arising out of the Minutes

Transcription

1 Council Meeting Wednesday, December 7 from 9:00 a.m. to 5;00 p.m. and Thursday, December 8 from 9:00 a.m. to 1:00 p.m. Agenda 9:00a.m. 1. Agenda Review Decision 9:05 a.m. 2. Minutes of Meetings Decision 2.1 Minutes of the Council meeting of September 22, Business Arising out of the Minutes 9:10 a.m. 4. Finance Committee meeting report November 10, 2016 Decision 4.1 Unaudited Financial Statements for the nine months ended September 30, Council stipend and expense policies Operating and capital budgets 10:15 a.m. Break 5. Strategic Issues 10:30 a.m. 5.1 Nurse Practitioners prescribing controlled substances Amendments to the Controlled Act regulation for circulation, to authorize Nurse Practitioner prescribing of controlled drugs and substances Amendments to the Register By-Law (Article 44.1), for circulation, to include a notation regarding completion of continuing education courses required to prescribe controlled substances Approval of continuing education courses required to prescribe controlled substances Decision

2 Council Agenda December 7 and 8, :30 Lunch 1:30 p.m. 5.2 Election of the Executive Committee By-Law amendments regarding the election of the Executive Committee Amendments to the Election and Appointments Committee Terms of Reference Decision 2:00 p.m. 5.3 The changing regulatory landscape Information and discussion 2:30 p.m. 5.4 Future quality assurance program Information and discussion 3:00 p.m. 5.5 Practical Nurse program approval La Cité Decision 3:15 p.m. Break 6. Reports 3:30 p.m. 6.1 Executive Director Update Information 4:00 p.m. 6.2 Executive Committee meeting November 10, November 29, 2016 Information 7. Council Operations and Governance 4:15 p.m. 7.1 Question period during the Executive Committee election Decision 2

3 Council Agenda December 7 and 8, 2016 December 8 9:00a.m. 8. The Governance Vision Perspectives from and dialogue with your Task Force Discussion 10:30 a.m. Break 1030 a.m. 9. Recommendations of the Leading in Regulatory Governance Task Force Decision 12: Other business 12: Evaluation of the Council meeting Self reflection Council s governance role Discussion 1:00 p.m Lunch Next Meeting: Wednesday and Thursday, March 8 and 9,

4 Agenda Item 2.1 Council September 22, 2016 at 9:00 a.m. Minutes Present M. Sloan, Chair P. Andrade C. Barnet C. Beemer Y. Blackwood D. Burger D. Cutler R. Davidson C. Egerton G. Fox J. Furletti D. Graystone M. Hogard T. Holland J. Jamieson A. Jewell R. MacKay M. MacMillan-Gilkinson C. Manning D. Mattina A. Molloy N. Osbourne James D. A. Prillo S. Robinson G. Rudanycz L. Sanderson M. Sheculski M. Tuomi D. Walia C. Ward C. Williams H. Whittle I. Wiltshire-Stoby Regrets T. Dion C. Evans A. Fox Staff J. Anderson A. Coghlan J. Hofbauer, Recorder E. Horlock D. Jones B. Knowles K. McCarthy K. McGovern S. Mills C. Stanford Governance M. Sloan reviewed the rationale for adding items to the agenda at least two weeks before a meeting: to allow for the preparation of briefing materials to support informed decision-making; and to ensure all members of Council have notice of all decisions to be made at the meeting. Council was informed that the discussion of the assessment of international applicants was added to the agenda by a Council member

5 Council Minutes September 22, 2016 Agenda The agenda had been circulated. Motion 1 Moved by A. Molloy, seconded by R. MacKay, CARRIED That the agenda for the Council meeting of September 22, 2016 be approved as circulated. Minutes Minutes of the Council meeting of June 9, 2016 had been circulated. Motion 2 Moved by R. Davidson, seconded by M. Hogard, CARRIED That the minutes of the Council meeting of June 9, 2016 be approved as circulated. The confidential appendix to the minutes of the Council meeting of June 9, 2016 had been circulated. Motion 3 Moved by H. Whittle, seconded by C. Egerton, CARRIED That the confidential appendix to the minutes of the Council meeting of June 9, 2016 be approved as circulated Minutes of the Council teleconference meeting of July 28, 2016 had been circulated. This was a special meeting at approve the amendments to the registration regulation after its circulation

6 Council Minutes September 22, 2016 Motion 4 Moved by C. Egerton, seconded by G. Rudanycz, CARRIED That the minutes of the Council meeting of July 28, 2016 be approved as circulated. Fees By-law M. Sloan noted that: in March, Council selected the approach to the fee increase from among options; and in June, Council approved draft by-law amendments for circulation based on the selected option. Council had decided on a stepped increase which met the College s fiscal needs while avoiding large increases. The approach defers increasing fees until the funds are needed. Council received a report of the feedback to the circulation of the by-law. It was noted that there was considerable positive feedback to the stepped increase. On an enquiry from a Council member, it was confirmed that the fee increase includes provisions for enhancements to the College s quality assurance program. M. Sloan noted that the question for Council s consideration is whether there was anything in the feedback that led Council to believe the increase is not in the public interest. Before voting, the President reminded Council that a 2/3 majority is required to approve a bylaw amendment. Motion 5 Moved by C. Manning, seconded by M. McMillan-Gilkinson, CARRIED That Council approve the proposed amendments to Article 5.06 of By-Law No. 2: Fees, as it appears in attachment 1 to the briefing note. Follow-up Action Update by-laws Collect new fees with 2017 renewal Executive Director and CEO - 3 -

7 Council Minutes September 22, 2016 Cross-College Psychotherapy Document M. Sloan reminded Council that the Regulated Health Professions Act was amended in 2007 to include the controlled act of psychotherapy. That section has never been proclaimed and therefor is not in effect. Since its passage, the six Colleges whose members will have access to the controlled act, including the College of Nurses, have been working together to prepare for its proclamation. One of the impediments to proclaiming the controlled act was its lack of clarity. In 2015, the Ministry asked the Colleges involved to develop a document that would assist in clarifying what the controlled act is. M. Sloan noted that the document Council is considering was prepared by those colleges. Council was informed that the Ministry has asked that the Councils of all the Colleges involved approve the clarification document in principle, to support further consultation and education. There was some discussion about the appropriateness of allowing nurses to have access to the controlled act of psychotherapy because it is not included in the basic nursing program. It was noted that nurses perform other acts not included in the basic program. It is each nurse s accountability to know their competence and, where required, to seek the needed education to be competent to perform any act. Council was reminded that it has put in place an added protection. RNs and RPNs can only perform the controlled act of psychotherapy if there is an order. That will ensure that a health care practitioner with the needed diagnostic expertise will determine when the patient requires the controlled act of psychotherapy. Motion 6 Moved by R. MacKay, seconded by D. Cutler, CARRIED That the proposed cross-college document entitled The Controlled Act of Psychotherapy: A Clarification, as it appears in attachment 1 to the briefing note, be approved in principle. Follow-up Action Inform government and collaborating colleges of Council s approval Executive Director and CEO Governance Principles The Governance Task Force is recommending approval of the governance principles. M. Sloan noted that Council had the opportunity to provide input into the principles at the culture - 4 -

8 Council Minutes September 22, 2016 workshop in September 2015 and the June 2016 governance workshop. M. Sloan informed Council that the Task Force has carefully considered the feedback from Council in finalizing the principles. The principles are intended to be a crisp, clear and accessible commitment to what the public can expect of Council in governing. M. Sloan identified that Council needs to consider if the principles will guide and support it and future Councils in effective governance. Motion 7 Moved by C. Williams, seconded by D. A. Prillo, CARRIED That Council adopt the governance principles, as they appear in attachment 1 to the briefing note. There was discussion about the proposed model for governance and particularly the size of the Council. It was noted that the final decision about the changes to the governance of health regulatory colleges rests with government, and the government is watching the work of the Council as it considers modernizing of the governance of health regulators. In December, Council will be considering the expert advice of the Task Force, which will include a future vision for governance. Council will also explore what will need to be done over time bring the vision to life. It was noted that will likely be the work of Council over the next few years. It was confirmed that the government will be a key stakeholder. The government has signalled that they want engagement with the College in determining how regulatory governance can best serve the needs of the public of Ontario. Follow-up Action Final recommendations of the Governance Task Force to Council in December Executive Director and CEO Quality Assurance follow up M. Sloan noted that over the last few years, some Council members have expressed concerns about the College s quality assurance program and whether the College is meeting its commitment to the public that nurses are engaged in continuous improvement

9 Council Minutes September 22, 2016 In March of this year, Council had an opportunity to consider possible futures for the program. Council members received the notes of the workshop and highlights of the current program. Changing the quality assurance program is a major project. Over the coming year, staff will undertake a literature review and will explore best practices in regulatory quality assurance in both nursing and other professions, in Canada and abroad. The thinking from the workshop will inform and guide staff. Council will receive this information at Council meetings. This will support Council to meet its commitment to evidence and best practice informed decisions when discussing options for future directions for the College s quality assurance program. An update will be brought to Council in December. Interest was expressed in whether there is potential to enhance the quality assurance program as part of the collaboration with nursing regulators in British Columbia. It was also suggested that the College explore whether there are quick wins that can be implemented in the short term. Follow-up Action Quality assurance project update to Council in December Executive Director and CEO Assessment of International applicants D. Graystone requested that this issue be added to the agenda. She noted that there are concerns about the fact that fewer applicants are successful going through the new process and that this could impact the availability of nursing services in some communities. K. McGovern and S. Vogler provided background on the issues related to the assessment of international applicants. Council was reminded that the National Nursing Assessment Service is a national collaboration involving most nursing regulators from across Canada. The Service s assessment tool is new and it took time to develop confidence in its validity. At the beginning, regulators were cautious and it was agreed nationally to use the reports generated as a result of the tool as advisory. The College has come to the determination that the tool is valid and is the most fair and consistent way of assessing applicants as a first step in the assessment process. Staff are proposing a new process which they believe will provide a rigorous assessment and enhance the opportunities for international applicants to provide evidence that they meet the entry to practice competencies. If approved, the College will review the assessments from all - 6 -

10 Council Minutes September 22, 2016 international applicants who had been assessed as not meeting requirements since the National Service began providing the College with reports. The changes in the process were highlighted: accepting programs that are assessed by the national service as meeting the threshold for equivalence to a Canadian program; and adding an assessment of past and current practice for those applicants whose program is assessed as not equivalent by the National Service. The College will be exploring how it will address the impact of the change on applicants. It was clarified that there is no change in the assessment of Nurse Practitioners. The National Service addresses the general class. Motion 8 Moved by H. Whittle, seconded by C. Egerton, That Council approve, effective February 1, 2015, in accordance with clause 1(iii.)(B.) of subsection 2(1) of Ontario Regulation 275/94, the following evaluations for the purpose of determining whether an applicant applying for Registered Nurse (RN) registration possesses the equivalent knowledge, skill and judgment of a current Canadian graduate: Content analysis of the curriculum of the nursing education completed by the applicant compared to the curriculum of a representative sample of current Canadian nursing programs Assessment of the applicant s past and current nursing practice Objective clinical assessment CARRIED There was discussion about whether the motion should specifically refer to the National Nursing Service. It was identified that ultimately the decision rests with the College and flexibility is included in the wording. Motion 9 Moved by A. Molloy, seconded by H. Whittle, That Council approve, effective February 1, 2015, in accordance with clause 1(iii.)(B.) and (v.) of subsection 3(1) of Ontario Regulation 275/94, the following evaluations for the purpose of determining whether an applicant applying for Registered Practical Nurse (RPN) registration possesses the equivalent knowledge, skill and judgment of a current Canadian graduate: - 7 -

11 Council Minutes September 22, 2016 Content analysis of the curriculum of the nursing education completed by the applicant compared to the curriculum of a representative sample of current Canadian nursing programs Assessment of applicant s past and current nursing practice Assessment of applicant self-report of practice experience CARRIED It was clarified that the final step in the assessment process is different for applicants seeking to become RPNs than those seeking to become RNs because currently there is not an objective structural clinical examination available for applicants to become RPNs. Follow-up Action Review international applicants who have been assessed as not meeting equivalence and determine status based on new process. Executive Director and CEO Financial acumen S. Mills presented on financial acumen for board members. He noted the things that Council members should watch for, such as unexplained variances and declining cash during periods of surplus. He noted the importance of maintaining the surplus within the guidelines set by the Canada Revenue Agency. Finance Committee Report L. Sanderson presented the report of the Finance Committee meeting of September 1, She highlighted the unaudited financial statements for the six months ended June 30, She pointed out that the six-month surplus of $1.37 million is $.9 million more than budgeted. She noted that as the result of advice from the auditors, the College has changed how it is presenting the expenditures for the new computer system in the financial statements. Motion 10 Moved by L. Sanderson, seconded by M. Hogard, CARRIED That Council accept the unaudited financial statements for the six-months ended June 30, C. Stanford provided an update on the development of the College s new information system. In response to a question, S. Mills noted that the College is spending more on the information - 8 -

12 Council Minutes September 22, 2016 system than planned. He noted that some of the overages will be offset by other variances in the College s expenses. Some of the College s investment will be recoverable from the rest of the consortium because the College is working on developing functionality that will be shared. S. Mills explained the change in accounting for the new information system. He noted that the costs of the system had been included in the capital budget. Advice from the auditors is that, because the system is not something the College can lease out or sell, the expenditure needs to be included in the operating budget. A small portion that covered the cost of hardware will remain in the capital budget, but the rest has been moved to the operating budget. S. Mills noted that variances through the year may cover the added operating expenses. In response to a question, it was identified that when the new system goes live the College does not plan to run the old system as well. The College will keep the old system available. However, the College is confident in the rigor of the development and testing process and that the new system will work. What s Hot Council was informed that the registration regulation that it approved in July has been submitted to government. Once a final version has been prepared by the government, the College will sign and it will go through the final government approval process. Council will be informed when the regulation is approved by government. An issue of The Standard will be sent to members so that they are informed about the changes. The annual renewal for 2017 will go live on November 7 th. Notice of the start date will be included in The Standard in September and October. The Minister released the recommendations of the Sexual Abuse Task Force on September 9 th. The Ministry sent a request to all health regulatory colleges for more information. The Ministry has indicated that they require this information to draft legislative amendments. The Minister s comments about the recommendations flagged two changes that will impact the College including: legislation to add to the acts that result in mandatory revocation; and increasing transparency by adding to register and website. Council was reminded that a year ago it accepted by-laws to increase the information on the register. It is not clear whether there will be additional changes. Council was informed that the College has established an academic reference group. It is part of an overall strategy to enhance the College s relationship with educators. The goals of the reference group include improving the success of implementation of regulatory changes, understanding the impact of programs and initiatives and increasing awareness of educational issues that may impact the College

13 Council Minutes September 22, 2016 Council members were informed that new requirements under the Accessibility for Ontarians with Disabilities Act mean that not only all staff but all volunteers must have training on how to provide accessible customer service. The training will be provided through CNO s on-line education centre. The College is required to report to government at year end on how it is meeting the requirements. A question was raised about how whether the sexual abuse legislation changes will impact unregulated care providers. A. Coghlan noted that it is unclear at this time. On several occasions both the Deputy and Assistant Deputy Ministers have indicated that they are exploring how to address unregulated care providers. They have acknowledged that the same regulatory mechanisms are not appropriate for every care provider. The Ministry has signalled its intent to move forward with regulatory reform, which may include considering different regulatory mechanisms for different providers. Executive Committee Council members had received the draft minutes of the Executive Committee meeting of September 1, M. Sloan noted that the Council briefing notes have been changed to include both the public interest and public safety rationale for recommendations. Code of Conduct approach to development In June, Council asked the Executive to identify a process for revision of the Code of Conduct. The Executive is recommending the establishment of a small working group to develop revisions to the Code. Council received proposed terms of reference of the group, which included a proposed structure, timeframe and terms of reference. The Executive had recommended the workgroup be five members, including two members of the Executive and three other members of Council. In discussion, Council identified that it wanted the membership to be more open, with the only restriction being that there be at least one nurse and one public member. Motion 11 Moved by G. Fox, seconded by R. Davidson, CARRIED That a Council workgroup be established to develop a revised Code of Conduct, in accordance with the terms of reference identified in attachment 1 to the briefing note, with the membership of five Council members, at least one nurse and 1 public member

14 Council Minutes September 22, 2016 Council identified the following criteria for membership on the work group: Experience useful in developing the Code e.g. policy making, governance experience Good grasp of clear language principles easy and accessible to understand, minimum of legalese Time to perform the task Interest Strong experience in facilitating, project management and negotiation skills The Executive had identified the following options for how members of the work group would be selected from among volunteers: election appointment The results of a straw vote showed a preference for an election. A call for volunteers will be sent out shortly. Following closure of the call for volunteers, all Council members will receive an electronic ballot. Council will be informed of the results of the election. Follow-up Action Call for volunteers to serve on the workgroup and circulation of electronic ballot. Reports of the workgroup will be added to the December 2016, March 2017 and June 2017 Council meeting agendas. Executive Director and CEO How public members join the Executive In March, some Council members identified concerns about how the public members of the Executive were selected. The issue was referred to the Executive Committee for consideration. The Executive presented two options to Council: an enhanced appointment process or election. A number of members spoke in support of election. It was identified as transparent, equitable and fair. It was noted that in order to move forward with an election process, by-law amendments are required. Motion 12 Moved by A. Molloy, seconded by G. Fox, CARRIED That by-laws be prepared for review by Council in December 2016 to implement election of the members of the Executive who are not officers, beginning in March of

15 Council Minutes September 22, 2016 Follow-up Action Prepare by-law amendments for Council in December. Add to agenda for December 2016 Council meeting. Executive Director and CEO Committee appointments The Executive had made a number of committee appointments to address vacancies. Motion 13 Moved by R. Davidson, seconded by M. Hogard, That Council confirm the following committee appointments made by the Executive Committee: Maria Sheculski, public member to the Inquiries, Complaints and Reports Committee until June 2017, Sherry Simo, RPN as an appointed committee member on the Inquiries, Complaints and Reports Committee until June of 2018; and Janna Schroder, RPN as an appointed committee member on the Quality Assurance Committee until June of CARRIED Dates of Council meetings In response to Council s interest in more opportunities for education and for generative discussion, the 2017 budget will include the resources for two-day Council meetings. The exact length of the meetings will be determined once an agenda is prepared. M. Sloan noted that the Executive is suggesting a shift in the timing of the December 2016 meeting to allow Council to address the two complex issues in the morning the budget on Wednesday, December 7 th and the final report and recommendations of the Governance Task Force on Thursday December 8 th. Motion 14 Moved by D. Walia, seconded by N. Osbourne James, That the following be dates for Council meetings: Wednesday, December 7 (all day) and Thursday, December 8 (until 1:00 p.m.), 2016 Wednesday and Thursday, March 8 and 9, 2017 Wednesday and Thursday, June 7 and 8,

16 Council Minutes September 22, 2016 Tuesday and Wednesday, September 19 and 20, 2017 Wednesday and Thursday, December 6 and 7, CARRIED Evaluation Council discussed how the Council meeting reflected the governance principles and whether there were any improvements for future meetings. Next meetings Council will meet next all day on December 7, 2016 and the morning of December 8, Conclusion At 3:00 p.m. it was Motion 15 Moved by R. MacKay, seconded by H. Whittle, That Council conclude. CARRIED Chair

17 Agenda Item 4 Report of the November 10, 2016 Finance Committee Meeting Contact for questions or more information Stephen Mills, Director of Corporate Services The Finance Committee met on November 10, Financial Statements The unaudited financial statements for the nine months ended September 30, 2016 (Agenda item 4.1) were discussed, together with the confidential Management Discussion and Analysis. For the year-to-date to the end of September the College has an operating surplus of $1.1 million. This is $0.9 million better than the budgeted surplus of $0.2 million. These results include the costs for the new information system which is being recorded as an operating expense rather than capital, consistent with current best practice. Members of the Finance Committee reviewed the detailed variance analysis included with the statements. The Finance Committee recommends: That Council approve the unaudited financial statements for the nine-month period ending September 30, Report of the Sub-Committee on Compensation Pam Hubley, Chair of the Sub-Committee presented its report and recommendations. Staff Compensation The Finance Committee was informed that no changes were proposed to the College s salary and benefits program. There was a discussion about plans related to controlling the costs and inequities in the College s pension plan

18 The Sub-Committee on Compensation advised the Finance Committee that the 2017 compensation program is congruent with the College s Compensation Principles and best practices in human resources. Stipend and Expense policies The Sub-Committee recommended changes to the amount for use of a private automobile and is recommending an amount for hotel accommodation. Those recommendations are addressed in the briefing on stipend and expense policies (agenda item 4.2) Budget The Finance Committee discussed the draft operating and capital budgets for 2017, along with projections to the end of 2020 (see agenda item 4.3). It was noted that the format of the budget package has changed significantly, with less data and more information. In summary, the draft 2017 operating budget estimates an operating surplus of $0.71 million which is the result of: budgeted revenues increasing by 20.7%. This is due to the 2017 fee increase; and budgeted expenses increasing by 10.3%. The Finance Committee noted that the operating budget calls for the College s accumulated surplus at the end of 2017 to equal 4 months of operating expenses. The projections for the next three years, 2018 to 2020, forecast that the accumulated surplus will remain close to the 4-month level. One of the goals for the fee increase to maintain the operating surplus at the middle of the range rather than have wide swings appears to have been achieved. The proposed capital budget for 2017 is $1.859 million. Major expenditures include waterproofing the north garage roof and continuing to provide the technology infrastructure required to function effectively. The Finance Committee recommends: That Council approve the 2017 operating and capital budgets. ATTACHMENTS 1. Draft minutes of the Finance Committee meeting of November 10,

19 Agenda Item 4.1 COLLEGE OF NURSES OF ONTARIO FINANCIAL STATEMENTS AND NOTES FOR THE NINE MONTHS ENDED SEPTEMBER 30, 2016 (Unaudited) TABLE OF CONTENTS Statement of Financial Position Statement of Operations Statement of Changes in Net Assets Statement of Cash Flows

20 College of Nurses of Ontario Statement of Financial Position As at September 30 ASSETS September September December Current Assets Cash 5,991,807 2,680,384 25,007,975 Investments 12,673,494 12,347,609 12,526,052 Sundry receivables 73, ,298 70,740 Prepaid expenses 546, , ,446 19,285,356 15,772,529 38,268,213 Investments 6,121,498 9,787,239 5,525,345 Capital assets Furniture and fixtures 2,169,226 2,118,171 2,157,673 Equipment - non computer 1,116,149 1,091,775 1,112,765 Computer equipment 2,793,842 2,744,482 2,611,361 Building 6,610,336 6,502,403 6,502,403 Building improvements 3,923,184 3,923,184 3,923,184 Land 3,225,009 3,225,009 3,225,009 Art 44,669 44,669 44,669 19,882,415 19,649,693 19,577,063 Less:Accumulated amortization 12,382,503 11,676,459 11,719,902 7,499,912 7,973,234 7,857,161 Intangible Assets 4,321,127 4,179,807 4,177,820 Less:Accumulated amortization 4,164,160 4,034,948 3,968,057 LIABILITIES 156, , ,763 33,063,734 33,677,861 51,860,483 Current Liabilities Accounts payable and accrued liabilities 3,178,594 2,869,073 6,520,289 Deferred membership and examination fees 6,580,963 6,461,100 23,138,109 9,759,557 9,330,173 29,658,398 Accrued pension liability 644, , ,600 10,404,157 9,777,428 30,302,998 NET ASSETS Net assets invested in capital assets 7,656,879 8,118,093 8,066,924 Unrestricted net assets 15,002,698 15,782,340 13,490,561 22,659,577 23,900,433 21,557,485 33,063,734 33,677,861 51,860,483 1

21 College of Nurses of Ontario Statement of Operations Nine Months Ending September Year to Date September 2015 Year to DateSeptember 2016 Budget Budget Actual Variance Budget Actual Variance Remaining Approved Fav./(Unfav.) Fav./(Unfav.) $ $ $ $ $ $ $ $ REVENUES Membership 20,609,885 20,902, ,442 20,464,242 20,501,738 37,496 6,567,786 27,470,113 Application Assessment 1,352,100 1,673, ,197 1,300,000 1,392,097 92,097 (108,897) 1,564,400 Verification & Transcripts 45,350 54,800 9,450 35,725 55,330 19,605 (1,175) 53,625 Interest Income 257, ,593 77, , ,892 (49,874) (43,393) 291,200 Examination 1,750,750 1,651,618 (99,132) 2,324,625 2,180,763 (143,862) 419,132 2,070,750 Other 181, ,916 (432) 161, ,423 8,353 45, ,575 Total Revenues 24,196,822 24,797, ,729 24,695,428 24,659,243 (36,185) 6,879,112 31,676,663 EXPENSES Executive Office 1,408,953 1,351,846 57,107 1,389,008 1,208, , ,316 2,004,162 Strategy and Innovation 2,796,959 2,836,237 (39,278) 1,839,975 1,639, , ,254 3,764,491 Quality 9,664,539 9,142, ,007 9,562,598 8,476,956 1,085,642 3,884,480 13,027,012 Administration 10,127,118 10,364,844 (237,726) 10,938,815 11,514,811 (575,996) 4,847,305 15,212,149 Total Expenses 23,997,569 23,695, ,110 23,730,396 22,840, ,968 10,312,355 34,007,814 Excess of Revenues over Expenses (Expenses over Revenues) 199,253 1,102, , ,032 1,818, ,783 (3,433,243) (2,331,151) Opening Net Assets 21,557,485 22,081,618 Closing Net Assets 22,659,577 23,900,433 2

22 College of Nurses of Ontario Statement of Changes in Net Assets Nine Months Ended September Invested in Capital and Intangible Assets Unrestricted Total December $ $ $ $ Balance, beginning of the period 8,066,924 13,490,561 21,557,485 22,081,618 Excess of (expenses over revenues) revenues over expenses (858,704) 1,960,796 1,102,092 (116,060) Purchase of capital assets 305,352 (305,352) - - Purchase of intangible assets 143,307 (143,307) - Defined Benefit Pension Plan (408,073) Balance, as of the end of the period 7,656,879 15,002,698 22,659,577 21,557,485 3

23 College of Nurses of Ontario Statement of Cash Flows Nine Months Ended September September September $ $ Cash flows from operating activities Excess of expense over revenues for the period 1,102,092 1,818,816 Adjustments to determine net cash provided by (used in) operating activities Amortization of Capital Assets 662, ,301 Amortization of intangible Assets 196, ,112 Intangible Assets Written off 1,175,602 Interest not received during the year capitalized to investments (243,596) (347,004) Interest received during the year previously capitalized to investments Funding of pension benefits (801,333) (857,264) Pension benefit expense 801, ,264 Changes in non-cash working capital items 1,717,200 3,711,827 Decrease/(Increase) in sundry receivables (2,846) 979,699 Decrease/(Increase) in prepaid expenses 116,977 (273,296) Decrease in accounts payables and accrued liabilities (3,341,695) (3,560,561) Decrease in deferred membership fees (16,557,146) (16,439,480) Cash flow from investing activities (18,067,510) (15,581,811) Purchase of investment (4,216,976) (10,516,460) Proceeds of disposal of investments 3,716,977 14,328,849 Purchase of capital Assets (305,352) (327,520) Purchase of Intangible assets (143,307) (394,599) (948,658) 3,090,270 Net (decrease) in cash during the period (19,016,168) (12,491,541) Cash, beginning of period 25,007,975 15,171,925 Cash, end of period 5,991,807 2,680,384 4

24 Agenda Item 4.2 Decision Note December 2016 Council Stipend and expense policies proposed revisions Contact for questions or more information Stephen Mills, Chief Administrative Officer Decision for consideration re. recommendations of the Executive and Finance Committees That Council approve the proposed revised stipend and expense policies as they appear in attachment 1 to the briefing note, to come into effect on January 1, Background Stipend and expense policies (attachment 1) are reviewed biennially and as special needs arise. In accordance with the committees respective terms of reference, the Sub-Committee of Compensation makes recommendations regarding changing amounts to the Finance Committee and the policies to the Executive Committee. The policies were last reviewed in 2014 for changes to come into effect on January 1, Amount of the daily stipend no change recommended: According to the stipend policy, stipend is a fixed amount, agreed upon by Council. It is given to Council and committee members in recognition of the service provided on Council and committees or in carrying out Council business. The same stipend is paid to all RN, NP and RPN Council and committee members. Public members, appointed by the Lieutenant-Governor-in-Council, are paid by the government and receive $150 a day. It has been the practice of the Sub-Committee to use 75% of top of the salary scale for a daily shift for RNs as set out in the Ontario Nurses Association (ONA) agreement as a benchmark for stipend. The current stipend, which came into effect on January 1, 2015 is 75.18% of the maximum ONA shift salary for April For that reason, an increase was not recommended. 1

