Contingency Planning for Private Practice

Consider the following scenario. You have a thriving private practice, with many different types of clients. Some clients are at higher nutrition risk and require frequent follow up.

 Something unforeseen occurs, requiring you to take time away from your practice or ending your therapeutic relationship with a client. This could include:

  • Unexpected time away that is longer than a holiday would reasonably be.
  • Requiring a permanent closure of your practice.
  • Absence from a solo practice, or in a multidisciplinary practice (with or without other dietitians).
  • Requiring the use of CDBC Right to Refuse Treatment Policy.

How should you proceed?  It is important to have contingency plans in place. The following questions are designed to make you pause and think about your practice and how to ensure you are adequately prepared for an unforeseen prolonged absence from, or closure of, your practice.

Q1: Why is it important to have a contingency plan in place for my private practice?

In the context of privacy and access to information legislation, CDBC Bylaws 73-75 apply [1]:

  • all records… must be kept in a suitable systematic permanent form, such as paper or electronic record-keeping or accounting systems, provided that the information can be reproduced promptly in written form when required…”.
  • upon request, [a registrant must] provide access to personal information in accordance with the pertinent Acts and all other relevant legal requirement”.
  • a registrant must make any… documentation relevant to records…, available at reasonable hours for inspection by representatives of the college, including the registrar, members of the inquiry, discipline and quality assurance committees, assessors and inspectors appointed under any provision of these bylaws or the Act”.

The CDBC Bylaws are the basis for the CDBC Standards of Practice, and one of the focuses of these standards is the provision of client-centred care. Multiple Standard/Indicator combinations have been identified as relevant rationale for development and maintenance of a contingency plan. See Q2 for details.

Furthermore, BC’s Personal Information Protection Act (PIPA) [2] stipulates that a client must be allowed to request access to their personal information. This translates to the privacy officer role, who is required to develop a published procedure that allows a client to have access to their own records [3].

With that in mind, the BC Public Advisory Network (BC PAN) is regularly consulted for public perspectives on what is expected from a regulated health professional. BC PAN is a group of members of the BC public that are representative of the population of BC, put together in 2019 to discuss regulation from a public point of view. In June of 2021, the topic of contingency planning was discussed [4] and the main outcomes of this informed regulators about how to create policies and guidelines for registrants to best protect the public, specifically in the context of a public lens. This group identified the following main concerns when a clinic or healthcare provider closes a practice:

  • Who will be my healthcare provider?
  • Who will hold my medical information, and will it be secure? Can I have my medical information?
  • Will I be given enough time to find a new healthcare provider?
  • What if I have medical needs that are time sensitive?
  • Will I have a voice in the process to transition from one healthcare provider to another? Will it be transparent?

If you are in the position of being unable to see or follow-up with your clients, or if you have chosen to act on the CDBC Right to Refuse Treatment Policy [5], it is for a valid reason whereby you cannot follow clients based on personal/life or specific suboptimal therapeutic relationship circumstances. It is important to remember that, as a dietitian, you must uphold the CDBC Standards of Practice, even as you are unable to see a client or clients, leaving your practice for a extended defined or undefined amount of time, or closing your practice.

 

  1. CDBC Bylaws. https://collegeofdietitiansofbc.org/cdbc-bylaws/.
  2. Personal Information Protection Act. https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/00_03063_01, accessed August 22, 2022.
  3. CDBC Privacy Guide. Available on the Quality Assurance Page.
  4. BC PAN. Meeting June 9/10, 2021. Practitioners leaving practice. https://www.bcpan.ca/summary/practitioners-leaving-practice/, accessed August 8, 2022.
  5. CDBC Right to Refuse Treatment Policy. Available on the Quality Assurance Page.
Q2: Which CDBC Standards indicate my requirement to have a contingency plan?

In the context of the CDBC Bylaw requirements, CDBC Standards of Practice, and the BC PAN questions above, and as useful preparation for your annual CCP if you have developed a goal to implement or revise a contingency plan, the relevant Standards of Practice that apply include [1]:

  • Standard 5. A Dietitian practices in compliance with privacy legislation; Indicators 1-5 apply.
  • Standard 12. A Dietitian provides quality professional services that reflect the unique needs, goals, values, and circumstances of the client; Indicators 2-6 apply.
  • Standard 14. A Dietitian uses critical thinking to obtain assessment data, determine practice problems, plan, implement and evaluate professional services; Indicators 6, 8-10 apply.
  • Standard 15. A Dietitian maintains clear and accurate records that document communications and the provision of professional services; Indicator 1 applies.
  • Standard 16. A Dietitian leads and organizes effective and timely delivery of services; Indicators 1 and 5 apply.

 

  1. Standards of Practice. Available on the Quality Assurance Page.
Q3: Are you the Custodian and/or Privacy Officer of the medical records?

Generally, the company/clinic owner is the Custodian of the records. Is this you? Review Q12 of the Privacy Q&A to determine if you are considered the Custodian [1].  If so, you are likely also the Privacy Officer of your company. The Privacy Officer, as defined on page 47 of the CDBC Privacy Guide [2], is responsible for the Privacy Management Program. You may find it useful to review “Step 1: Be Accountable”, on page 9 of the CDBC Privacy Guide, to ensure you have a good understanding of what the role of the Privacy Officer is.

