Complaints

By Lynne Latulippe, Manager of Professional Conduct

The following briefly describe complaints that were recently reviewed by the Complaints Committee and provide excerpts of the Committee’s decisions in these matters.

Audiology Complaint

Hearing Aid Re-evaluation
A complainant filed a complaint against an audiologist, indicating that she suffered a variety of significant physical side effects as a result of a hearing aid re-evaluation. The complainant stated the following:

• She became significantly ill following a procedure done by the member who was using a new machine, and “something was not done right.” The complainant was not aware of what was being done or why, and, in the meantime, she was being exposed to “some kind of chemical or radiation” that was harming her.

• The complainant wonders if the member was unfamiliar with the new machine that she used when she performed the procedure.
• Because of the procedure, the complainant had to discontinue use of her hearing aids.
• The hearing aid vendors who dispensed the aid indicated to her that the procedure was not required.

The member provided a response in which she described the services provided to the complainant and addressed the complainant’s allegations.

Decision and Reasons
The panel first considered the allegation that the hearing aid re-evaluation conducted by the member resulted in the significant physical side effects reported by the complainant. The panel is aware that real ear measurements allow an audiologist to evaluate the function of hearing aids while a patient/client is wearing the aid, and that the tests were designed to regulate the loudness of the sound going into the ear and to ensure patient/client safety. During the procedure, a thin, soft flexible tube, about the width of fishing line, is placed in the ear canal close to the eardrum. The tube is sufficiently soft and flexible that it will not scratch the ear canal. The audiologist follows guidelines to measure the length of the tube needed to go down each patient’s ear canal without touching the eardrum. Sounds are directed into the ear and measurements are taken.

The panel noted that any potential negative effects of this procedure that might occur would consist of the tube contacting the eardrum or the ear canal. The panel, however, indicated that due to the malleability of the tube, this contact would not result in any scratching or abrasion of the eardrum or ear canal and that any pain resulting from such contact, if any contact did occur, would be of short duration and of limited intensity. The equipment is designed to ensure that the patients/clients are not exposed to inappropriate sound levels. The panel also noted the member’s comment that the real ear testing required measurement done in the right ear, while the complainant has reported pain on the left.

The member reported that the instrument had been calibrated in compliance with the College’s PPG on Prescription of Hearing Aids to Adults, which requires that equipment should be calibrated at least annually.

The panel also examined the complainant’s statements questioning the necessity for the re-evaluation. The panel reviewed the College’s PPG on Prescription of Hearing Aids to Adults and found that the member was required to perform real ear measurement as part of the process of prescription of a hearing aid.

The panel also reviewed the complainant’s allegation that perhaps the member had not received the appropriate training in the use of the instrument and concluded that the training described by the member was sufficient to ensure her competency in the use of the instrument.

The panel noted that it is not aware of any evidence to support linking the real ear measurement procedure to the difficulties reported by the complainant. The panel is not aware of any other person reporting side effects similar to those described by the complainant, either through direct professional experiences in using this procedure with patients/clients, anecdotal information, or research or any other published information. Use of the equipment does not result in exposure to chemicals or radiation. The panel also could not conceive of a situation involving this procedure, as described by both the member and the complainant, which would produce the results reported by the complainant.

Due to the reasons cited above, the panel found that the member met professional standards in conducting the real ear measurement procedure with the complainant.

The panel then examined the complainant’s concern that she “just followed orders” and “didn’t have a clue to what the member was doing or why.” Following its review of the information provided, the panel concluded that the burden of the evidence supports the suggestion that the member did obtain appropriate consent from the complainant. 

The panel determined that in providing services to the complainant, the member met the standards of practice of the profession. Having regard to all the circumstances, the panel is of the opinion that the allegations do not warrant referral to a discipline hearing, and that no further action is required.

The panel expressed its sympathies to the complainant regarding the significant symptoms she described suffering and expressed its hopes for her recovery.

Health Professions Appeal and Review Board
The complainant requested a review of the Committee’s decision by the Health Professions Appeal and Review Board but withdrew her request before the review occurred.

Speech-Language Pathology Complaint

Dysphagia Services
The complainant indicated that he was dissatisfied with the dysphagia services provided to his mother by a speech-language pathologist. The complainant indicated that his elderly mother was hospitalized with a broken hip for about three weeks during which time the SLP services were provided to her.

Both parties in the complaint provided lengthy submissions regarding the complaint. With the complainant’s consent, the College obtained a copy of the patient/client’s chart. The information obtained was forwarded to a CASLPO member for the provision of an independent expert opinion regarding the complaint allegations.

Decision and Reasons
Allegation: The member assessed the patient/client as NPO (nil per os) on the basis of a single observation of the patient/client making “gurgling sounds” when the member gave her some water to drink.

The panel noted that there is no evidence in the patient/client record indicating that the member provided the patient/client with water to drink and/or observed her drinking water. The panel also noted the expert’s conclusion that the documentation supports the member’s recommendation for NPO as appropriately based on repeated observations and reports of the patient/client’s reduced level of alertness.

Allegation: The member failed to act in a responsible and caring manner by not providing the patient/client promptly with the nutrition she needed to regain her strength.

The panel noted and verified the expert’s statement that the member, in both her daily notes and in the physician’s orders, recommended alternate means of nutrition/hydration. The panel also concurred with the expert’s opinion that it is not the responsibility of the SLP to provide the recommended nutrition and that the member did perform her professional duties in a responsible and caring manner with regard to the patient/client’s need for nutrition/hydration.

Allegation: The member failed to show openness of mind and flexibility in not doing a second assessment while the patient/client was awake and alert.

The panel noted the expert’s opinion that the member’s notes in the record appear to indicate that she made an independent decision to follow up with reassessment on a regular basis and that given that the patient/client was reported by many service providers as being drowsy much of the time, the member could not be assured of a time when the patient/client would be awake and alert. The panel concurred with the expert’s opinion and determined that these allegations were not substantiated.