25 Guidelines for payment of stipend Item 4 describes how stipend amounts are calculated. The policy currently states that members will be reimbursed a ½ day stipend for a meeting at the College that takes at least 2 hours. There would be no circumstance where we ask members to attend a meeting at the College and we would not give the member stipend. To make the policy consistent with practice, it is recommended that the policy be revised to state that attending a meeting at the College for any time under four hours will result in a stipend payment of ½ day. Allowance for use of a private automobile The College s currently pays $0.50/km for use of a private automobile. This rate came into effect on January 1, 2015 and was based on an average of the regulatory colleges surveyed and data about the costs of automobile use. It is adjusted from time to time, usually in response to significant increase in the costs of gasoline. There is often a lag between changing costs and an adjustment to the rate. The Canada Revenue Agency establishes and publishes reasonable (i.e. tax free) maximum allowable kilometre rates each year. This amount is adjusted annually to reflect cost changes. The Canada Revenue Agency rates for 2016 are $0.54/km for the first 5000km in a year and $0.48/km after that. These are national rates. Rates for the Northwest Territories, Yukon and Nunavut are higher. It is recommended that the rate paid for use of a private automobile be linked to the maximum allowable rates set annually by the Canada Revenue Agency. The recommendation is that the rate paid by the College would be set at 2 cents per kilometre under the applicable maximum allowable rate. The reduction provides for continuing to reflect the benchmarking results obtained from other regulatory colleges. If the policy was in effect for 2016, the College s rate for private use of an automobile would be $0.52/km (for the first 5000km), an increase of 2 cents per kilometre over the actual 2016 rate. If the proposed change is approved, at the beginning of each year, based on the policy, the amount will be adjusted and Council and committee members will be informed. Hotel Accommodation The College has two corporate hotels the Chelsea and the Bloor-Yorkville Marriott. Due to high levels of use the College is able to negotiate significantly reduced rates at both hotels as compared with other regulators. Both hotels are increasing our rates for 2017 The College s current policy speaks only to staying at one of the two corporate hotels. 2

26 The proposed policy frees members to stay at any hotel that they prefer and be reimbursed by the College to the maximum within the guideline of hotel (excluding taxes) and travel between the College and the hotel of $225 per night. This is sufficient to cover hotel accommodation and money towards travel between the hotel and the College. The College will pay the hotel directly for members staying at rooms within the College s guidelines at one of the corporate hotels (Chelsea or deluxe room at the Chelsea, standard room at the Marriott), thus reducing up front travel costs for members who chose this option. Council and committee members have experienced difficulty in booking rooms at our corporate rates. The difficulty is more acute for the Marriott because it is a small hotel. In addition, the costs are higher so there is not the flexibility to book at a slightly higher rate and get a room. The Chelsea is larger and less expensive. Deluxe rate rooms there cost less than the College is paying at the Marriott for standard rooms. There are still times when standard and deluxe rooms are not available. In addition to providing flexibility in choice of hotel, recognizing that there are times when members can still not get rooms at the daily rate, an exception has been provided. The proposed policy clearly outlines the member s accountability for booking rooms early and provides a mechanism for approval of hotel costs outside of the College s guidelines where the member meets that accountability and still cannot find a room at any of the rooms at the College rate at the Chelsea (Chelsea or deluxe) or the Marriott (standard). The member is expected to use their best efforts to find an acceptable room at a reasonable rate. Changing travel options To recognize the changing realities for travel in cities, it is proposed that the College s policies be amended to explicitly allow the use of ride sharing services and the Union Pearson (UP) Express. Given the need to be responsible with member money, ride sharing will not be reimbursed when surge pricing is in effect. Under those circumstances, the member would be expected to use another option, for example taxi. Meals The policy related to meals has been amended to clarify that where the College provides beverage and meal service during meetings, members choosing alternatives will be required to bear that cost. This does not include breakfast. 3

27 Editorial Changes Two additional editorial changes are suggested for clarification: Stipend policy 6 has been edited to identify that taxes deducted from stipend payments will be based on the member s TD-1 form. In the Overview and the Related Procedures and Requirements of the Expense Policies, it is clarified that itemized receipts are required. Attachments: 1. Current stipend and expense policies with proposed changes marked 2. Summary of Stipend and expenses of other regulatory bodies 4

28 Attachment 1 Stipend and Expense Policies OVERVIEW This policy on stipends covers RN (including NP) and RPN members of Council and committees. Stipend is a fixed amount, agreed upon by Council, which is given to RN and RPN Council and committee members in recognition of the service provided on Council and committees or in carrying out Council business. 1. STIPENDS Stipends payable under this policy are: a) $ per day for Council and committee members; and b) $ per day for Chairs of Council and statutory committees, statutory committee panel chairs, when chairing meetings or hearings, including deliberations and reason writing (when done by the panel), except for chairing the Executive Committee; and c) $ per day for the President for any meeting attended or chaired on behalf of CNO, except attendance at educational conferences and workshops; and d) $ per day for each Vice-President for any meeting attended or chaired on behalf of CNO, except attendance at educational conferences and workshops. 2. AUTOMATIC STIPEND 3. CLAIMABLE STIPEND A stipend payment under this policy will be automatically paid for: a) time in attendance at meetings of Council committees; b) a full day stipend will be paid for a scheduled one day meeting where the meeting is prematurely terminated; c) preparatory time for meetings attended for the following committees where the preparatory time for decision-making is ongoing and burdensome, at the rates stipulated 1 : i) Registration Committee one and a half stipend days for each day of meeting; ii) Inquiries, Complaints and Reports Committee (ICRC) two stipend days for each day of meeting; iii) ICRC Chair an additional one quarter stipend day for each day of meeting for review of decisions; iv) Executive Committee one stipend day for each day of meeting; v) Discipline Committee pre-hearing conferences one half stipend day for 250 pages of reading, pro-rated to 70 pages/hour; vi) Discipline Committee motion preparation on personal time 1 hour stipend for every 30 pages of required reading; vii) Quality Assurance Committee one half stipend day per day of meeting; viii) Fitness to Practise Consent Order meetings 1 hour stipend for every 30 pages of required reading; and ix) Finance Committee 1 day per day of meeting. A stipend payment under this policy may be claimed for: a) time while otherwise engaged in the business of Council (e.g. speaking engagements) for which prior eligibility for stipend has been confirmed; 1 Where relevant, preparatory time will be pro-rated based on the rates established and a 7 hour day 5

29 b) preparatory time payable under 2(b) if a member is suddenly and unexpectedly unable to attend a meeting and has done the preparatory work; c) time spent in drafting the reasons and decision of a Discipline hearing, under the following circumstances: i) the member has been assigned the task of drafting reasons on behalf of a panel and is doing the work on her or his own time; and ii) the amount paid is based on the amount of time spent in preparing the reasons, in accordance with the criteria itemized in section 4 of this policy. 4. CRITERIA FOR DETERMINING AMOUNT PAID The following criteria will be used in determining the amount of stipend to be paid/claimed for any one calendar day in attendance at the College: two to under four hours of meeting time four to nine hours of meeting time over nine hours of meeting time one half of the daily stipend (item 1a)stipend day one stipend day daily stipend one and a half stipend days daily stipends 5. CONFERENCE CALL STIPEND Stipend paid for conference call meetings is pro-rated based on the current daily stipend and a 7 hour day. The time value of a conference call will be determined by the Chair and recorded in the minutes. Preparatory stipends will be paid for conference calls based on the policies for preparatory stipend regarding committees [section 2(c)] and pro-rated in accordance with the time value of the conference call to the nearest half hour. 6. PAYEE Upon written confirmation from the member, her or his stipend cheques for meeting attendance will be made payable to the member s employer as a fee for service and no income tax deduction will be made. In all other instances, stipend cheques will be made payable to the member as taxable income, subject to income tax deduction and issuance of a tax form at year end. Income tax of 10% will automatically be deducted from a member s stipend based on the information submitted on the TD-1 form. unless specific direction is given by the member to deduct a greater or lesser amount. 7. PRESIDENT S HONORARIUM The President will receive an annual honorarium of $5, PRESIDENT S EMPLOYER CNO will offer to provide a lump-sum payment to the employer of the President of up to 25% of the President s salary to a maximum of $20,000 in any one year. 9. ADDRESSING CONCERNS Effective January 1, 2016 If a member is concerned about a decision regarding automatic or claimable stipend, the concern should first be discussed with the Executive Director and CEO. If the member is still concerned, she or he may appeal to the President. 6

30 Expense Policies OVERVIEW CNO provides for remuneration of expenses of RN (including NP) and RPN Council and committee members in order to ensure that involvement in Council and committee business does not place a financial burden on Council or committee members. The College will either reimburse the member for out of pocket expenses on receipt of a completed expense claim form, or will arrange and prepay for select services (e.g. hotel, air travel). To be eligible for reimbursement, expenses must: be related to Council or committee business; and be supported by itemized receipts 2. Members are expected to be fiscally responsible in the use of services, attempting where possible to minimize costs to the College through selection of the most cost-effective alternative and/or through sharing of services (e.g., taxis) where possible. Members are expected to follow the travel policies and procedures. All expense requests are subject to third party review (audit). Employers may be contacted to verify stipend claims for salary loss. RELATED PROCEDURES AND REQUIREMENTS Prior to incurring any expenses outside regular Council and committee involvements (e.g. speaking engagements), the member is required to obtain authorization from the Executive Director and CEO s office. Itemized receipts are required to support expenses. A written explanation must accompany any expenses not so supported. The College will pay hotel room charges, parking and taxes. Other charges on hotel bills are the responsibility of the member, and may be claimed as expenses if they fall within the parameters of the policies. Prior authorization from the Executive Director and CEO s office is required to cover any exceptions to the following specific policies. SPECIFIC POLICIES 1. OVERNIGHT ACCOMMODATION Allowable/reimbursable expenses related to specific accommodation facilities and services will be reimbursed by the College in accordance with the following policies: The cost of overnight accommodation will be paid by the College for attendance for College business. If a meeting has been cancelled in advance, the College will not be responsible for the cost of overnight accommodation. a) Hotel/Motel: Subject to sub-item ii below, the maximum daily allowable expense for hotel (exclusive of taxes) and transportation between the hotel and the College is $ Receipts are not required to claim the allowance for private accommodation under policy # 1(b) and the incidental allowance under policy #5. 7

31 Council and committee members may stay at any hotel and will be reimbursed this maximum for the hotel room and transportation between the hotel and the College. i) The College will pay the hotel directly if members stay at either of the Chelsea (Chelsea room or deluxe room) or the Toronto Marriott Bloor- Yorkville (standard room no concierge access). ii) Members are expected to book rooms not later than five business days following notification of a meeting. If the member provides evidence of being unsuccessful in booking a room at all of the room types listed above in (i) within the five days, staff may authorize above rate accommodation. The member must contact the committee administrator or Council Affairs Coordinator for authorization. It is expected that the member will use best efforts to find the most reasonable rate available. Members do not need to stay at one of the corporate hotels. For outside Toronto, a hotel will be selected by the College that offers the rate closest to the CNO s corporate rate at the corporate hotels. Charges for failure to cancel accommodation are the responsibility of the member. Hotel accommodation is not generally provided to members who reside within a radius of 40km 3 of the meeting site. To take advantage of corporate rates: i) In Toronto All requirements for overnight hotel accommodation in Toronto must be arranged in accordance with the travel policies and procedures. ii) Outside Toronto The committee staff resource person will, upon request, arrange for accommodation in other centres. Members need to verify the charges against the bill before checking out. An initialled copy of the bill needs to be attached to the expense form to facilitate expense administration. b) Private Accommodation: For members who are eligible to stay in a hotel (see above), an allowance of $50.00 per night may be claimed, without receipt, for private accommodation used. 2. TRAVEL The College will cover the costs of travel from the member s electoral district (either home or work) to the College for College business. a) Between cities: The following are allowable expenses for transportation required between centres: i) Economy airfare 4 ; ii) Train: Economy class for journeys of two hours or less; or 3 Eligibility to stay in a hotel will be decided based on the shortest travel distance between the member s home and the College on Google maps. 4 Air travel must be booked through Vision using the most economical option. 8

32 Business class for journeys exceeding two hours. iii) Bus; iv) Private automobile at the rate published by the College at the start of each calendar year and equal to the applicable maximum allowable Canada Revenue Agency rate less 50 2 cents per kilometre, plus tolls, to a total not to exceed the economy airfare; and v) Car rental. Travel expenses claimed must reflect travel via the most expedient means, consistent with convenience and economy. If a more time-consuming mode of travel is selected voluntarily by the member, the maximum entitlement under this policy is the equivalent of those reasonable expenses had economy airfare been selected. Note: All air travel arrangements are made through Vision b) Within a City: The following are allowable expenses for transportation within a city for travel related to College business (including the Council dinner): i) Private automobile at a rate published by the College at the start of each calendar year and equal to the applicable maximum allowable Canada Revenue Agency rate less50 2 cents per kilometre; ii) Parking for private automobile; iii) Taxis, with receipts (ensure that the date and the to and from locations are included on the receipt); iv) Ride sharing service, regular pricing (surge pricing is not an allowable expense); v) Use of the Union Pearson (UP) Express between Pearson International Airport and the city centre or vi) Bus/subway fare (no receipt required). c) Business Travel Insurance All Council and committee members are provided, at College expense, with accidental death and dismemberment insurance in the principal sum of $100,000. This insurance provides 24-hour protection for members while travelling on College business. 3. MEALS The cost of meals for travelling members is an allowable expense to a maximum of $65.00 per day inclusive of taxes and gratuities. In-town members may claim the cost of a meal with Council or committee members for business purposes. Expense claims must be supported by receipts. Where the College is providing meals and beverages during meetings, the cost of replacing that meal or beverage is not an allowable expense. This does not include breakfast. 9

33 4. SALARY LOSS a) A member may claim up to the maximum of the equivalent to the current daily stipend for salary loss which she or he cannot recover by rearranging her or his work schedule for: i) time committed to meetings which are unexpectedly cancelled or prematurely terminated; ii) travelling time related to scheduled meetings of Council and committees, meetings which are unexpectedly cancelled, and time while otherwise engaged in Council business (e.g. speaking engagements) for which prior authorization has been confirmed. b) For time committed to meetings which are unexpectedly cancelled or prematurely terminated, a member who works part time, casual or contract and who has declined to schedule work in order to attend a meeting scheduled for a full day, may claim up to the maximum of the equivalent to the current daily stipend for salary loss which she or he cannot recover by rearranging her or his schedule. c) A half stipend day may be claimed by members who work a 12-hour shift as follows: i) a member may claim stipend if the four-hour differential results in salary loss when the member receives a one day stipend; or ii) a member may claim the differential, to be paid to the member s employer, if the member was replaced by her or his employer and the four-hour differential has resulted in additional cost to the employer. 5. INCIDENTALS A daily incidental allowance of $10.00 may be claimed without supporting receipts for each day for which the member required overnight hotel accommodation. (The incidental allowance is intended to cover costs for telephone calls and other un-receipted expenses such as tips that are incurred while staying in a hotel.) 6. GRATUITIES Gratuities for taxis and limousines will be limited to the higher of $1.50 or 15% of the metered charge, whichever is more. 7. NON- REIMBURSABLE EXPENDITURES Gratuities for meals will be limited to a maximum of 15% of the total bill. The College will not reimburse for the following expenses: Child or elder care; Dry cleaning, shoe shines and other personal services; Movie rentals; Parking violations; Tips for porters, housekeeping; Telephone calls; and Meals upon return home. 8. WEEKEND STAYS A member attending a Friday or Monday meeting who chooses to remain in Toronto over a Saturday night, with a resultant savings in travel cost, may claim the costs for hotel and meals 10

34 up to a maximum of 80% of the cost savings. The member must request the expenses on the CNO expense account sheet with an attachment itemizing: the cost of the full economy air fare; the reduced travel cost; the cost savings; and the eligible expenses. Expenses incurred must continue to fall within CNO guidelines to be climbable. This policy does not apply to members who stay in Toronto because of meetings on both Friday and Monday. Full expense reimbursement in those instances will be considered on an individual basis. 9. CANCELLED MEETINGS & EXTENDED STAYS DUE TO UNFORESEEN CIRCUMSTANCE The College will reimburse Council and committee members for unavoidable expenses incurred relating to: a cancelled meeting for which it was not possible to cancel travel plans, and extended stays due to unforeseen circumstances such as cancelled flights caused by inclement weather. Effective January 1,

35 Attachment 2 Stipend and Expense comparison COLLEGE STIPEND CHAIR/OFFICER DIFFERENTIAL Nurses $260 $100 President/Chair $50 Vice-President Teachers No stipend paid school board is reimbursed for costs of replacement if needed Council Chair is full time paid position, seconded from school board Vice-Chair of Council and committee chairs no differential Dentists $1060 $1565 President $12370 Chair Docs $932 $1199 President $987 Vice-President CAR ALLOWANCE $0.50/km $0.54/km until 5,000 $0.48/km after 1 $0.54/km until 5,000 $0.48/km after $0.55/km MEAL ALLOWANCE $65 (includes tax and gratuities) Lunch provided $20 for breakfast $25 for lunch $50 for dinner Except for breakfast, members are not reimbursed where the College provides a meal $15 for breakfast $20 for lunch $50 for dinner Lunch and dinner served for Council meetings HOTEL ALLOWANCE Use corporate hotels Use Intercontinental only Other hotels will not be reimbursed $300/night $300/day for hotel and maintenance for out of town members, includes meals Physiotherapists $275 - planning increase $375 for Chair/Pres. $0.41/km $120/day: $25 breakfast, $30 lunch, $65 dinner Use Hilton hotel or allowance of $276 1 This is the rate that the Canadian Revenue Agency has identified is reasonable to receive as a non-taxable expense. 12

36 COLLEGE STIPEND CHAIR/OFFICER DIFFERENTIAL Occupational Therapists $225 VP $250 President/Chair $300 Pharmacists No stipend paid daily allowance see notes under meal allowance and incidentals Dental Hygiene $265 President 40% extra ($106) VP and Committee Chair 25% extra CAR ALLOWANCE MEAL ALLOWANCE lunch provided for meetings and not covered when provided $0.50/km $70 lunch provided for meetings, member not reimbursed for lunch when provided $0.45/km ($66.25) Ministry of Health $150 $100 $.40/km until 5,000 $.35/km after The Ministry pays a $.01 differential for northern travel $0.50/km $90 Do not reimburse for liquor HOTEL ALLOWANCE $250 $300/day for each day the member is attending a meeting out of her/his community to cover all expenses except travel Additional $210 when arrival is needed the night before the meeting $165/day when a meeting is held in the member s community this would include the cost of travel to the meeting $40, includes lunch with meal maxima: Breakfast $8.75 Lunch $11.25 Dinner $250 Hotels based on government of Canada Guidelines. Allow for CNO the Eaton Chelsea and the Marriott (have made specific exception for Marriott expecting lower taxi charges) 13

37 Attachment 3 College of Nurses of Ontario 2017 Draft Operating & Capital Budget Table of Contents Page Summary of Revenue and Expenses Capital Budget Financial Position Cash Flow

38 College of Nurses of Ontario Summary of Revenue and Expenses ($000) Draft Operating and Capital Budget for the Year Actual 2015 Actual 2016 Approved Budget 2016 Forecast 2017 Draft Budget 2017 Budget Over / (Under) 2016 Budget 2018 Proj'n 2019 Proj'n 2020 Proj'n REVENUES Membership Fees 26,782 27,241 27,470 27,640 33,715 6, % 35,840 37,192 38,643 Application Assessment 1,347 1,721 1,564 1,951 1, % 1,638 1,674 1,695 Endorsements & Transcripts % ,195 29,032 29,088 29,653 35,712 6, % 37,527 38,916 40,392 Interest Income % Exam Revenue 5,633 2,477 2,071 1,843 1,981 (90) -4.3% 2,057 2,112 2,123 Other Revenue 1, (55) -24.1% Total Revenue 35,639 32,310 31,677 32,107 38,219 6, % 40,102 41,516 42,974 EXPENSES Executive Office 1,975 1,770 2,004 1, (1,447) -72.2% Strategy and Innovation 3,100 3,448 4,811 4,902 5, % 5,165 5,295 5,397 Quality 16,308 13,732 14,167 13,471 14, % 13,943 15,077 15,978 Administration 10,924 13,476 13,026 13,123 16,232 3, % 18,529 19,434 20,300 Total Expenses 32,307 32,426 34,008 33,412 37,505 3, % 38,205 40,386 42,267 (Deficit)/Surplus of Revenue over Expenses 3,332 (116) (2,331) (1,305) 714 3, % 1,897 1, Opening Net Assets 10,013 12,446 12,201 13,491 12,550 12,382 13,630 14,242 Net Capital Assets (900) 1,161 (724) 364 (882) (649) (518) 253 Closing Net Assets 12,446 13,491 9,146 12,550 12,382 13,630 14,242 15,203 Accumulated Surplus (# of months)

39 College of Nurses of Ontario 2017 Capital Budget and Projections ($000) Draft Operating and Capital Budget for the Year Fixed Asset Category Description 2017 Building Improvement HVAC Equipment /Air Compressor Replacement 185 Replacement of Heat and Smoke Detector, Sensor/Relays 30 Garage Waterproofing - Exterior North Lounge / Garage Area 345 Hardware Server Peripherals (hard drives) 503 Mobile Computers (Council and committees) (50) 60 Mobile Computers (training) (9) 7 Mobile Computers (new and refresh) (53) 63 AV+SPL Microphone Replacement 242 Hardware Peripherals (scanner, monitor, switches) 76 Software Servers 293 Personal Computers 54 Total Capital for , Fixed Asset Category Description 2018 Building Improvement HVAC efficiency project 370 Bilge and sewer pump rebuild 8 Garage waterproofing - Exterior South Lounge/ garage area 300 Space planning, renovation, general contracting (mechanical/electrical) 795 Hardware Server Peripherals (hard drives) 147 Network Printers 20 Personal computer 63 Other 52 Software Servers 25 Personal Computers 9 Total Capital for ,788 3

40 College of Nurses of Ontario 2017 Capital Budget and Projections ($000) Draft Operating and Capital Budget for the Year Fixed Asset Category Description 2019 Furniture & Fixtures Workstations & Modules Space planning Renovations 800 Hardware Server Peripherals (hard drives) 92 Network Printers 10 Personal Computers 60 Other 816 Software Servers 25 Personal Computers 9 Total Capital for , Fixed Asset Category Description 2020 Building Improvement HVAC Equipment 200 Mechanical Systems 150 Structures/Envelope 200 Other 550 Hardware Server Peripherals (hard drives) 150 Personal Computers 75 Software Servers 250 Personal Computers 25 Total Capital for ,600 4

41 College of Nurses of Ontario Statements of Financial Position as at Decemeber 31 ($000) Draft Operating and Capital Budget for the Year Actual 2015 Actual 2016 Approved Budget 2016 Forecast 2017 Draft Budget ASSETS Current Assets: Cash 15,172 25,008 15,153 12,695 10,942 13,147 12,711 15,509 Investments 18,921 12,526 15,538 16,308 17,048 15,432 15,568 15,035 Sundry receivables 1, Prepaid expenses Proj'n 2019 Proj'n 2020 Proj'n 35,544 38,268 31,104 29,749 28,691 29,230 28,600 30,864 Investments 6,679 5,525 6,020 12,000 13,000 12,338 14,627 15,257 Capital Assets: Land 3,225 3,225 3,225 3,225 3,225 3,225 3,225 3,225 Building 6,502 6,502 6,502 6,664 6,664 6,664 6,664 6,664 Building Improvements 3,904 3,923 4,343 3,945 4,505 5,978 5,978 6,528 Computer Hardware 2,484 2,611 2,926 2,843 3,795 4,077 5,055 5,280 Furniture and Equipment 3,207 3,315 3,403 3,344 3,344 3,344 4,144 4,144 19,322 19,577 20,400 20,021 21,534 23,288 25,066 25,841 Less: Accumulated Amortization 11,039 11,720 12,765 12,591 13,474 14,491 15,658 16,815 Intangible Assets 8,283 7,857 7,635 7,430 8,059 8,796 9,408 9,026 Computer application software 4,438 3,655 5,760 3,798 4,144 4,178 4,211 4,486 Jurisprudence Exam Dev. Costs ,961 4,178 6,283 4,321 4,668 4,701 4,735 5,010 Less: Accumulated Amortization 3,608 3,968 4,232 4,039 4,132 4,253 4,381 4,527 1, , ,315 13,592 15,706 19,713 21,595 21,582 24,389 24,766 Total Assets 51,859 51,860 46,810 49,462 50,286 50,813 52,989 55,630 LIABILITIES Current Liabilities: Accounts Payable & Accrued Liabilities 6,430 6,520 4,866 5,695 5,613 4,443 5,714 6,335 Deferred Membership Fees 22,901 23,138 22,762 22,660 22,851 22,601 22,351 23,798 29,330 29,658 27,628 28,355 28,464 27,044 28,065 30,134 Accrued pension liability ,777 30,303 27,978 29,199 29,308 27,939 28,985 30,918 NET ASSETS Invested in Capital Assets 9,636 8,067 9,686 7,713 8,595 9,244 9,762 9,509 Unrestricted 12,446 13,491 9,146 12,550 12,382 13,630 14,242 15,203 22,082 21,557 18,831 20,263 20,977 22,874 24,004 24,711 Total Liabilities and Net Assets 51,859 51,860 46,810 49,462 50,286 50,813 52,989 55,630 5

42 College of Nurses of Ontario Statements of Cash Flows ($000) Draft Operating and Capital Budget for the Year 2017 Cash flows from operating activities Excess of expenses over revenues for the period Adjustments to determine net cash provided by (used in) operating activities Amortization of capital assets Amortization of intangible assets Intangible assets written off 2014 Actual 2015 Actual 2016 Forecast 2017 Draft Budget 2018 Proj'n 2019 Proj'n 2020 Proj'n 3,332 (116) (1,305) 714 1,897 1, ,017 1,166 1, ,071 Decrease (increase) net pension expenses over funding (322) (211) (200) 0 (50) (75) 135 Interest capitalized on investments (40) (18) (211) (120) (75) (75) (75) 4,171 1,931 (774) 1,571 2,910 2,274 2,071 Change in non-cash working capital (Increase) decrease in sundry receivables (1,010) 1, (15) 0 (Increase) decrease in prepaid expenses (51) (302) Decrease (increase) in inventory (Decrease) increase in accounts payables and accrued liabilities (193) (82) (1,170) 1, (Decrease) increase in deferred membership fees (278) 238 (478) 191 (250) (250) 1,447 2,638 2,976 (493) 1,725 1,540 3,616 4,140 Cash flows from investing activities Purchase of investments (17,832) (14,166) (26,705) (19,112) (13,672) (14,391) (14,144) Proceeds from disposal of investments 18,055 21,733 15,473 17,492 16,125 12,151 13,852 Purchase of capital assets (1,091) (416) (444) (1,512) (1,754) (1,778) (775) Purchase of intangible assets (893) (290) (143) (346) (34) (34) (275) (1,760) 6,860 (11,820) (3,479) 666 (4,052) (1,342) Net (decrease) increase in cash during year 877 9,836 (12,313) (1,754) 2,206 (436) 2,798 Cash, beginning of the period 14,294 15,172 25,008 12,695 10,942 13,147 12,711 Cash, end of the period 15,172 25,008 12,695 10,942 13,147 12,711 15,509 6