If you are the Custodian and/or Privacy Officer of the medical records, it is your responsibility to ensure that there are plans in place such that the medical records can change hands from you to another Custodian, should you be required to leave your clinic, become incapacitated, or pass away.

The most comprehensive way you can ensure that the medical records stay secure if you were to suddenly be removed from dietetic work, is to plan ahead [3,4]. Make arrangements before the need to take leave that can be implemented at the beginning of an extended time away from your practice (illness, injury, for example), as well for the permanent closure of your practice (incapacitation, death, for example). These plans can be part of your business plan and your Privacy Management Program. You may arrange for another healthcare practitioner to take over your record storage obligations; however, Custodians need not be healthcare practitioners. In the most extreme instance of your death and without a contingency plan, the medical records would become part of your estate, legally owned by the estate trustee until they are passed along to the new permanent recipient of the records. This person could be your spouse or family member, who would then become the Custodian and potentially the Privacy Officer. Review the role and details of the Privacy Management Program, as defined on page 47 of the CDBC Privacy Guide, and understand that there are resources such as the Office of the Information and Privacy Commissioner of BC (OIPC) [5] document: Getting Accountability Right with a Privacy Management Program. Ensure that your successor is aware of these resources.

If you are not the Custodian nor the Privacy Officer, it is not your responsibility to have a contingency plan for medical record storage. However, the subsequent care and follow-up of your existing clients must be assured and may require you to refer to another dietitian.

  1. Privacy Q&A.
  2. CDBC Privacy Guide. Available on the Quality Assurance
  3. College of Dietitians of Ontario (CDO). Private Practice RDs: Do you have plans in place to manage client health records?

https://www.collegeofdietitians.org/regulation-matters/2022-issue-1-may/private-practice-rds.aspx, accessed July 19, 2022.

  1. College of Physicians and Surgeons of BC (CPSBC). Registrar’s message: contingency planning and coverage for an unexpected absence. https://www.cpsbc.ca/news/publications/college-connector/2022-V10-01/01, accessed August 10, 2022.
  2. Office of the Information and Privacy Commissioner. Contact Us. https://www.oipc.bc.ca/about/contact-us/, accessed July 19, 2022.
Q4: What does a recipient of the medical records that were formerly in my care need to know about their obligations?

This is a great question, especially when there are circumstances, for example, whereby an inheritor (new Custodian) of the medical records is not a regulated healthcare professional.

Privacy in a dietitian’s private practice is governed by PIPA, the Personal Information Protection Act [1]. The purpose of PIPA is “to govern the collection, use and disclosure of personal information by organizations in a manner that recognizes both the right of individuals to protect their personal information and the need of organizations to collect, use or disclose personal information for purposes that a reasonable person would consider appropriate in the circumstances.”

It is important for anyone assuming the Custodian role to understand the requirements by PIPA, and they are encouraged to contact the Office of the Information and Privacy Commissioner of BC (OIPC) for help to interpret their obligations [2]. As in Q3, you should also put in place a policy whereby your successor is aware of resources such as the OIPC document: Getting Accountability Right with a Privacy Management Program.

 

  1. Personal Information Protection Act (PIPA). https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/00_03063_01, accessed July 18, 2022.
  2. Office of the Information and Privacy Commissioner. Contact Us. https://www.oipc.bc.ca/about/contact-us/, accessed July 19, 2022.

 

Q5: Do I have an obligation to let my clients know that I am leaving my practice?

Within the CDBC Standards of Practice, “Standard 12. A Dietitian provides quality professional services that reflect the unique needs, goals, values and circumstances of the client. 6. Arrange for the transfer of clients, as applicable, when leaving a practice position and when care is transferred to a new practitioner” [1]. You should endeavour to provide your clients with as much notice as possible if you are temporarily or permanently closing your practice.

If you are in a solo private practice, you are encouraged to develop an alliance or partnership with another solo practitioner. Agree ahead of time to help each other out. If you are unable to inform your clients and office staff yourself, consider having a written policy for your office or your predetermined partner to be able to follow if you are temporarily or permanently leaving your practice. Consider including a log of who has been informed of your absence and how [2,3].

 

  1. Standards of Practice. Available on the Quality Assurance Page.
  2. Canadian Medical Protective Association (CMPA). Practically speaking: Contingency planning for the unplanned absence from Practice. https://podcasts.apple.com/ca/podcast/contingency-planning-for-unplanned-absence-from-practice/id1530251704?i=1000498420337, accessed August 9, 2022.
  3. College of Physicians and Surgeons of BC (CPSBC). Registrar’s message: contingency planning and coverage for an unexpected absence. https://www.cpsbc.ca/news/publications/college-connector/2022-V10-01/01, accessed August 10, 2022.
Q6: How do I ensure that my clients have access to their medical records if I am no longer practicing, whether temporarily or permanently?