Allegation: The member’s participation in the team’s decision to allow the patient/client’s family to feed her orally was contradictory and distressing in view of the team’s earlier refusal to allow the family to feed the patient/client by mouth, even after the family produced a quasi-legal letter requesting permission to do so.

The panel concurred with the expert’s opinion that the member did in fact comply with the family’s request to feed the patient/client and that there is no documentation of the member interfering with family attempts to feed the patient/client after receipt of the letter. The panel also concurred with the expert’s statement that the documentation indicates that the member made judgments in keeping with best practices and that the member was acting in the best interests of the patient/client. Thus, the panel concluded that these allegations were not substantiated.

Allegation: The member is incorrect in maintaining that the patient/client had pre-existing dysphagia, based on information that the dietitian received from the complainant’s sibling. 

The panel concurred with the expert’s opinion that a combination of factors may contribute to the clinical opinion of dysphagia, and that the member did not base her opinion of pre-existing dysphagia solely on the report from the complainant’s sibling.

The panel also noted the expert’s concerns regarding the member’s use of the term “dysphagia” to describe the behaviours reported to her by the complainant’s sibling and those noted in the chart by other service providers. The panel did not agree with the expert that the use of the term “dysphagia” represents a diagnosis. The panel did, however, concur with the expert that the behaviours described should have been referred to differently by the member. The panel advised the member that the term “dysphagia” should be based on observations of swallowing, and not on behaviours reported by others that are suggestive of dysphagia.

Allegation: The member is incorrect in maintaining that the patient/client had end-stage dementia prior to her admission.

The panel noted the expert’s statement that the member’s use of that term was not specific to the patient/client’s status prior to her hospital admission.

The panel also noted the expert’s statement that documentation in the chart from other service providers does not include the specific term “end-stage dementia” but rather terms such as “multi infarct dementia” and “very advanced dementia.” The panel agreed with concerns expressed by the expert regarding the member’s use of the term “end-stage dementia.” The panel reminded the member to use caution in her use of similar terminology. For example, when using terms outside her scope of practice and/or referring to clinical findings established by other professionals, the member was advised to ensure she quotes the term accurately and when necessary, she refers to the source of the term.

Allegation: The member opposed the family’s attempts to provide the patient/client with the nutrition she needed and was obstructionist and oppositional in respecting the family’s wishes to feed the patient/client orally.

The panel concurred with the expert’s view that the member was acting responsibly in the situations described, that the member respected the family’s wishes upon hearing them, and that these actions do not indicate obstruction or opposition.  

Allegation: The member may have written an order for a pureed dysphagia diet but it appears the order was not communicated to the physician or nurses, given that the patient/client was not provided with the pureed diet.

The panel concurred with the expert’s opinion that in writing the diet order, the member did respect the complainant’s request and that other factors beyond her scope of practice as a speech-language pathologist resulted in the diet order not being carried out.

Allegation: The member’s decision not to do a swallowing assessment did not maximize the patient/client’s health or safety, as required in CASLPO’s PPG for Dysphagia, but the result was the opposite, placing the patient/client at greater risk as she was kept without nutrition for a week.

The panel concurred with the expert’s opinion of what constitutes a swallowing assessment and that, in effect, from her first visit the member was conducting a swallowing assessment. The panel also agreed with the expert’s opinion that it is understandable that the member decided not to conduct trial swallows in order to protect the patient/client and that the member was not responsible for keeping the patient/client without nutrients for a week. 

Allegation: The member did not follow the requirement in CASLPO’s PPG for Dysphagia which emphasizes a patient-centered approach.

The panel concurred with the expert’s opinion that the member acted in the patient/client’s best interest, was accessible for family discussions, provided a rationale for decisions and recommendations, complied with the family’s request to feed the patient/client, and provided instruction to guide the family in safe feeding practices.

Allegation: The member failed to correctly comprehend the patient/client’s cognition and level of awareness.

The panel concurred with the expert’s opinion that the documentation from the member’s frequent visits to the patient/client and from interprofessional discussions of the patient/client’s cognitive status, in addition to the nursing notes support the member’s concerns regarding the patient/client’s alertness and the resulting limitations in conducting swallow trials with the patient/client. The panel determined that these allegations were not substantiated.

Allegation: The member did not document an exchange regarding the patient/client’s throat injury.

The panel noted the expert’s statement that no documentation exists, by any member of the health care team, of a throat injury associated with the insertion of an NG tube. The panel noted the expert’s opinion that while the family may have expressed its concerns at the family meeting, it would not have been within the member’s scope of practice as a speech-language pathologist to participate in an exchange regarding this concern

The panel determined that the member met the standards of practice of the profession in her provision of dysphagia services to the patient/client. Having regard to all the circumstances, the panel was of the opinion that the allegations did not warrant referral to a discipline hearing, and that no further action was required.

NEWS
December 2006 Council Highlights

Council held its regular Council meeting on December 8, 2006. The following are the highlights.

• A status report was presented on the New Directions Report from the Health Professions Regulatory Advisory Council (HPRAC) to the Minister of Health and Long-Term Care related to hearing health care and other matters. Council was advised that the RHPA legislation that was introduced in the Legislature on December 7, 2006 did not contain any of the recommendations related to further regulation of hearing health care. The minister has received many submissions from audiologists and speech-language pathologists objecting to the HPRAC recommendation that a new college of Hearing and Speech-Language Professionals be created.
• CASLPO wil make written and oral submissions to the standing comittee that will be holding consultation sessions on the legislation relating to the Regulated Health Professions Act. The submission will be made available to all members.
• There was a discussion on the general issue of self-regulation. The HPRAC report has raised awareness of the importance of ensuring that the professions of audiology and speech-language pathology are truly self-regulated within the CASLPO governance structure. It was felt that there is a need for the two professions to be given the opportunity and responsibility to deal with, and make recommendations to, council on practice issues that affect the respective professions independently. Audiologists should develop policies and standards that affect audiologists and speech-language pathologists should do likewise for speech-language pathologists, independent of the other profession. Council decided that to ensure that the policy matters affecting the practice of speech-language pathology are discussed and developed by speech-language pathologists, a new practice committee consisting of four Council SLPs, two non-Council SLPs, and two public members will be created for a one-year trial period Likewise, to ensure that policy matters affecting the practice of audiology are discussed and developed by audiologists, a practice committee consisting of four Council audiologists, two non-Council audiologists, and two public members will be created for a one-year trial period.

