June
21, 2017
PUBLIC ACCOUNTS COMMITTEE
Pursuant to Standing Order 68, John Finn, MHA for Stephenville Port au Port,
substitutes for Scott Reid, MHA for St. Georges Humber.
The
Committee met at 9:15 a.m. in the House of Assembly Chamber.
CHAIR (Brazil):
(Inaudible) 48th session of
the House of Assembly's hearings. The hearing today is with Health and Community
Services.
I'll
introduce myself and then I'll ask Members of the Committee to introduce who
they are and the district they represent. Then I'll ask the witnesses and the
Auditor General's staff to introduce themselves. Then I'll ask the Deputy Clerk
if she'll do the swearing in of the witnesses.
So I'll
just introduce I'm David Brazil; I'm the Chair of the Public Accounts
Committee and I'm the Member for the District of Conception Bay East Bell
Island.
MR. BRAGG:
Derrick Bragg, I'm the
Vice-Chair of the Public Accounts Committee and MHA for Fogo Island Cape
Freels.
MS. P. PARSONS:
Pam Parsons, I'm the Member
for Harbour Grace Port de Grave District and a Member of the Public Accounts
Committee.
MR. KING:
I'm Neil King; I'm a Member of the Public Accounts Committee and the MHA for the
historic District of Bonavista.
MR. FINN:
Good morning, John Finn, MHA
for Stephenville Port au Port. I'm substituting for Scott Reid today.
MS. ROGERS:
Good morning, I'm Gerry
Rogers and I work for the good people of St. John's Centre, and I am a Member of
the Public Accounts Committee.
MR. PETTEN:
Barry Petten, MHA for
Conception Bay South and also a Member of the Public Accounts Committee.
CHAIR:
Okay, I can start here.
Michelle.
MS. JEWER:
Michelle Jewer, ADM, Corporate Services, Department of Health.
MR. ABBOTT:
John Abbott, Deputy Minister, Department of Health and Community Services.
MS. TUBRETT:
Denise Tubrett, Assistant Deputy Minister of Regional Services with the
Department of Health.
MS. WADDLETON:
Deena Waddleton, Health Consultant with the Department of Health.
MS. BATSTONE:
Angie Batstone, Director of Medical Services, Department of Health and Community
Services.
MR. PADDON:
Terry Paddon, Auditor General.
MS. RUSSELL:
Sandra Russell, Deputy Auditor General.
MS. KEATS:
Trena Keats, Audit Principal of Performance Audit.
CHAIR:
Okay, welcome to everybody.
I'm
going to ask Elizabeth now if she'll do the swearing in of the witnesses,
please.
Swearing of Witnesses
Ms.
Michelle Jewer
Mr.
John Abbott
Ms.
Denise Tubrett
Ms.
Deena Waddleton
Ms.
Angie Batstone
Mr.
Terry Paddon
Ms.
Sandra Russell
Ms.
Trena Keats
CHAIR:
Thank you, Elizabeth.
Just to
start off the process here, we're looking at the issue identified by the Auditor
General, particularly as it pertains to Health and Community services. In
principle, what we're doing here is really having six hearings in one day. It's
a fairly ambitious agenda. Some of it may be very easily answered and the
questions may be poignant and direct, then the answers are good.
We've
done it in a format where, from our assessment, we feel the first two or three
items may be easier to get through, and then the more contentious ones, or ones
that need more explanation, where there may be more questions asked, would take
a little bit longer.
So I do
ask that when you're asking a question if it's already been asked, fair enough,
if we can move for the expedient process; if you're answering a question, if you
could keep it to the point as much as possible for relevance purposes. Also,
with that being said, we're not going to confine anybody from not asking
questions if they have some issues of clarification they need, nor for the
witnesses having an opportunity to actually explain exactly what they're doing
to be proactive of this.
Periodically, maybe more often than not, we will be asking the Auditor General
for an opinion on certain things and for his and his staff's view on specific
issues that have been shared with us. It's an opportunity for us to ask
questions as a committee and for the line department and officials to explain
exactly how you're moving forward, your proactive approach to addressing the
issue outlined by the AG.
The
first process is that I turn it over to Mr. Abbott, as the deputy minister, to
have some introductory remarks.
MR. ABBOTT:
Thank you, Mr. Chair.
I
certainly appreciate this opportunity. Again, what we will be able to report I
think as a result of the Auditor General's report and our initial responses,
through the course of each one of these items, we will give you an update as to
where we are since June of 2015, as well as November 2016.
Needless to say, we've obviously taken each of the report items seriously. We're
working closely with our key stakeholders, and each of these pretty well has
been either the regional health authority or the private operators that they
oversee.
There's
been a lot of progress over the time since the reports have been issued, and
we'll be more than happy to speak to those as we go through.
