I would like to take this opportunity to provide further insight into the regulatory rationale behind the proposed by-law amendments, to ensure feedback is as well informed and responsive as possible. Please be assured that ALL feedback will be reviewed by the relevant committee and discussed at Council. A reminder that feedback is due by August 30, 2019. The agenda for the September 13, 14, 2019 Council meeting will include a review of any committee recommendations.
I. Re: Draft Amendments to By-law 6: Election of Council Members
Under the Chiropractic Act, 1991, CCO has 9 elected Council members, and 6 or 7 public members. The 9 elected members are from different parts of the province, although three of those positions are in District 4, Toronto. The eligibility criteria to serve on CCO Council are set out in By-law 6.
Currently, employees, officers or directors of certain chiropractic organizations are not
eligible for CCO Council until 12 months have passed before the date of the election (a “cooling off period”). The currently listed organizations are: OCA, CCA, CCPA, AFC, CCEB, CSCE, and the CCEC of the FCC (acronyms defined in By-law 1: Definitions and Interpretations
). Currently, there is no “cooling off period” for administrators, officers and directors of CMCC and UQTR before being eligible for CCO Council and there are no restrictions on eligibility for other CMCC employees. Council has discussed the issue of eligibility for Council and the real or perceived conflicts of interest at various times over the past couple of years. CCO has received various feedback about eligibility to serve on CCO Council in response to other by-law circulations.
The proposed amendments would broaden the criteria for ineligibility to include employees of chiropractic educational institutions (including CMCC and UQTR), and former employees within the cooling off period, in the same manner as the other chiropractic organizations enumerated in the By-law. In recognition of the importance of having feedback from CMCC as the only accredited chiropractic educational institution in English Canada, a new advisory position would be created, whereby CCO could select from nominees provided by CMCC. This position would ensure that Council benefits from CMCC’s expertise and perspective during its deliberations. It would be up to Council to determine how best to utilize the expertise of an academic appointment/advisor for matters before Council. However, we note that this position should not have been described as an “ex officio” position in our consultation documents and proposed by-law language (as CCO cannot add to Council composition without amending the Chiropractic Act, 1991), but rather as a non-voting, advisory position.
The rationale behind the proposed amendment is to preserve Council’s access to the expertise brought by representatives of educational institutions, while avoiding any real or perceived conflict of interest occasioned by employees of educational institutions serving as voting members of Council.
As a reminder, CCO’s regulatory functions under the Regulated Health Professions Act, 1991, and the Chiropractic Act, 1991 include:
- establishing criteria and standards for admission to the profession;
- developing and administering the Legislation and Ethics Examination, which all applicants must successfully complete before being registered;
- developing and approving standards of practice, policies and guidelines to which the profession must conform;
- reviewing and making recommendations for any legislative changes including any changes to scope of practice;
- establishing continuing education requirements to ensure ongoing competency;
- administering a complaints and discipline process designed to ensure a thorough and fair investigation of any accusation of professional misconduct, consistent with the legislation;
- interpreting legislation, standards of practice, policies and guidelines approved by Council; and
- facilitating a review of and compliance with CCO’s mission, vision, values and strategic objectives.
Examples (not exhaustive) of how conflicts of interest can arise include:
- participating in a committee decision recommending continuing education (CE) when the provider of CE is likely to include CMCC;
- having CE provided personally by a Council member who is employed by CMCC;
- participating on a discipline panel in which an allegation of professional misconduct is related to a particular style of practice not taught or incorporated in the core curriculum at CMCC; and
- making policy recommendations as a member of the Registration Committee or Council that affect the educational requirements or competencies for examination/evaluation for applicants, especially where the Council member’s employer has publicly taken a position differentiating its approach to such programs and competencies from that of other accredited chiropractic educational programs in the world.
Some of these types of conflicts were criticized as unacceptable in the Professional Standards Authority Report entitled An Inquiry into the Performance of the College of Dental Surgeons of British Columbia and the Health Professions Act dated December 2018 by Harry Cayton.
Other Regulators Under the Regulated Health Professions Act, 1991 (RHPA)
Different regulators in Ontario have different mechanisms for ensuring input from educational institutions, and/or managing the possible conflict of interest issues which can arise where a member of Council’s duties to an educational institution may be perceived to influence his or her judgment in the matters under consideration by Council or its committees. For example, some regulators have designated Council positions for members of educational institutions, and others have restrictions on what issues Council members from educational institutions can vote on.