• In addition, to ensure that the two professions are equally represented, the number of members on the Executive Committee will be increased from five to six, so that the Committee will now consist of two audiologists, two speech-language pathologists, and two public members. As well, one audiologist and one speech-language pathologist will be elected as vice-presidents and be the chairs of their profession-specific policy committee.

• Council reviewed various issues related to the draft records regulation. There was discussion with respect to whether or not one year was an adequate length of time to keep a record for screening. There was also discussion as to whether or not records should be kept when a member provides consultative or peripheral services in light of legal counsel’s comments on shared member accountability for all advice given in a professional context. The draft records regulation and explanatory guide were referred to the two Practice Advisory Committees for review and comment to Council.

• Council approved a draft Preferred Practice Guideline on Dispensing Hearing Aids for circulation to the members for comment.

• Council reviewed a draft Preferred Practice Guideline on Assessment of Children by Speech-Language Pathologists. Council referred the draft PSG to the new SLP Practice Advisory Committee for review and comment.

• Council approved the draft Preferred Practice Guideline on Dysphagia for circulation to the members for comment

• Council approved a policy to consult with the Canadian Alliance of Regulators of Audiology and Speech-Language Pathology to the greatest extent possible on all new policies and standards to ensure that standards are consistent across Canada, to the greatest extent possible.

For more information on any of these topics please contact David Hodgson, Registrar at 416 975 5347 ext 215 or by e-mail at dhodgson@caslpo.com

NEWS
Canadian Alliance of Regulators of Audiology and Speech-language Pathology (CAR)

The Colleges in Alberta, Ontario, and Quebec and the provincial professional associations in Manitoba, New Brunswick, and Saskatchewan that regulate the practice of audiology and speech-language pathology are pleased to announce the creation of the Canadian Alliance of Regulators of Audiology and Speech-language Pathology (CAR). These six provinces have established regulatory bodies by legislation with the mandate to set standards and engage in other activities to regulate their registered members. Well over 80% of audiologists and speech-language pathologists in Canada are regulated and practice in a regulated jurisdiction.

The regulatory bodies believe CAR will enable them to take a leadership role in regulatory matters affecting audiology and speech-language pathology. It will give the regulators a voice to help eliminate the confusion around who actually regulates audiologists and speech-language pathologists in Canada. It will also facilitate the coordination of our activities and decisions in the interests of the public. Many, if not most, regulated professions have national forums for these purposes.

Establishing CAR will help regulatory bodies to maximize and perhaps even save resources. Many of us are working already on the development of standards and tools to assist our members to comply with them that can have application across Canada. Regulators will also share the costs of translating documents.

Provincial governments have given their regulatory bodies several basic mandates including:

• To regulate the professions and govern members
• To develop, establish, and maintain standards of qualification for persons to be issued certificates of registration
• To develop, establish, and maintain standards of knowledge and skill and programs to promote continuing competence among members
• To establish standards of practice
• To establish standards of professional ethics

Regulatory bodies have a duty to “serve and protect the public interest.” With this in mind it is essential that the regulators take a leadership role in regulatory matters affecting audiology and speech-language pathology and coordinate their activities in the public interest.

The first formal meeting of CAR took place in Calgary in October 2006. David Hodgson, Registrar of the College of Audiologists and Speech-language Pathologists of Ontario was appointed as the first Chair of CAR. At the meeting there was a valuable exchange of information on regulatory issues and many opportunities for cooperative effort were identified. It was agreed that the many regulatory documents in each province such as regulations, position statements, and practice guidelines would be reviewed with the goal of harmonizing standards to the greatest extent possible across Canada over time.

As a start it was agreed that the members of CAR would work together on the revision of the Preferred Practice Guideline on Dysphagia, the Position Statements on Supportive Personnel and Audiometric Screening, and on the development of a position on the Doctoral Degree for Audiologists.

As the regulatory bodies take a more coordinated leadership role in reviewing existing standards, harmonizing standards where possible, and setting the course for new standards they will consult with the professional associations and the universities.

For more information on CAR contact your college or association if you are in one of the six regulated provinces or David Hodgson at dhodgson@caslpo.com.

MEMBERS IN THE NEWS
Giving Great Care…Getting Notable Recognition

By Barbara Meissner Fishbein, Director of Professional Practice

The more CASLPO Today publishes about the accomplishments of our members, the more our members inform us of the distinguished work that they do and the credit they receive. This partnership allows all of us together to educate the public about the important contribution that CASLPO members make in the lives of individuals with communication impairments.

It is common knowledge that speech-language pathologists see school-aged children with speech and language deficits. It is also common knowledge that school-aged children may experience behavioural and emotional difficulties. It is not common knowledge that all these factors may intersect, and very little is known about the role of the speech-language pathologist in bridging that gap. Jocelyn Kadish and Connie Taras-Gold, speech-language pathologists at Thistletown, a children’s mental health centre in Toronto, are changing that by the recognition that they have received. 

Kadish and Taras-Gold work for the INTERFACE Program which stands for Integrated Resources for Family Assessment, Consultation and Education. The program is a family-based service that provides a range of services including developmental assessment/consultation, outpatient treatment services, as well as day treatment programs for students who are having difficulties in school and in the community due to problems with conduct, socialization and learning. Kadish and Taras-Gold identify the children’s communication difficulties, which research shows are commonly undetected in this population. They then work with the students, their families, and the other members of the interdisciplinary team in order to give the children the communication support that they require. They educate parents and staff so that they may understand the impact of  the child’s communication disability on their behaviour, learning, and social-emotional adjustment as well as the role that language can play in regulation of a child’s behaviour and emotions. They point out that some of these children may choose to look “bad” in order to mask their disability.

