Redefining the Practice of Medicine

Euthanasia in Quebec

An Act Respecting End-of-Life Care (June, 2014)

Sean Murphy*

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Appendix "B": Disciplinary and Complaint Procedures

B1. Professional privileges

Application for and renewal of privileges

B1.1 Physicians or dentists must apply for privileges to practice or to renew their privileges with the executive director of an institution. If the council of physicians, dentists and pharmacists recommends the application, the director must submit the application to the board of directors.1 The board may grant privileges, but (except in emergencies, or to replace personnel) not without the approval of the regional health agency.2

B1.2 A resolution granting privileges to a physician or dentist must include, among other things, their undertaking " to fulfil the obligations attached to the enjoyment of the privileges."3 The physician or dentist must provide written proof that he has read the resolution.4

B1.3 Pharmacists must also apply to the executive director to practise of an institution, and a similar process is followed in processing the application.5

B1.4 Midwives must apply to boards of directors, which, upon the recommendation of the council of midwives,6 may contract with her for three years, the terms of the contract specifying her rights and obligations.7

B2. Refusal, suspension and revocation of privileges

B2.1 The board may refuse to grant privileges based on the needs of the institution, qualifications, scientific competence or conduct, and "fulfilment of the obligations attached to the enjoyment of the privileges granted."8

B2.2 In emergencies, professional privileges of physicians, dentists and pharmacists can be suspended for up to ten days pending a decision by the board of directors "by the director of professional services, the chairman of the council of physicians, dentists and pharmacists, the head of the clinical department concerned or, if these persons are absent or unable to act, or fail to act, the executive director."9 The same actions can by taken in urgent situations with respect to midwives by the midwifery services coordinator, chairs of the professional council having jurisdiction, or, in their absence or as a result of their failure to act, by the executive director.10

B2.3 Directors of nursing may limit or suspend a nurse's right to engage in some advanced practices; in urgent cases, if they fail to act, directors of professional services or clinical department heads may do so.11

B3. The complaints process

B3.1 Every regional health and social services agency and every institution must appoint a service quality and complaints commissioner to investigate complaints concerning health care delivery (See Appendix "A"). The regional complaints commissioner is responsible for responding to complaints about community organizations or private facilities or seniors' residences that are regulated by the regional agency or formally associated with it by accreditation or agreement.12 Local complaints commissioners must investigate complaints about the institutions for which they are responsible.

B3.2 Complaints commissioners may address complaints about administrative or organizational problems involving medical, dental or pharmaceutical services that do not result from the conduct of a physician, pharmacist, dentist or medical resident. Complaints about physicians, pharmacists, dentists or medical residents must be referred to the institutional Medical Examiner for investigation. The Medical Examiner also has sole jurisdiction over complaints involving the supervision or assessment of medical, dental or pharmaceutical acts.13

B3.3 Complaints at both levels can be dismissed by the Complaints Commissioners if they are "frivolous, vexatious or made in bad faith."14 On the other hand, neither regional nor local complaints commissioners need wait until they receive complaints before taking action. Both may commence investigations on their own initiative "when there are reasonable grounds to believe that the rights of a user or group of users are not being enforced."15

B3.4 Complaints Commissioners can access most documents and communications relevant to the subject of a complaint and require anyone involved to provide information or attend meetings.16 If they uncover apparent breaches of discipline by professionals or others, they report them to the highest responsible authority within the institution or organization in question.17 Those authorities are then responsible for investigating the alleged breach and must keep the complaints commissioners apprised of the progress and the outcome of their investigations, including any disciplinary measures taken. That information is, in turn, communicated to complainants by the complaints commissioners.18

B4. Medical Examiners' investigations

B4.1 A Medical Examiner who receives a complaint concerning a physician, dentist or pharmacist, or a medical resident may dismiss the complaint if satisfied that it is "frivolous, vexatious or made in bad faith."19 In other cases, the Examiner must

a) investigate the complaint himself20

b) refer the complaint to the institutional council of physicians, dentists and pharmacists, which must form a committee to investigate it,21

c) in the absence of a council of physicians, dentists and pharmacists, handle the complaint as directed by government regulations22

d) in cases involving a medical resident, refer the complaint to the authority designated by government regulation.23