In private practice, you, or your successor, will be in possession (Custodian) of medical records for at least one year after the date of last entry. In your contingency plan, you should include a resource such as this OIPC Guidance, which can be included in your written policy as discussed above in Q5, providing information to your clients about how to obtain their medical records [1]. This may be particularly helpful in the event that your successor is not a dietitian or other regulated health professional.

If the closure of your practice doesn’t happen abruptly and you have time to plan for it, you may choose to provide a copy of the medical record, or a detailed summary of the medical record, to each of your clients. This allows clients to be an important part of their own ongoing care and their transfer of care, as well as providing transparency to the process during a time of potential uncertainty. It is important to note that you are providing a COPY of their medical record and not an original. [2]

 

  1. Office of the Information and Privacy Commissioner. Tip Sheet: Requesting Records from a Public Body or Private Organization. https://www.oipc.bc.ca/guidance-documents/2073, accessed July 20, 2022.
  2. Canadian Medical Protective Association (CMPA). Practically speaking: Contingency planning for the unplanned absence from Practice. https://podcasts.apple.com/ca/podcast/contingency-planning-for-unplanned-absence-from-practice/id1530251704?i=1000498420337, accessed August 9, 2022.
Q7: What are my obligations if I close my practice and remain the Custodian of the medical records for clients who choose not to be followed by another dietitian?

Consult Standard 5 of the CDBC Record Keeping Standards to determine how long you are required to securely retain a client medical record [1]. In planning for the closure of your practice, you may choose to provide a copy of the medical record to each of your clients. It is important to note that you are providing a COPY and not an original. It is equally important to note that there is no time limit on when a former client could file a complaint with the CDBC against you. In that case, the CDBC would initiate an investigation, requesting information from the client medical record. Although you are required to keep the medical records secure for the minimum time as required by law, the College encourages you to consider keeping them as long as you remain registered with the CDBC. This would facilitate a complaint investigation should allegations regarding your practice come at a later time. However, the CDBC follows privacy legislation (PIPA) [2] to gather information for complaint cases and a dietitian who safely disposes of medical record information after the minimum required amount of time is within their legal right to do so [3].

 

  1. CDBC Standards for Record Keeping. Available on the Quality Assurance
  2. Personal Information Protection Act (PIPA). https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/00_03063_01, accessed July 18, 2022.
  3. Canadian Medical Protective Association (CMPA). Practically speaking: Contingency planning for the unplanned absence from Practice. https://podcasts.apple.com/ca/podcast/contingency-planning-for-unplanned-absence-from-practice/id1530251704?i=1000498420337, accessed August 9, 2022.
Q8: Who will look after the follow-up of my clients?

Standards of Practice 12.6 indicates that you must “provide quality professional services that reflect the unique needs, goals, values and circumstances of the client… by arrang[ing] for the transfer of clients, as applicable, when leaving a practice position and when care is transferred to a new practitioner.”  [1]

Whether or not you are the Custodian of the medical records, the clients are yours, and it is a requirement for you to have a short-term plan in place in the event that you are unable to follow them. Have a formal agreement in place, in the case of a shared practice [2,3] or develop a partnership in the case of a solo practice, as discussed in Q5. This is particularly important for clients who may have higher nutrition risk and immediate needs for follow-up in case of an unforeseen absence.

 

  1. Standards of Practice. https://collegeofdietitiansofbc.org/registrants/quality-assurance-program/
  2. Canadian Medical Protective Association (CMPA). Practically speaking: Contingency planning for the unplanned absence from Practice. https://podcasts.apple.com/ca/podcast/contingency-planning-for-unplanned-absence-from-practice/id1530251704?i=1000498420337, accessed August 9, 2022.
  3. College of Physicians and Surgeons of BC (CPSBC). Registrar’s message: contingency planning and coverage for an unexpected absence. https://www.cpsbc.ca/news/publications/college-connector/2022-V10-01/01, accessed August 10, 2022.
Q9: Is there a contingency plan checklist available?

Doctors of BC has a Contingency Toolkit , developed based on the update for the College of Physicians and Surgeons (CPSBC) requirement for contingency planning [1].  You may find parts of this toolkit applicable in maintaining, revising, or developing a contingency plan. There are considerations for personal contingency (a personal will, for example), continuity of business (dietetic coverage of your client caseload, for example), and emergency preparedness. In addition, the checklists within the toolkit prompt you to ensure that you have appropriate Insurance. While dietitians are obligated to have Liability Insurance, you are encouraged to determine if Commercial, Office Overhead, or other type of insurance would be to your benefit. For example, office overhead coverage may aid in the costs associated with an unanticipated absence, especially if you have employees or partners in your practice [2].

 

  1. Doctors of BC. Update on requirement for Contingency Planning. https://www.doctorsofbc.ca/news/update-requirement-contingency-planning, accessed August 9, 2022.
  2. Canadian Medical Protective Association (CMPA). Practically speaking: Contingency planning for the unplanned absence from Practice. https://podcasts.apple.com/ca/podcast/contingency-planning-for-unplanned-absence-from-practice/id1530251704?i=1000498420337, accessed August 9, 2022.

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