The effectiveness of their work was acknowledged when they received a “Make a Difference” award on February 1, 2006. This is a Ministry of Children and Youth Services employee recognition award which recognizes excellence and collaboration. In receiving this award, Kadish and Taras-Gold are honoured for the quality of the speech-language pathology that they practice, but their award also raises awareness of the role of the speech-language pathologist in treating pediatric mental health disorders which serves to identify unsuspected language disorders.

There is no way to quantify the extent of the loss when individuals suffer a stroke and suffer communication impairments due to aphasia. Vibrant, independent and social people are rendered speechless by the neurological damage the stroke can cause and thus become isolated by their inability to communicate. They are desperate to learn how to communicate again and look to their speech-language pathologists for help. Speech-language pathologists who provide this type of care are typically unsung heroes, working diligently to give these individuals the skills that they need to reach their communication potential. But recently a number of CASLPO members have flown above the radar and gained the attention of the media.

Lynn Buckle, a speech-language pathologist at Baycrest, was singled out by one of her patients/clients whose recovery was featured in the September 2006 issue of the Baycrest Bulletin. The patient was seen at the Louis and Leah Poslun’s Stroke and Cognition Clinic at Baycrest. He was quoted as saying, “The whole team was great, but I owe my success to Lynn who motivated me to do my best. She gave me practical strategies.” His wife added, “The work that Lynn did with him has made a lasting change. He will now talk to our grandchildren on the phone, book his own appointments, socialize, and he is generally happier.” This example beautifully illustrates that speech-language pathologists look beyond specific communication goals and work with their patients/clients to give them what they need to do what they want.  This is patient/client centred care at is finest.

Carol Harrison, speech-language pathologist of the Woodstock Speech and Voice Centre had the opportunity to explain to the Woodstock Sentinel Review on June 5, 2006 that “Living with aphasia builds barriers in people’s lives by affecting personal relationships and the ability to take part in family and community life. Those barriers can lead to depression, loneliness, and isolation.” She described the effectiveness of techniques which listeners can learn to support the conversation of individuals who have aphasia, which in turn allows the individuals to express themselves more fully. The article demonstrated that speech-language pathologists play a significant role in training others in these techniques by highlighting the workshop Harrison put on for the case managers at the local Community Care Access Centre.

Occasionally, a speech-language pathologist receives attention because someone on their caseload is a person of note. Bonnie Bereskin who is a speech-language pathologist at Baycrest and in private practice in Toronto had the privilege of counting Ian Scott as one of her patients/clients. Scott was a lawyer, civil-rights advocate, and politician best remembered as the Ontario Attorney General in David Peterson’s government from 1985 to 1990. He unfortunately suffered a stroke in 1994 which left him with a hemi paralysis and severe aphasia. When noting Scott’s numerous accomplishments after his death on October 11, 2006, an article in The Globe and Mail referred to his dogged determination to overcome his aphasia. Bereskin was credited with helping to improve Scott’s communication as well as training a group of his former colleagues and friends to assist him in participating in conversation. This attention served to reinforce the importance of speech-language pathologists working with the communication partners of their patients/clients in order to, as Bereskin points out, “support a knowledgeable and supportive communication environment which is not only efficacious and cost effective but sustaining.”

The public is well aware that hearing loss affects the elderly but it is not widely known that hearing loss can happen at any age. Given the misconception of hearing loss as an older person’s affliction, it is no wonder that as the baby boom generation floods into middle age, there is a tendency to deny hearing loss and pretend that it just isn’t there.
Rex Banks, chief audiologist at the Canadian Hearing Society knows this only too well. He was interviewed for a Globe and Mail article, “Say again: Hear! Hear! Boomers” on October 17, 2006.

The article described the tendency for baby boomers to experience hearing loss earlier than their parents due to increased exposure to loud noises in their youth. It suggested that while gradual hearing loss has always been a common occurrence, it is even more prevalent now. Banks stressed that this tendency of baby boomers to deny their hearing loss can be damaging to relationships with family and friends and end up being quite troubling for the individual. Banks pointed out that individuals with untreated hearing loss can experience frustration, isolation, and depression. He explained that those with hearing loss experience anxiety whenever communicating because of the stress of not being able to hear. Banks’ contribution to this article underscored the important role that audiologists play in not only identifying a hearing loss and providing recommendations for treatment, but the need to consider the individual in the context of their environment and their personal beliefs and biases to maximize the benefits of the treatment.

While audiologists and speech-language pathologists are the experts in communication, our members consistently face the challenge of communicating the wide breadth of scope that may be included in an audiology or speech-language pathology practice. For example, members of the public are generally unaware that speech-language pathologists play a valuable role in helping individuals interested in self-improvement improve their everyday communication skills.
This is why the article “Maybe your English isn’t as good as you think” in the Careers section of The Globe and Mail on Friday September 1, 2006 was so informative. The article focused on the work of Bonnie Gross, speech-language pathologist, and the services she provides through her training firm SpeechScience International Inc. It emphasized the importance of how one communicates and how one is understood in the business world, especially for those who are trying to advance their careers. Gross pointed out that while pronunciation is the most common issue that she works on with non-native English speakers, attention must also be paid to pacing and other speech patterns. She stressed that accent reduction might also be a goal but that “it’s important that you don’t try to get rid of an accent completely.” She went on to say, “I’m very clear on that because an accent tells people your heritage. Not only is that something to be proud of, it can indicate you are multilingual and have experience beyond Canada.”

The article also suggested that native English speakers might also benefit from communication skills coaching. Gross explained, “In the business world, where you have convey information precisely, if what you say is confusing or sounds too laid back, people will get the impression that you lack expertise and enthusiasm.” This article highlighted that speech-language pathologists have the unique expertise required to provide communication support to anyone who is looking to improve communication skills for any reason. 

That CASLPO members provide quality audiology and speech-language pathology services is no surprise. CASLPO is committed to working in partnership with our members to spread the word and raise awareness of the roles the professions play in improving quality of life.  Together we can ensure that the public understands the valuable contribution of audiologists and speech-language pathologists.

