Office of the Principal Allied Health Advisor Allied Health Assistant Supervision and Delegation Framework Final September 2012
Department of Health and Human Services CHIEF NURSE AND ALLIED HEALTH PRINCIPAL ALLIED HEALTH ADVISER Allied Health Assistants Supervision and Delegation Framework Application: Approved by: Effective Date: Custodian and Review Responsibility: Review Date: This framework covers delegation of clinical tasks from Allied Health Professionals to Allied Health Assistants Health Executive CEO THO-N; CEO THO-S, CEO THO-NW Principal Allied Health Advisor Allied Health Professional Executive From date of final clearance Principal Allied Health Adviser Version: 0.k August 2012 Background Three years from date of clearance In 2008-09, the Department of Health and Human Services (DHHS) Allied Health Assistants Working Group (the Working Group) led by the Principal Allied Health Adviser undertook a study of the DHHS Allied Health Assistant workforce in the professions of Dietetics and Nutrition, Occupational Therapy, Physiotherapy, Podiatry and Speech Pathology and researched the national and international issues for Allied Health Assistants in these professional groups. 1 The Working Group found the issues relating to Allied Health Assistants, both nationally and in the DHHS workforce to be: inconsistent use of title; clinical governance; scope of practice; appropriate level of qualification; access to profession development; and, lack of a career pathway. The Working Group also identified that Allied Health Professionals valued the role of Allied Health Assistants. In 2011 statewide forums were held for both Allied Health Assistants and Allied Health Professionals managing assistants to confirm the issues for Allied Health Assistants and the need for, and structure of, a statewide governance framework which was subsequently developed. In 2012, 2 workshops, Working with Allied Health Assistants were held and information provided by the facilitator of these workshops from the Royal Rehab College, NSW, was incorporated in this Framework. 1 Allied Health Assistants Project Report, DHHS, November 2009 Page 1
At the national level, the National Allied Health Assistants Working Group 2 (a Subcommittee of the National Allied Health Advisors Committee) found similar issues were present for this workforce nationally and in May 2010 submitted a paper to Health Workforce Australia recommending a nationally consistent approach to: 1. Development of the Allied Health Assistant workforce 2. Qualifications required to work as an Allied Health Assistant 3. Scope of Practice of the Allied Health Assistant workforce 4. Supervision, delegation and mentoring Across the jurisdictions, a significant body of work has developed around the governance of support staff/assistants working with allied health professionals since the work done in DHHS in 2008-9. Where relevant this work has been referenced. This work is continuing and aligns with the aims of Health Workforce Australia. Purpose of the Allied Health Assistant Supervision and Delegation Framework Client centred care is the basis for all clinical actions taken by Allied Health Professionals. The Allied Health Assistants Delegation and Supervision Framework aims to assist Allied Health Professionals in providing high quality care through a consistent approach to the management of Allied Health Assistants working within DHHS. While the framework applies to Allied Health Assistants working within the professions of Physiotherapy, Occupational Therapy, Speech Pathology, Dietetics and Nutrition and Podiatry, it has the flexibility to extend to assistant staff working in other allied health professions. The aim of the Framework is to promote consistent understanding of: Allied Health Assistant scope of practice and delegation; The supervision and delegation responsibilities of allied health professionals working with assistants; and Contribute to the ongoing support of the valued Allied Health Assistant workforce. This document is not intended to be a guide on how to delegate or supervise but rather to delineate the separate roles of management, supervision and delegation and provide a framework for the delegation process. The Framework is to be used in conjunction with other professional standards such as competency standards, policies, regulations and legislation relevant to delivering Allied Health Professional services. The scope of practice for Allied Health Assistants (what they can and can t do) is guided by the employing body, professional associations/regulatory bodies and level of certification 3. Delegation by an Allied Health Professional A delegation relationship exists when an Allied Health Professional delegates responsibility for aspects of client care, which they are competent to perform and which they would normally perform themselves, to an Allied Health Assistant. Delegations are made to meet client needs and to facilitate access to health care services. 2 National Allied Health Advisors Committee: Position Paper: Allied Health Assistants May 2010 3 For example, the Australian Physiotherapy Association Position Paper, Working with a Physiotherapy Assistant or Other Support Worker March 2008 Page 2