B4.2 If a Medical Examiner begins an investigation, he may, at any point, decide that it should be referred as indicated in (b), (c) or (d) above.24 Investigations must be completed within 45 days.25

B5. Review Committees

B5.1 A review committee must be established for every local authority operating a local health and social services network (See Appendix A5) and may be established by a public institution. Review committees act as tribunals hearing appeals from the decisions of medical examiners concerning complaints that have not been referred for disciplinary investigation.26

B6. Council of Physicians, Dentists and Pharmacists investigations

B6.1 When a complaint is referred to the Council of Physicians, Dentists and Pharmacists by the Medical Examiner or Review Committee, the Council must form a committee to investigate the complaint in accordance with government regulations. If the committee concludes that discipline is warranted, it must communicate its opinion to the board of directors and other interested parties.27

B7. Disciplinary powers

B7.1 A board that receives a complaint against an employee who is a member of a professional order or against a midwife may, if the gravity of the complaint warrants, forward the complaint to the professional order.28

B7.2 In other cases, following procedures authorized by government regulation,29 boards of directors can discipline physicians and dentists for "lack of qualifications, scientific incompetence, negligence, misconduct" and "non-compliance with the by-laws of the institution."30 Discipline can take the form of reprimand, changes in status, withdrawal, suspension or restriction of privileges and compulsory refresher training. When disciplinary action is taken, the professional regulator must be notified.31

B7.3 Boards can use the same process to discipline pharmacists after seeking the opinion of the institutional council of physicians, dentists and pharmacists. Disciplinary measures may range from reprimand to dismissal, and, again, the professional regulator must be notified.32

B7.4 The board of directors may discipline midwives for "lack of qualifications, incompetence, negligence, misconduct, non-compliance with the regulations of the institution" or failure to meet contractual obligations. Discipline can include "reprimand, modification or withdrawal of one or more rights under the contract and cancellation of the contract." The disciplinary process is similar to that for pharmacists.33

B8. Immunity

B8.1 No legal proceedings may be brought against Complaints Commissioners and their assistants, Medical Examiners, Review Committees, Councils of Physicians, Dentists and Pharmacists (individually or corporately), or Boards of Directors (individually or corporately) for acts or omissions done in good faith in the exercise of their responsibilities.34

B8.2 Except with respect to a question of jurisdiction, courts may not issue injunctions against any of the entities or persons in B8.1,35 even "when the enactment upon which the proceedings have been based or the judgment rendered is null or of no effect"36 or "there has been a violation of the law or an abuse of authority amounting to fraud and of such a nature as to cause a flagrant injustice."37

B9. Health and Social Services Ombudsman

B9.1 People who are not satisfied with the handling of their complaints at the institutional or regional level may appeal to the Health and Social Services Ombudsman.38

B9.2 The Ombudsman may intervene on his own initiative if he "has reasonable grounds to believe that a natural person or a group of natural persons has been or may likely be wronged by an act or omission" of an institution or agency or their employees or resources. However, he may not assume any control over "the supervision or assessment of medical, dental or pharmaceutical acts."39

B9.3 The Ombudsman intervenes by bringing to the attention of the highest authority in the institution in question "the act or omission that is the subject of the intervention and the facts or reasons warranting the intervention" and recommendations. It is expected that the institution will collaborate in resolving the issue within 30 days.40

B9.4 If the Ombudsman is not satisfied with the response, he may make a written report to the government and may also report the case to the National Assembly.41

B10. Professional Orders

B10.1 The Professional Code requires each order to adopt a code of ethics by regulation42 and sets out the complaints and disciplinary procedures that are to be followed.43 Every professional order has a disciplinary council44 chaired by government appointee.45

B10.2 The board of directors of each order must appoint a "syndic" (the term used for an official investigator) and, if need be, assistant and corresponding syndics who will form the "office of the syndic" of the order.46 Syndics must lodge complaints of professional misconduct with the disciplinary committee if requested to do so by the board of directors, and may do so upon their own initiative. Any other person may also lodge a complaint.47

B10.3 Of particular interest, anyone who "knowingly helps or, by encouragement, advice or consent" leads a member to violate the order's code of ethics can be fined not less than $1,500.00 and not more than $20,000.00 for each day the violation continues. In the case of an incorporated entity, the minimum and maximum fines are $3,000.00 to $40,000.00 per day.48