43 Agenda Item Decision Note December 2016 Council Nurse Practitioner Prescribing of Controlled Substances: Proposed Changes to the Controlled Acts Regulation Contact for Questions Kevin McCarthy, Director of Strategy Three Controlled Substances Briefing Notes: A Roadmap There are three briefing notes related to controlled substances each relating to the other. 1. The first briefing note relates to proposed changes to the regulation. This includes a proposed requirement that nurse practitioners attain controlled substances education before prescribing controlled substances. 2. The second briefing note relates to proposed changes to by-laws. This includes proposed content to enable the College to post and remove information related to the proposed education requirement. 3. The third briefing note relates to proposed controlled substances courses that will enable nurse practitioners to meet the proposed education requirement. This item is coming to Council at this time so that the College and members can plan for implementation. Motion for Consideration That the proposed amendments to Part III (Controlled Acts) of Ontario Regulation 275/94 (General) under the Nursing Act, 1991, as shown in Attachment 1 to the briefing note, be approved for notice and circulation to members and stakeholders. Public Interest and Public Safety Rationale The College is responsible for ensuring there are mechanisms in place to support safe nursing practice. Activities related to controlled substances, such as prescribing, are high risk given the increased risks associated with misuse, addiction and diversion. The proposed regulatory changes support nurse practitioners gaining the competencies to support safe, effective and ethical practice. Council needs to consider if they believe the regulations are drafted in the public interest. A clause-by-clause in Attachment 2 provides additional explanation regarding the proposed changes

44 What are the Proposed Changes? There is currently a provision in the Controlled Acts Regulation that prohibits nurse practitioners from prescribing and selling 1 controlled substances. The proposed changes enable nurse practitioners to perform these activities. However, in accordance with the proposed changes, these activities could only be performed if two conditions are met: nurse practitioners meet existing requirements related to prescribing and selling; and, nurse practitioners must complete education that teaches and assesses competencies to safely, effectively and ethically prescribe controlled substances 2. What Other Education Options were Considered? There were other options considered with respect to the education requirement. They are briefly outlined below. If the nurse practitioner did not complete controlled substances education, as a variation of what s proposed, the College explored applying a term, condition or limitation to a member s certificate of registration. This option required changes to the registration regulation. These are far more complex regulatory changes, which would have been difficult to achieve given the tight timelines 3. This option also provided a loophole to get around the requirement, which was a risk to the public (e.g., those seeking reinstatement/reapplication, labour mobility applicants). The other option that was considered was making the education mandatory. With respect to the education requirement, this option went the furthest in protecting the public. On the flip side, there were public interest concerns that if nurse practitioners moved to the general class (no longer working as nurse practitioners) that some clients might be disadvantaged if they lost their care provider. This option also would have required substantive changes to the registration regulation, which would have been very difficult to meet in the timelines given. There is an evaluation plan that will inform potential future changes. In the future Council could consider if there is anything in the College evaluation data or any new evidence to indicate the direction the College took is no longer in the public interest (e.g., should education be a mandatory requirement?). Background Federal laws (e.g., Controlled Drugs and Substances Act), which took effect in 2012, authorized nurse practitioners to prescribe controlled substances. However, these activities are currently prohibited in Ontario under the Nursing Act, 1991: 1 Selling a drug involves the transaction of money. Risks, such as conflict of interest, are already addressed in regulation (e.g., not making a profit on selling a drug). 2 This builds on competencies nurse practitioners already have related to prescribing drugs (the education would address the unique risks associated with controlled substances). 3 Including the time involved in engaging additional stakeholders

45 A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance 4. Since changes to scope of practice for any health profession are a Government decision, the College is moving forward with this work now given recent direction from Government (see attached letter from Minister Hoskins sent October 24, 2016). The College is in a good position to move forward with this. Since 2012, the College has been conducting policy work (e.g., gathering and assessing evidence) and operational work (e.g., developing new business processes) to support implementing this new area of practice. What are Controlled Substances? A controlled substance is a medication that is restricted by federal law. These medications are restricted because they present a high risk of abuse, addiction and diversion. Controlled substances are used in healthcare to treat a wide variety of conditions including pain, anxiety and sleep disorders (e.g., controlled substances include fentanyl, ativan, codeine, morphine, methadone). The use of these medications is essential for nurse practitioners to independently meet client needs. Regulation Making Authority Council has regulation making authority related to the proposed changes: Under subsection 95(1) of the Health Professions Procedural Code (Regulated Health Professions Act, 1991): (u) prescribing anything that is referred to in the health profession Act or this Code as being prescribed. Under subsection 5.1(1) of the Nursing Act, 1991: 8. Prescribing, dispensing, selling or compounding a drug in accordance with the regulations. National Harmonization A national working group under the Canadian Council of Registered Nurse Regulators (CCRNR) was launched in 2012 to establish consistent approaches in regulating this new area of practice. The group identified controlled substances education requirements that address federal jurisprudence, the unique risks of harm associated with controlled substances and strategies for mitigating risk of harm. Specific courses covering this content were recommended to the CCRNR board who in turn recommended these courses to their jurisdictions. With the exception of Ontario, all Canadian jurisdictions have authorized nurse practitioners to prescribe controlled substances. In fact, new national nurse practitioner competencies (2016) reflect controlled substances content. Discussions with jurisdictions indicate no concerns with implementing this new area of practice (e.g., no examples of patient safety issues). When jurisdictions were asked lessons learned, they stated that ongoing engagement with key 4 Part III (Controlled Acts) of Ontario Regulation 275/94 (General) under the Nursing Act,

46 stakeholders was critical to successful implementation. The College is already consulting with key stakeholders. Other Regulators The College has and will seek to learn from other regulators whose members have access to activities associated with controlled substances. For example, in Ontario, the College has been engaged with the College of Physicians and Surgeons of Ontario, the Ontario College of Pharmacists and the Royal College of Dental Surgeons of Ontario. Across Canada, jurisdictions have shared information and resources among nursing regulators. The College also has information from nursing regulators around the world. Their expertise and policies are one piece of evidence that inform and will continue to inform the College s work (e.g., development of practice expectations). Literature Review A comprehensive literature review was conducted to understand the unique risks associated with controlled substances so the College could identify appropriate regulatory mechanisms to support implementation of this high risk activity. Controlled drugs have the potential for misuse, abuse and diversion and thus pose a risk to the public i. Prescription opioids are increasingly recognized as one of the primary forms of illicit drug use ii,iii. In fact, nonmedical use of prescription pain medication is the second most common form of drug abuse (after marihuana) iv,v. The increase in morbidity and mortality from misuse, overuse and diversion of prescribed opioids vi,vii is a public health concern viii. Canada is the second largest per capita consumer of prescription opioids in the world ix. In fact, opioid pain relievers are used by 14.9% of Canadians (which is a decrease from 21.6% in 2008) x. Furthermore, Ontario has the highest rate of prescription opioid use in Canada xi. As prescription rates of controlled substances have increased, morbidity xii and mortality xiii,xiv rates have also increased. For example, from 2005/06 to 2010/11, there was almost a 250% increase in the number of emergency room visits related to narcotics withdrawal, overdose, intoxication, psychosis and other related diagnoses xv. In 2014, over 700 people died in Ontario from opioidrelated causes, a 266% increase since 2002 xvi. As described above, controlled substances are used to treat a wide variety of conditions including pain, anxiety and sleep disorders. Regulatory responsibility is dual: supporting access to evidence-informed treatment and addressing risks associated with controlled substances xvii. With respect to supporting appropriate treatment, pain is used as an example in this briefing note. Pain is the most common reason for seeking health care xviii,xix. Pain accounts for up to 78% of visits to the emergency department xx. In fact, one article stated that one in five Canadian adults suffer from chronic pain xxi. Pain can affect life physically, emotionally, socially, spiritually and economically xxii. Despite the frequency clients experience pain, undertreatment of pain is frequently reported in the literature xxiii,xxiv,xxv,xxvi,xxvii,xxviii,xxix,xxx,

47 In developing regulatory mechanisms, the College needs to consider and balance opposing risks: the risks of the client not receiving care needed and the unique risks associated with controlled substances. Consultation In 2013, the College conducted a survey of Ontario nurse practitioners to better understand practice realities associated with the use of controlled substances (e.g., relevance of specific controlled substances, learning needs, existing supports, and attitudes and concerns about the risks associated with controlled substances). Findings from this survey include: over 80% of Ontario nurse practitioners ask a physician at least a few times a month to prescribe controlled substances for their clients; 71% would prescribe controlled substances if given the legal authority; and, 64% perceived the need to have additional learning to prescribe controlled substances. In addition, in 2014, the College consulted on proposed core competency indicators and practice expectations associated with nurse practitioners prescribing controlled substances. The following stakeholders provided input: key informants (including a physician and pharmacist with expertise in controlled substances); Ontario nurse practitioners; Ontario nurse practitioner educators; Ontario nursing associations; select Ontario health regulators; and, registered nurse regulators across Canada. Findings from the 2014 consultation, in addition to consultation planned for December 2016, will inform the draft practice expectations for the Nurse Practitioner Practice Standard, which will be brought to Council for decision in March The College has had ongoing discussions with Government since 2012 and most recently engaged Ministry staff and their legal counsel in drafting the regulations proposed to Council. Furthermore, after direction was received from Government this Fall, the College engaged several key stakeholders to inform the work the College is conducting and to identify areas for collaboration and joint communication. Rationale for Education Requirement In March 2014, Council supported that, in principle, the College require Ontario nurse practitioners to complete College-approved education before prescribing controlled substances: That Council approve in principle that it be mandatory for nurse practitioners to complete College approved education before prescribing controlled substances until this new area of practice is incorporated into entry requirements

48 An education requirement is one mechanism that supports the safe implementation of this new area of practice. Education will ensure nurse practitioners have competencies that address the unique risks associated with controlled substances (nurse practitioners already have competencies associated with prescribing drugs this education builds on that). Individuals would be required to complete Council approved education until competencies related to controlled substances are integrated into nurse practitioner programs 5. Other regulatory mechanisms include changes to standards and the quality assurance program, and processes to deal with complaints and reports. These and other mechanisms will be part of the project plan. Other regulatory bodies who have implemented this high risk activity have required controlled substances education. All Canadian registered nurses regulatory bodies have required education for nurse practitioner to prescribe controlled substances. In the UK, additional training for nurses was recommended and these nurses had to demonstrate competency before being able to prescribe xxxi,xxxii. Mandatory education related to safe prescribing, with an objective test to ensure knowledge acquisition, has also been recommended as a requirement in the US to prescribe controlled substances xxxiii,xxxiv. The literature supports an education requirement. A report for Health Canada states that a good knowledge base is essential and proper training is critical to ensure client safety xxxv. Similarly, an Ontario forum recommended education related to prescribing opioids xxxvi. Education is also a part of Ontario s 2016 opioid strategy xxxvii. Literature recommend education to address dependence, addiction, misuse, abuse and diversion xxxviii,xxxix,xl. As described above, a working group under the Canadian Council of Registered Nurse Regulators identified educational content necessary for public protection and also recommended existing courses that met these requirements. This is further described in the December 2016 briefing note proposing controlled substances courses for Council approval. Communication Strategy Following direction from Government to proceed with enabling nursing practitioners to prescribe controlled substances, in October 2016, the College communicated these plans externally including plans to bring proposed regulations to Council. As described above, this Fall, the College also engaged key stakeholders. In addition, staff have developed a comprehensive communication strategy identifying various audiences, different modes of communication and timing of communication. 5 It remains a requirement for members so, for example, someone coming from another Canadian jurisdiction would be required to meet the requirement or have a notation on the register that they don t have the competencies to prescribe controlled substances

49 Next Steps Subject to Council s approval, the proposed regulation will be circulated to members and stakeholders for a 60 day feedback period. At the March 2017 Council meeting, a summary of stakeholder feedback will be provided to Council. Council will consider if there is anything in the feedback that suggests the regulations are not drafted in the public interest. At that time, subject to Council approval, the draft regulations will be forwarded to Government for their review and approval processes. Also at the March 2017 Council meeting, a revised Nurse Practitioner Practice Standard will be brought to Council for consideration, reflecting practice expectations related to controlled substances. Attachments 1. Proposed amendments to Part III (Controlled Acts) of Ontario Regulation 275/94 (General) under the Nursing Act, Clause-by-Clause description of the proposed changes 3. Letter from Minister Hoskins - 7 -

50 Attachment 1 Proposed amendments to Part III (Controlled Acts) of Ontario Regulation 275/94 (General) under the Nursing Act, 1991 Amending O. Reg. 275/94 (GENERAL) Ontario Regulation 275/94 is amended by deleting subsection 16(4) and substituting the following: (4) A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance, except where specifically authorized by the Act and this regulation. Ontario Regulation 275/94 is further amended by adding a new section 19.2 under the heading Prescribing and Selling Controlled Substances, as follows: PRESCRIBING AND SELLING CONTROLLED SUBSTANCES 19.2 (1) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member who complies with this section is authorized to prescribe and sell a controlled substance. (2) A registered nurse in the extended class who is otherwise authorized to prescribe or sell a controlled substance, shall only do so if he or she complies with the following requirements: 1. The member must have satisfied the Executive Director that he or she has, within any time period set by Council, successfully completed education approved by Council, which was specifically designed to educate registered nurses in the extended class to safely, effectively and ethically prescribe controlled substances. 2. The member complies with the provisions of section 17, where the member prescribes a controlled substance. 3. The member complies with the provisions of section 19.1, where the member sells a controlled substance. (3) For greater clarity, the education referred to in paragraph 1 of subsection (2) may be education independent of or part of the education and training required to become a registered nurse in the extended class

51 Attachment 2 Clause-by-Clause description of the proposed changes The purpose of this document is to give a detailed overview of the proposed changes to the controlled acts regulation (Part III of regulation 275/94 under the Nursing Act, 1991). Current Provision Proposed Change Rationale 16(4) A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance. N/A N/A (4) A member who is authorized to prescribe, sell or compound a drug shall not prescribe, sell or compound a controlled substance, except where specifically authorized by the Act and this regulation. PRESCRIBING AND SELLING CONTROLLED SUBSTANCES 19.2 (1) For the purposes of paragraph 8 of subsection 5.1 (1) of the Act, a member who complies with this section is authorized to prescribe and sell a controlled substance. (2) A registered nurse in the extended class who is otherwise authorized to prescribe or sell a controlled substance, shall only do so if he or she complies with the following requirements: This is a general provision for all nurses. Adding the wording at the end of this provision enables the development of relevant regulations for nurse practitioners while maintaining the prohibition for other nurses. 5.1(1) relates to the controlled acts nurse practitioners are authorized to perform under the Nursing Act, Paragraph 8 relates to prescribing and selling drugs. The proposed provision enables nurse practitioners to prescribe and sell controlled substances if certain conditions are met (nurses are already authorized to dispense controlled substances). Council has the authority to approve controlled substances education. The proposed regulation states that nurse practitioners must complete this education to be able to prescribe controlled substances. 1. The member must have satisfied the Executive Director that he or she has, within any time period set by Council, successfully completed education approved by Council, which was specifically designed to educate registered nurses in the extended class to Nurse practitioners must also comply with existing conditions in the regulation (i.e., conditions associated with prescribing and selling drugs)

52 safely, effectively and ethically prescribe controlled substances. 2. The member complies with the provisions of section 17, where the member prescribes a controlled substance. N/A 3. The member complies with the provisions of section 19.1, where the member sells a controlled substance. (3) For greater clarity, the education referred to in paragraph 1 of subsection (2) may be education independent of or part of the education and training required to become a registered nurse in the extended class. (3) is proposed so that, in the future, it is clear that controlled substances competencies can be integrated into program approval (and therefore become part of entry requirements). Also, if an individual already completed a program that had controlled substances content integrated (e.g., a program in the US), this can be assessed and brought to Council for consideration. (This would no longer be needed once the content is part of the College s program approval)

53 Endnotes i Van Zee, A The promotion and marketing of oxycontin: Commercial triumph, public health tragedy. American Journal of Public Health, 99(2), ii Expert Working Group on Narcotic Addiction. (2012). The Way Forward: Stewardship for Prescription Narcotics in Ontario (Report to the Ontario Minister of Health and Long-Term Care). Retrieved from en/public/publications/mental /docs/way_forward_2012.pdf iii NCSBN. (2008). Our Collective Voice: Orchestrating the future of Regulatory Excellence, Attachment A. NCSBN 2008 Annual Meeting. iv Houston, T. (2012). Opioid abuse and pain management. American Family Physician, 84(7), v Office of National Drug Control Policy. Prescription drug abuse. Retrieved June 11, 2013 from vi Lipman, A. (2012). Pain management, palliative care, and substance abuse. Journal of Pain and Palliative Care Pharmacotherapy, 26, vii Kahan, M., Mailis-Gagnon, A., Wilson. L., & Srivastava, A. (2011). Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 1: general population. Can Fam Physician, 57, viii Lipman, A. (2012). Pain management, palliative care, and substance abuse. Journal of Pain and Palliative Care Pharmacotherapy, 26, ix National Advisory Committee on Prescription Drug Abuse (2013) First do no harm: responding to Canada s prescription drug crisis. Canadian Centre on Substance Abuse x Canadian Center on Substance Abuse. (2015). Canadian Drug Summary. Retrieved from xi Expert Working Group on Narcotic Addiction. (2012). The Way Forward: Stewardship for Prescription Narcotics in Ontario (Report to the Ontario Minister of Health and Long-Term Care). Retrieved from en/public/publications/mental /docs/way_forward_2012.pdf xii Dhalla, I.A., Mamdani, M.M., Sivilotti, M.L.A., Kopp, A., Qureshi, O., Juurlink, D.N. (2009) Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal, 181(12), xiii Dhalla, I.A., Mamdani, M.M., Sivilotti, M.L.A., Kopp, A., Qureshi, O., Juurlink, D.N. (2009) Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal, 181(12), xiv CPSO. (2010). Avoiding abuse, achieving a balance: tackling the opioids public health crisis. xv Expert Working Group on Narcotic Addiction. (2012). The Way Forward: Stewardship for Prescription Narcotics in Ontario (Report to the Ontario Minister of Health and Long-Term Care). Retrieved from en/public/publications/mental /docs/way_forward_2012.pdf xvi Ontario Government. (2016). Retrieved from xvii Heretick, S. Tri-Regulator Symposium October 17, Combating Opioid Prescription Abuse. xviii McCarberg, B. (2011). Pain management in primary care: strategies to mitigate opioid misuse, abuse, and diversion. Postgraduate Medicine, 123(2), xix Canadian Pain Coalition and Canadian Pain Society. Pain in Canada Fact Sheet xx Canadian Pain Coalition and Canadian Pain Society. Pain in Canada Fact Sheet xxi Moulin, Clark et al. 2002; Schopflocher, Jovey et al. 2011) IN Canadian Pain Coalition and Canadian Pain Society. Pain in Canada Fact Sheet xxii NCSBN. (2008). Our Collective Voice: Orchestrating the future of Regulatory Excellence, Attachment A. NCSBN 2008 Annual Meeting. xxiii Lipman, A. (2012). Pain management, palliative care, and substance abuse. Journal of Pain and Palliative Care Pharmacotherapy, 26, xxiv Chapman, S. (2012). Cancer pain part 2: assessment and management. Nursing Standard, 26(48),

54 xxv Hughes, L. (2012). Assessment and management of pain in older clients receiving palliative care. Nursing Older People, 24(6), xxvi Creedon, R., & O Regan, P. (2010). Palliative care, pain control and nurse prescribing. Nurse Prescribing, 8(6), xxvii Grant, M., Cordts, G., & Doberman, D. (2007). Acute pain management in hospitalized clients with current opioid abuse. Topics in Advanced Practice Nursing ejournal, 7(1). xxviii NCSBN. (2008). Our Collective Voice: Orchestrating the future of Regulatory Excellence, Attachment A. NCSBN 2008 Annual Meeting. xxix Grant, M., Cordts, G., & Doberman, D. (2007). Acute pain management in hospitalized clients with current opioid abuse. Topics in Advanced Practice Nursing ejournal, 7(1). xxx FSMB. (2004). Model Policy for the Use of Controlled Substances for the Treatment of Pain xxxi Snow, T. (Nov. 25, 2005). Independent Nurse: Nurse prescribing - More rigorous training for prescribers proposed. GP, p03. xxxii Rassool, G. H. (2004). Prescription for change: perspective on prescribing authority for addiction nurses in the UK. Journal of Addictions Nursing, 15, xxxiii Schonwald, G. (2012) What is the role of urine drug testing in the management of chronic non-cancer pain with opioids? Pain Medicine, 13, xxxiv Schonwald, G. (2012) What is the role of urine drug testing in the management of chronic non-cancer pain with opioids? Pain Medicine, 13, xxxv Industrial Economics, Incorporated. (2011). The potential costs and benefits of the new classes of practitioners regulations. Prepared for Health Canada. xxxvi CPSO. (2010). Avoiding abuse, achieving a balance: tackling the opioids public health crisis. xxxvii Ontario Government. (2016).Strategy to Prevent Opioid Addiction and Overdose. Retrieved from xxxviii American Society of Addiction Medicine (2012) Public Policy Statement on Measures to Counteract Prescription Drug Diversion, Misuse and Addiction xxxix Arnstein, P. St. Marie, B. (2010). Managing chronic pain with opioids: a call for change xl NCSBN. (2008). Our Collective Voice: Orchestrating the future of Regulatory Excellence, Attachment A. NCSBN 2008 Annual Meeting

55 Attachment 3 Ministry of Health and Long-Term Care Office of the Minister 10 1h Floor, Hepburn Block BO Grosvenor Street Toronto ON M7A 2C4 Tel Fax Mlnlstere de la Sante et des Solns de longue duree Bureau du ministre Edifice Hepburn, 10" etage BO, rue Grosvenor Toronto ON M7A 2C4 Tel Telec j.. _,. Onlario OCT Ms. Anne L. Coghlan, RN Executive Director College of Nurses of Ontario 101 Davenport Road Toronto ON M5R 3P1 HL TC29681T OCT Z Dear Ms. Coghlan: The ability of nurse practitioners to prescribe controlled drugs and substances is important to ensuring services are delivered more quickly and safely across Ontario. This has been part of my drive towards a patient's first health care system in Ontario. My recent mandate letter from Premier Wynne speaks to providing better supports to those with addictions, including those with opioid use disorder. I see nurse practitioners playing a significant role in helping Ontarians with this disorder to manage and ultimately overcome it. Moreover, recent federal legislation has nurse practitioners as the only clinician, other than physicians, who may lead or aid medical assistance in dying. Given this context, I would like to see the College of Nurses of Ontario view nurse practitioners' broad scope of practice in determining the range of controlled drugs to be authorized to the profession. This will be reflective of how other Canadian jurisdictions have broadened the prescribing authority for nurse practitioners. Of course, this range of drugs would be balanced by nurse practitioners education, and those quality and oversight mechanisms that the College may view as necessary to ensure patient safety. As Assistant Deputy Minister Denise Cole has communicated to you, I would like to see nurse practitioners in a position to prescribe controlled drugs and substances as soon as possible and no later than March The ministry will work closely with you and the Council of the College to bring this to fruition. In closing, let me thank the College and its members for your ongoing contribution to the healthcare system in Ontario and for your continued partnership on this and a number of important initiatives. Yours sincerely, Dr. Eric Hoskins Minister 13

56 14

57 Agenda Item Decision Note December 2016 Council Nurse Practitioner Prescribing of Controlled Substances: Proposed By-Law Changes Contact for Questions Kevin McCarthy, Director of Strategy Motion for Consideration That the proposed amendments to College of Nurses of Ontario By-Laws, as shown in Attachment 1 to the briefing note, be approved for notice and circulation to members and stakeholders. Public Interest and Public Safety Rationale Subject to approval of proposed regulatory changes, prescribing controlled substances will become part of nurse practitioner scope of practice in Ontario. Prescribing controlled substances is high risk and it is important that only individuals who have the appropriate education can prescribe controlled substances. It is also important that information be available to employers, other health professionals and the public. Background Attachment 2 provides a clause-by-clause description of the proposed changes. The proposed by-law changes are dependent on Council s approval of the proposed regulation changes. If a nurse practitioner is not able to perform activities related to controlled substances, to support transparency and the provision of information to the public and other stakeholders, the proposed by-law changes enable the College to post and remove information relevant to this area of practice. Education Requirement If the College does not have evidence a nurse practitioner completed approved controlled substances education, the register would state that the nurse practitioner is entitled to practise with restrictions. Clicking on this restriction will provide additional information (e.g., the nurse practitioner cannot prescribe controlled substances because they have not completed controlled substances education). There are also proposed by-law changes that enable this information to be removed (e.g., if the nurse practitioner completes approved education)

58 Health Canada Notices The proposed by-law changes also enable the College to post and remove information about Health Canada notices (these are described below). What is a Health Canada Notice? A Health Canada notice is a letter sent by Health Canada to inform pharmaceutical companies and pharmacies that they must not: sell or provide a controlled substance to a nurse practitioner; and/or, fill a nurse practitioner s prescription for a controlled substance(s). The notice is also sent to the relevant regulatory body. Health Canada must issue a notice if the: nurse practitioner requests it (e.g., voluntarily); College requests it because the nurse practitioner contravened a rule of conduct; and, nurse practitioner is found guilty of a designated drug offence or an offence under the federal regulations. Health Canada may issue a notice if it has reasonable grounds to believe the nurse practitioner: contravened certain provisions of the regulations; self-prescribed, or prescribed for an immediate family member, on more than one occasion and contrary to accepted practice; and, is unable to account for a quantity of controlled substance for which they were responsible. There are mechanisms for retracting a notice. Whether the notice was voluntarily sought or imposed, Health Canada requires written confirmation from the College agreeing to the retraction. Next Steps Subject to Council s approval, the proposed by-law changes will be circulated to members and stakeholders for a 60 day feedback period. At the March 2017 Council meeting, a summary of stakeholder feedback will be provided to Council. Council will consider if there is anything in the feedback that suggests the by-laws are not drafted in the public interest. Council will be asked to approve the by-laws at that time - which would only take effect subject to approval of the regulations. Attachments 1. Proposed amendments to College of Nurses of Ontario By-Laws. 2. Clause-by-Clause description of the proposed changes

59 Attachment 1 Proposed amendments to College of Nurses of Ontario By-Laws Add definition in Article 1.01: restricted by a lawful authority of Canada, as that phrase is used in paragraph 5.02 of Article , includes a situation where a notice pursuant to the Controlled Drug and Substances Act (Canada) and/or its regulations has been issued that directly or indirectly affects a member s ability to prescribe, procure, provide and/or dispense a controlled substance. Additional Register Information In accordance with the authorization provided by paragraph 14 of subsection 23(2) of the Code and subject to Article , the following additional information shall be kept in the register of the College: 1. Any change to each member s name which has been made in the register of the College since he or she first became registered with the College. 2. Where a member is engaged in nursing practice in Ontario, the name and address of the person or business for whom or through which the member primarily engages in nursing practice in Ontario. 2.1 Where the College is aware of the fact that a member is currently registered or licensed to practice nursing in another jurisdiction, a notation to that effect including the name of the jurisdiction. (Approved June 2015; Effective December 15, 2015) 3. Each member s certificate of registration number. 4. The classes of certificate of registration held by each member and the date on which each was issued. 5. The specialty certificate held by each member and the date on which each was issued Where a member holds an extended class certificate of registration as an RN (Nurse Practitioner), a notation that the member is entitled to practise with restrictions and a summary of the restriction(s) where, - 3 -

60 a. the member has not satisfied the Executive Director that the member has met the prescribed requirements to be able to prescribe controlled substances; or b. the College is aware and the Executive Director is satisfied that the member is not entitled to prescribe controlled substances for any other reason Where the College is aware and the Executive Director is satisfied that a member s ability to prescribe, procure, provide and/or dispense a controlled substance has been restricted by a lawful authority of Canada, a notation that the member is entitled to practise with restrictions and a summary of any restriction which the College has reason to believe is currently in effect. 5.1 Where known to the College, the name of each hospital and health facility in Ontario where a member holding a Certificate of Registration as a Registered Nurse in the Extended Class has professional privileges, as well as all revocations, suspensions or restrictions of these privileges reported to the College under subsection 85.5 of the Code, which the College has reason to believe are currently in effect. (Approved June 2015; Effective December 15, 2015) 6. Where a member resigned, the date upon which the resignation took effect and where the resignation did not relate to all certificates of registration, the certificate of registration to which the resignation applied. 7. Where the College is satisfied based upon reliable information that a person ceased to be a member as a result of his or her death, a notation to that effect and the date upon which the person ceased to be a member if that date is known to the College. 8. Where an allegation of professional misconduct or incompetence has been referred to the Discipline Committee in respect of the member and is outstanding, a. the date of the referral; b. a brief summary of each specified allegation; c. a copy of the notice of hearing; (Approved March 2015; Effective December 15, 2015) d. the date of the hearing if the hearing date has been set; e. if the hearing has commenced but not yet completed, the next scheduled date for the continuation of the hearing, if the hearing was adjourned to a specific date, or, if the hearing was adjourned without a specific date, a notation to that effect; and f. if the hearing of evidence and arguments is completed and the parties are awaiting a decision of the panel of the Discipline Committee, a statement of that fact. (Approved March 2015; Effective December 15, 2015) - 4 -