Delegating through a process of decision making within a sound risk management, professional, regulatory and legislative framework is a considered, rational process 4. Clinical supervision of an Allied Health Assistant can only be undertaken by an Allied Health Professional and the responsibilities and statement of principles described below provide guidance to Allied Health Professionals about processes that will help to ensure safe quality client outcomes are maintained whilst delegating activities to Allied Health Assistants. (Also refer to Delegation Flowchart) The Allied Health Assistant Governance Framework does not condone or authorise the substitution of less qualified health workers for Allied Health Professionals when the knowledge and skills of an Allied Health Professional are required. The Allied Health Assistant Supervision and Delegation Framework provides Allied Health Professionals with a mechanism to: Consider, determine and self-assess individual practice. Stimulate discussion regarding professional issues. Raise awareness of professional scopes of practice and decision-making. Identify practice that falls outside the accepted scope of practice for Allied Health Assistants and other support workers. Identify decision-making processes that are not congruent with the principles of the Allied Health Assistant Supervision and Delegation Framework. The Allied Health Assistants Supervision and Delegation Framework provides Allied Health Assistants with a mechanism to: Consider and self-assess their individual practice. Stimulate discussion regarding professional issues. Raise awareness of professional scopes of practice and decision making. Clarification of their responsibilities of their roles. Qualification DHHS supports Allied Health Assistants attaining a Certificate IV in Allied Health Assistance. Consistent Allied Health Assistant training and qualifications will facilitate the development of an Allied Health Assistant workforce that is competent in a range of clinical tasks within specified allied health environments. A Certificate IV in Allied Health Assistance has the following speciality streams: Physiotherapy, Podiatry, Occupational Therapy, Speech Pathology, Community Rehabilitation and Nutrition and Dietetics. A consistent level of qualification will facilitate appropriate understanding of an Allied Health Assistant s competency to support the Allied Health Professional and deliver safe quality services. DHHS can support this qualification level for the allied health assistant workforce through the employment process, training on the job and through RPL of related training certification and additional gap training. 5 Allied Health Assistants Scope of Practice The focus of duties for an Allied Health Assistant is to assist the Allied Health Professional with providing high quality care to clients. This is achieved through accepting delegation of clinical tasks 4 Adapted from Allied Health Assistant Program, Delegation, Monitoring and Evaluation of Allied Health Assistants Western Australian Country Health Services (October 2009 5 Options for qualification attainment include: Training undertaken by the staff member prior to employment; training provided by the employer through apprentice/trainee schemes; training supported by employer and Skills Australia through the Productivity Placement program. Page 3
from the Allied Health Professional that are within the competency of the Allied Health Assistant. The competency of an Allied Health Assistant is established by formal training, professional certification, task-based vocation training and experience, and on the job assessment of practice. A consistent level of ongoing training and competency assessment enables clarity for both Allied Health Assistants and Allied Health Professionals as to which tasks are reasonable to delegate. Those tasks, which are reasonable and appropriate for an Allied Health Professional to delegate and an Allied Health Assistant is competent to perform, make up the scope of practice of an Allied Health Assistant. Activities outside the scope of practice for an Allied Health Assistant, include, but are not limited to: Providing patient triage or diagnosis. Providing interpretative information following the application of screening tests or standardised/non standardised clinical assessments. Developing, implementing or evaluating clinical care programs without the supervision and guidance of a qualified Allied Health Professional. Governance It is the responsibility of the supervising Allied Health Professional to establish the required level of supervision appropriate for the individual Allied Health Assistant based on the complexity of the environment of the service and the client and the skill level of the individual Allied Health Assistant. The Allied Health Assistant Supervision and Delegation Framework provides broad guidance for the Allied Health Professional to delegate responsibility for aspects of patient care to an Allied Health Assistant and promotes a consistent approach to decision-making about allied health practice for both Allied Health Professionals and Allied Health Assistants. Decision-making is complex and dependent on a range of inter-related factors. Use of the Allied Health Assistant Supervision and Delegation Framework will assist Allied Health Professionals to consider these factors in decisions and discussions about allied health service delivery. In some circumstances the experience of the Allied Health Assistant will exceed the experience of the Allied Health Professional. In this circumstance, such as when the Allied Heath Professional is a new graduate, it may seem inappropriate for the Allied Health Professional to be delegating tasks to a more experienced individual, but it must be recognised the Allied