NEWS
The ABCs of CLACs

A Primer on CASLPO’s Requirements for the Continuous Learning Activity Program

By Barbara Meissner Fishbein, Director of Professional Practice

Over the past two years, CASLPO’s Continuous Learning Activity (CLAC) program has matured and been refined. In the course of the move to a more self-directed learning program, CASLPO has entrusted its members with more autonomy for their continuing professional education. 

CASLPO members have distinguished themselves by showing their commitment to life long learning. Audiologists and speech-language pathologists have embraced the new program with their questions, their compliance, and their constructive suggestions. CASLPO has responded by incorporating many of the suggestions into the refinement of the program.

A) Approach
The underlying philosophy of the program has not changed. CASLPO’s approach to continuous learning is based on the following basic tenets:

1. Continuous professional learning is important to ensure members remain current in their practice
2. Learning is more meaningful and will have a greater impact on clinical practice if it is self directed.
3. CASLPO members are self motivated to maintain rigorous continuous professional learning.

B) Back to Basics
The basic criteria of the Continuous Learning Activity Credit program are very similar to former continuing education programs with some minor adjustments to accommodate self-directed learning. To fulfill the requirements of the CLAC program members need to complete the form for each year in the Opportunities for Growth and Change section of the Self Assessment Tool. All members must:

1. Have a minimum of three learning goals per year.
2. Ensure that all learning activities are associated with a learning goal are counted as a CLAC.
3. Check that all learning activities meet the criteria set out in the Self Assessment Guide.
4. Review their learning activities at the end of each year and make a statement about progress in meeting the goal.
5. Rate the impact the learning has had on their practice at the end of each year.
6. Accumulate 45 CLACs in every three year cycle.

C) Challenges
It is recognized that the CLAC program requires members to think differently about their continuing education. Members have asked many questions regarding the method of recording and reporting CLACs as they strive to understand the requirements and ensure their compliance. The following are some common questions that have been asked:

Do I need to submit my CLACs to CASLPO at the end of each year?
No. CASLPO abolished the annual reporting requirement of continuous professional learning in 2004. CASLPO members were overwhelmingly compliant and demonstrated the personal accountability required to make a self-directed learning program successful. As a result, annual reporting of CLACs is not required; however, members are required to record their CLACs on an annual basis as well as comment on progress in meeting learning goals and rate the impact of the learning on practice. This must be done on an annual basis.

Do I need to submit my CLACs to CASLPO at the end of the three year cycle?
Each year 250 members are randomly selected to submit their Self Assessment Tools. As CLACs are reported on the Opportunities for Growth and Change section of the Self Assessment Tool this is required as part of that submission. CLACs are reviewed to ensure that they are complete and meet the requirements of the program. Individual learning plans are not evaluated for the quality and type of learning; this is a self-directed learning program after all. Even if members are not selected to submit the Self Assessment Tool, they still must complete the CLAC form each year.

Do I need to accumulate 45 CLACs in a three year cycle if I have not been practicing for part of that time?
All CASLPO members registered in the General and Academic categories must accumulate 45 CLACs in each three year cycle. If you are registered in the non practicing category, you do not have to accumulate CLACs while you are non practicing but, if you wish to return to practice, you will have to demonstrate at a minimum that you have three learning goals for the year that you intend to return to practice. Even if you are non practicing for part of a cycle, you still need to accumulate 45 CLACs by the end of the cycle.

How can I accumulate CLACs if I don’t have the opportunity to go to courses?
The CLAC program is a self-directed learning program. As a result, there are only minor limits on the amount of self study that can be done. If a member acquires CLACs for being mentored by another more experienced mentor, a maximum of 15 CLACs can be counted. If a member credits CLACs for preparation time for a poster, presentation, or course, a maximum of five CLACs can be counted. Other than that, there are no restrictions on self study. Members may read materials, review video or audio tapes, or participate in a study group and none of these activities need be limited. Documentation of the self study must be maintained.

Which CLAC cycle am I in?
In 2005, CASLPO abolished different continuing education cycles for members. Now all members are in the same cycle. The current cycle runs from 2005 to 2007. That means that all members must accumulate 45 CLACs by the end of 2007, provided they have been registered for the entire three years of the cycle.

D) Definition
CASLPO members are adept at writing goals for audiology and speech-language pathology. These same skills can be applied to the writing of learning goals. As the Quality Assurance Committee has reviewed the learning goals of members randomly selected to submit their Self Assessment Tools, they have come to realize that the definition of a well formed learning goal needs to be refined. This has resulted in a clarification of the components of a learning goal. All learning goals must:

1. Define the information to be learned and incorporate the purpose of the learning.
2. Include sufficient detail to determine if the learning objective was met.
3. Relate to the member’s clinical practice.
4. Refer to a learning activity.
5. Address any areas of partial or non-compliance on the Self Assessment Tool.

Members have appreciated the direction provided in writing learning goals (See “Continuing Professional Education Continues to Develop: Clarification of the Continuous Learning Activity Program” in the August 2006 issue of CASLPO Today) but have requested further assistance. In a further analysis of submitted learning goals, the Quality Assurance Committee has developed a template which may support members as they try to make sure that all the criteria are met (Figure 1).

The standard wording to refer to the learning activity would begin:

To learn more about…
To acquire knowledge of…
To further knowledge of…

The standard wording to state the purpose of learning would begin:

In order to…
To provide…
To ensure…

The following table shows examples of how the template can be applied:
Submitted Learning Goals                              Goals Using Template
Develop consultation skills to ensure client perspective is reflected.                    To acquire knowledge about communication techniques in order to develop consultation skills to provide care where client perspective is reflected.
To maintain client confidentiality            To learn more about techniques to assist in maintaining client confidentiality in order to ensure that the sensitive nature of personal health information is respected.
As part of improved record keeping, will update report format to include data from new assessments.    To further knowledge of record keeping methods in order to update report format so that new assessment information can be included.
To explore community education opportunities regarding infant health and development  To acquire knowledge about infant health and development education resources in the community to better understand the needs of children and families on my caseload.
To increase exposure to professional discussion related to all areas of practice, increase communication with other SLPs for case discussion and brainstorming.                      To learn more about how colleagues utilize clinical knowledge in problem solving specific cases to be able to improve goal setting in therapy.
To read articles to increase professional knowledge       To further knowledge of childhood language disorders to ensure that current techniques are used in my practice.