61 8.01 Where a decision of the Inquiries, Complaints and Reports Committee, made on or after December 1, 2015, requires a member to attend before a panel of that committee to be cautioned, as authorized by paragraph 3 of subsection 26(1) of the Code, a. a notation of that fact, b. a summary of the caution, c. the date of the panel s decision, and d. if applicable, a notation that the panel s decision is currently under review or appeal, which notation shall be removed once the review or appeal is finally disposed of. (Approved September 2015; Effective December 1, 2015) 8.02 Where a decision of the Inquiries, Complaints or Reports Committee, made on or after December 1, 2015, requires a member to complete a specified continuing education or remediation program, as authorized by paragraph 4 of subsection 26(1) and subsection 26(3) of the Code, a. a notation of that fact, b. a summary of the specified continuing education or remediation program, c. the date of the panel s decision, d. once all of the programs are completed, a notation to that effect, and e. if applicable, a notation that the panel s decision is currently under review or appeal, which notation shall be removed once the review or appeal is finally disposed of. (Approved September 2015; Effective December 1, 2015) 8.2 If an application for reinstatement has been referred to the Discipline Committee and the hearing date has been set, a. the date of the hearing; b. if the hearing has commenced but not yet completed, the next scheduled date for the continuation of the hearing, if the hearing was adjourned to a specific date, or, if the hearing was adjourned without a specific date, a notation to that effect; and c. if the hearing of evidence and arguments is completed and the parties are awaiting a decision of the panel of the Discipline Committee, a statement of that fact. (Approved March 2015; Effective December 15, 2015) 8.3 Where the College is aware that a finding of professional misconduct or incompetence or other like finding has been made against a member by a body that governs any profession, whether inside or outside of Ontario, a. a notation of that fact, b. the date of the finding, c. the name of the governing body that made the finding, and d. where the finding is under appeal, a notation of that fact, which notation shall be removed once the appeal is finally disposed of. (Approved June 2015; Effective December 15, 2015) - 5 -

62 9. Where the question of the member s capacity has been referred to the Fitness to Practise Committee and not yet decided, a. a notation of that fact; and b. the date of the referral. 10. Where the results of a disciplinary proceeding are contained in the College s register, the date on which the panel of the Discipline Committee made the finding of professional misconduct or incompetence and the date on which the panel ordered any penalty If an application for reinstatement has been decided by a panel of the Discipline Committee, the results of the hearing including the date of the decision and any order made. (Approved March 2015; Effective December 15, 2015) 11. Where a decision of the Discipline Committee has been published by the College with the member s name included in any medium, a. a notation of that fact; and b. identification of the specific publication of the College which contains that information. 12. Where the result of an incapacity proceeding is contained in the College s register, the date on which the panel made the finding of incapacity and the effective date of any order made by the panel. 13. Where a member has any terms, conditions or limitations in effect on his or her certificate of registration, the effective date of those terms, conditions and limitations and where applicable, the Committee responsible for the imposition of those terms, conditions and limitations. 14. Where a member has terms, conditions or limitations on his or her certificate of registration varied, the effective date of the variance of those terms, conditions and limitations and where applicable, the Committee responsible for the variance of those terms, conditions and limitations. 15. Where a member s certificate of registration is revoked, suspended, cancelled, expired or otherwise terminated, a notation of that fact and the effective date and the basis of the revocation, suspension, cancellation, expiry or other termination which shall include but not be limited to circumstances where a. a member s certificate of registration is subject to an interim order of the Executive Committee or the Inquiries, Complaints and Reports Committee; - 6 -

63 b. a member s certificate of registration is suspended for non-payment of the annual fee or any fee required by the College; or c. a member s certificate of registration is suspended for failure to submit to a physical or mental examination as ordered by a Board of Inquiry or the Inquiries, Complaints and Reports Committee. 16. Where a suspension on a member s certificate of registration is lifted or otherwise removed, the effective date of the lifting or removal of that suspension and where applicable, the Committee responsible for the lifting or removal of the suspension. 17. Where a member s certificate of registration is reinstated, the effective date of the reinstatement and where reinstated by a panel of the Discipline or Fitness to Practise Committee, the name of the Committee responsible for the reinstatement. 18. Where a member s specialty certificate is revoked, suspended, cancelled or otherwise terminated, a notation of that fact and the effective date and the basis of the revocation, suspension, cancellation or other termination. 19. Where a member s specialty certificate is reinstated, the effective date of the reinstatement. 20. Where a finding of professional negligence or malpractice is contained in the College s register, the information provided by the member who was the subject of the finding including a. the notice of and a description of the finding; b. the date the finding was made against the member; c. the name and location of the court that made the finding against the member; and d. the status of any appeal respecting the finding made against the member A summary of any existing charge against a member, of which the College is aware, commenced on or after Dec. 1, 2015, which in the opinion of the Executive Director is relevant to the member s suitability to practise nursing, in respect of, i. any offence under the Criminal Code of Canada, ii. any offence under the Controlled Drugs and Substances Act, (Canada) or iii. any other offence in any jurisdiction. (Approved June 2015; Effective December 15, 2015) 20.2 A summary of any current restriction that relates to or otherwise impacts a member s practice imposed by a court or other lawful authority against the member, of which the College is aware, including the date of and a summary of the restriction imposed. (Approved March 2015; Effective December 15, 2015) - 7 -

64 20.3 A summary of any finding of guilt made by a court or other lawful authority against a member, of which the College is aware, in respect of (i) any offence under the Criminal Code of Canada, (ii) any offence under the Controlled Drugs and Substances Act, (Canada), or (iii) any other offence which in the opinion of the Executive Director is relevant to the member s suitability to practice nursing, including, a. the date of and a brief summary of the finding; b. the date of and the sentence imposed, if any; and c. where the finding is under appeal, a notation to that effect. (Approved March 2015; Effective December 15, 2015) 21. Any information the College and the member have agreed should be included in the register. 22. The date on which each certificate of authorization was issued by the College. 23. Where a certificate of authorization is revised, a notation of the effective date of the revision. 24. Where a certificate of authorization is revoked, suspended, cancelled or otherwise terminated, a notation of the effective date of the revocation, suspension, cancellation or other termination. 25. Any information the College and a health profession corporation to which the College has issued a certificate of authorization have agreed should be included in the register All of the information referred to in Articles and is information designated to be withheld from the public pursuant to subsection 23(6) of the Code such that the Executive Director may refuse to disclose to an individual or post on the College s website any or all of that information if the Executive Director has reasonable grounds to believe that disclosure of that information may jeopardize the safety of an individual Where as a result of an appeal or review from the decision of the Inquiries, Complaints or Reports Committee, a member is no longer required to attend before a panel of that committee to be cautioned, the information placed in the register as a result of paragraph 8.01 of Article shall be removed, once the appeal or review has become final. (Approved September 2015; Effective December 1, 2015) Subject to Article , information placed in the register as a result of paragraph 8.01 of Article , shall be automatically removed once three years has expired after the member attended the Inquiries, Complaints and Reports Committee and received the caution

65 (Approved December 3, 2015; Effective December 15, 2015) Information shall not be removed pursuant to Article if i. in the opinion of the Executive Director, the caution was, related to conduct involving sexual abuse or a boundaries violation with a patient or former patient; or ii. after the decision was made by Inquiries, Complaints and Reports Committee requiring the member to attend to receive a caution, the College has received information relating to the member s conduct which is of concern to the Executive Director, including but not limited to a complaint or mandatory report under the Code. (Approved December 3, 2015; Effective December 15, 2015) Information placed in the register as a result of paragraph 8.01 of Article and not removed pursuant to article , shall be removed if i. the member has made a written request to the Executive Director to remove the information; ii. at least three years has expired after the member attended the Inquiries, Complaints and Reports Committee and received the caution; and iii. the Executive Director is satisfied, having considered all information in the College s possession related to the member, including the member s history with the College, that there is no public benefit to maintaining the information on the register. (Approved December 3, 2015; Effective December 15, 2015) Where as a result of an appeal or review from the decision of the Inquiries, Complaints or Reports Committee, a member is no longer required to complete a specified continuing education or remediation program, the information placed in the register as a result of paragraph 8.02 of Article shall be removed, once the review or appeal becomes final. (Approved September 2015; Effective December 1, 2015) Subject to Article , information placed in the register as a result of paragraph 8.02 of Article , shall be automatically removed once three years has expired after the member successfully completed all of the requirements of the specified continuing education or remediation program. (Approved December 3, 2015; Effective December 15, 2015) Information shall not be removed pursuant to Article if i. in the opinion of the Executive Director, the specified continuing education or remediation program was related to conduct involving sexual abuse or a boundaries violation with a patient or former patient; or ii. after the decision was made by Inquiries, Complaints and Reports Committee requiring the member to complete a specified continuing education or remediation program, the - 9 -

66 College has received information relating to the member s conduct which is of concern to the Executive Director, including but not limited to a complaint or mandatory report under the Code. (Approved December 3, 2015; Effective December 15, 2015) Information placed in the register as a result of paragraph 8.02 of Article and not removed pursuant to article , shall be removed if i. the member has made a written request to the Executive Director to remove the information; ii. at least three years has expired after the member successfully completed all of the requirements of the specified continuing education or remediation program; and iii. the Executive Director is satisfied, having considered all information in the College s possession related to the member, including the member s history with the College, that there is no public benefit to maintaining the information on the register. (Approved December 3, 2015; Effective December 15, 2015) The information placed in the register as a result of paragraph 20.1 of Article shall be removed once the charges are no longer outstanding Information placed in the register as a result of paragraph 5.01 of Article shall be removed if the Executive Director is satisfied that the member has met the prescribed requirements to be able to prescribe controlled substances and that there is no other legal impediment, of which the Executive Director is aware, preventing the member from doing so Information placed in the register as a result of paragraph 5.02 of Article shall be removed if the Executive Director is satisfied that the restriction referred to in that paragraph is no longer in effect

67 Attachment 2 Clause-by-Clause description of the proposed changes The purpose of this document is to give a detailed overview of the proposed by-law changes. Current Provision Proposed Change Rationale N/A N/A N/A 1.01 restricted by a lawful authority of Canada, as that phrase is used in paragraph 5.02 of Article , includes a situation where a notice pursuant to the Controlled Drug and Substances Act (Canada) and/or its regulations has been issued that directly or indirectly affects a member s ability to prescribe, procure, provide and/or dispense a controlled substance Where a member holds an extended class certificate of registration as an RN (Nurse Practitioner), a notation that the member is entitled to practise with restrictions and a summary of the restriction(s) where, a. the member has not satisfied the Executive Director that the member has met the prescribed requirements to be able to prescribe controlled substances; or b. the College is aware and the Executive Director is satisfied that the member is not entitled to prescribe controlled substances for any other reason Where the College is aware and the Executive Director is satisfied that a member s ability to prescribe, procure, provide and/or Defines restricted by a lawful authority of Canada (e.g., related to Health Canada notices). This provision proposes what will be posted on the register: that a nurse practitioner is entitled to practise with restrictions, with a summary of what that restriction is. This ensure transparency to the public and other stakeholders including employers: communicating that a nurse practitioner is not authorized to perform an activity that is within their scope of practice. a. relates to the proposed regulation: the controlled substances education requirement. b. ensures there is no other public safety reason why there should be a restriction relates to Health Canada notices. Health Canada notices, as described above, can relate to activities including prescribing. This ensure transparency

68 N/A N/A dispense a controlled substance has been restricted by a lawful authority of Canada, a notation that the member is entitled to practise with restrictions and a summary of any restriction which the College has reason to believe is currently in effect Information placed in the register as a result of paragraph 5.01 of Article shall be removed if the Executive Director is satisfied that the member has met the prescribed requirements to be able to prescribe controlled substances and that there is no other legal impediment, of which the Executive Director is aware, preventing the member from doing so Information placed in the register as a result of paragraph 5.02 of Article shall be removed if the Executive Director is satisfied that the restriction referred to in that paragraph is no longer in effect. to the public and other stakeholders including employers: communicating that a nurse practitioner is not authorized to perform an activity that is within their scope of practice (the register includes a summary of the information contained in the notice). These proposed provisions deal with the removal of the restrictions described above (e.g., related to the education requirement or Health Canada notices). For example, a nurse practitioner may complete approved controlled substances education in the future. At that time, the restriction would be removed with no information left in their history on the Register

69 Agenda Item Decision Note December 2016 Council Proposed Controlled Substances Courses Contact for Questions Kevin McCarthy, Director of Strategy Motion for Consideration That Council approve the following educational courses, completed within the last three years, as approved education for the purposes of clauses 19.2(2)1 and 19.2(3) of Part 3 (Controlled Acts) of Ontario Regulation 275/94 (General): 1. Athabasca University s Prescription and Management of Controlled Drugs and Substances course 1 ; and, 2. University of Ottawa s Prescribing Narcotics and Controlled Substances course 2 on or after January 17, Public Interest and Public Safety Rationale The College is responsible for ensuring there are mechanisms in place to support safe nursing practice. Activities related to controlled substances, such as prescribing, are high risk given the increased risks associated with misuse, addiction and diversion. The proposed courses support nurse practitioners gaining the competencies to support safe, effective and ethical prescribing and management of controlled substances. Background In March 2014, Council approved in principle a requirement that would limit prescribing of controlled substances to those nurse practitioners who successfully completed Council approved education. This was to ensure that individuals carrying out this high risk activity would have controlled substances competencies. 1 More information on this course: This same course is used in Athabasca s foundation nurse practitioner programs and is entitled NURS531 Controlled Drugs and Substances for NP Prescribers. 2 More information on this course: 3 January 17, 2014 is the date feedback from the CCRNR working group was integrated into the course. University of Ottawa offered another variation prior to this (starting in 2011); conversely, Athabasca only began to offer their course after integrating feedback from the CCRNR working group in

70 The proposed courses are dependent on Council s continued support for an education requirement for nurse practitioners (i.e., the proposed regulations and corresponding by-law amendments). Please refer to the December 2016 proposed regulations briefing note (see Rationale for Education Requirement from agenda item 5.1.1) for general background on an education requirement (e.g., what evidence supports the proposed education requirement). The courses proposed to Council are accessible (online modules) and low cost (approximately $200). Both courses have an objective test component to ensure the individual attained the required competencies. The accessible format of these courses give individuals the flexibility to complete it according to their own schedule. Three Year Requirement The requirement to have completed the course within the last three years relates to literature on knowledge retention, which has previously informed Council decisions. Findings suggest that when not used, knowledge and skills fade over time. In general, there is a positive correlation with the amount of knowledge and skills lost, and time. A reference list related to this literature is found in attachment 2. Course Review As described in the proposed regulations briefing note, a national working group 4 under the Canadian Council of Registered Nurse Regulators (CCRNR) identified controlled substances education requirements that address federal jurisprudence, the unique risks of harm associated with controlled substances and strategies for mitigating risks of harm. Nurse practitioners already have competencies related to prescribing and managing drugs. The recommended courses build on these competencies and address the unique risks associated with controlled substances. The two courses proposed to Council were recommended to the CCRNR board who in turn recommended these courses to their jurisdictions. The recommended courses are currently used by other Canadian jurisdictions. The College also conducted specific activities in 2016 to ensure up-to-date information and evidence was being used to inform Council s decisionmaking. CCRNR Process: Using the Canadian core competency framework, eighteen competencies that reflect the nurse practitioner knowledge, skill and judgement to prescribe and manage controlled substances were identified by the CCRNR working group. 4 All Canadian jurisdictions except Quebec participated on the working group (Quebec provided some input)

71 2. Related to controlled substances, indicators specific to each of the eighteen competencies were developed. These were informed by a literature review, environmental scan (e.g., policies from other regulators) and subject matter experts. 3. Course materials from four Canadian courses that were in existence at the time were reviewed. Four members of the working group, from four different jurisdictions including Ontario, independently reviewed each course using the competencies and indicators, and then met as a group to review findings. 4. No one course was found to meet all eighteen competencies and indicators. Feedback was provided to the educational institutions regarding gaps identified. Changes were made to the two courses that are being recommended to CNO Council for approval following feedback from the national working group (this was subsequently validated by the CCRNR working group with a review of the updates). 5. College staff redrafted indicators into higher-level statements (see Attachment 1) to facilitate curriculum development and mapping (feedback was sought by Ontario educational institutions and staff). The College Process: College staff conducted a gap analysis, including an updated literature search, to determine if anything in the evidence or landscape changed in the last two years that would require the indicators to change. There were no substantive changes needed. 2. In collaboration with Athabasca and Ottawa universities, College staff verified the content previously assessed remained in the course. (There is some new content for example, new content reflecting changes to federal jurisprudence.) 3. In discussions with other Canadian nursing regulators, and Athabasca and Ottawa universities, no issues with implementation were identified. Subject to approval of the proposed regulations and by-laws, if the College does not have evidence a nurse practitioner successfully completed Council approved controlled substances education, the day the regulations take effect the register would reflect this (e.g., the nurse practitioner is entitled to practise with restrictions). In other words, once prescribing controlled substances becomes a part of nurse practitioner scope of practice, if a nurse practitioner does not have the competencies to conduct this activity, this will be stated on Find a Nurse. Next Steps - Subject to Council s Decision Finalize processes internally, and with Athabasca and Ottawa universities. Finalize system changes so the College is able to accept and track information from the universities. Finalize communication materials so the College is able to inform nurse practitioners and applicants of the proposed requirement to give them time to complete the requirement before the regulations take effect (Subject to Council approval, we plan to communicate the requirement December 2016). Attachment 1. Competency Indicators Required to Address the Unique Risks Associated with Controlled Substances - 3 -

72 Attachment 1 Competency Indicators Required to Address the Unique Risks Associated with Controlled Substances 5 Epidemiology of prescription medication misuse and addiction. Jurisprudence related to prescribing controlled substances, including: o NP authorities and restrictions; o prescription requirements; o narcotics monitoring system; o record retention requirements; and, o reporting requirements. Indications for prescribing, and pharmacotherapy of, various classes of controlled substances: o narcotics; o benzodiazepines and targeted substances; and, o controlled drugs (parts I, II and III). Evidence-informed strategies that can be used in health assessment, diagnosis and therapeutic management to identify and mitigate medication misuse, addiction and diversion. Examples of aberrant behaviour that may indicate misuse, addiction and/or diversion. Comprehensive approaches to the treatment plan, which includes: o establishing evidence-informed rationale for client selection; o establishing clear treatment goals and measures by which those goals will be assessed; o considering different modalities, when applicable; o using evidence-informed strategies for assessing, monitoring and managing risks; o conducting regular reviews of risks, progress and treatment efficacy; o considering when and how to alter or discontinue treatment if goals are not met; and, o identifying indications for consulting or referring to others (e.g., pain specialists, mental health/addictions). Poly-pharmacy risks, including high-risk drug combinations involving controlled substances. Informed consent from clients for a comprehensive approach to treatment, and tools to support informed consent (e.g., treatment agreements). Objective and credible evidence-informed resources to support practice, including links to relevant organizations and tools (e.g., research clearinghouses, evidence-based assessment/screening tools). Ethical considerations associated with decisions about when to initiate and discontinue treatment using controlled substances. 5 The University course would have to have written measurable objectives and an appropriate evaluation to test the written measurable objectives

73 Reinforce the leadership necessary to provide appropriate treatment while managing expectations and dealing with the pressure to prescribe from multiple sources (e.g., clients, employers, other health care professionals). Misconceptions and client stigmatizations that may be held by health professionals

74 Attachment 2 Literature Review Related to Knowledge Retention Bacon, D. R., & Stewart, K. A. (2006). How Fast Do Students Forget What They Learn in Consumer Behavior? A Longitudinal Study. Journal of Marketing Education, 28(3), Braun, L., Sawyer, T., Kavanagh, L., & Deering, S. (2014). Facilitating physician reentry to practice: perceived effects of deployments on US army pediatricians' clinical and procedural skills. Journal of Continuing Education in the Health Professions, 34(4), Bultas, M. W., Hassler, M., Ercole, P. M., & Rea, G. (2014). Effectiveness of High- Fidelity Simulation for Pediatric Staff Nurse Education. Pediatric Nursing, 40(1), 27-32, 42. Conway, M. A., Cohen, G., & Stanhope, N. (1991). On the very long-term retention of knowledge acquired through formal education: Twelve years of cognitive psychology. Journal of Experimental Psychology: General, 120(4), D'Angelo, A. D., Ray, R. D., Jenewein, C. G., Jones, G. F., & Pugh, C. M. (2015). Residents' perception of skill decay during dedicated research time. Journal of Surgical Research, 199(1), Darland, D. C., & Carmichael, J. S. (2012). Long-Term Retention of Knowledge and Critical Thinking Skills in Developmental Biology. Journal of Microbiology & Biology Education, 13(2), Farr, M.J. (1987). The Long-Term Retention of Knowledge and Skills. New York: Springer-Verlag. Federation of State Medical Boards. (2012). Report of the Special Committee on Reentry to Practice. Retrieved on October 1, 2015 from

75 General Medical Council (UK). (2014). Skills fade literature review. Retrieved on October 1, 2015 from Grace, E. S., Korinek, E. J., Weitzel, L. B., & Wentz, D. K. (2010). Physicians reentering clinical practice: characteristics and clinical abilities. Journal of Continuing Education in the Health Professions, 30(3), Gronlund, S.D., & Kimball, D.R. (2013). Remembering and Forgetting From the Laboratory Looking Out. Retrieved on May 10, 2016 from and_kimball_decay_chapter_final_ pdf Iserbyt, P., & Mols, L. (2014). Retention of CPR skills and the effect of instructor expertise one year following reciprocal learning. Acta Anaesthesiologica Belgica, 65(1), Jarrell, J. L., O Neill, D. G., & Hasse, L. A. (2009). A clinical research training efficacy study with a comparison of subjects who did and did not use learning within 4 months of training. Journal of Chemical Health and Safety, 16(2), Jenison, E. L., Gil, K. M., Lendvay, T. S., & Guy, M. S. (2012). Robotic surgical skills: Acquisition, maintenance, and degradation. Journal of the Society of Laparoendoscopic Surgeons, 16(2), Kenagy, G., Schneidman, B., Barzansky, B., Dalton, C., Sirio, C., & Skochelak, S. (2011). Physician Reentry into Clinical Practice: Regulatory Challenges. Journal of Medical Regulation, 97(1), Madden, C. (2006). Undergraduate nursing students acquisition and retention of CPR knowledge and skills. Nursing education today, 26, Mosley, C., Dewhurst, C., Molloy, S., & Shaw, B. N. (2012). What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20. Medical Teacher, 34(6), e

76 Patel, J., Posencheg, M., & Ades A. (2012). Proficiency and retention of neonatal resuscitation skills by pediatric residents. Pediatrics, 130(3), Rawson, K. A., Dunlosky, J., & Sciartelli, S. M. (2013). The Power of Successive Relearning: Improving Performance on Course Exams and Long-Term Retention. Educational Psychology Review, 25(4), Semb, G. B., Ellis, J. A., & Araujo, J. (1993). Long-term memory for knowledge learned in school. Journal of Educational Psychology, 85(2), Smith, A., Gray, A., Atherton, I., Pirie, E., & Jepson, R. (2014). Does time matter? An investigation of knowledge and attitudes following blood transfusion training. Nurse Education in Practice, 14(2), Winfred, A. Jr., Winston, B. Jr., Stanush, P. L., & McNelly, T. L. (1998). Factors that Influence skill decay and retention: A Quantitative Review and Analysis. Human Performance, 11(1),

77 Agenda Item Decision Note December 2016 Council By-Law amendments - election of the Executive Committee Contacts for Questions or More Information Kevin McCarthy, Director of Strategy Decision for consideration That, to provide for the election of all members of the Executive Committee, Council approve the proposed amended By-Law No. 1: General, as it appears in attachment 2 to this decision note. Background In September 2016 Council decided that all members of the Executive Committee would be elected beginning in March In order to implement that decision, amendments are required to By-Law No. 1: General (the General By-Law). Current Legislative Framework Council s officers 1 are elected under the Nursing Act. According to the Nursing Act, the Vice- Presidents must be an RN and an RPN. The President can be an RN, RPN or a public member. The General By-Law sets out the structure of the Executive Committee: The Executive Committee shall be composed of five councillors two of whom shall be public councillors and shall include the President and the Vice-Presidents. This article means that: the officers are automatically a part of the Executive; there are two and no more than two public members on the Executive; if the President is a nurse, the other members of the Executive are public members; and if the President is a public member, the other members of the Executive will be one public member and one nurse. 1 Schedule 1 of the General By-Law defines Council s officers as the President and two Vice-Presidents. 1

78 Unlike the officers who join the Executive because of their election as officers, the by-laws currently set out that the other members of the Executive are appointed based on recommendations from the Election and Appointments Committee. Draft By-Law amendments Draft by-law amendments have been prepared to implement Council s direction that all members of the Executive be elected. They have been drafted based on maintaining the current structure of the Executive and election fundamentals: term limits remain the same : officers can serve two one-year terms in any position; there are no term limits on the other members of the Executive; the requirements for nominations remain the same (three nominators and candidate consent); and candidates must receive a majority of the votes to be elected. Schedule 1 of the by-laws sets out in detail the process for the election of the officers and now includes provision to address election of the other members of the Executive. Since the outcome of the election of President is needed to determine who would be eligible to run for election to the two other positions on the Executive, the election of officers will take place first. If a nurse is elected President: the two other members of the Executive will be public members. To simplify the election process Council members will be able to vote for two public members on one ballot. This mirrors the Council election process; if there are two positions being elected, members may vote for two candidates. If a public member is elected President: one public member and one nurse will be elected to the other positions on the Executive Committee. Since nurse members of Council may not have realized in advance that this opportunity was a possibility, the proposed by-law allows nominations for the nurse position either in writing or orally. Three nominators and candidate consent will still be required. While not stated in by-law, if a public member is elected President, there will be a break at some time before the election of the nurse member of the Executive to allow interested members to seek nominations. Attachments: Attached to this decision note are: Attachment 1 is an illustration of the proposed election process; Attachment 2 is the amended by-law; and Attachment 3 is a comparison table showing the current by-law, amendments and rationale. Deletions are crossed out and new content is in bold faced italics. 2

79 Attachment 1 Process for Electing the Executive Committee Before the March Council Meeting Request for nomination Circulated in advance Candidate information Council receives information on nominated candidates During the March Council Meeting Officer election (President, Vice-President RN and Vice-President RPN) Nominations from the floor Speeches Voting Counting Announcing results New Process Public Member president Public member election (1) Nominations from the floor Speeches Voting Counting Announcing results + RN/NP/RPN member election (1) Nominations from the floor Speeches Voting Counting Announcing results Nurse president Public member election (2) Nominations from the floor Speeches Voting (2 votes/member) Counting Announcing results After the March Council Meeting Results Numeric results provided to candidates on request Note: In all cases, candidates must be elected by a majority of the Council members present and voting. If there is not a candidate elected by majority, the candidate with the fewest votes is dropped from the ballot and voting recommences.