Health Professional and the Allied Health Assistant have a different set of competencies and responsibilities. At all times, the Allied Health Professional retains accountability for the provision of safe quality care to the client. Thus, it is appropriate for an Allied Health Professional, including a new graduate, to delegate tasks to an Allied Health Assistant with more experience. Statement of principles 1. The primary motivation for any decision about allied health intervention is to meet the client s health needs or to enhance health outcomes. Decisions about the delegation of activities and tasks are made in a planned and careful fashion. Therapeutic and program related activities are provided: Whenever possible, in partnership with the client, their families and support network and in collaboration with other members of the health care team; Based on the Allied Health Professional completing a comprehensive assessment of the client and the client s needs; Page 4
When there is a justifiable, evidence-based reason to perform the specified intervention; and, After identifying the potential risks/hazards associated with the intervention, developing strategies to avoid those risks/hazards. 2. Allied Health Professionals wishing to delegate a therapeutic or program related activity or task to an Allied Health Assistant must ensure: The task to be delegated is within the scope of practice and professional competence of the Allied Health Assistant; The delegated task is within the scope of practice for their discipline; They have the necessary skills and experience to adequately supervise the Allied Health Assistant s delivery of the specific activity; The Allied Health Assistant s competence is assessed by a qualified, competent Allied Health Professional or registered training provider relevant to the discipline(s) they work in; The Allied Health Assistant is confident in their ability to perform the activity safely and competently and understands their level of accountability for the activity; The Allied Health Assistant has the necessary authorisations or certifications and organisational support to conduct the activity or task; The performance of the activity or task by an Allied Health Assistant will achieve the desired patient outcomes, and the patient consents, if at all possible, to the activity being performed by an Allied Health Assistant; and, There is an Allied Health Professional available to provide the required level of supervision and support to the Allied Health Assistant. 3. Decisions about allied health interventions are made in partnership with the client whenever possible. Decisions are based on clinical need and are supported by legal and regulation considerations including: Organisational support in the form of local policies/guidelines/protocols for the performance of this activity by an Allied Health Assistant; Professional consensus and evidence for the performance of this activity by an Allied Health Assistant; Legislative and/or professional requirements for the activity to be performed by a particular category of Allied Health Professional or Allied Health Assistant; and, Organisational requirement for a person with specific authority, certification or credentialing to perform the activity. 4. Allied Health Assistants are accountable for making responsible judgements about when a delegated therapeutic or program related activity or task is beyond their own capacity or scope of practice and for initiating discussion with their supervising Allied Health Professional. Judgements are based on considerations of: The Allied Health Assistant s individual scope of practice; An assessment of risk and the actions required to mitigate and acceptance of the level of risk to permit appropriate interventions. An appropriate level of Allied Health Professional supervision being available (direct, indirect, remote); Page 5
Compliance with legislation, standards, DHHS policies, protocols and guidelines and the context of practice; and, Whether there is organisational support, including sufficient staffing levels and appropriate skill mix, for the delegated task or activity. Where all these conditions are met the Allied Health Professional can delegate the activity and ensure the appropriate level of supervision is provided. If any of these conditions are not met, the activity should not be delegated until such time as any deficiencies have been remedied. Allied Health Professional Responsibilities Allied Health Professionals are responsible for supervising and supporting Allied Health assistants to whom they delegate tasks and for monitoring the Allied Health Assistant s performance of the tasks they delegate. The Allied Health Professional responsible for managing the Allied Health Assistant must establish systems and processes that appropriately record the level of supervision provided to the Allied Health Assistant(s), either individually or as a group, and their performance of delegated tasks. While an Allied Health Assistant will only have a single clinical practice supervisor they may potentially have several Allied Health Professionals delegating clinically focused tasks to them. The roles of the Manager, Supervisor and Assistant are outlined below. Manager of Allied Health Professionals Provides a safe work environment that enables appropriate delegation of tasks from Allied Health Professionals to Allied Health Assistants. Oversees the professional development of the Allied Health Assistant providing opportunity for