If members decide to use this template, it may be helpful in determining whether the requirements for learning goals are met. This is illustrated in the table below:
Refer to a Learning Activity                           Define the Information to be Learned        State the Purpose                                     Relate to Practice
To learn more about      Communication techniques                              In order to     Develop consultation skills
To acquire knowledge of                                    Childhood language disorders          To provide       Current techniques in therapy
To further knowledge of Clinical problem solving                                   To ensure      Better clinical problem solving
 
In this manner:

• The information to be learned is defined and the purpose stated.
• Sufficient detail is included.
• There is a relationship to the member’s clinical practice.
• The learning activity is declared.

E) Evaluation
As CASLPO and its membership became more familiar with this self-directed learning program, it was apparent that the peer assessment process presented a perfect opportunity for a member and a professional peer to discuss all aspects of the CLAC program. Peer assessors reported that members appreciated the chance to further refine their learning plans and that members were devising some innovative and effective learning strategies. Members requested feedback on their compliance with the program. The program is unfamiliar and members have reported feeling unsure whether they are maximizing their learning within this new structure. Members wanted to know how they were doing.

This led the Quality Assurance Committee to decide that during the 2007 Peer Assessment Cycle, peer assessors and the Quality Assurance Committee would give members feedback on their learning goals and their CLACs. Peer assessors will review all aspects of the CLAC program with the member. They will look at the member’s completed forms for 2005 and 2006 as well as their learning goals for 2007. The peer assessors will assist the member in determining whether their learning goals meet the criteria for a learning goal. They will then ensure that all the reported CLACs meet the criteria as set out on page 21 of the Self Assessment Guide. The peer assessor and the member together will look at the member’s progress statement and how the member rated the impact of the learning on his/her practice. This discussion will allow the member to take advantage of the peer assessor’s knowledge and experience and find out what other members are doing in order to enhance their continuing education experience with new ideas. This will provide member with the chance to consider other approaches to continuing professional education. This discussion will also allow the peer assessor to learn from the member. Peer assessors report that the members that they come to know through a peer assessment are a great resource of inventive and novel ideas. Thus this information can be shared with other members. And so the cycle continues and the CLAC program continues to develop.

F) Forms
Some members have reported that the CLAC forms, which are in the Opportunities for Growth and Change section of the Self Assessment Tool are not adaptable. There may not be enough room to record all of the learning activities. If learning goals are to be changed or rearranged the form does not allow this to be done easily. The form is available in Word format on the CASLPO website (www.caslpo.com) under Self Assessment in the Member Information section. Some members have downloaded this form onto their personal computers and saved a digital version. This allows them the flexibility to incorporate as many learning activities as they want for any one learning goal. They also have the opportunity to review and revise learning goals as their learning program requires. All members can take advantage of this and tailor the form to allow them to get the most out of the CLAC program.

During 2007, CASLPO will be exploring other options for the CLAC forms. Revised forms may be available on the website for members to try out and give feedback. Members are encouraged to check the Web site often to see the most recent CLAC form.

True the CLAC program continues to develop but the changes are being made to assist and support members to meet the requirements of the program. The changes are being made to make CLAC collection and recording easier. Our goal is to make collecting CLACs as easy as ABC.

Outcomes of Mandatory Termination Reports

Every year, the College receives a small number of reports from employers indicating that they have terminated the employment of a CASLPO member due to reasons of professional misconduct, incompetence, or incapacity. Under the Regulated Health Professions Act (RHPA), employers are required to forward these reports to the Registrar within 30 days of the employment termination. Three such employment termination reports were received in 2006, and four in 2005.

Upon the receipt of an employment termination report, the Executive Committee will carry out its own review of the concerns. If necessary, the Executive Committee will seek further information from the employer regarding the matters that led to the termination. The member will then be provided with information regarding the concerns expressed by the employer and provided with the opportunity to respond. The Executive Committee may also take further steps such as directing the appointment of an investigator to obtain further information.

Following its review of the information obtained, the Executive Committee has a variety of options available, which can be combined, including:

• Referring allegations of professional misconduct to the Discipline Committee
• Referring allegations of incapacity to a Board of Inquiry
• Referring the member to the Quality Assurance Committee for review
• Issuing a caution to a member
• Providing advice to the member
• Negotiating an undertaking with the member
• Taking no further action

The following are examples of outcomes of the College’s review of concerns raised by termination reports received by the Registrar.

Referring Allegations of Professional Misconduct to the Discipline Committee
A report of termination of employment stated that an Initial Practice Registrant had performed a medical procedure outside the member’s scope of practice that placed the patient/client at significant risk of harm. The Executive Committee investigated the concerns raised by the former employer and referred the matter to the Discipline Committee and suspended the member’s registration with the College pending the outcome of a discipline hearing.

A Discipline Committee hearing was held but due to procedural issues, the Committee did not issue a decision following completion of the hearing. Prior to the Committee arriving at its final determination, discussions between the College and the member resulted in a mutually agreed upon settlement which included a suspension of registration, mentorship with close supervision, and the passing of the CASLPA exam. 

Referring Allegations of incapacity to a Board of Inquiry
An employer claimed that a member had violated patient/client boundaries, leading to employment termination. Upon reviewing the information, the Executive Committee appointed a Board of Inquiry which is a panel whose function is to inquire into whether a member is incapacitated. The legislation defines incapacity as follows:

…that the member is suffering from a physical or mental condition or disorder that makes it desirable in the interest of the public that the member no longer be permitted to practise or that the member’s practise be restricted.