80 Attachment 2 Proposed amended by-laws to provide for election of all members of the Executive Committee 9. Election of the Executive Committee 9.01 At the March Council meeting each year, the Council shall elect from among councillors eligible for election the Executive Committee, in accordance with this by-law and the Process for Election of the Council Officers and Other Members of the Executive Committee, which is set out in Schedule A councillor is not eligible for nomination or election as a Council Officer if the councillor held that elected position during the previous two consecutive terms A councillor who held elected office pursuant to the provisions of Article will not be considered to have been the President or Vice-President during that term for the purposes of Article Subject to the provisions of this by-law, the term of office of the members of the Executive Committee shall commence at the June Council meeting following the election and continue until the new members of the Executive Committee take office at the June Council meeting in the following calendar year. 10. Removal and Replacement of Members of the Executive Committee A member of the Executive Committee may be removed from office by a two-thirds majority vote of the councillors present at a Council meeting duly held for that purpose. 4

81 10.02 In the event that the President or a Vice-President or another member of the Executive Committee is removed from the office or position, resigns or dies or the office or position becomes vacant for any other reason, Council shall elect, in accordance with this by-law and the Process for Election of Council Officers and Other Members of the Executive Committee, which is set out in Schedule 1, a new President or Vice-President or another member of the Executive Committee, as the case shall be, to hold the office or position which became vacant for the remainder of the term of office. 16. Executive Committee Subject to article 16.02, the Executive Committee shall be composed of five councillors, two of whom shall be public councillors, and shall include the President and the Vice-Presidents The Executive may be composed of five councillors, three of whom are public councillors, where the position of President is filled under article Election and Appointments Committee The Election and Appointments Committee shall be composed of six councillors, two of whom are RNs, two of whom are RPNs, and two of whom are public councillors Deleted December The members of the Election and Appointments Committee shall be appointed by Council at the March Council meeting, upon the recommendation of the Executive Committee. (Amended June 2013) The term of office of the Election and Appointments Committee shall be from the June Council meeting following the appointment of the committee members until a new committee takes office at the June Council meeting in the following calendar year. (Amended June 2013) 5

82 24.05 Deleted March 4, The Election and Appointments Committee s responsibilities include, but are not limited to, i) dealing with disputes relating to elections of elected councillors as provided in the by-laws; (Amended March 2013) ii) making recommendations to Council on how to fill vacancies created by the death, resignation or disqualification of an elected councillor; (Amended September 2008) iii) iv) preparing a list of members who are eligible to be appointed as appointed committee members; (Added September 2008) making recommendations to Council, at the March Council meeting or at such other times as Council or the Executive Committee may request, on the appointment of councillors, appointed committee members and other persons to committees of the College; (Amended June 2013) v) preparing a list of members who are eligible to be appointed as appointed committee members for use by the Executive Committee in the event a vacancy occurs in a committee; and (Added September 2008) vi) making recommendations to Council where there is no candidate declared for a Council officer position or insufficient candidates for the other positions on the Executive Committee. 6

83 Schedule No. 1 to By-Law No. 1 Process for Election of Council Officers and Other Members of the Executive Committee Revised version March, 2013 In this Schedule, Council Officers means the President and two Vice-Presidents of the Council and Council Officer means one of the President or Vice-Presidents of the Council. 1. Prior to any Council meeting, where councillors are expected to elect one or more Council Officers and/or other members of the Executive Committee, nomination forms for the nomination of the Council Officers and/or other members of the Executive Committee to be elected at that meeting shall be sent by the Executive Director to persons who the Executive Director expects to be councillors at the meeting of Council where the elections are to be held. 2. Subject to paragraphs 8 and 34, to be nominated for election as a Council Officer or another member of the Executive Committee, a councillor must submit a completed nomination form including the written consent of the councillor wishing to stand for election for that position and the signatures of three persons who, at the time of the nomination, were councillors. 3. A councillor may not run for election for more than one Council Officer position. 4. A councillor may withdraw as a candidate at any time. 5. A councillor nominated for more than one Council Officer position must, prior to the commencement of the election, withdraw as a candidate from all but one Council Officer position, failing which the councillor shall not be eligible to run for election for any Council Officer position. 6. The chair of the Election and Appointments Committee or his or her designate shall preside as chair of that portion of the meeting of Council where the election of Council Officers and/or other members of the Executive Committee takes place. 7. Council shall appoint three scrutineers for the election. 7

84 Election of Council Officers 8. The chair will call for nominations from the floor which nominations must be in writing and must comply with paragraph 2 above. 9. Ballots will be distributed for election of the Council Officers to be elected at that Council meeting. Each ballot will include all Council Officer positions to be elected and will include the names of all candidates whose nomination forms have been properly completed and submitted as of close of business on the date prior to the election. 10. The chair will announce the names of all candidates running for election for each Council Officer position and direct the councillors to add to the ballot the name of any properly nominated candidate whose name is not already on the ballot and to remove from the ballot any councillor who has submitted a withdrawal as a candidate or is not eligible to run in that election. 11. If no councillor has been nominated for any Council Officer position for which an election was to be held at that Council meeting, the Election and Appointments Committee will nominate a candidate or candidates for the office(s). 12. If only one candidate has been nominated for a Council Officer position, the chair shall declare the candidate elected by acclamation. 13. Each candidate for election shall be offered the opportunity to briefly address Council. 14. Voting shall be by secret ballot and shall take place simultaneously for all Council Officer positions which are subject of election at that Council meeting. 15. The completed ballots will be deposited in a ballot box and the ballot box given to scrutineers. 16. A staff member designated by the chair will count the ballots under the supervision of the scrutineers. 17. The scrutineers will report to the chair the results in writing including the number of votes cast for each candidate for each Council Officer election. The chair will announce the results to Council without referring to the number of votes cast for each candidate. 8

85 18. A candidate receiving a majority of the votes cast for that Council Officer position shall be declared the successful candidate. Where there were more than two candidates running for election for a Council Officer position and no candidate received a majority of the votes cast, the candidate with the lowest number of votes shall be dropped from the election and another vote (ballot) shall be taken. The same process shall be followed until one candidate receives a majority of the votes cast for that Council Officer position. In the event that two candidates remain with an equal number of votes which tie, in the opinion of Council, is unlikely to be broken by additional ballots, the tie shall be broken by the chair by lot. 19. Where in the course of the election a tie vote occurs respecting two or more candidates having the lowest number of votes in that election and it is necessary to break that tie in order to determine which of the candidates shall be dropped from the ballot, the Council shall vote by secret ballot to determine which of the candidates shall be dropped from the ballot unless the tie, in the opinion of Council, is unlikely to be broken by additional ballots, in which case the tie shall be broken by the chair by lot. Election of the Balance of the Executive Committee 20. Following the election of the Council Officers, the remaining two members of the Executive Committee shall be determined by election using a secret ballot and in a manner consistent with the election of Council Officers, unless otherwise specifically provided for in this Schedule. For greater clarity the provisions of paragraphs 9, 10, 11, 13, 15, 16, 17, 18 and 19 apply with necessary modification to the election(s) of other members to the Executive Committee. Process where the President is a member of the College 21. The provisions of paragraphs 22 to 27 apply where the President elected at the meeting is member of the College and therefore two public councillors are to be elected to be members of the Executive Committee. 22. The Chair shall request nominations for the two public councillor positions on the Executive Committee which nominations must be in writing and must comply with paragraph 2 above. 9

86 23. If only two public councillor candidates have been nominated for election to the Executive Committee, the chair shall declare those candidates elected by acclamation. 24. If only one public councillor candidate has been nominated for election to the Executive Committee, the chair shall declare that candidate elected by acclamation. 25. If insufficient public councillors have been nominated for election to the Executive Committee for which an election was to be held at that Council meeting, the Election and Appointments Committee will nominate a candidate or candidates for the position(s). 26. Where more than two eligible candidates have been nominated for election to the Executive Committee, elections shall be held in a manner consistent with the process for election of Council Officers save and except that each councillor will be entitled to cast a vote for not more than two of the candidates. 27. For greater clarity, a ballot cast under paragraph 26 shall not be considered spoiled simply because a councillor only votes for one candidate. Process where the President is a Public Councillor 28. Where the President elected at the meeting is public councillor, the provisions of paragraphs 29 to 37 shall apply in order to elect one additional public councillor and one additional councillor who is a member of the College, to the Executive Committee. 29. The Chair shall request nominations for the public councillor position on the Executive Committee, which nominations must be in writing and must comply with paragraph 2 above. 30. If only one public councillor candidate has been nominated for election to the Executive Committee, the chair shall declare that candidate elected by acclamation. 31. If no public councillor has been nominated for the Executive Committee position the Election and Appointments Committee will nominate a candidate for the position. 32. If more than one eligible candidate is nominated, an election shall be held in a manner consistent with the election of Council Officers. 10

87 33. The chair shall then call for nominations for the remaining position on the Executive Committee which position shall be filled from among eligible councillors who are members of the College. 34. Nominations for the position referred to in paragraph 33 may be in writing, in compliance with paragraph 2 or may be made orally at the meeting if supported either orally or in writing by three persons who, at the time of the nomination, were councillors, provided the person being nominated for election consents to being a candidate. 35. If only one candidate has been nominated for that Executive Committee position, the chair shall declare the candidate elected by acclamation. 36. If no councillor has been nominated for that Executive Committee position the Election and Appointments Committee will nominate a candidate for that position. 37. If more than one eligible candidate is nominated, an election shall be held in a manner consistent with the election of Council Officers. 38. The following rules and procedures apply to all elections held in accordance with this Schedule: 1. If a request by a candidate is made within thirty days of the election, the chair of the Election and Appointments Committee will advise the candidate of the number of votes cast for each candidate in respect of any position for which he or she ran for election. 2. Unless Council directs otherwise, ballots shall be destroyed immediately following the chair declaring the successful candidates for all positions. 11

88 Attachment 3 Proposed amendments to By-Law No.1: General to provide for election of the full Executive Committee Current By-law Proposed amendments What does this mean? Why is it proposed 9. Election of Council Officers 9. Election of Council Officers the Executive Committee To clarify the change in the scope of the election 9.01 At the March Council meeting each year, the Council shall elect by secret ballot from among councillors eligible for election the Council Officers in accordance with this by-law and the Process for Election of Council Officers which is set out in Schedule A councillor is not eligible for nomination or election if the councillor held that elected position during the previous two consecutive terms At the March Council meeting each year, the Council shall elect by secret ballot from among councillors eligible for election the Council Officers Executive Committee, in accordance with this by-law and the Process for Election of the Council Officers and Other Members of the Executive Committee, which is set out in Schedule A councillor is not eligible for nomination or election as a Council Officer if the councillor held that elected position during the previous two consecutive terms. To add the election of other members. by secret ballot has been removed as that is addressed in Schedule 1 This clarifies that the term maximums apply only to the officers A councillor who held elected office pursuant to the provisions of Article or will not be considered to have been the President or Vice-President during that term for the purposes of Article The term of office of Council Officers shall commence at the June Council meeting following the election and continue until the new Council Officers take office at June Council 9.03 A councillor who held elected office pursuant to the provisions of Article or will not be considered to have been the President or Vice-President during that term for the purposes of Article Subject to the provisions of this by-law, the term of office of Council Officers the members of the Executive Committee shall commence at the June Council meeting following the Articles and address removal and filling vacancies. They have been combined into a new To clarify the beginning of the term of office for all members of the Executive Committee. 12

89 Current By-law Proposed amendments What does this mean? Why is it proposed meeting in the following calendar year. election and continue until the new Council Officers members of the Executive Committee take office at the June Council meeting in the 10. Removal of President or Vice-President The President or a Vice-President may be removed from office by a twothirds majority vote of the councillors present at a Council meeting duly held for that purpose In the event that the President or a Vice-President is removed from office, Council may elect a new President or Vice-President to hold office for the remainder of the term In the event that the President or a Vice-President resigns or dies or the position of President or Vice- President becomes vacant for any other reason, the following calendar year. 10. Removal and Replacement of Members of the Executive Committee The President or a Vice-President A member of the Executive Committee may be removed from office by a two-thirds majority vote of the councillors present at a Council meeting duly held for that purpose In the event that the President or a Vice-President or another member of the Executive Committee is removed from the office or position, resigns or dies or the office or position becomes vacant for any other reason Council may shall elect, in accordance with this by-law and the Process for Election of Council Officers and Other Members of the Executive Committee, which is set out in Schedule 1, a new President or Vice-President or another member of the Executive Committee, as the case shall be, to hold the office or position which became vacant for the remainder of the term of office In the event that the President or a Vice-President resigns or dies or the position of President or Vice- President becomes vacant for any other reason, the To clarify that the provisions include replacement and cover all positions on the Executive Committee To clarify this removal provision relates to all positions on the Executive Committee This combines the provisions of and to address all of the ways that a position on the Executive Committee can become vacant. In this specific article, the officers are included explicitly because they are elected under the Nursing Act as officers, and then appointed to the Executive Committee under the provisions of Article The provisions of this paragraph have been integrated into

90 Current By-law Proposed amendments What does this mean? Why is it proposed Council may elect a new President or Vice-President to hold office for the remainder of the term. Council may elect a new President or Vice-President to hold office for the remainder of the term Subject to 16.02, the Executive Committee shall be composed of five councillors, two of whom shall be public councillors, and shall include the President and the Vice- Presidents The Executive may be composed of five councillors, three of whom are public councillors, where the position of President is filled under Article Article has been added to recognize that there may be a time where a President who is a nurse is replaced mid-term by a public member President. That would result in three public members on the Executive which would not be validly constituted without the provision in Election and Appointments Committee No councillor who wishes to run for the office of President or Vice-President shall serve on the Election and Appointments Committee The Election and Appointments Committee s responsibilities include, but are not limited to, vi) making recommendations to Council where there is no candidate declared for a Council officer position. 24. Election and Appointments Committee No councillor who wishes to run for the office of President or Vice-President shall serve on the Election and Appointments Committee The Election and Appointments Committee s responsibilities include, but are not limited to, vi) making recommendations to Council where there is no candidate declared for a Council officer position or insufficient candidates for the two other positions on the Executive Committee. The role of the Election and Appointments Committee in the election of the Executive is limited to identifying candidates for positions if there are insufficient candidates for acclamation. A member running for election for a position in which there are insufficient candidates would be expected to follow the conflict of interest expectations for Council members. To ensure that there are at least sufficient candidates for acclamation for all Executive Committee positions. 14

91 Current By-law Proposed amendments What does this mean? Why is it proposed Schedule No. 1 to By-Law Schedule No. 1 to By-Law To include election of the No. 1 No. 1 other members of the Process for Election of Process for Election of Executive Council Officers Council Officers and Other Members of the Executive Committee In this Schedule, Council Officers means the President and two Vice- Presidents of the Council and Council Officer means one of the President or Vice- Presidents of the Council. 1. Prior to any Council meeting, where councillors are expected to elect one or more Council Officers, nomination forms for the nomination of the Council Officers to be elected at that meeting shall be sent by the Executive Director to persons who the Executive Director expects to be councillors at the meeting of Council where the elections are to be held. In this Schedule, Council Officers means the President and two Vice- Presidents of the Council and Council Officer means one of the President or Vice- Presidents of the Council. 1. Prior to any Council meeting, where councillors are expected to elect one or more Council Officers and/or other members of the Executive Committee, nomination forms for the nomination of the Council Officers and/or other members of the Executive Committee to be elected at that meeting shall be sent by the Executive Director to persons who the Executive Director expects to be councillors at the meeting of Council where the elections are to be held. Change to add the election of the other members of the Executive Committee 2. Subject to paragraph 8, to be nominated for election as a Council Officer, a councillor must submit a completed nomination form including the written consent of the councillor wishing to stand for election for that position and the signatures of three persons who, at the time of 2. Subject to paragraphs 8 and 34, to be nominated for election as a Council Officer or another member of the Executive Committee, a councillor must submit a completed nomination form including the written consent of the councillor wishing to stand Addition of paragraph 34 recognizes that if a public member is elected President, nurse members may not have anticipated the opportunity to run for election to the Executive Committee and may need flexibility of verbal nominations. 15

92 Current By-law Proposed amendments What does this mean? Why is it proposed the nomination, were councillors. for election for that position and the signatures of three persons who, at the time of the nomination, were councillors. 3. A councillor may not run for election for more than one Council Officer position. 3. A councillor may not run for election for more than one Council Officer position. 4. A councillor may withdraw as a candidate at any time. 4. A councillor may withdraw as a candidate at any time. 5. A councillor nominated for more than one Council Officer position must, prior to the commencement of the election, withdraw as a candidate from all but one Council Officer position, failing which the councillor shall not be eligible to run for election for any Council Officer position. 5. A councillor nominated for more than one Council Officer position must, prior to the commencement of the election, withdraw as a candidate from all but one Council Officer position, failing which the councillor shall not be eligible to run for election for any Council Officer position. 6. The chair of the Election and Appointments Committee or his or her designate shall preside as chair of that portion of the meeting of Council where the election of Council Officers takes place. 6. The chair of the Election and Appointments Committee or his or her designate shall preside as chair of that portion of the meeting of Council where the election of Council Officers and/or other members of the Executive Committee takes place. 16

93 Current By-law Proposed amendments What does this mean? Why is it proposed 7. Council shall appoint three scrutineers for the election. 7. Council shall appoint three scrutineers for the election. Election of Council Officers Heading added for clarity 8. The chair will call for nominations from the floor which nominations must be in writing and must comply with paragraph 2 above. 8. The chair will call for nominations from the floor which nominations must be in writing and must comply with paragraph 2 above. 9. Ballots will be distributed for election of the Council Officers to be elected at that Council meeting. Each ballot will include all Council Officer positions to be elected and will include the names of all candidates whose nomination forms have been properly completed and submitted as of close of business on the date prior to the election. 9. Ballots will be distributed for election of the Council Officers to be elected at that Council meeting. Each ballot will include all Council Officer positions to be elected and will include the names of all candidates whose nomination forms have been properly completed and submitted as of close of business on the date prior to the election. 10. The chair will announce the names of all candidates running for election or each Council Officer position and direct the councillors to add to the ballot the name of any properly nominated candidate whose name is not already on the ballot and to remove from the ballot any councillor who has submitted a withdrawal as a candidate or is not 10. The chair will announce the names of all candidates running for election or each Council Officer position and direct the councillors to add to the ballot the name of any properly nominated candidate whose name is not already on the ballot and to remove from the ballot any councillor who has submitted a withdrawal as a candidate or is not 17

94 Current By-law Proposed amendments What does this mean? Why is it proposed eligible to run in that election. eligible to run in that election. 11. If no councillor has been nominated for any Council Officer position for which an election was to be held at that Council meeting, the Election and Appointments Committee will nominate a candidate or candidates for the office(s). 11. If no councillor has been nominated for any Council Officer position for which an election was to be held at that Council meeting, the Election and Appointments Committee will nominate a candidate or candidates for the office(s). 12. If only one candidate has been nominated for a Council Officer position, the chair shall declare the candidate elected by acclamation. 12. If only one candidate has been nominated for a Council Officer position, the chair shall declare the candidate elected by acclamation. 13. Each candidate for election shall be offered the opportunity to briefly address Council. 13. Each candidate for election shall be offered the opportunity to briefly address Council. 14. Voting shall be by secret ballot and shall take place simultaneously for all Council Officer positions which are subject of election at that Council meeting. 14. Voting shall be by secret ballot and shall take place simultaneously for all Council Officer positions which are subject of election at that Council meeting. 15. The completed ballots will be deposited in a ballot box and the ballot box given to scrutineers. 15. The completed ballots will be deposited in a ballot box and the ballot box given to scrutineers. 18

95 Current By-law Proposed amendments What does this mean? Why is it proposed 16. A staff member designated by the chair will count the ballots under the supervision of the scrutineers. 16. A staff member designated by the chair will count the ballots under the supervision of the scrutineers. 17. The scrutineers will report to the chair the results in writing including the number of votes cast for each candidate for each Council Officer election. The chair will announce the results to Council without referring to the number of votes cast for each candidate. 17. The scrutineers will report to the chair the results in writing including the number of votes cast for each candidate for each Council Officer election. The chair will announce the results to Council without referring to the number of votes cast for each candidate. 18. A candidate receiving a majority of the votes cast for that Council Officer position shall be declared the successful candidate. Where there were more than two candidates running for election for a Council Officer position and no candidate received a majority of the votes cast, the candidate with the lowest number of votes shall be dropped from the election and another vote (ballot) shall be taken. The same process shall be followed until one candidate receives a majority of the votes cast for that Council Officer position. In the event that two candidates remain with an equal number of votes which tie, in the opinion of Council, is unlikely to be broken by additional 18. A candidate receiving a majority of the votes cast for that Council Officer position shall be declared the successful candidate. Where there were more than two candidates running for election for a Council Officer position and no candidate received a majority of the votes cast, the candidate with the lowest number of votes shall be dropped from the election and another vote (ballot) shall be taken. The same process shall be followed until one candidate receives a majority of the votes cast for that Council Officer position. In the event that two candidates remain with an equal number of votes which tie, in the opinion of Council, is unlikely to be broken by additional 19

96 Current By-law Proposed amendments What does this mean? Why is it proposed ballots, the tie shall be broken by the chair by lot. ballots, the tie shall be broken by the chair by lot. 19. Where in the course of the election a tie vote occurs respecting two or more candidates having the lowest number of votes in that election and it is necessary to break that tie in order to determine which of the candidates shall be dropped from the ballot, the Council shall vote by secret ballot to determine which of the candidates shall be dropped from the ballot unless the tie, in the opinion of Council, is unlikely to be broken by additional ballots, in which case the tie shall be broken by the chair by lot. 19. Where in the course of the election a tie vote occurs respecting two or more candidates having the lowest number of votes in that election and it is necessary to break that tie in order to determine which of the candidates shall be dropped from the ballot, the Council shall vote by secret ballot to determine which of the candidates shall be dropped from the ballot unless the tie, in the opinion of Council, is unlikely to be broken by additional ballots, in which case the tie shall be broken by the chair by lot. 20. If a request by a candidate is made within thirty days of the election, the chair of the Elections and Appointments Committee will advise the candidate of the number of votes cast for each candidate in respect of any ballot for the Council Officer position for which he or she ran for election. 20. If a request by a candidate is made within thirty days of the election, the chair of the Elections and Appointments Committee will advise the candidate of the number of votes cast for each candidate in respect of any ballot for the Council Officer position for which he or she ran for election. Since these provisions now relate to the election of all members of the Executive Committee, they have been moved to the bottom of the schedule (see paragraph 38) 21. Unless Council directs otherwise, ballots shall be destroyed immediately following the chair declaring the successful candidates for all positions. 21. Unless Council directs otherwise, ballots shall be destroyed immediately following the chair declaring the successful candidates for all positions. 20

97 Current By-law Proposed amendments What does this mean? Why is it proposed Election of the balance of the Executive Committee To clarify the purpose of the following paragraphs 20. Following the election of the Council Officers, the remaining two members of the Executive Committee shall be determined by election using a secret ballot and in a manner consistent with the election of Council Officers, unless otherwise specifically provided for in this Schedule. For greater clarity the provisions of paragraphs 9, 10, 11, 13, 15, 16, 17, 18 and 19 apply with necessary modification to the election(s) of other members to the Executive Committee. To clarify that the election of the other members of the Executive takes place once the President has been elected. Since whether the President is a nurse or a public member impacts on the remaining process, the remaining schedule is divided based on those two options. Process where the President is a member of the College 21. The provisions of paragraphs 22 to 27 apply where the President elected at the meeting is member of the College and therefore two public councillors are to be elected to be members of the Executive Committee. 22. The Chair shall request nominations for the two public councillor positions on the Executive Committee which nominations must be in writing and must comply with paragraph 2 above. This section deals specifically with a President who is a nurse and therefore two public members are to be elected to the Executive. The process follows the process for election of officers. To provide for election of two public members by majority, each councillor will be able to cast votes for two public members. 21

98 23. If only two public councillor candidates have been nominated for election to the Executive Committee, the chair shall declare those candidates elected by acclamation. 24. If only one public councillor candidate has been nominated for election to the Executive Committee, the chair shall declare that candidate elected by acclamation. 25. If insufficient public councillors have been nominated for election to the Executive Committee for which an election was to be held at that Council meeting, the Election and Appointments Committee will nominate a candidate or candidates for the position(s). 26. Where more than two eligible candidates have been nominated for election to the Executive Committee, elections shall be held in a manner consistent with the process for election of Council Officers save and except that each councillor will be entitled to cast a vote for not more than two candidates. Paragraphs 26 and 27 together clarify the voting parameters to support electing public member by majority with one ballot. 27. For greater clarity, a ballot cast under 26 shall not be considered spoiled simply because a councillor votes for one candidate. 22

99 Current By-law Proposed amendments What does this mean? Why is it proposed Process where the President is a Public Councillor 28. Where the President elected at the meeting is public councillor, the provisions of paragraphs 29 to 37 shall apply in order to elect one additional public councillor and one additional councillor who is a member of the College, to the Executive Committee. Article limits the number of public members on the Executive to two. If the President is a public member, one of the other members of the Executive must be a nurse ( member of the College ). 29. The Chair shall request nominations for the public councillor position on the Executive Committee, which nominations must be in writing and must comply with paragraph 2 above. 30. If only one public councillor candidate has been nominated for election to the Executive Committee, the chair shall declare that candidate elected by acclamation. 31. If no public councillor has been nominated for the Executive Committee position the Election and Appointments Committee will nominate a candidate for the position. 32. If more than one eligible candidate is nominated, an election shall be held in a manner consistent with the election of Council Officers. 23

100 Current By-law Proposed amendments What does this mean? Why is it proposed 33. The chair shall then call for nominations for the remaining position on the Executive Committee which position shall be filled from among eligible councillors who are members of the College. This is to clarify that, since a nurse is being elected, there may need to be new nominations. 34. Nominations for the position referred to in paragraph 33 may be in writing, in compliance with paragraph 2 or may be made orally at the meeting if supported either orally or in writing by three persons who, at the time of the nomination, were councillors, provided the person being nominated for election consents to being a candidate. Since the fact of a public member President may not have been foreseen, this provides an option for verbal nominations for the nurse member. The base requirements of 3 nominators and candidate consent remain. 35. If only one candidate has been nominated for that Executive Committee position, the chair shall declare the candidate elected by acclamation. 36. If no councillor has been nominated for that Executive Committee position the Election and Appointments Committee will nominate a candidate for that position. 37. If more than one eligible candidate is nominated, an election shall be held in a manner consistent with the election of Council Officers. 38. The following rules and procedures apply to all elections held in These provisions were moved from the end of the 24

101 Current By-law Proposed amendments What does this mean? Why is it proposed accordance with this Schedule: 1. If a request by a candidate is made within thirty days of the election, the chair of the Election and Appointments Committee will advise the candidate of the number of votes cast for each candidate in respect of any position for which he or she ran for election. 2. Unless Council directs otherwise, ballots shall be destroyed immediately following the chair declaring the successful candidates for all positions. section addressing Officer election as they relate to all elected positions. 25

102 Agenda Item Decision Note December 2016 Council Election of the Executive Committee: Amendments to the Election and Appointments Committee Terms of Reference Contacts for Questions or More Information Kevin McCarthy, Director of Strategy Decision for consideration That the proposed revised Terms of Reference for the Election and Appointments Committee, as they appear in attachment 1 to this decision note, be approved. Background In September 2016 Council decided that all members of the Executive Committee would be elected beginning with the March 2017 elections. In addition to changes to the By-Laws, this change has implications for terms of reference of the Election and Appointments Committee. The Election and Appointments Committee s role includes oversight of the election of Council members, recommending a slate of committee members to Council and identifying candidates to fill unfilled positions for the election of Council officers. The Chair of the Election and Appointments Committee, or her or his delegate, chairs the election of officers (to become the Executive Committee). No changes are being proposed at this time to the role of the committee with respect to committee assignments. In 2008, recognizing the importance of the work done by statutory committees to public safety, the complexity of the work and the scrutiny which statutory committee decisions can face, Council made several changes to the process for determining committee assignments to support committee effectiveness. These changes included: Shifting from electing to appointing non-council committee members, to allow for the identification and recruitment of specific skills and backgrounds to meet committee needs (e.g. a nurse practitioner for the Quality Assurance Committee); and Maintaining committee assignments throughout a member s term of office to leverage the expertise that committee members develop during their time on statutory committees.