development and maintenance of competencies. Provides supervision and support to the Allied Health Assistant. Assesses the appropriateness and complexity of the delegated task for the individual Allied Health Assistant. Primary Supervisor (Where this level of supervision does not exist within a service or team, the Allied Health Professional delegating to the Allied Health Assistant will assume these responsibilities.) Ensures clear lines of reporting. Provides guidance, assistance and support to the Allied Health Assistant through the use of Performance Development Agreements and other suitable communication/development methods. Assesses general competence of the Allied Health Assistant. Is an appropriately skilled supervisor. Ensures the Allied Health Assistant understands the accountability of the delegation. Allied Health Professional Supervisor Responsible for Delegating to an Allied Health Assistant To maintain a high standard of care when delegating activities, the Allied Health Professional s responsibilities are to: Have the appropriate skills in supervision. Delegate responsibility only for the delegated task, retaining accountability. Page 6
Ensure delegated tasks are within the Scope of Practice and professional competence of the individual Allied Health Assistant. Assess the level of supervision required (direct, indirect or remote). Monitor, review and evaluate client outcomes. Allied Health Assistant Responsibilities A key component of delegation is the readiness of an Allied Health Assistant to make an informed decision to accept the delegation. The Allied Health Assistant has the responsibility to: Request, in good faith, the teaching, competence assessment and level of clinically-focussed supervision required to complete the task. Notify the Allied Health Professional in a timely manner if unable, or unwilling, to perform the activity for an ethical, professional or other reason. Be aware of the extent of the delegation and the associated monitoring and reporting requirements (including that accountability for the task remains with the Allied Health Professional). Seek support and direct clinically-focussed supervision until confident of their ability to perform the activity. Perform the activity safely. Participate in evaluation of the delegation. Document patient interaction for Allied Health Professional reference. Identify ongoing training needs. It is important there is open dialogue between Allied health Professionals and Allied Health Assistants relating to their knowledge, skills and ability to undertake tasks. If an Allied Health Assistant is concerned about their capacity to undertake a task, it is appropriate they raise their concern directly with the Allied Health Professional seeking to delegate the tasks to them. An open discussion about their concerns should identify instructions or supports that are needed to enable the Allied Health Assistant to undertake the task. If, following discussion with the Allied Health Professional, the Allied Health Assistant still feels uncomfortable undertaking an activity they feel they are not competent to perform they should speak directly with the Allied Health Professional Manager. Delegation Flow Chart Figure 1 is a flow chart of the delegation process from an Allied Health Professional to an Allied Health Assistant. Page 7
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FIGURE 1: FLOW CHART ACCEPTANCE OF DELEGATION FROM AHP TO AHA In all instances the accountability for a task delegated to an Allied Health Assistant by an Allied Health Professional remains with the Allied Health Professional. IF YES TO ALL PROCEED Yes Yes Yes Yes Yes Scope of Practice Is the activity within the scope of the AHA role? Individual Competency Do I have the competency to undertake the activity safely, or Is there an adequate plan for education to enable competency prior to the activity? Risk Management Do I have sufficient skills and knowledge and resources to manage the risk and constraints for the activity? Support Do I have access to an AHP to clarify the activity if required? Feedback and Documentation Is the expectation for feedback and documentation on task completion agreed to? NO NO NO NO NO IF NO TO ANY SEEK ADVICE Page 1 Page 9
Glossary For the purposes of this framework, the following definitions have been adopted. Accountability/accountable Accountability means that Allied Health Professionals and Allied Health Assistants must be prepared to answer to others, such as clients, a regulatory authority, employer and the public for their decisions, actions, behaviours and the responsibilities that are inherent in their roles. Activity/activities An activity is a service provided to patients as part of a plan of care. Activities may be clearly defined individual tasks, or more comprehensive care. The term can also refer to interventions, or actions taken by an Allied Health Professional or Allied Health Assistant to produce a beneficial outcome for a client. Clinical Supervision Clinical supervision is formal supervision by an Allied Health Professional of an Allied Health Assistant to develop and monitor the skills and competency of the Allied Health Assistant to provide safe quality care to clients. Competence/competent Competence is the combination of knowledge, skills, attitudes, values and abilities that underpin effective performance in a profession. It encompasses confidence and capability. Competence assessment Assessment of an individual s competence may occur through structured