Chiropractic is somewhat unique in that there are only two approved educational institutions in Canada. However, our registrants include members from a wide variety of accredited educational institutions, including Anglo-European College, Barcelona College, Cleveland College, D’Youville College, Durban University of Technology, l’Institut Franco-Européen de Chiropraxie, Life Chiropractic College West, Life University, Logan University, MacQuarie University, Murdoch University, National University of Health Sciences, New York Chiropractic College, New Zealand College, Northwestern Health Sciences University, Palmer College of Chiropractic (Iowa, Florida and California), Parker University, Royal Melbourne Institute of Technology, Sherman College, Southern California University of Health Sciences, Texas Chiropractic College, Université du Québec à Trois-Rivières, University of Bridgeport and University of Western States. CCO registrants who successfully complete the requirements, including national competency examinations, are eligible for registration if they have graduated from any one of a number of accredited institutions, each of which may have a somewhat different view of chiropractic or what should be emphasized in the curriculum, but each of which has met accreditation standards. Approximately 30% of CCO registrants graduated from accredited schools other than CMCC.
A regulator in a somewhat analogous position to CCO is the College of Optometrists of Ontario, which also has two accredited schools in Canada. Members of the College of Optometrists also have the doctor title, and the controlled act of communicating a diagnosis. The College of Optometrists has a specific academic appointment to Council from one district, and in its by-laws, has the following provision:
College of Optometrists of Ontario By-laws
6.04 Eligibility for Election of Council Members for Districts 1 Through 5
(1) A Member shall be eligible for election to Council if:…
(iii) the Member is not a member of the Faculty of the University of Waterloo School of Optometry and Vision Science.
Further, the College of Massage Therapists of Ontario establishes an academic district and then includes as one of the eligibility requirements for non-academic districts the following:
Does not qualify to run for election as an academic Council member.
One option is for CCO to amend the by-laws to establish, like the College of Optometrists and the College of Massage Therapists, a specific electoral district for academic members and to disqualify school employees from running in other districts. In recommending the proposed amendment previously circulated, it was thought that the best approach for CCO at this time, in order to preserve the current electoral districts and to ensure that the diverse perspectives and approaches of the profession are represented, was to have an academic advisory position involving the participation of an employee of CCMC, rather than a specific voting, Council position. The extent of participation would be up to Council. A rationale for this change includes managing any real or perceived conflicts of interest. It is also a way of addressing what appears to be the adoption of advocacy positions, reflected for example in the News Release received by CCO on March 27, 2019 indicating CMCC’s agreement to be a signatory to the International Clinical and Professional Chiropractic Education Position Statement, which included a reference to overwhelming support (98%) from the faculty of CMCC of the content of the Position Statement. Issues such as an acceptable definition of subluxation, patient confidentiality, and advice to patients about the frequency of treatment are important regulatory discussions. Strongly held positions with apparent nearly universal support of its employees creates a unique situation for CCO, which is different from other RHPA colleges. Even without an actual conflict of interest, employees of CMCC who deal with complaints, discipline, registration, quality assurance, or who debate policy positions relating to advertising or statements made by chiropractors on such topics may have an appearance of bias.
I trust the information above will help facilitate further valuable input from stakeholders on By-law 6: Election of Council Members. Amendments to the by-laws can also help to ensure members facing complaints and discipline are judged by practising chiropractors amongst the professional panel members and ensures diversity (geographical, type of practice) on Council.
II. Draft Amendments to By-law 16: Professional Liability Insurance
The proposed amendment to By-law 16: Professional Liability Insurance increases the limits of the total protection provided from $1,000,000 per occurrence and $3,000,000 per year, to $5,000,000 per occurrence and $5,000,000 per year, which enhances public protection and is consistent with the increased limits available through the current carriers of insurance or membership in the CCPA. There is no intention to require members to only obtain insurance or protection from one provider. Currently, members comply with the provisions from a number of different carriers. The term protection would include both membership in a protective association and insurance coverage from an underwritten company.
Please note that all feedback to by-laws, standards and guidelines is carefully considered. I encourage all stakeholders including members to provide respectful, professional feedback through the lens of public interest protection by August 30, 2019, so the feedback can be carefully considered before recommendations are made to Council. These are challenging, difficult considerations and they require thoughtful discussion at Council, based on well informed stakeholder feedback. Thank you for your ongoing commitment and interest in CCO’s important mandate to regulate chiropractic in the public interest.
Dr. Dennis Mizel,