103 With the changes to the process for selection of the Executive Committee, a number of changes are proposed to the Terms of Reference for the Election and Appointments Committee (see attachment 1). It is proposed that Section 2 be renamed from Officer Election to Executive Committee Election. Throughout, section 2, it is proposed that the references to election be broadened from officer to the Executive Committee. In addition, it is proposed that item 2.2 a) be revised to address the possibility of public member candidates for election not being reappointed by government. It is proposed that references to the Executive Committee be removed from Section 3 which addresses Assignment of Members to Statutory Committees. It is also proposed that item 2 be removed from the membership. That precludes someone standing for office from being on the Election and Appointments Committee. The role of the Election and Appointments Committee with respect to the officer (now Executive) election is limited to the nomination of candidates for unfilled positions. The Chair or her or his delegate chairs the election of the Executive Committee. Should a member of the Election and Appointments Committee find themselves running for the Executive, and there be a need to nominate a candidate for an unfilled position, that member would be expected to declare a conflict of interest and leave the room for the discussion and decision. Should the Chair of the Election and Appointments Committee decide to run for election, he or she would be expected to delegate chairing the election of the Executive Committee to another member of the Election and Appointments Committee. Attachment: Election and Appointments Committee Terms of Reference with proposed amendments. 2

104 Changes in bold faced italics Attachment 1 Election and Appointments Committee Terms of Reference The Election and Appointments Committee is appointed in March of each year. The committee carries out the human resource function for Council, fulfilling a specific adjudicative role with respect to the elections of Council and committee members and preparing a complete slate for the election of Council officers and appointment of members to committees. Specific terms of reference are: 1. Council member elections: 1.1 Review the election results and declare the elected candidates. If a tie vote occurs, designate who will break the tie by lot, and declare the candidate so selected as elected (Article 53.26). 1.2 Adjudicate disputes on eligibility for candidacy and voting. 1.3 Make recommendations to Council for filling of vacancies in accordance with Articles and of the General By-Law. 1.4 Report election results to Council in June. 2. Officer election Election of the Executive Committee 2.1 The Election and Appointments Committee shall ensure that there is a complete slate for election of the Council President. and Vice-Presidents, and other members of the Executive Committee including: All consenting candidates who are Council members whose term of office has not expired or who are running for re-election, duly nominated in writing by three Council members; and 3

105 For unfilled positions, candidates will be nominated by the Election and Appointments Committee. 2.2 The Election and Appointments Committee Chair or her or his delegate(s) shall notify: a) Council of any candidates standing for office election to the Executive and who were defeated in the College general election or not reappointed to Council by government; b) Candidates for nomination by the Election and Appointments Committee to ascertain their willingness to stand; c) Candidates for election as officers to the Executive Committee of the numerical results of election for the position for which they stood, on request, within 30 days of the election. 2.3 The Election and Appointments Committee Chair, or her or his delegate, 1 shall chair the election of members of the Executive Committee officers of the Council. 3. Assignment of Members to Statutory Committees 3.1 The Election and Appointments Committee recommends a slate of members of the following committees to Council: Statutory Committees (Council and committee members) Executive (Council members only, excluding Officers Discipline; Fitness to Practise; Inquiries, Reports and Complaints; Quality Assurance, Registration Standing Committee (Council members) Finance 3.2 The following factors will be considered in making recommendations to Council about the slate of committee members: Maintaining as much continuity as possible on all committees; Filling vacancies with new members, considering members time availability, experience and responses to the conflict of interest form; Identifying the public members for the Executive based on membership criteria; and 1 In accordance with Article 7.15 of the General By-Law, the member who carries out this duty must be a member of Council. 4

106 Considering members requests for changes in committee, based on specific criteria. Membership 1. The Executive Committee shall appoint for ratification by Council in March six members (two RNs, two RPNs, and two public members) to the Election and Appointments Committee. The Committee shall appoint a Chair from among the members of the Committee whose term extends beyond June. 2. Members cannot serve on the Election and Appointments Committee and run for the offices of President or Vice-President. 3. The Chair shall arrange for a specific committee member to act as chair in her/his absence. 4. The term of office shall be from the time of appointment until the December Council meeting in the next year. For that reason, preference will be given to members whose term of office extends beyond June of following year. Approved by Council December

107 Agenda Item 5.3 Information Note December 2016 Council The changing regulatory landscape Regulation Rethought At Council, Anne Coghlan will be providing an update on trends in the regulation of professions. As part of her presentation, she will highlight the recently released report of the UK Professional Standards Authority: Regulation Rethought: Proposals for reform. A copy of the report is attached, for your information.

108 Regulation rethought Proposals for reform October 2016

109 About the Professional Standards Authority The Professional Standards Authority for Health and Social Care promotes the health, safety and wellbeing of patients, service users and the public by raising standards of regulation and registration of people working in health and care. We are an independent body, accountable to the UK Parliament. We oversee the work of nine statutory bodies that regulate health professionals in the UK and social workers in England. We review the regulators performance and audit and scrutinise their decisions about whether people on their registers are fit to practise. We also set standards for organisations holding voluntary registers for people in unregulated health and care occupations and accredit those organisations that meet our standards. To encourage improvement we share good practice and knowledge, conduct research and introduce new ideas including our concept of right-touch regulation. We monitor policy developments in the UK and internationally and provide advice to governments and others on matters relating to people working in health and care. We also undertake some international commissions to extend our understanding of regulation and to promote safety in the mobility of the health and care workforce. We are committed to being independent, impartial, fair, accessible and consistent. More information about our work and the approach we take is available at

110 1. Introduction This paper sets out our proposals for a transformation of the regulation of health and care professionals. We suggest how we could put into practice the ideas set out in our paper Rethinking regulation (2015) 1. It should therefore be read in the context of that earlier publication. We have not repeated here the arguments or the evidence we set out there, but all of the proposals we put forward in this paper have been formed with the intention of offering solutions to those problems. The public often find the regulatory system baffling and hard to navigate, particularly when they have a concern or complaint and want to report it in the right way; the role of the regulator is easily misunderstood. Employers have to engage with multiple regulators in order to check their workers registration, report concerns and support revalidation and continuing professional development. People in multi-disciplinary teams work to different standards and may be subject to different decisions by different regulators for the same or similar events for which they have individual and shared responsibility. They may be subject to different sanctions which patients, employers and registrants find hard to reconcile. Educators too are affected by multiple regulators with different standards and quality assurance mechanisms. This may inhibit their ability to train practitioners who are centred on patients needs, with shared values, and who can work across professional boundaries within health and care. Team roles and functions may 1 Professional Standards Authority (2015) Rethinking regulation. Available at: org.uk/docs/default-source/publications/thought-paper/ rethinking-regulation-2015.pdf There is a real need for legislative reform; without legislation, the changes proposed in this paper cannot be fully realised change as population needs, technological innovations or service requirements alter. Those striving to re-design service delivery, integrate care, or introduce new working practices may be frustrated and delayed by the difficulties inherent in flexing scopes of practice or creating new roles, because of protected titles and boundary protection by particular professions. Those seeking to bring about change are also seeking independent assurance about the standards and competencies of those who are not subject to statutory professional regulation. Regulation is often cited as a barrier to innovation, although that is not always so, whereas its position should be one of enabling both change to practice and flexible roles in the workforce. Our proposals are intended to support the achievement of the ambitions of the Five Year Forward View 2, and other plans for workforce and service change across the UK. In particular the flexibilities we propose may be of value in the discussions currently taking place about new roles in the NHS, such as physician associates and nursing associates and about the role of regulation in the devolved Greater Manchester Health and Social Care Strategic Partnership. Fitness to practise processes are lengthy and costly in both financial and personal terms. The confrontational nature of proceedings and the stress that hearings engender can affect the health and wellbeing of all concerned. The approach inherent in our existing fitness to practise arrangements runs counter to our growing understanding of the situations where things go wrong, and the inter-connections between workplace, leadership, culture, systems, human factors 2 NHS England (2014) Five Year Forward View Regulation rethought 1

111 and human behaviour. Regulators would prefer to shift their focus and expenditure, as a number are now trying to do, towards the prevention of harm and the maintenance of standards, building on these insights to achieve greater effectiveness, efficiency, and a reduction in harm to patients. In this paper, we recognise the intentions of the government announced by the former Parliamentary Under-Secretary of State, Ben Gummer MP 3, in December 2015 when he set out the government s objectives for regulatory reform saying, Our priorities for reform in this area are better regulation, autonomy and cost-effectiveness while maintaining and improving our focus on public protection. We intend to consult on how these priorities can be taken forward, taking account of the Law Commissions work on simplification and consistency and building on the Professional Standards Authority for Health and Social Care s paper Rethinking regulation published in August We will present proposals that give the regulators the flexibility they need to respond to new challenges in the future without the need for further primary legislation 4. In Rethinking regulation we argued that the whole regulatory system needed reform, including system regulators such as the Care Quality Commission, if regulation is going to be effective for patients and professionals alike. That is still our view. However, we have focused here on professional regulation alone. There is a real need for legislative reform; without legislation, the changes proposed in this paper cannot be fully realised. We have also discussed in this paper improvements of approach, which might be achieved 3 Ben Gummer MP was appointed Minister for the Cabinet Office and Paymaster General on 14 July Regulation of Health and Social Care Professionals: Written statement - HCWS417, 17 December 2015 through collaboration, innovation, imagination and determination, rather than through legislative and structural change to the institutions of regulation. Those qualities will not, we are sure, be lacking in the regulators. However, real progress is necessary and while some change can be achieved within the legal framework we have this does not remove the need for new legislation. The objectives we set out in Rethinking regulation align to a considerable extent with the government s intentions. They are: A shared theory of regulation based on righttouch thinking Shared objectives for system and professional regulators and greater clarity of roles Transparent benchmarking to set standards A rebuilding of trust between professionals, the public and regulators A reduced scope of regulation so it focuses on what works A proper risk assessed model of who and what should be regulated put into practice through a continuum of assurance Breaking down boundaries between statutory professions and accredited occupations Making it easier to create new roles and occupations within a continuum of assurance A drive for efficiency and reduced cost which may lead to functional mergers and deregulation Placing real responsibility where it lies; with the people who manage and deliver care. A shared theory of regulation would encompass a common purpose, common objectives, and a shared understanding of the differences between regulation, inspection and quality improvement. At the conclusion of Rethinking regulation we wrote some of this needs merely a change in thinking, a new attitude, a willingness to do less 2 October 2016

112 regulating and to take more responsibility for the quality of our own work, our team s performance, our organisation s delivery. Other changes will need legislation and a willingness to deregulate, and to sharpen regulatory tools where necessary. When in 2011 the Law Commissions set out on the task of revising the legal framework for professional regulation, they were charged with simplifying the law and improving public protection. In this paper we propose a series of improvements to professional regulation. Our proposals are primarily focused on public protection and professional responsibility. They are intended to create clarity for patients, and allow greater flexibility of approach for regulators, employers, policy makers and others shaping the workforce. They will encourage a wide variety of regulatory interventions and responses to the regulatory challenges arising across different professions. We have sought to embody the idea of agility as one of the principles of good regulation, an idea we first put forward in 2008 when we wrote that regulators must be consistently in a state of readiness to respond to changes and developments in healthcare professional practice and circumstances 5. We have adopted three principles against which to test our proposals for change. They are that the health professional regulatory system should be: Proportionate to the harm it seeks to prevent Simple to understand and operate Efficient and cost-effective. 5 Council for Healthcare Regulatory Excellence (2008) Advice to the Department of Health and the Pharmacy Regulation and Leadership Oversight Group on aspects of the establishment of the General Pharmaceutical Council. Available at default-source/publications/policy-advice/establishing-thegeneral-pharmaceutical-council-advice.pdf Regulation rethought Those proposals which would require legislation might result in the removal of statutory regulation from some of the groups that are currently subject to it and in a reduction in the scope of statutory regulation. At the same time our proposal for a single register for health and care professions and occupations will potentially extend registration (though not statutory regulation) to a much larger group of health and care workers. It will also provide broader assurance to the public and employers about more of those working in health and care services, whether regulated or not. Our proposals apply right-touch regulation principles, which advocate an efficient, risk-based approach to regulation, focused on the prevention and reduction of harm. In our publication Right-touch regulation 6 we also identify the different agents, such as employers, professional bodies, individual professionals, and service users, responsible for mitigating the potential risks presented by health and social care professionals. These same people will all have a role to play in honing, supporting, and implementing the changes suggested in this paper, particularly if the scope of regulation becomes more clearly focused. We recognise that regulation at the national level can be a blunt instrument for mitigating risks of harm, as regulators are distant from the actual risks that they seek to manage. With the four UK health and care systems continuing to diverge, the improvements we propose would strike a balance between consistency and flexibility across and within the four countries of the UK to allow for the development of both local and national approaches where desirable. Our proposals would allow regulators to 6 Professional Standards Authority (2015) Right-touch regulation. Available at uk/docs/default-source/publications/thought-paper/righttouch-regulation-2015.pdf 3

113 apply different approaches flexibly and creatively, striking the right balance between regulators and local management, and appropriate to the risks arising from the practice of their registrants. This would enable regulators to maximise their impact and influence to protect patients from harm. In developing our proposals for regulatory reform we have drawn on our understanding of the current regulatory framework, including accredited registers, and on conversations with colleagues in the regulators and registers, with government officials and with health professionals, patients and service users in the UK. We have also made use of our understanding and experience of professional regulation in other jurisdictions around the world, particularly Canada and Australia. We have drawn on the many academic studies which are building an evidence base and we acknowledge the influence on our thinking of Professor Malcolm Sparrow of Harvard University 7. We have adopted three principles against which to test our proposals for change. They are that the health professional regulatory system should be: Proportionate to the harm it seeks to prevent Simple to understand and operate Efficient and cost-effective In a separate but complementary paper, Right-touch assurance: a methodology for assessing and assuring occupational risk of harm (2016) 8, we propose a methodology by which decisions about the risk of harm 7 Malcolm Sparrow (2008) The Character of Harms and other works 8 Professional Standards Authority (2016) Right-touch assurance: a methodology for assessing and assuring occupational risk of harm 4 posed by occupations and professions could be profiled and how decisions could be made as to the proportionate level of assurance that is needed for each. We have summarised the methodology in Section 9 of this paper. 2. A shared purpose for regulators We propose that in future, all parts of the regulatory system should have a shared purpose: Protecting patients and reducing harms Promoting professional standards Securing public trust in professionals; and that all regulatory functions and activities should be directed towards and only towards those purposes. This will ensure clarity of purpose and alignment of effort towards common goals, supported by shared professional standards. It will enable regulators and others to operate more effectively as a safety system, rather than working in silos with separate objectives and diluted impact. In pursuit of our objective of simplicity and better understanding of regulation by the public we consider that a change of language is needed. The technical language of regulation is obscure and alienating for service users and registrants alike. The government itself has made a start in changing the language that relates to our appeal powers from unduly lenient to insufficient to protect the public. We propose that terms like fitness to practise, impairment and revalidation are avoided, and replaced with plain English. Further work will need to be undertaken to explore ways of describing regulation that are more readily accessible to everyone. We believe that the arrangements for licensing that we propose at Section 5 will be an important step towards public understanding. October 2016

114 3. A renewed focus on core functions We propose that the set of core functions carried out by regulators should be: To maintain a shared, public register of appropriately qualified health and care practitioners To award and renew licences to practise in specific occupations To set common standards that all registrants must meet To investigate allegations that registrants do not meet the standards and take action. Implicit within these core functions are such roles as assuring that once registered, practitioners remain appropriately qualified and that they continue to meet professional standards. In the absence of legislation, we are aware that some regulators are looking for a closer alignment of regulatory operations, and considering opportunities to work together to deliver functions on a shared basis. This should be particularly the case across occupations in similar working environments. This would apply for example to those working from High Street commercial premises such as many registrants of the General Dental Council, General Optical Council, General Pharmaceutical Council, Pharmaceutical Society of Northern Ireland 9, General Osteopathic Council and the General Chiropractic Council. In relation to the regulators of those professionals working in the High Street we think that there would be merit in exploring the possibility of their assuming regulatory responsibility for the 9 We note that the PSNI is the only regulator in the UK which combines professional representation with regulation and that the Department of Health, Northern Ireland has recently consulted on its future. environments in which registrants work, as part of an improved strategic alignment of regulatory responsibilities. Under current arrangements, the CQC inspects dentists and GPs premises but not pharmacies or the premises of opticians, osteopaths or chiropractors. Merging the regulation of people and premises has advantages for patient safety as pharmacy regulation has shown. We propose that the regulation of premises of those working in High Street practice is brought within the scope of the professional regulators. In the longer term there would be merit in merging regulators to simplify access, improve efficiency and reduce costs. We discuss this further in Section 4, see page 6. Some regulators may wish to explore that option voluntarily in relation to alignment of their functions where this is possible within existing legislation. We propose nevertheless a move to a shared and public-facing register for all people working in health and care, with a range of registration and licensing arrangements depending on the level of assurance needed. We believe that a single register, together with our proposal for common standards that apply to all, will support multi-disciplinary working, individual and collective accountability and team-based regulation. The register could be established as a shared portal and ultimately as a single entity. We make specific proposals about reform of the approach to concerns about professionals conduct or competence including replacing the language of fitness to practise with the concept of giving and taking away licences to practise certain occupations. This is discussed in Section 5. We encourage discussion of a new approach to quality assurance of higher education at Section 8. Regulation rethought 5

115 We propose that the functions carried out by regulators should be: To maintain a shared, public register of appropriately qualified health and care practitioners To award and renew licences to practise in specific occupations To set common standards that all registrants must meet To investigate allegations that registrants do not meet the standards and take action 4. Effectiveness and efficiency In pursuit of their objectives, regulatory bodies should direct their resources solely to those functions and activities that support their purpose. They should avoid activities which are better delivered through other organisations: employers, professional associations, unions, Royal Colleges, patient organisations and others. Regulators should continue to pursue cost-effective working. We propose that regulators in future should be held accountable for using their income for those purposes necessary to fulfil their functions as regulators, focused on ensuring that the required standards are being met. This should be a discipline within which all regulatory expenditure is framed. We propose therefore that regulators report annually on their cost-effectiveness, to support analysis, benchmarking and learning. As there are several forms which mergers could take we have not explored in any detail here the cost benefits that might flow from merging regulators. However, our previous work on cost-effectiveness indicates there are significant savings to be made. Regulators should actively consider opportunities to reduce their number and share functions if savings can be realised by doing so. The Health and Care Professions Council, and the Australian Health Practitioner Regulation Agency demonstrate that multi-professional regulators can be both efficient and cost-effective. Several accredited registers, not constrained by statute, have already merged or are considering doing so. When the opportunity exists for new legislation, we propose the creation of a single assurance entity for all health and care occupations. We describe this proposal in the Figure below. It would be responsible for a range of functions for all registered groups, including registration and licensing, the publication of a single register, maintaining a common set of standards for all registrants, and the receipt, investigation and prosecution of concerns about breaches of standards. It would contain regulatory bodies responsible for issuing licences, setting standards, quality assuring specialist education and training, and providing expertise where needed for the operation of the common functions. An independent tribunal service would perform the adjudication function across all professional groups for whom this type of quasi-judicial approach was deemed appropriate. This proposed structure draws to some extent on the Health and Care Professions Council s multi-profession model and the Australian Health Practitioner Regulation Agency, both of which demonstrate the effectiveness of shared regulatory functions with no diminution of professional expertise. It would offer benefits to the public, employers and others in terms of the accessibility and transparency of regulation, providing a single destination to check registered practitioners and to raise concerns. While we acknowledge that there would be significant transition costs, it would 6 October 2016

116 Figure: a single assurance body also offer the potential to realise substantial efficiency and economies of scale in its operating costs once established and over the long term, and thus for reduction in registration fees. Some elements of this proposal are realisable within existing legislation, in particular a shared register, which we discuss below. 5. A shared, public register and a system of licensing We propose that the regulators collaborate to establish a shared, public register for statutorily regulated professions, which in due course is extended to encompass accredited registers and other currently unregistered occupations, subject to proper risk profiling. This will make it easier for the public and employers to access and to understand, and together with shared professional standards, should support multi- disciplinary working, individual and collective accountability and team-based regulation. A single register, or initially a single portal, will provide a simple means for the public, employers, commissioners and others to find every registered practitioner, and check that they are licensed. We propose that under this arrangement becoming registered would involve signing up to a statement of professional practice, a shared set of core standards that would apply to all health and care practitioners on the single register. The statement of professional practice would define the standards of conduct, behaviour and ethics required of all registrants, irrespective of their profession or occupation. Profession or occupation-specific standards would of course also be required, tailored to the clinical practice of each. We propose that higher risk occupations would then be Regulation rethought 7

117 issued with a licence by their regulator allowing them to practise and appear on the register in that capacity. Others namely those currently under the remit of accredited registers but also those in future covered by credentialing 10 would be registered and accredited but not licensed, and therefore subject to proportionate registration and renewal requirements. Among the licensed groups, a range of requirements could apply for awarding and renewing of the licence, depending on the levels of assurance required, including restricting scopes of practice where necessary. A wider part of the workforce such as care assistants could be registered, signing up to the statement of professional practice in a similar way to the employers code of conduct for such groups used in Scotland. Registration and deregistration could be linked to the Disclosure and Barring Service. The creation of a shared public-facing register and a licensing system would provide a simple means for the public, employers, commissioners and others to find registered practitioners, and check they are licensed. It would also help better public understanding of the purpose of regulation, since the concept of licensing is well understood by the public, in particular of course in relation to driving licences and the Driver and Vehicle Licensing Agency (DVLA). We do not claim that driver licensing is as complex as regulating health professionals, but we do believe that the language of registration and licensing would provide a frame through which the purpose and functions of regulation can be made clearer and more accessible to everyone. 10 Credentialing in this context refers to the NHS project developing a method of ensuring safety of patients and staff for unregulated occupations, ahead of encouraging the formation of an accredited register. This is distinct from the GMC use of the term credentialing for specific areas of medical practice for doctors who are already on a register. 8 For this model to be consistent and risk based we need a rational and consistent approach to which occupations are or are not registered or regulated. To support this we have developed a methodology for determining the appropriate level and type of assurance needed to protect the public from the risk of harm, which we set out in our complementary paper Right-touch assurance: a methodology for assessing and assuring occupational risk of harm (2016) and summarise below in Section Working in partnership to prevent harm and promote professionalism Research and studies of human factors, safety science, behavioural science and organisational psychology, major inquiries and investigations incontrovertibly demonstrate the behavioural links between systems, organisations, places and people. Therefore, preventing and reducing harm, promoting professionalism, improving quality and encouraging compassionate care require a coordinated approach by regulators, employers, educators and professional bodies. Professional and system regulators and educators need to share intelligence and alert each other to heightened risk of harms. They need to use their insights to support employers to recognise the circumstances in which harm occurs, and to support the development of cultures, workplaces and systems that empower registrants to comply with professional regulatory standards. Fitness to practise data in particular can yield insights to help others who are closer to potential problems to take preventative action. Its analysis can assist in the identification of situational factors most prone to be associated with complaints. It provides a starting point for further analysis and research into why such patterns exist and how they might be best addressed. October 2016

118 This requires the continuation of the change of emphasis by regulators from responding to complaints to contributing insight and knowledge to the active prevention and reduction of harms. It also requires a careful approach to ensure that in working in this way, the responsibilities of different organisations remain clear and organisational boundaries are maintained. Regulators will need to continue to work with stakeholders to build the relationships through which they can exert influence and achieve impact, building on the insights that are already emerging through data analysis. The focus of this work should be to support preventative measures being taken by those who are closest to problems. 7. Maintaining standards, preventing harm Fitness to practise proceedings are protracted and expensive, the number of cases which go through the process resulting in a decision to take no further action is too high, and patients and the public feel disenfranchised from the process even where they may feel that they have paid a high personal price for raising a concern with a regulator. The experience of patients, professionals and employers of the current procedures often fail the trust and confidence tests we set ourselves in thinking about a new way of doing things. Regulators themselves are frustrated by the limitations of the legislation within which their processes operate. Therefore we believe that a significant change of approach is needed. We propose that the purpose of procedures to assess, investigate, prosecute and adjudicate on competence, conduct and health concerns across the professions should reflect the proposed purpose of the regulatory system as a whole, as set out in the first paragraph of Section 2 (see page 4): Protecting patients and reducing harms Promoting professional standards Securing public trust in professionals. We propose that regulators focus should remain on whether a registrant is fit to practise (although described with plainer language). It should not become a complaints process with the focus on redress or other remedies for people who complain. The tests of conduct and competence applied in fitness to practise proceedings are important and need to remain. However, we do believe the regulators should continue to move towards shorter, less costly and more consensual ways to close cases. Regulators also need to identify trends, correlations with organisational and human factors and potential risks of harm that should be brought to the attention of healthcare providers, other regulators and improvement bodies to contribute to reducing harms. The purpose of fitness to practise procedures: Protecting patients and reducing harms Promoting professional standards Securing public trust in professionals We do however believe that the language used to describe fitness to practise processes should be more plain English to make them easier for all to understand. The adoption of a licensing system and associated language would, we believe, make the purposes of fitness to practise more accessible and create clearer expectations for people who complain. Regulation rethought 9

119 Local resolution The health and care regulators have worked hard over recent years to make the experience of raising a concern, and appearing as a witness at a hearing, less stressful and time-consuming for the public. However, it is their role as a witness to the regulator s proceedings that is often dissatisfying to people who complain; the focus of the process is the registrant not the patient. We consider that a larger proportion of those cases currently handled by regulators fitness to practise processes could be resolved locally by employers, registrants and local mediation where available. Many cases which may not require regulatory attention are subject to investigation and processing. If the Responsible Officer role were expanded to all regulated professions it would provide a means of encouraging better complaints handling by registrants, and better use of local processes, ensuring that matters were resolved more quickly and effectively. It would also support the separation of complaints from fitness to practise concerns, and enable appropriate handling of both. We believe that some of the other changes that we are proposing in particular the idea of a single shared register and a system of licensing for professionals will help the public to understand the role of regulation, and the distinction between regulatory proceedings and a complaints procedure. The idea of a licence to undertake particular activities such as driving is well understood as are different driving tests and licences for different vehicles and the idea of points on a licence or removal of a licence for the most serious offences. Adopting an inquiring instead of a confrontational approach We believe that under new legislation there should be a change from the current adversarial approach in fitness to practise to one which is more inquisitorial, in other words, based more on inquiring into the circumstances of a case. The process should allow for non-confrontational exploration of the circumstances in which alleged misconduct occurred, with opportunities for resolving a case through discussion and agreement, without the need for a formal hearing. Of course the committees of regulators currently have the ability to be inquiring but this is not their primary approach. Our proposal would build on that and would provide the basis for a more proportionate, quicker and more cost-effective resolution, with less reliance on a final hearing. In order to achieve this it will be necessary to add to the various methods of resolving complaints or concerns about registrants which are currently available (short of a full panel hearing) in order to make registrants more likely to accept these alternatives. There might also have to be a strengthening of powers or abilities to deal with registrants restrictively who do not engage or cooperate. Clearly this would require new legislation. There needs to be a greater emphasis on addressing cross-professional or organisational questions which are difficult for the current model to deal with. New processes could allow an adjudicator to suggest to a registrant that, on the basis of the untested evidence, there was a real question about their fitness to practise. This could then be addressed by remedial activity, or in cases of wider public interest agreement to an appropriate sanction. 10 October 2016

120 The key advantage would be for the case to be looked at as a whole, identifying the risk to the public posed by the behaviour concerned. If a professional is given an indication of how seriously his or her regulator views their conduct at an early stage, this could result in resolution without recourse to a full hearing. The employer might have input to, and oversight of, any remedial activity and ensure that learning is utilised, at a local level. For those cases that did require a public hearing (and criteria would need to be developed to describe this category of case), the file of evidence obtained by the regulator should be considered by an adjudicator to identify the questions which need to be addressed by the regulator and the registrant. Achieving efficiency and consistency through shared delivery of investigation, prosecution and adjudication There is scope for considerable benefits in terms of consistency and efficiency to be achieved by regulators collaborating to deliver their investigation, prosecution and adjudication functions in a shared way. There would be particular benefits from shared adjudication across all professions, by a separate tribunal service, building on the model developed by the Medical Practitioners Tribunal Service. This would reduce variability and would potentially generate cost savings from economies of scale. There would be other benefits such as more straightforward monitoring of performance and statistics, and the opportunity to develop greater expertise of hearing panellists. A number of the regulators are already exploring with the GMC the possibility of a shared tribunal service. Similarly, we also believe that there would be merit in exploring how regulators could collaborate to establish shared investigations and prosecutorial arms, whether in-house or by managing legal services provided by panel firms. This would help to increase consistency both in the conduct of investigations and in the way that cases are presented to panels, thereby removing or at least alleviating in particular the underprosecution that the Authority continues to identify in a number of cases. 8. Exploring a new approach to education and training regulation There is currently a wide range of practices and approaches across the regulators in relation to the way in which they quality assure higher education courses. These are to some extent determined by different legislative requirements. We recognise that these also reflect the fact that different occupations require different types and levels of education and that education has changed over time. Regulators have adapted their approaches to the various models of assessment, examination, education and training that exist for the different professions. Individual regulators assure the quality of assessment, education and training against different sets of standards, and there are various methods used to determine how and when on-site inspections and desk-based assessments are undertaken. Some regulators are making particular efforts to ensure that the courses they quality assure are preparing students for the roles of the future, for example, the General Optical Council has recently commenced a review of the standards of competence that students must meet and how they are assessed in view of future effects of technological change and enhanced services. Others are seeking to Regulation rethought 11