educational programs or a peer review process. Evidence of a person s competence may include: Written transcripts of the skills/knowledge they have obtained in a formal course In-service education session records Direct observation of their skill Questioning of their knowledge base Assessment from the consumer s perspective using agreed criteria Self assessment through reflection on performance in comparison with professional standards. Context Context refers to the environment in which care is being provided. It includes: The characteristics of the consumer and the complexity of care required; The model of care, type of service or health facility and physical setting; The amount of clinical support and/or supervision that is available; and, The resources that are available, including the staff skill mix and level of access to other health care professionals. Education Formal education includes courses leading to a recognised qualification. Informal educational methods include, but are not limited to: Reading professional publications Completing self-directed learning packages Attending in-service education sessions Attending seminars or conferences Individual, one-to-one education with a person competent in the subject or skill Reflection on practice alone or with colleagues. Practical experience and assessment of competence by a qualified person are key components of any educational preparation for the performance of a health care activity. Evaluation/evaluate Page 10
Evaluation is the systematic collection of evidence, measurement against standards or goals, and judgement to determine merit, worth or significance. It can also be used to determine the appropriateness of continuing to undertake an activity, or to delegate it. Governance Framework The governance framework is the document providing the structure upon which local policies and strategies for implementation are built. Organisation/organisational support Employers/organisations are responsible for providing sufficient resources to enable safe and competent care for the patients for whom they provide health care services. This includes policies and practices that support the needs and expectations of patients, within a risk management framework. Risk assessment/risk management An effective risk management system is one incorporating strategies to: Identify risks/hazards Assess the likelihood of the risks occurring and the severity of the consequences if the risks do occur Prevent the occurrence of the risks, or minimise their impact. Scope of Practice Occupation Scope of Practice The scope of practice of an occupation is the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that occupation are educated, competent and authorised to perform. Some functions within the scope of practice of an occupation may be shared with other occupations, individuals or groups. The scope of practice of an occupation is influenced by the wider environment, the specific setting, legislation, policy, education, standards and the health needs of the population. Individual scope of practice The scope of practice of an individual is that which the individual is educated and competent to perform. The scope of practice of an individual will be within the scope of practice of their profession. Practise within the full scope of practice of the profession may require individuals to update or increase their knowledge, skills or competence. Decisions about both individual and professional practice can be guided by the use of decision-making tools (see flowchart page 7). When making these decisions, both the scope of practice of the profession and the competency of the individual need to be considered. Supervision/supervise There are two types of supervision in a practice context: Managerial supervision involving performance appraisal, rostering, staffing mix, orientation, induction, team leadership etc Clinically-focussed supervision, as part of delegation. Clinically-focused supervision includes: Providing education, guidance and support for individuals who are performing the delegated activity Directing the individual s performance Monitoring and evaluating outcomes, especially the consumer s response to the activity. There is a range of clinically-focussed supervision from direct to indirect. Both parties (the delegator and the person accepting the delegation) must agree to the level of clinically-focussed supervision that will be provided. Page 11
Direct supervision Direct supervision occurs when the supervising Allied Health Professional is actually present and personally observes, works with, guides and directs the Allied Health Assistant who is being supervised. Indirect supervision Indirect supervision occurs when the supervisor works in the same facility or organisation as the supervised person, but does not constantly observe their activities. The supervisor must be available for reasonable access. What is reasonable will depend on the context, the needs of the client and the needs of the Allied Health Assistant being supervised. Remote Supervision Remote supervision occurs when the supervising Allied Health Professionals normally works at a different facility to the Allied Health Assistant being supervised. The supervision and instruction provided is via telephone, video conference or some other remote means. The supervisor must be available for reasonable contact. What is reasonable will depend on the context, the needs of the client and the needs of the Allied Health Assistant being supervised. Page 12