The Board of Inquiry reviewed reports from an investigator and also interviewed the member. The Board of Inquiry identified a number of issues that had come forward relating to the member’s termination of employment, and also other matters relevant to the inquiry of whether the member was incapacitated, such as boundary issues, appropriateness of patient/client treatment, record-keeping, breach of confidentiality, and the member’s emotional state.

As a result of the information obtained, the Board of Inquiry required the member to attend for an examination by a psychiatrist who concluded that the member was not incapacitated but did provide some recommendations. The Board forwarded its findings to the Executive Committee, which negotiated an undertaking with the member. The member agreed to practice under the guidance of a mentor for one year, review CASLPO’s Position Statement on Professional Relationships and Boundaries with the Registrar, and to undergo a course of psychological therapy with the psychiatrist, with the psychiatrist providing reports to the Executive Committee.

In another matter of employment termination, a former employer notified the College of an employment termination attributed to record-keeping issues, billing discrepancies, and time-management difficulties. The member informed the College of her personal difficulties and consented to have her physician, psychotherapist, and psychiatrist share information with College. On the basis of information obtained, a Board of Inquiry was appointed. Following the Executive Committee’s review of the Board’s proceedings, the member signed an undertaking agreeing to practice under the supervision of a mentor to address issues leading to the employment termination, to continue to receive psychiatric therapy and to have her treating psychiatrist and her mentor provide reports to the Executive Committee.

Referring the Member to the Quality Assurance Committee for Review
Under the College’s Regulations, the Registrar and the Executive Committee are permitted to refer a member to the QA Committee for a peer assessment. This has been the outcome of some termination reports. For instance, employer concerns in the areas of record keeping and communication with families, schools, and a long-term facility which led to the member’s termination, resulted in the Registrar referring the member to undergo a peer assessment. 

One member was referred for peer assessment subsequent to the receipt of concerns by a former employer regarding record keeping, inappropriate discharging of patients/clients and lack of follow-up to a physician referral for swallowing concerns. The Registrar then obtained information from the former employer and the member and, upon reviewing the matter, referred the member to the Quality Assurance Committee to undergo a peer assessment.

In a third situation, the Executive Committee received information regarding employment termination from a former employer, but received no response from the member to its requests for further information.  The member also did not renew her registration with the College. The member will undergo a peer assessment upon her eventual return to practice in Ontario.

Issuing a Caution to a Member
An employer reported termination due to work performance markedly below expectations in areas such as record keeping, protecting and advocating for patients/clients, referral recommendations, quality of care, truthful interaction with colleagues, and entering workload and attendance statistics for patients/clients not treated. An investigator obtained patient/client records and interviewed staff at the former employer’s. A review of the information indicated that concerns such as record keeping (failure to chart for extended periods), service provision (discharging a client because of lack of knowledge of treatment strategies, ceasing individual therapy prematurely), and professional conduct (failing to be truthful with colleagues, falsifying workload and attendance statistics). In the interview with the investigator, the member acknowledged many of the concerns as being fully justified.

The Executive Committee chose to issue a letter of caution to the member. The letter stated that the Executive Committee was very concerned regarding the circumstances of the employment termination and cautioned the member regarding several areas of practice. The member also signed an undertaking stating that, upon resumption of employment, she would practice under the guidance of a mentor for a year, with the mentor required to provide over 100 hours of direct and indirect mentorship, to review 55% of the member’s patient/client records and to forward written reports of the mentorship to the Executive Committee.

Taking No Further Action except Advising the Member
An acute care hospital reported that a speech-language pathologist had her employment terminated for not meeting the hospital’s standards of care. After reviewing the member’s response to the matters raised, the College reminded the member to document services in accordance with the College’s Proposed Regulation for Records, and advised her to comply with the requirements in the College’s Preferred Practice Guideline for Dysphagia, but took no further action.

CASLPO works with member and employers to ensure that the public continues to receive high-quality member services. The College conducts its own examination of the matters raised by employers and when appropriate, it focuses on member remediation, allowing for protection of the public interest while providing members with the opportunity to demonstrate competence to practice.

Health Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act
85.5 (1) A person who terminates the employment or revokes, suspends, or imposes restrictions on the privileges of a member or who dissolves a partnership, a health profession corporation or association with a member for reasons of professional misconduct, incompetence, or incapacity shall file with the Registrar within thirty days after the termination, revocation, suspension, imposition, or dissolution a written report setting out the reasons. 

Same
(2) If a person intended to terminate the employment of a member or to revoke the member’s privileges for reasons of professional misconduct, incompetence or incapacity but the person did not do so because the member resigned or voluntarily relinquished his or her privileges, the person shall file with the Registrar within thirty days after the resignation or relinquishment a written report setting out the reasons upon which the person had intended to act.

Application
(3) This section applies to every person, other than a patient, who employs or offers privileges to a member or associates in partnership or otherwise with a member for the purpose of offering health services. 

QA UPDATE
2007 SELF ASSESSMENT/PEER ASSESSMENT SCHEDULE

January 16, 2007                      Members randomly selected to submit Self Assessment Tools notified.

February 16, 2007                   Randomly selected Self Assessment Tool submission deadline.

February 28, 2007                   Members randomly selected to undergo Peer Assessment are notified.

March 23, 2007                       Evidence of compliance submission deadline for members undergoing Peer Assessment.

April – October 2007               Peer Assessments completed.

GREY AREAS
Mandatory Reporting Obligations

Due to a recent decision of the Supreme Court of Canada, regulators may have to educate practitioners about their legal protections when making a mandatory report.

The Issue
Most practitioners have some duty to report any risk of harm to the public by their colleagues (and sometimes even by their clients). Often this duty is contained in statute. Sometimes it is a professional obligation (e.g., where the incompetence or dishonesty of a colleague is likely to harm others). At common law (i.e., under case law) practitioners generally have a duty to report a risk of serious physical harm that is discovered during the practice of the profession.