121 simplify and rationalise the standards they apply for example, the General Medical Council from January 2016 has introduced a single set of standards covering its span of both undergraduate and postgraduate medical education. The responsibilities of the GMC for postgraduate and specialty training are significantly different from those of other regulators. We consider however that the current arrangements for the regulation of undergraduate and other pre-registration training tend to duplication of regulatory responsibilities between professional regulators and other regulators in education, and this may be resulting in unnecessary expense and regulatory burden on higher education and training institutions. We recommend that the health professional regulators should ensure that their focus is upon setting and assessing the learning outcomes required for registration, since it is through examination and assessment that a student or trainee actually demonstrates competence in the relevant profession and therefore that they are suitably qualified for registration. This would leave other regulators and quality assurance mechanisms to deal with broader questions of course management. Regulators would continue to work in partnership with higher education institutes (HEIs) and other training providers to understand the impact of future population and workforce needs. We believe that such a change of approach would offer the potential for cost-savings and efficiency in the way that registrants prove their suitability for registration, as well as reducing the regulatory burden on HEIs. The introduction of a common statement of professional practice discussed in Section 5, see page 7 would provide a focus for ensuring consistency in the values that underpin training courses across professions. For these reasons we propose a review of regulatory approach and responsibilities in this area, working together with other bodies involved in the regulation of universities and other training institutions, and with the bodies delivering training themselves. The objectives of the review would be to ensure that regulators have a clear focus, are sharing intelligence appropriately, and are not duplicating each other s responsibilities. A review would also seek to ensure that there is a clear rationale for differences of practice and approach, and that such differences are proportionate and risk-based. 9. Right-touch assurance: a methodology for assessing and assuring occupational risk In parallel with our proposals for regulatory practice improvement we have proposed a methodology for assessing occupational risk, with which to determine which occupations should be statutorily regulated, which risks are effectively controlled within an accredited register, and which can be well managed by employers. This approach should help the Department of Health and others make more objective and transparent decisions in relation to roles such as physician associate and nursing associate. This aspect of the reforms we propose is not dependent on legislative change and aligns closely with the principles of right-touch regulation. The proposed methodology is set out in detail in our paper Right-touch assurance: a methodology for assessing and assuring occupational risk of harm (2016). In the short term, we anticipate that our developing approach will be employed to assess new occupations to determine what type of oversight would be appropriate to manage risk of harm. In the long term, the methodology could have a broader function of determining the appropriate level of assurance for those occupations already on 12 October 2016

122 either the statutory or accredited registers, recommending the appropriate point on the continuum of assurance (see below) at which any given occupation should sit. The methodology may also be used or adapted by the regulators to aid decisions on whether or not specialties should be regulated, if there should be other types of annotation on the register, as well as reviewing provisional and student registration. Our intention is that the methodology should be used to support decisions about the type and degree of assurance needed to manage the risk of potential harm. This approach supports the single register and licensing model set out above. Our proposed methodology for right-touch assurance is a two-stage process. Whilst we employ scoring, the decision to be made by government is a matter of judgement based on information, not a matter of science or of ideology. The first stage is to create a risk profile of an occupation taking into account the intrinsic risks of harm arising from clinical care or practice, the context of the practice and the agency of the patient and service user. Hazards associated with the practice of an occupation are grouped into three broad categories as outlined in Righttouch regulation. These are intervention (the complexity and inherent dangers of the activity), context (the environment in which the intervention takes place) and agency (service user vulnerability or autonomy). For existing professional groups, an important source of evidence will be fitness to practise data, to establish actual harm that has been caused, its severity and its prevalence. Based on an assessment of the evidence related to the hazard, a risk score is allocated to each category and then to the occupation overall. By plotting the score on a radar chart, a risk profile can be created for each occupation. This is illustrated below. Once the hazards are understood and the risk of harm described through an occupation s risk profile and volume, in a second stage the occupation or profession will be considered against the assurance assessment criteria. This assessment will inform where the profession or Figure: risk profiles Regulation rethought 13

123 occupation sits on the continuum of assurance and allow the formulation of advice to government. The criteria identify extrinsic factors that may mitigate the risk of harm occurring or, conversely, increase it thereby altering the risk volume. This allows the use of a right-touch approach and ensures that any action is proportionate. 10. Conclusion In Section 1 of this paper we set out three principles against which to test our proposals. We believe that a health professional regulatory system reformed in the way that we propose would be: Proportionate to the harm it seeks to prevent: because it would be risk based, because decisions on regulatory arrangements would be determined through the continuum of assurance, and because it would have a clear and shared purpose and set of core functions Simple to understand and operate: because of the greater simplicity of a single register and other merged functions, because of the adoption of a well-understood licensing regime, and through reforms to the language with which regulatory processes are described Effective and efficient: because it would seek to benefit from available economies of scale through mergers and other alignments of regulatory responsibility, it would use its intelligence towards prevention of harm away from costly fitness to practise processes, and because it would focus its use of resources on its core functions. The Authority is committed to working with partners and stakeholders to take forward reform in our sector. There is already considerable momentum and energy for future change, to make regulation yet more focused on the interests of the public and to ensure more efficient spending on regulatory functions. We believe that the proposals we have set out in this paper will build on this and help achieve these aims. Detailed work will be needed to develop plans for implementing these proposals, and further, to prepare for future opportunities for legislative change. With cooperation, imagination, innovation and determination much may be achieved, but it is only with new legislation that the radical reform we propose in this paper can be fully realised. Figure: the continuum of assurance Employer controls Credentialing Voluntary registration Statutory registration/ licensing Lower risk occupations Higher risk occupations 14 October 2016

124 Annex A: Table of proposed changes Shared purpose Single register Common standards Licensing Practice changes proposed Agreement on common purpose across the sector: explore common interpretation and explore scope to harmonise and agree common outcomes. Adopt plain English in public-facing communications. Establishment of a single assurance body holding a shared public-facing register of all health and care professions and occupations. Agreement on statement of professional practice, i.e. common professional standards agreed by consensus between regulators and accredited register holders to apply to all registrants whether licensed or not. Develop profession/occupation specific standards as necessary. Establishment of a licensing regime. Adopt language change to align with a licensing process, similar to DVLA. Explore scope for issuing licences within existing legislation and proportionate approaches to different professions. Legislative change required? Change to statutory objectives required to achieve outcome. Required to establish a single assurance body. If required to codify a common set of standards applicable to all registrants. Required to establish formal power to issue licences. Regulation rethought 15

125 Fitness to practise Co-operation with others Education Costeffectiveness Right-touch assurance Adoption of shared approach to key elements of fitness to practise: investigation, prosecution, and adjudication (building on MPTS); explore scope to further harmonise sanctions; explore scope for achieving a more inquisitorial approach within existing legislation. Use of clearer, more public-focused language. Further co-operation with employers to achieve local resolution at an earlier stage where possible. Further implementation of cooperative working in particular to use regulatory data and insight in partnership with others to reduce harm. Review arrangements for quality assurance of education in view of current and future needs. Explore new approach to align with licensing regime, based on assessment of applicant. Introduce accountability for costeffective working with regular formal assessments of regulators cost-effectiveness and efficiency. Implement methodology set out in Right-touch assurance: a methodology for assessing and assuring occupational risk of harm. To enable adoption of an inquisitorial approach and to enable harmonisation of sanctions. Legal duty of co-operation only if required to achieve change. As required to enable change of focus. New legislation required if decision taken to pursue merger of regulators. Legislation not required. 16 October 2016

126 Annex B: Table 1 Statutorily regulated professions, accredited registers of occupations, and other occupations Type of regulation Regulator Occupation/other Statutory General Chiropractic Council Chiropractors General Dental Council Dentists Dental hygienists Dental therapists Clinical dental technicians Orthodontic therapists Dental nurses Dental technicians General Medical Council Doctors General Optical Council Dispensing opticians Optometrists Students Optical businesses General Osteopathic Council Osteopaths General Pharmaceutical Council Health and Care Professions Council Nursing and Midwifery Council Pharmaceutical Society of Northern Ireland Pharmacists Pharmacy technicians Pharmacy premises Arts therapists Biomedical scientists Chiropodists/Podiatrists Clinical scientists Dietitians Hearing aid dispensers Occupational therapists Operating department practitioners Orthoptists Paramedics Physiotherapists Practitioner psychologists Prosthetists/Orthotists Radiographers Social workers in England Speech and language therapists Nurses Midwives Pharmacists Pharmacy premises Regulation rethought 17

127 Professional Standards Authority Accredited Registers programme 12,13 NOTE all of these registers are voluntary to join, meaning that it is not a requirement so some of the workforce in these occupations may choose not to join and therefore be unregulated. In addition there are a number of other voluntary registers that have either not yet gained or have not sought accreditation, however these have not been included for this purpose Academy for Healthcare Science Alliance of Private Sector Practitioners Association of Child Psychotherapists Association of Christian Counsellors British Acupuncture Council British Association for Counselling and Psychotherapy British Association of Play Therapists British Association of Sport Rehabilitators and Trainers Healthcare science practitioners working in a wide variety of disciplines, including: Physiological sciences Microbiology Nuclear medicine Life sciences Health informatics Physical sciences Healthcare science Haematology Biomedical science Biomechanical engineering Bioinformatics Audiology Anatomical pathology technologists Genetic technologists Ophthalmic science practitioners Tissue bankers Including: Foot health practitioners Including: Psychoanalytic child psychotherapists Adolescent psychotherapists Including: Psychotherapists Counsellors Including: Acupuncturists Including: Psychotherapists Counsellors Including: Play therapists Including: Graduate sport rehabilitators 12 Please note that the occupations listed in this section of the table are not exhaustive for each accredited register, given the large number of modalities and disciplines in some areas. 13 Please note that two of the accredited registers (Save Face and Treatments you can Trust) register people who are only statutorily regulated. 18 October 2016

128 British Psychoanalytic Council Complementary and Natural Healthcare Council COSCA (Counselling & Psychotherapy in Scotland) Federation of Holistic Therapists Genetic Counsellor Registration Board Human Givens Institute Including: Psychotherapists Counsellors Complementary therapists working in a range of modalities including: Sports therapists Nutritional therapists Reflexologists Naturopaths Massage therapists Hypnotherapists Microsystems acupuncturists Craniosacral therapists Bowen therapists Alexander Technique teachers Including: Counsellors Psychotherapists Complementary healthcare therapists working in a range of modalities including: Yoga therapists Sports therapists Shiatsu practitioners Reiki healers Reflexologists Nutritional therapists Massage therapists Naturopaths Kinesiologists Hypnotherapists Homeopaths Craniosacral therapists Aromatherapists Bowen therapists Acupuncturists Alexander Technique practitioners Including: Genetic counsellors Including: Psychotherapists Counsellors Regulation rethought 19

129 National Counselling Society National Hypnotherapy Society Play Therapy UK Register of Clinical Technologists Save Face Society of Homeopaths Treatments You Can Trust UK Council for Psychotherapy UK Public Health Register Including: Psychotherapists Counsellors Including: Hypnotherapists Including: Play therapists Clinical technologists working in a variety of disciplines, including: Renal technology Radiation physics Rehabilitation engineering Radiotherapy physics Radiation engineering Medical engineering Clinical technology Nuclear medicine Healthcare science Clinical science Including: Doctors Nurses Dentists Covering non-surgical cosmetic injectables Including: Homeopaths Including: Doctors Nurses Dentists Covering non-surgical cosmetic injectables Including: Counsellors Psychotherapists Including: Public health practitioners Public health specialists Specialist registrars 20 October 2016

130 Table 2: Unregulated occupations Currently unregulated occupations NOTE this is intended to be indicative only and not a comprehensive list as the status of different occupations is subject to change Category Physical health Health promotion and protection Mental health and wellbeing Social work and care Roles Including: Physician associates Health care assistants Nursing associates (new role to be created) Alternative therapists practitioners not covered by relevant accredited registers Including: Health records and patient information Clinical management Including: Psychological therapy practitioners and counsellors not covered by relevant accredited registers Including: Care workers/care assistants Home care workers Personal assistants Regulation rethought 21

131 Professional Standards Authority for Health and Social Care Buckingham Palace Road London SW1W 9SP Telephone: Fax: Website: Professional Standards Authority for Health and Social Care October 2016

132 Agenda Item 5.5 Decision Note December 2016 Council Practical Nurse Program Approval La Cité Contact for Questions or More Information Anne Marie Shin, Manager, Education Program Decision for Consideration re. Recommendation from Staff That Council defer the approval decision for La Cité s Practical Nurse Diploma Program for the purpose of subparagraph 1 (i) of subsections 3(1) of the College s Registration Regulation [being Part II of the Ontario Regulation 275/94, as amended made under the Nursing Act (1991)] until March 2017, provided that La Cité resubmit a curriculum for review and continue to voluntarily suspend new admissions to the current program. Public Interest and Public Safety Rationale for the Proposal The College s entry-to-practice commitment to the public is that individuals who become nurses have the knowledge, skill, judgement and character to practise safely. A number of registration requirements are in place to support meeting this commitment. One such requirement is that individuals must have graduated from a program that prepares them with the required entry-to-practice competencies. This is achieved through Council s authority, under the registration regulation, to approve programs. Council does this where it has confidence, based on its review of the evidence, that the program meets the standards required to prepare graduates to enter the profession safely. There is a significant risk to the public if individuals enter the profession without the foundational knowledge to enter practice safely. Background Please refer to attachment 1 for an overview of the Program Approval Process for Practical Nursing Programs. On March 10, 2016, Council approved the following motion deferring its decision regarding La Cité s Practical Nurse Program until March 2016: That Council defer the decision on whether to continue to approve La Cité s Practical Nurse Program for the purposes of subparagraph 1(i) of subsection 3(1) of the College s Registration Regulation (being Part II of Ontario Regulation 275/94, as amended, made

133 under the Nursing Act, 1991) until Council s December, 2016 meeting, provided that La Cité continue to voluntarily suspend new admissions to that program. La Cité s Practical Nurse Diploma Program was informed in writing on March 22, 2016 of Council s decision to defer the decision about the program s recommended status. The letter also stated the current Practical Nurse Diploma Program will no longer be evaluated. If you want to offer a new program, it must undergo a review by the College and have Council s approval before students are admitted. In order to keep the public safe and ensure students were not being admitted or transferred into the practical nursing program, the College had La Cité sign and agree to the actions below: Confirm that no new students would be admitted to the September 2016 academic year Suspend the transfer and admission of students into the program Refrain from admitting practical nursing students until permitted to do so by CNO s Council. La Cité complied with these actions and confirmed this by letter dated October 31, Preliminary Review of La Cité s Curriculum: On September 16 th, La Cité submitted a new curriculum for approval under the Preliminary Review process for new programs (see Attachment 2). The review indicates that La Cité s curriculum Does Not Meet Expectations. The College would like to continue to work with La Cite to allow La Cité to resubmit their curriculum in January 2017 for Council to make a decision in March Since no new students are being enrolled, there is no risk in extending the deferral of a final decision until March If Council approves the Preliminary Review in March 2017, the following outlines the next steps in the review process: Preliminary Review Annual Review Annual Review Full Review Review Year (2017) YEAR 1 (2019) YEAR 2 (2020) YEAR 3 (2021) Curriculum Student Student Statistics Student Statistics KPI data: Student Statistics KPI data: Satisfaction KPI data: Student Graduation Rate Student Satisfaction Exam Results Satisfaction Graduation Rate Graduate Satisfaction Exam Results Curriculum

134 Next Steps: If Council decides to extend the deferral of a final decision to March of 2017: 1. La Cité will resubmit a new curriculum for Preliminary Review to CNO by January 3, The new curriculum for La Cité would be presented to Council in March 2017 for an approval decision. Attachments: 1. Program Approval Process 2. Preliminary Review Process Flowchart for New Programs

135 Attachment 1 Program Approval Process In December 2011, Council approved a practical nursing program approval process which includes a combination of full and annual reviews of each program against key review components. Full reviews of all evaluation components take place every five years. Annual reviews allow for re-evaluation of the components to make sure that each program maintains expectations for approval. Annual Review Components Every program is evaluated against four review components. Each component may be evaluated as meets expectations, borderline or does not meet expectations. The following is information that is gathered to evaluate each review component: 1. Student Statistics A program s student intake and attrition statistics are reviewed to track general student progression trends within the program. For each academic year, programs submit to the College the total number of new students admitted into the program and the total number of students that withdrew from the program. These statistics are not evaluated directly and have no impact on a program s evaluation outcome. However, the information is reviewed in context with other components that are evaluated. 2. Entrance Exam Exam result trends are reviewed each year as an outcome indicator of a program s ability to consistently prepare competent graduates. For each program, the results of graduates first-time writes are collected and standardized against the provincial average. First-time write results are used because they are more reliable indicators of program performance than repeat write results. The exam results are standardized to allow for comparing a program s results over time, even when there are varying exam cohorts and difficulty levels with each administration of the exam. 4. Key Performance Indicators (KPI) A program s KPI trends are reviewed each year as another outcome indicator for program approval. The College collects KPI data for each program from the Ministry of Advanced Education and Skills Development using Ministry official definitions which include: 4

136 Student Satisfaction: Total percentage of students who were satisfied with the quality of their learning experiences, support services and educational resources within their program. Graduate Satisfaction: Total percentage of graduates who were satisfied that their program education was useful in achieving their goals after graduation. Graduation Rate: Total percentage of students who graduate within 200% of the normal program duration of instruction. Each program s KPIs are evaluated against the provincial average in order to trend the program s results over time. Every five years a program s curriculum is also evaluated. Approval Categories Attachment 2 is the report summary of each program s evaluation results for this review cycle, and the overall program approval recommendations to Council. Overall approval recommendations are based on the following conditions: Approval Category Category 1: Approved Category 2: Approved with Conditions Condition The program s: Curriculum has no noteworthy competency gaps, KPI results are within or above the provincial average, AND Exam results are within or above the provincial average The program s: Curriculum has noteworthy competency gaps, KPI results are below the provincial average for 2 consecutive years, OR Exam results are below the provincial average for 2 consecutive years Category 3: Not Approved For 3 consecutive years with no substantive improvement, the program s: Curriculum has noteworthy competency gaps, KPI results are below the provincial average, OR Exam results are below the provincial average 5

137 Attachment 2 Preliminary Review Process Flowchart for New Programs Start of Preliminary Review of a New Program School Submits Preliminary Review Documents as outlined in the Practical Nurse Diploma Guide CNO verifies and accepts complete submission documents CNO conducts Preliminary Review and makes a recommendation to Council Outcome of preliminary review: Meets Expectation Borderline Does Not Meet Expectations Council makes a decision: Conditional Approval Not Approved CNO communicates Council s decision to the program 7

138 Agenda Item 7.1 Decision Note December 2016 Council Question period during the Executive Committee election Contacts for Questions or More Information Kevin McCarthy, Director of Strategy Decision for consideration That, beginning in March 2017, the candidate speeches for the election to the Executive Committee be extended from 3 to 5 minutes and each candidate be asked to respond to one question about the College s mandate and one question about the Governance Principles. Background At the March 2016 Council meeting, the lack of clear guidelines and expectations for the officer election question period was raised. The Executive made a commitment to bring a proposal to Council in December of 2016, to ensure that guidelines and expectations regarding questioning were clear for the first election of the Executive Committee in March of The College s by-laws related to the officer election (to be amended in December to provide for election of all members of the Executive Committee) do not make reference to a question and answer period. They do include the opportunity to briefly address the Council (Schedule 2, item 13). Council has the ability to decide how the speeches/question period will work. History Prior to March of 2014, the election of officers took place at the first meeting of the new Council in June. Newly elected and appointed Council members voted. In the past, these members had expressed discomfort with voting for these important roles because they lacked enough information about the roles and the candidates to make an informed decision. 1

139 The question period and a candidate lunch were added to the officer election process by Council to address these concerns. In June, 2013, Council amended the by-laws so that beginning in March of 2014 the officers were elected by experienced Council members. While the candidate lunch was discontinued, the questions remained as part of the process. What s new March of 2017 is the first time that Council will be electing the full Executive Committee. The question and answer period was designed to fulfill a function that may no longer be relevant. Council members who are voting know the roles and the candidates. The election takes place at the end of a two-day Council meeting which includes a dinner. Council members will have time to connect with candidates if they need more information to make an informed decision when voting. What do other regulators do? The College surveyed other regulators around a number of governance issues. 6 regulators responded that they have elections of officers. Of those 6, the following were responses related to processes included in the election: Number Pre-circulation of candidate information 4 Candidate speeches 5 Question period 1 Other (individual describes interests and qualifications at meeting) 1 The respondent that identified that they have a question period does not have guidelines. What is being proposed? The Executive acknowledged that, while the initial reason for having a question period may no longer be relevant, responding to questions supports informed voting. The Executive identified that, even with guidelines, and if questions are put through the chair, a question that is ruled out of order can have an impact. For that reason, the Executive is suggesting that there no longer be a question and answer period during the election of the Executive Committee. 2

140 Rather than a question and answer period, the Executive is suggesting that each candidate be asked to incorporate a response to two Council-approved questions in their speech. If Council supports this approach, the length of candidate speeches would be increased from 3 to 5 minutes. The Executive suggests that one question relate to the College s mandate and another to the governance principles. Each year in December, Council will review the questions. The Executive discussed whether to have each candidate to respond to the same questions or to allow candidates to choose 1 question related to each topic from a bank of Council approved questions. The Executive decided to seek Council s perspective. Questions for Council: 1. Does Council support ending the question and answer period during the election of the Executive Committee? 2. If Council supports ending the question and answer period, which option does Council prefer for the questions that candidates will address in their speeches: Should all candidates respond to the same questions? or Should candidates have a choice of questions? Questions for Candidates The Executive is suggesting that candidates, in addition to their three minute speech, respond to one question about the College s regulatory mandate and one question about the governance principles. Below are a few draft questions from each category. At the Council meeting, the Executive will be seeking the input of Council on these questions and suggestions for others. Attached, for your information, are the College objects (statutory mandate) and the Governance Principles. Possible questions regarding the College s public interest mandate: How will you support Council s focus on the College s public interest mandate? Can you give examples of how you contributed to the College s mandate to protect the public at Council? 3

141 Possible questions regarding the Governance principles: Identify a governance principle and how it will inform your Council deliberations and decision-making? How will you foster a culture in which all Council members will regulate/govern in accordance with the governance principles. Questions for Council: Any suggestions for change to the above questions? and What other questions would you want candidates to address, related to: the College s public interest mandate; the governance principles? Attachments: 1. College mandate as set out in the Health Professions Procedural Code 2. Governance principles 4

142 Attachment 1 Regulatory Mandate as set out in the Health Professions Procedural Code Statement of purpose, sexual abuse provisions 1.1 The purpose of the provisions of this Code with respect to sexual abuse of patients by members is to encourage the reporting of such abuse, to provide funding for therapy and counselling for patients who have been sexually abused by members and, ultimately, to eradicate the sexual abuse of patients by members. 1993, c. 37, s. 5. Objects of College 3. (1) The College has the following objects: 1. To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and by-laws. 2. To develop, establish and maintain standards of qualification for persons to be issued certificates of registration. 3. To develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession. 4. To develop, establish and maintain standards of knowledge and skill and programs to promote continuing evaluation, competence and improvement among the members. 4.1 To develop, in collaboration and consultation with other Colleges, standards of knowledge, skill and judgment relating to the performance of controlled acts common among health professions to enhance interprofessional collaboration, while respecting the unique character of individual health professions and their members. 5. To develop, establish and maintain standards of professional ethics for the members. 6. To develop, establish and maintain programs to assist individuals to exercise their rights under this Code and the Regulated Health Professions Act, To administer the health profession Act, this Code and the Regulated Health Professions Act, 1991 as it relates to the profession and to perform the other duties and exercise the other powers that are imposed or conferred on the College. 8. To promote and enhance relations between the College and its members, other health profession colleges, key stakeholders, and the public. 9. To promote inter-professional collaboration with other health profession colleges. 10. To develop, establish, and maintain standards and programs to promote the ability of members to respond to changes in practice environments, advances in technology and other emerging issues. 11. Any other objects relating to human health care that the Council considers desirable. 1991, c. 18, Sched. 2, s. 3 (1); 2007, c. 10, Sched. M, s. 18; 2009, c. 26, s. 24 (11). Duty (2) In carrying out its objects, the College has a duty to serve and protect the public interest. 1991, c. 18, Sched. 2, s. 3 (2). 5

143 Governance Principles Council is individually and collectively committed to regulating in the public interest in accordance with the following principles: Accountability We make decisions in the public interest We are responsible for our actions and processes We meet our legal and fiduciary duties as directors Adaptability We anticipate and respond to changing expectations and emerging trends We address emerging risks and opportunities We anticipate and embrace opportunities for regulatory and governance innovation Competence We make evidence-informed decisions We seek external expertise where needed We evaluate our individual and collective knowledge and skills in order to continuously improve our governance performance Diversity Our decisions reflect diverse knowledge, perspectives, experiences and needs We seek varied stakeholder input to inform our decisions Independence Our decisions address public interest as our paramount responsibility Our decisions are free of bias and special interest perspectives Integrity We participate actively and honestly in decision making through respectful dialogue We foster a culture in which we say and do the right thing We build trust by acting ethically and following our governance principles Transparency Our processes, decisions and the rationale for our decisions are accessible to the public We communicate in a way that allows the public to evaluate the effectiveness of our governance 6

144 Final Report: A vision for the future Leading in Regulatory Governance Task Force December 2016 A proactive, expert and evidence informed review An ongoing commitment to positive and empowering change

145 Members of the Task force Leading in Regulatory Governance Task Force Evelyn Kerr, RN, Chair Anne Coghlan, RN Rob Lapper Ella Ferris, RN Don McCreesh Megan Sloan, RPN Former Members Nancy Sears, RN Angela Verrier, RPN 2

146 Table of Contents Leading in Regulatory Governance Task Force Report 4 Recommendation 5 Vision 11 Governance Model 21 Principles 22 Governance review milestones 23 3

147 Introduction Council s Leading in Regulatory Governance Task Force is pleased to present its final report and recommendations to the College of Nurses of Ontario s Council. Leading in Regulatory Governance Task Force When Council established the Task Force in December of 2014, it set out the following goal and purpose. These guided the Task Force throughout its work: Overall Goal: The College is recognized as a leader in regulatory governance. Purpose: To conduct a proactive, objective, expert, best-practice and evidence-based review of all aspects of College governance. To seek new governance perspectives and approaches to enhance Council s excellence in governance. To engage Council in an informed conversation to determine what, if any, changes are needed to governance principles and processes, so that the College is recognized as a leader in regulatory governance. The following informed the recommendations: a report of a point-in-time (Spring 2015) evaluation of Council governance by external governance expert, Cathy Trower; a review of academic studies about relevant aspects of governance and group dynamics; an review of trends and best practices in the governance of regulators around the world; a report of a survey of regulators about governance; and Council s input and insights provided at governance workshops. The Task Force also learned about the unique nature of regulatory governance and about self-regulation. The regulatory literature that the Task Force reviewed reflected the changing nature of regulatory governance and of regulatory models. The underlying theme in all of these was that regulators must be proactive in order to strengthen public trust. The participation of the profession in regulation is the core of self-regulation. The Task Force believes that Council needs to consider what is fundamental to self-regulation and what needs to change to maintain public trust in nursing regulation in Ontario. Attachment 4 is a summary of the project timelines, reflecting Council s commitment to, and engagement in, this work. When developing its recommendations, the Task Force did not limit its thinking to the project goal of leading in regulatory governance. It was informed by the College s Strategic Plan, particularly the goal to build public trust, as well as the commitment to innovation and evidence-based approaches, which are integrated in the recommended governance vision. 4

148 Recommendation: 1. That Council adopt the recommended vision: Vision: The College of Nurses of Ontario s Board of Directors for 2020 (attachment 1). Leading in Regulatory Governance Task Force Implementation recommendations: 1. That Council share the governance principles, vision, Task Force reports and supporting documents with government, the public, other regulators, nurses and other stakeholders to broaden the dialogue about the future governance of regulators of professions; 2. That, in June 2017, Council establish a working group of five Council members to work with Council to develop a plan for implementing the governance vision. The plan will include the communications and stakeholder engagement needed to build understanding of and support for the vision to enhance the likelihood that the needed legislative change will happen in 2020; and 3. That the working group s terms of reference include working with Council to identify changes to advance the governance vision that can take place before legislative change, and developing an action plan to support implementing those changes. Recommendation 1: That Council adopt the recommended vision: Vision: The College of Nurses of Ontario s Board of Directors for 2020 (attachment 1). Implementing this vision for governance will equip the board to support the College in meeting its strategic vision of leading in regulatory excellence and further the College s public interest mandate. The Task Force has identified an integrated vision rooted in the evidence, best practice in regulatory governance and input from Council. The Task Force considered presenting Council with options, but agreed unanimously that its task was to prepare a vision recommendation that was informed by evidence and best practice. Attachment 2 is a model illustrating this vision. In a June 2016 workshop, Council discussed the building blocks of the vision. The Task Force presented each vision element along a continuum within which Council identified the optimal position. To support its discussions, Council was provided with evidence and information on trends in regulation. At this discussion, Council supported having a small Council, equal public and nurse members, and directors (board members) and committee members having the competencies needed to fulfil their roles. The Task Force developed a model as a result of evidence, best practices and Council s feedback from this meeting, and presented it to Council in September In September 2016, when exploring the model Council flagged some issues. Every member of the Task Force participated in that workshop and listened carefully to the issues raised. The Task Force reviewed the evidence and best practice, explored emerging practices and requested additional information before defining the recommended vision. The vision includes many aspects of the model discussed by Council in September. It also includes changes made as a result of Council s feedback. 5

149 Diversity An issue raised by Council was whether a board of 12 members 6 public and 6 nurses would have the needed diversity. With this integrated model, the Task Force believes that diversity will be strengthened in several ways: An emerging practice in governance is advisory groups that are established by the board to bring different perspectives. They report directly to the board. For the College, these groups can be made up of consumers, nurses from different practice sectors (e.g. remote/ marginalized, community, long-term care), different aspects of practice (e.g. clinical, education), members of other professions, or a combination. It would be up to the board at any time to consider the gaps in its perspectives based on the issues under consideration. The board would identify the needed advisory groups and what it needed from a specific group. Appointment rather than election of board members supports diversity. For example, our current electoral system is based on regions, and while there are two northern regions, they do not guarantee that the unique needs of remote and rural patients are considered. Usually, candidates from the large teaching hospitals in the north are elected. In an appointments process, the board can identify and seek nurses who work with specific types of patients, such as a nurse who works with high risk communities A small board intentionally structured to bring different perspectives, composed of members possessing governance competencies, and provided with additional perspectives through feedback from Advisory Groups and stakeholder engagement, will be able to raise and discuss these diverse perspectives more effectively. Leading in Regulatory Governance Task Force Appointment of Board members At the September 2016 governance workshop, divergent views were expressed about moving from election to appointment of board members. In particular, some Council members stated that the election is an opportunity for nurse engagement and that nurses and the public could perceive appointments as less transparent. The Task Force weighed this input, including data on member engagement in the election and the committee appointments process. The data shows that fewer than 15% of members vote in the Council election. While 10 to 20 candidates stand for election each year, over 100 usually volunteer to serve on a statutory committee. The Task Force believes better, more appropriate mechanisms exist for member engagement, such as advisory groups, consultations and a more engaging quality assurance program. A theme in the literature about regulatory governance is that electing professional members to regulatory boards sets up a conflict of expectations. This was clearly identified in the Trends in Regulatory Governance document and was flagged by Richard Steinecke in Will the Real Public Interest Please Stand Up. Regulatory board members serve the public, not the profession. An election process sets up an expectation of, and perception of, a representational role. In addition to the concern about the misperceptions created by an election, the following informed the Task Force as it weighed whether to recommend continuing with electing members of the board following a competency screen or moving to an appointment process: 6

150 Leading in Regulatory Governance Task Force In September, Council expressed concerns regarding ensuring diversity of perspectives on the board. While the election process can be enhanced through a competency screen, once the candidate passes that bar, there is no ability to screen for a needed perspective or area of practice. This was highlighted in more detail earlier. Council has identified the importance of succession planning to effective governance. An appointments process supports succession planning; an election process does not. Public members currently are appointed. The Task Force is recommending that in the future they be appointed based on competencies. The Task Force believes that all members should come onto the board in the same way. Doing so builds mutual respect as each member has met the same expectations and gone through the same process to join the board. As part of the implementation process, a robust, objective and transparent recruitment and appointments process would be developed by Council. This process could be piloted for the appointment of committee members, evaluated and further refined. A competency screen could be developed for people seeking to serve on the board. It could be tested as a pre-screen for the election and further refined in anticipation of legislative change and a move to the appointment process. To further strengthen the outcome of an appointments process, the Task Force is also recommending having a boot camp for people interested in participating on the board or committees. This idea was raised in the Octover 2016 issue of Grey Areas, Screening Committee Members, where it was suggested that the appointment of committee members should be competency based. The boot camp would support potential board and committee members understanding the voluntary roles they are considering and the requirements needed to serve. It would mean that once appointed, they would begin the orientation process with a basic understanding of the roles and expectations. Role of the Governance Committee The last issue raised at the workshop that the Task Force will address is the view that the Governance Committee, as envisioned in the model presented in September, was too powerful. The perspective was that another Executive Committee was being created. That input gave the Task Force an opportunity to rethink the role of the Governance Committee. In the proposed vision, the functions initially proposed for the Governance Committee are split as follows: A Nominating Committee will recommend appointments for directors and committee members who are not directors, and address succession planning for those roles. To bring broad perspectives, the committee will include directors and individuals who are not directors. The Governance Committee made up of directors will support the board in remaining attentive to changes in governance, steer evaluation processes, support the board in identifying the competencies, and recommend the appointments of board and committee leadership. The Task Force also recommends that the terms of reference for both of these committees which will be determined by Council include requirements for ongoing engagement of the full board in their work. 7

151 Leading in Regulatory Governance Task Force Implementation Recommendation 1: That Council share the governance principles, vision, Task Force reports and supporting documents with government, the public, other regulators, nurses and other stakeholders to broaden the dialogue about the future governance of regulators of professions. Government and other regulators have expressed considerable interest in the work being done by Council on governance. The Task Force is recommending releasing all the information generated by the review in order to support the ongoing dialogue about regulatory governance in Ontario and elsewhere. The Task Force believes that releasing its reports, the literature review, trends in regulatory governance and report of the survey of regulators will support achieving two of the objectives from the Strategic Plan: Advancing the use of CNO knowledge: The significant resources the College developed to support the Task Force and Council in working through the governance issues are relevant to government and other regulators. Sharing this information will provide all stakeholders with evidence that supports the governance dialogue. Leading in regulatory innovation: Sharing the supporting materials will provide leadership to others exploring governance issues and will lead transformative change. For example, The Advisory Group for Regulatory Excellence has already made a commitment to reviewing governance, and the Ministry of Health and Long-Term Care has identified governance as part of its project to modernize the health professions. By sharing this information, the Council will provide leadership to the exploration of new regulatory governance approaches in Ontario. In addition, releasing the Task Force s reports as well as the briefing materials supports transparency, which is one of Council s governance principles. Implementation Recommendation 2: That, in June 2017, Council establish a working group of five Council members to work with Council to develop a plan for implementing the governance vision. The plan will include the communications and stakeholder engagement needed to build understanding of and support for the vision to enhance the likelihood that the needed legislative change will happen in The Task Force recognizes that governance change will not happen immediately. Many of the proposed changes require legislative change. Some are a change from the current regulatory paradigm. For example, the proposal in the vision that the board be half public and half nurses is different from the current constitution of the councils of Ontario health regulators, where there is a small majority of nurses on all councils. The Task Force recommends that Council establish a working group of Council members to develop a plan to be ready to implement the vision in This would mean proposing legislative change to government in The Working Group s terms of reference will be determined by Council and explicitly include the requirement that it does its work in collaboration with the full Council. 8

152 Governance is the board s business and the board needs to be engaged in, and directing, the process at all times. Leading in Regulatory Governance Task Force The suggested timing of appointing the working group in June of 2017 is to give time for Council to review and provide input into terms of reference and decide how members will be selected in March of 2017, and to appoint the members in June of The Task Force believes it is important to engage stakeholders, including other health regulators and government, in order to achieve the vision. In addition to releasing the Task Force materials, the Task Force suggests developing a communications and engagement plan that includes the President and Executive Director sharing Council s work with other health regulatory Councils, nursing stakeholders and government. Implementation Recommendation 3: That the working group s terms of reference include working with Council to identify changes to advance the governance vision that can take place before legislative change, and developing an action plan to support implementing those changes. The Task Force believes that several aspects of the vision can be implemented before legislative change and have a positive impact on governance. The Task Force notes that Council has already implemented a number of changes in how it works and believes this should continue. The following might be considered for implementation before legislative change: Establish one or more Advisory Groups: perhaps starting with a pilot of a consumer advisory group in late 2017/early 2018; Pilot test competency-based appointments using committee member appointments: identify competencies needed for statutory committees and add collection of information needed to assess competencies in a computer app to be used in the fall of 2017 for the appointments; establish a rigorous, fair and objective appointments process to be pilot tested with the committee member appointments in late 2018 for the appointments. To ensure the public s confidence that the College s Council and committees are focused solely on the public interest, conflict-of-interest provisions for Council and committee members need to be reviewed to ensure they remain appropriate and consistent for today s high scrutiny environment. Develop boot camp programs for those seeking election to Council and those seeking appointment to statutory committees so they understand the College s mandate and the expectations for the role. Develop and implement an evaluation framework that includes evaluation of Council meetings, self and peer evaluation of Council members and an evaluation of Council effectiveness carried out by an external expert every three years. 9

153 Conclusion In 2014, Council began a journey to advance regulatory governance. It was done with foresight and to support the College s vision of being a leader in regulatory excellence. This report is not the end of that journey it is a fork in the road. As Cathy Trower said in her assessment report: Good governance is a journey. The Task Force proposes that good governance is a journey without end. Leading in Regulatory Governance Task Force Adopting the recommended vision of the Task Force means that Council and future College of Nurses boards will always be attentive to governance. The Task Force appreciates the opportunity to have participated in your journey. It took courage to bring outside eyes and outside perspectives to examine your processes. It took courage and foresight to empower the Task Force with such a broad mandate. Council and staff have already changed how governance at the College works. We have seen this at the governance workshops that we attended where there was so much engagement and thoughtful dialogue. The Task Force recognizes that it is recommending transformative change and it will take time to fully implement. It will be dependent on the government making changes to the paradigm for regulatory governance in the province. We have heard that the government has an appetite for that change. While the major changes being recommended in the vision will take time to be implemented, many other measures can be taken in the interim to continue Council s never-ending governance journey. Attachments: 1. Vision: The College of Nurses of Ontario s Board of Directors for A governance model based on the vision 3. Council s Governance Principles 4. A timeline of the governance review 5. A literature review on governance (on the portal for Council members) 6. A review of trends in regulatory governance (on the portal for Council members) 7. A survey of regulators regarding governance (on the portal for Council members) 10

154 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Leading in Regulatory Governance Task Force Introduction In 2014, Council established the Leading in Regulatory Governance Task Force and charged it with developing recommendations that would position Council as a leader in regulatory governance. The recommended governance vision is designed to put in place an integrated governance model that will move from a council to a board of directors model. The vision acknowledges the value of the input nurses bring to the board, while building the public s trust that the board is focused on the public s needs and interests by moving to equal public and nurse membership. It is designed to position the board as a leader in regulatory governance and support the College in achieving its strategic vision of leading in regulatory excellence. The Task Force identified this vision after completing a two-year journey that included: ongoing engagement with Council; reviewing a point-in-time assessment of Council governance that was conducted by an external governance expert (Cathy Trower); considering an extensive examination of peer-reviewed academic literature about governance and group dynamics; considering a comprehensive report on trends and best practices in the governance of organizations that regulate professions; and reviewing the results of a survey of other regulators about their governance practices. Governance Vision for 2020: With a commitment to the public, the College of Nurses of Ontario s board of directors (the board) will govern the regulation of the nursing profession in accordance with: the College s regulatory mandate as set out in Ontario s health regulatory legislation; and the governance principles approved by the board. A small governing board made up of an equal number of public and nurse members - with all members having the needed governance competencies, appropriate conflict of interest provisions and ongoing education and evaluation - will be able to meet the governance principles and the changing expectations of society. It will be, and will be seen to be, a proud protector of the public. 11

155 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 The following is the detailed vision for governance of the College of Nurses of Ontario beginning in 2020: Components of recommendation Size The board will have 12 members (see page 13 for composition) An Executive Committee will no longer be needed. The board will be small enough to engage in generative discussions with contributions from all members who together provide a balance of the needed competencies and diversity. The addition of advisory groups (e.g. consumer, educator, clinician) and a stakeholder engagement approach will ensure diverse input on issues the board will consider. Evidence/rationale Evidence about board governance and group dynamics shows that: small boards (e.g. 6 to 9) make more-effective decisions. The proposed size of 12 is a compromise recognizing the need to include both nurse & public on a regulatory board. a smaller board fosters input from all directors and makes it more comfortable for individual directors to speak up. social loafing occurs with larger boards, meaning not all perspectives are on the table. regulatory governance is moving away from large, representative elected boards to smaller, competency based appointed boards. With a small board, an Executive Committee is not needed. Having an Executive Committee is no longer seen as good governance practice Council members provided feedback, starting with the Cathy Trower review, that size is an issue in relation to effective discussion. smaller groups work better [the Task Force believes this is valid experiential evidence]. they would prefer to discuss issues in small groups as they feel more able to participate in those circumstances [this is not congruent with the legislative requirements for open meetings and the principle of transparency]. Principles Accountability A small board will not require an Executive Committee. The board will have full accountability for its agenda and decisions. Every member will be expected to participate. Individual directors will carry the expectation for personal accountability. Adaptability A small board will enable the group to come together quickly to respond to emerging issues. Diversity Evidence shows that with a small board all members participate and as a result, diversity of perspectives is more likely to be gained. 12

156 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Composition The board will have equal numbers of public and nurse members (including at least 1 RN, 1 RPN, 1 NP). Competency based Directors will be selected based on having the competencies (knowledge, skills and attitude) needed for the role. Individual directors will have competencies required: governance, leadership and regulation (protecting the public interest), and analytic, strategic and creative thinking. Individual directors will have a commitment to the public interest and a passion for nursing regulation. The board will have the ability to balance innovation and risk. Evidence/rationale This composition: is the direction in regulation internationally as it reinforces public confidence that the board is focused on the public and not on professional interests. reflects the board s commitment to the public interest and confirms the value of nurses expert input. is the best compromise between public trust and maintaining professional expertise in regulation (selfregulation). A board of equal public and nurse members will be seen to be impartial and not controlled by the profession. Literature supports competencybased boards. A move to competency-based boards is a trend in regulatory governance, as well as in other sectors. Roles, responsibilities and expectations for boards and directors are rapidly changing and expanding. Directors will need specific competencies to meet these expectations. Public confidence will be enhanced if skills and competencies on the board are transparent. Principles Independence A board made up of equal numbers of nurse and public directors will facilitate both professional and public input into governance decisions. Integrity A board made up of equal numbers of nurse and public directors will maintain, and be seen to maintain, its regulatory integrity through its focus on the public interest. All Having all directors with the needed competencies and attributes will support the board to meet all of the principles. 13

157 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Competency-based application and appointments process Board, statutory and standing committee members, and board and committee leadership are all appointed by the board based on competencies A transparent, open appointments process will be developed by the board, including structure and terms of reference of a Nominating Committee (composed of directors and non-directors) that would recommend appointments of board and committee members and of a Governance Committee to recommend the competencies and board and committee leadership. Attendance at a boot camp for individuals interested in applying for appointment will be required. All applications will be reviewed by the Nominating Committee. Each year the board will review the criteria for appointment, including addressing any specific needs for the coming years. The board will identify the needed checks and balances in the process to promote appropriate succession and ensure the needed competencies are in place. Reappointments to all positions will be based on meeting role expectations as evidenced by director evaluation and peer feedback. Evidence/rationale It is not the role of regulatory directors to represent the electorate. However, there is evidence in the regulatory literature that election of members of a regulatory board sets up an inherent conflict and potential misunderstanding of the role among members of the profession who believe they are being represented. The public may also believe that an election means representation and that the nurse members of Council are there to represent nurses and not serve the public. Appointment allows the board to consider specific needs for the board at a given time and to identify the competencies and backgrounds needed to meet those needs. Appointment is a way of ensuring diversity of perspectives. Council has flagged the importance of succession planning: as confirmed in Cathy Trower s report. Election does not support succession planning, while appointment does. Principles Competence Appointment based on competencies will allow the board to build and maintain a strong, competent group to support evidence-informed, public focused decision-making. Diversity Appointment will allow the board to ensure that it will have the needed diversity of perspectives and skills. Independence An appointed board will be, and be perceived to be, independent of influence by voters, who may be seen to have a professional interest. Transparency Transparency will be supported by clear and public criteria for appointment an open process to volunteer to serve an objective and fair process for reviewing candidates, and a clear rationale for the selection of directors and leadership, including communication with the individuals who were not selected. 14

158 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Chair and Vice-Chair Effective leadership will be characterized by: The Chair and Vice-Chair having the leadership competencies identified by the board. Appointment/succession being recommended by the Governance Committee and approved by the board Director and board development Each director will be supported in understanding and meeting their role expectations and accountabilities. Participation in a boot camp (see page 7) during the appointment process will ensure applicants understand the needed competencies and the regulatory and governance roles and commitments. Orientation and ongoing development will be expected. Continuous learning will be part of the board culture. Directors will be well supported in informed decision-making Decision-support materials will be evidence informed. Staff will provide regulatory expertise, as needed. Advisory Groups will be constituted by the board to help inform the board on views across the profession and the public. Evidence/rationale Selection of board leadership is consistent with competencybased appointment. Selection of board leaders based on leadership competencies vs professional designation will support strong leadership. A succession plan will build and maintain strong leadership. In assessing Council governance, Cathy Trower recommended strong orientation and ongoing education. Orientation and ongoing education: are best practices in governance. build on the learning from the boot camp prior to appointment to the board. Ongoing education was identified as a priority in the September 2015 Council workshop on culture. The board needs knowledge to keep changing and adapting as the expectations and evidence of what is good governance evolves. Principles Accountability The board will have accountability for setting the leadership competencies and a succession plan. Competence Selecting the best and most competent leaders will support the board in meeting this principle. Transparency How and why members were appointed as chair and vice-chair will be clear to all members of the board. All Having all directors with a sound foundation through orientation and ongoing education and the briefing materials needed to support informed decision-making will support all directors in meeting the governance principles. 15

159 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Evaluation of Board and Directors Good governance will be recognized as a journey. The performance bar on the board and individual directors will keep rising. The board will constantly improve through: A Governance Committee that will support the board in meeting its commitments to strong governance. Ongoing meeting, selfevaluation, peer feedback and board evaluation to support continuous improvement. An evaluation of governance effectiveness by an external expert every 3 years, with the results being publicly available. This will also support continuous improvement and public accountability. Terms of reference for the Governance Committee will be developed by Council as part of the implementation plan and will include provisions for ongoing board engagement in its processes. Evidence/rationale A commitment to governance, championed by the Governance Committee together with the board, and supported by strong evaluative and ongoing improvement processes, will ensure that the board maintains its commitment to leading in regulatory governance. The board needs to continually improve to meet changing expectations. The board will identify competencies. The evaluation processes will measure if specific competencies meet the board s changing needs. Evaluation will identify gaps, help to identify the Advisory Groups needed, and support succession planning. Principles Accountability Evaluation will allow the board to measure whether it is meeting its public interest mandate and will allow directors to determine if they are meeting their duties while identifying opportunities for improvement. An external evaluation will allow the board to report to stakeholders including the Ministry and the public about how it is meeting its accountability for regulating nursing in the public interest. Competence One indicator of the competence principle is: We evaluate our individual and collective knowledge and skills in order to continuously improve our governance performance. Transparency Conducting oral evaluations of board meetings in the open board supports transparency, as does sharing the results of external evaluations. 16

160 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Role clarity of board and statutory committees The roles, responsibilities, expectations and accountabilities of the board and statutory committees will be clearly stated and differentiated. Evidence/rationale Mandates are unique and require different competencies for governance and statutory decision-making. The board sets policies and the statutory committees apply them with respect to individual members and those seeking to become nurses in Ontario. Separation of board and statutory committee functions is a trend in regulation in other jurisdictions. Independence: The group that sets policy should not be making statutory decisions. There is a potential to bring bias and perceptions of bias from the board to statutory committees and vice versa. Principles Accountability Reporting mechanisms will ensure that statutory committees are accountable to board and public for fulfilling their statutory mandates. Competence Directors and members of statutory committees will be specifically selected through a board-approved process to ensure they have the competencies needed to fulfil their respective roles. Independence Having no directors on statutory committees will enhance the perception of the independence of those committees. 17

161 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Statutory committees Statutory committee members will be appointed by the board on the recommendation of the Nominating Committee. Statutory Committee chairs will be appointed by the board on the recommendation of the Governance Committee. The board will appoint all statutory committee members and Chairs based on competencies required to fulfil the statutory committees mandates and on the background needed for the specific committee. Statutory committees will be composed of non-directors. Statutory committees will report to the board on their legislated mandates. Evidence/rationale The work of statutory committees is different from that of the governing board, and therefore the competencies and attributes needed for these two distinct roles are different. The board s commitment to excellence in regulation requires having the right person with the right competencies and attributes doing the right work. With separate board and statutory committee members, individuals can develop expertise in specific roles. As members will not move back and forth between the detailed statutory committee role and the broad governing board role, there will be no role confusion. The risk of conflict from being both a board and statutory committee member is eliminated. Statutory committee members will gain an appreciation for the regulatory mandate, and some may ultimately seek to join the board if they have the needed governance competencies. Principles Accountability Reporting mechanisms will ensure that statutory committees are accountable to the board and the public for fulfilling their statutory mandates. Competence Members of statutory committees will be specifically selected to have the competencies needed to fulfil their roles. Independence Having no directors on statutory committees will enhance the perception of the independence of those committees from the College. 18

162 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Standing Committees There will be two new standing committees: Governance and Nominating Terms of reference for those committees will be developed by Council and will include provision for ongoing Council input into the work of the committees The Governance and Nominating committees will have roles in the appointment of directors, committee members and board and committee leadership Evidence/rationale It is good practice to pay ongoing attention to governance. A Governance Committee, working with the board, will ensure that attention is paid to changing practices and expectations. The Governance and Nominating committees will ensure effective, competency based appointments (see appointments on page 6) The Governance Committee will support evaluation processes (see page 7.) Principles Accountability Reporting mechanisms will ensure that statutory committees are accountable to the board and the public for fulfilling their statutory mandates. Competence Members of statutory committees will be specifically selected to have the competencies needed to fulfil their roles. Independence Removing directors from statutory committees will enhance the perception of the independence of those committees from the College. All Having committees focusing on governance processes will support the board in meeting all governance principles. 19

163 Recommended Vision: The College of Nurses of Ontario s Board of Directors in 2020 Components of recommendation Terms of office Directors: 3-year term 2-term maximum Leadership roles (Chair, Vice- Chair, Committee Chairs: 1-year term with one possible reappointment A 1-year term extension on the board is provided for a Chair to serve a second term if the Chair has reached the maximum 6 years of service term on the board Committee members: 3-year term 2-term maximum Reappointments will be made within term limits and based on meeting role expectations Funding governance processes The College will be accountable for funding the governance and statutory processes. Since all directors and committee members will be required to meet specific competencies and assessed against those competencies: all directors will receive the same honorarium; and, all committee members will receive the same honorarium. Evidence/rationale Terms of office will ensure appropriate transition and succession. Appointment rather than election ensures that strong directors are retained and those with new perspectives regularly join the board. Provisions for a 1-year extension for the Chair will provide for maintenance of effective leadership. Separating statutory committees and governance allows individuals to serve a maximum of four terms on the board and committees (current limit is three terms). There has been feedback from Council that the unequal remuneration of nurse and public directors is unfair. Equal pay for equal work is a fundamental societal value. Principles Competence Term limits support bringing needed new competencies and backgrounds to the board. Diversity Regular change allows for new perspectives to be brought to the table. All principles will be supported by having a board where directors feel treated as equals. Equal compensation will allow the College to draw from a broader pool, including individuals in active employment. 20

164 Governance Model Advisory Group Advisory Group Advisory Group Registrar & CEO Board of Directors Role = governance Chair + Vice Chair Directors appointed recommended by Nominating Committee. Chair & Vice Chair appointed recommended by Governance Committee. Appointed by the Board Accountable to the Board for mandate Appointed by the Board Make recommendations to the Board Statutory Committees Chair + members (no directors) Competency based appointments Standing Committees No Executive Committee Finance Directors and External Members Governance Directors Nominating Directors and External Members FOUNDATION Public Interest Mandate Governance Principles Evidence Informed Continuous Improvement

165 Governance Principles Leading in Regulatory Governance Task Force Council is individually and collectively committed to regulating in the public interest in accordance with the following principles: Accountability We make decisions in the public interest We are responsible for our actions and processes We meet our legal and fiduciary duties as directors Adaptability We anticipate and respond to changing expectations and emerging trends We address emerging risks and opportunities We anticipate and embrace opportunities for regulatory and governance innovation Competence We make evidence-informed decisions We seek external expertise where needed We evaluate our individual and collective knowledge and skills in order to continuously improve our governance performance Diversity Our decisions reflect diverse knowledge, perspectives, experiences and needs We seek varied stakeholder input to inform our decisions Independence Our decisions address public interest as our paramount responsibility Our decisions are free of bias and special interest perspectives Integrity We participate actively and honestly in decision making through respectful dialogue We foster a culture in which we say and do the right thing We build trust by acting ethically and following our governance principles Transparency Our processes, decisions and the rationale for our decisions are accessible to the public We communicate in a way that allows the public to evaluate the effectiveness of our governance Approved by Council September

166 Leading in Regulatory Governance Task Force Governance review milestones What s been done? September 2014 December 2014 February 2015 March 2015 Governance review approved in principle by Council Scope and terms of reference for an evidence and expert informed governance review set by Council. Cathy Trower of Trower and Trower commissioned to undertake a review of current governance and identify opportunities for improvement. Expert Leading in Regulatory Governance Task Force appointed by Council. Council members participate in a survey on the strengths and weaknesses of College governance. Council and staff leaders participate in interviews. May 2015 Task Force on Leading in Regulatory Governance holds its first meeting. Report on assessment of Council governance provided to the Task Force. June 2015 September 2015 December 2015 Cathy Trower joins Council for its first governance workshop, discussing key findings of her review. Council workshop on culture, possible immediate changes to governance processes quick wins identified. Council adopts quick wins recommended by the Task Force January to April 2016 College staff undertake research to support the review, and prepare : Literature review Report on trends in regulatory governance Survey of regulators re. governance processes June 2016 September 2016 Council governance workshop provides input on governance principles and key components of a new governance model: Council size and composition How members join Council Leadership and Statutory committees Council approved the Governance Principles (attached) Council provided feedback on governance model recommendations What s next December 2016 Final report and recommendations of the Leading in Regulatory Governance Task Force 2 Cathy Trower s summary of the Council survey and final report are in the Governance folder on the Council portal. 3 These reference documents and all Task Force reports are in the Governance folder on the Council portal. 23

167 101 Davenport Rd. Toronto, ON M5R 3P1 Tel.: Toll-free: Fax: DEC

168 Updated on November 28, 2016 Governance Literature Review Background: The purpose of this literature review is to identify peer reviewed, research-based literature related to governance. The search has explored literature outside of regulatory governance, including areas such as: not-for-profit, for-profit sector, as well as psycho-social literature based on assessed relevance. The table below provides an overview of the literature findings. The review has been categorized thematically based on the following governance areas: Board size Board composition Board member competencies Board effectiveness (e.g. best practices) Board compensation and remuneration Literature Search: Four main searches were conducted for this review. A total of 370 results were identified. Approximately 50 articles were selected based on quality and relevance. Full text articles were reviewed to ensure relevancy and accurate interpretation of findings related to the governance areas listed above. The First Search Explored literature on not-for-profit boards impacting performance, size, composition and recruitment methods. The online databases used for this search included: Proquest (69 databases), ABI Inform, Social Science Index, Business Source Premier, Health Business Elite, and Google Scholar. Search terms included: non profit organizations, non profit services, not for profit, not for profit organizations, non profit companies, board of directors, boards of directors, governance, size, recruitment, composition. The Second Search Explored research from the psycho-social literature. The search focused on the impact of group size and performance on group dynamics. Databases used to find relevant papers included: PscyINFO, Health Business Elite and Google Scholar. Search terms included: group size, group processes, and effectiveness. 1