There is a legal protection, or immunity, for making such reports even if they turn out to be wrong. Despite this very significant protection, in its January 28, 2006 decision of Young v. Bella, 2006 SCC 3, the Supreme Court of Canada held Professor Bella and her employer liable for $839,400 of damages for making a report without foundation. The headlines about the case will raise concerns that making such reports is risky. However, the actual reasoning of the Supreme Court of Canada really states the contrary.

The Facts
Ms. Young was a student at Memorial University in Newfoundland. She wanted to be a social worker. She wrote a paper for Professor Bella about treatment of juvenile sex offenders. To illustrate her point that victims of sexual abuse often become abusers themselves she attached a first hand account of a woman who sexually abused a child while baby sitting. Ms. Young failed to footnote the source of the story. However, it was from a source cited in the bibliography. Despite the fact that there was no indication that the first hand account had anything to do with Ms. Young, Professor Bella wondered whether it was in fact a personal account by Ms. Young. Professor Bella thought it might be a “cry for help”.

Professor Bella discussed the mater with some of her colleagues and the authorities. The authorities did not encourage Professor Bella to make a report because, without particulars, it would be difficult to investigate. However, in the end Professor Bella’s Director made the report to the child welfare authorities. Ms. Young was placed on the child abuse registry. Numerous other people learned about it. Ms. Young’s faculty mentors discouraged her from going into social work. She was not accepted in the social work program. She had difficulty getting work in the field.

Inexplicably, more than two years later the child welfare authorities notified her of the concern. This was the first she heard of it. Within 24 hours Ms. Young demonstrated that the first hand account was a quote from a published text and did not relate to her.

The Court’s Analysis
The Court upheld the jury finding that there was no basis for Professor Bella or her Director to suspect that the first hand account related to Ms. Young. Nothing in the wording of the first hand account or the context in which it was presented supported such a belief. That belief was mere conjecture and speculation.

However, the Court went at some length to support the need to make mandatory reports and the protection that would in almost every circumstance (except one like this) provide legal immunity for the report. The Court made the following points:

• Legal immunity for making mandatory reports is essential to make the system work.
• There is no obligation on the person with the information to investigate the facts. That is the role for the authorities who receive the report.
• The person making the report does not have to believe that the underlying concerns are valid. The reporter only needs to believe, on reasonable grounds, that the concern raises an issue that ought to be investigated by the authorities to find out one way or the other.
• There is immunity even if the report is based on misinformation (e.g., a reporter being told that certain facts exist when, in fact, those facts do not exist).
• Whether there was reasonable cause to make a report is an objective test. It is in fact a very low test. However, there must be some data upon which a reasonable person would believe that a report ought to be made for the authorities to investigate.

In the end, the Court concluded that despite these significant and necessary protections, Professor Bella and her supervisor had no reasonable cause to make such a report.
The Court was also influenced by some other considerations. For example, it appears that other faculty of the University had been informed of the concerns. These communications to faculty members would not be protected in the same way as the report to the child welfare authorities. In addition, Professor Bella communicated with Ms. Young about her concerns about plagiarism but did not use that occasion to clarify the obvious question of the origin of the first hand account. Finally, the failure of the child welfare authorities to follow up on the concern for over two years certainly aggravated the harm to Ms. Young.

Regulators would be wise to use this case to educate practitioners that, despite the media headlines on the Young case, significant protections exist for mandatory reports.
A copy of the Young case can be found at: www.lexum.umontreal.ca/csc-scc/en/rec/html/2006scc003.wpd.html.

This article has been reproduced with permission from Grey Areas, No. 95 (January 2006). Grey Areas is a newsletter published by Steinecke Maciura LeBlanc, a law firm practising in the field of professional regulation. Grey Areas is also available on their Web site: www.sml-law.com.

Mandatory Reporting Obligations of CASLPO Members

• The Regulated Health Professions Act (RHPA) requires CASLPO members to file a report with the Registrar if they have reasonable grounds, obtained in the course of practising the profession, to believe that a member of the same or different college has sexually abused a patient (RHPA, Sec 85.1).
• The RHPA requires employers to report employees who have been dismissed or were about to be dismissed for reasons of professional misconduct, incompetence, or incapacity (RHPA, Sec 85.5).

NOTE: There is no specific regulatory obligation for members to report the potential misconduct, incompetence, or incapacity of another member of the same or different College in situations other than those described above. However, members may feel compelled to report on the conduct of another member in order to ensure the protection of the public.

• The Child and Family Services Act requires that individuals, including CASLPO members, who work with children have an obligation to report to a children’s aid society if they have reasonable grounds to suspect that a child is or may be in need of protection from abuse. The Act defines abuse as emotional and or physical neglect, abandonment, refusal of cures and treatments, and refusal to supervise a child who is harming others (Child and Family Services Act, Sec. 72).
• The Nursing Homes Act requires that individuals, including CASLPO members, must report to local regional office of the Ministry of Health and Long-Term Care when they have reasonable grounds to suspect that a nursing home resident has suffered or may suffer harm as a result of: unlawful conduct, improper or incompetent treatment or care, and/or neglect. This act applies to residents of nursing homes, charitable homes, and homes for the aged (Nursing Home Act, Sec. 25).<END BULLET LIST>

Allied Health Profession Development Fund

REMINDER

CASLPO members are eligible to apply for a maximum of $1,500 for professional development courses and/or programs from the HealthForceOntario Allied Health Profession Development Fund. The professional development must be completed between April 1, 2006 and March 31, 2007.

Funding is limited. Note that applications will be considered on a first-come first-served basis.

Applications must be received by March 31, 2007.

HealthForceOntariois a an innovative health human resources strategy designed to ensure the province has the right supply and mix of healthcare professionals and make the province a more attractive place to practice. The Allied Health Profession Development Fund is a $1 million fund intended to extend skill and knowledge development opportunities for medical radiation technologists, medical laboratory technologists, physiotherapists, occupational therapists, speech-language pathologists, and audiologists. 

Applications and more information about the fund can be found at the CASLPO website: www.caslpo.com in the What’s New section of the homepage, as well at the Allied Health Profession Development Fund website: www.ahpdf.ca.