CHAIR:
Okay, thank you; we welcome
that.
The
normal process that we're going to use today is that we'll give five minutes to
each of the speakers to ask their questions. You don't necessarily have to take
the whole five minutes. Some of them maybe easily answered if the question is
relevant to one or two particular issues and it's answered, then we can move on
to that. I'll start with Mr. Bragg and we will start with the first heading,
sorry, the Prescription Drug Program.
MR. BRAGG:
Thank you very much and
thank you, guys, for coming out this morning.
Actually, I won't be too long with you because I just reviewed, the last couple
of days, the report you guys gave us and the top two headings are the ones I
think we'll look for more of an update on, the progress of these. I may be wrong
in how I pronounce this; would it be the Medigent system, refill business? You
were saying anticipated in March you are going to have some action on that.
MR. ABBOTT:
Yes, that's the Medigent.
For the 10 recommendations that have been identified, I think it's fair to say
that of those 10, nine have been fully implemented and we can speak to those.
The one that you're referring to, Recommendation 1, is partially implemented.
I'll
ask Michelle Jewer to speak to the specifics, but we feel that we're not going
to be able to, I guess, concur with the Auditor General's recommendation really
because of technical issues with that applying the rules under Medigent to our
program.
Maybe
I'll get Michelle to speak to the specifics of that.
MS. JEWER: The
refill business rule that was referred to in the report, we did review that with
the vendor and it was determined there are limitations with the rule. There are
implications for pharmacies from an operational point of view. It would be a
delay in the pharmacies potentially, and that would mean beneficiaries would
have delay in getting their prescriptions. So that was one big one for us.
There were also issues with being able to track the
original prescription number because of change in processes. Right now,
pharmacists are able to extend prescriptions. So that would mean a prescription
refill might not get tracked the same way as if a physician would put a
prescription in the system.
There are certain limitations with it, that we decided that
business rule, we can't implement; but, what we are doing, we are doing
post-payment audit of refills. So that would check if there's misbilling for
refills. In addition, part of the recommendation was to look at other courses of
action in case this business rule didn't work.
So it's partially implemented because we are currently
working with the vendor to determine if there's another business rule that we
can put in place that could prevent misbilling of refills.
MR. BRAGG:
Okay, thank you.
I guess that's the same thing for the second part of that,
the second recommendation, is it, a similar answer?
MR. ABBOTT:
Well, the second one, in fact, has been fully implemented.
MR. BRAGG:
Okay. It says not implemented here when you guys gave it to us. It was to
reduce the risk of unauthorized claims and payments of inappropriate
professional fees
.
MR. ABBOTT:
Yes, okay.
So, again, Michelle Jewer will respond.
MS. JEWER: So
we're saying fully implemented for this one because the recommendation said:
The Department should determine whether modifications to the Medigent system
can reduce the risk of unauthorized claims and payment of inappropriate
professional fees for compounds and prescription splitting.
We have determined that rule put in Medigent will not
prevent inappropriate professional fees for prescription splitting or compounds.
And a reason for that is because the Canadian Pharmacy Association develops
claim standards to provide orderly and efficient online processing of
prescription claims. Part of those standards does not take into account
compounds, and the different ingredients for compounds. Because that isn't in
place, it's very difficult for us to put a rule in. So that's one reason.
Another thing, there is a FPT,
federal/provincial/territorial group, a director, a pharmacy director forum,
that has this issue on its agenda to look at the claim standards and revise it
for compounds. So that's one thing that's still in process.
Prescription splitting, again, is something that we can't track by a rule in
Medigent. Again, it's the quantities that cover products dispense must be in
accordance with prescription to maximize of 90 days' supply, and there are some
exceptions to that. So we can't put all the exceptions in as a rule, but what we
are doing to ensure that we are paying appropriate claims for compounds and
prescription splitting is we are doing a post-payment audit of those claims that
come in.
MR. BRAGG:
Okay, thank you.
I'm
good, Mr. Chair.
CHAIR:
Good there, okay.
Mr.
Petten, questions on this heading?
MR. PETTEN:
The questions that Derrick
had was pretty well all I had on that section. It appears everything else seems
to be implemented.
CHAIR:
Okay, perfect.
Ms.
Parsons.
MS. P. PARSONS:
I don't have anything on the
Prescription Drug Program.
CHAIR:
Okay.
Ms.
Rogers.
MS. ROGERS:
Thank you, and thank you so
very much for being with us here this morning.
When we
look at some of the findings of the Auditor General, it seems that perhaps it
indicates an audit sector that is somewhat overwhelmed when we look at the
finding that 58 per cent of the audits outstanding as of September 30, 2014 had
been in progress between three and eight years.
I'm
wondering if staffing is one of the issues in being able to do the work that's
required.
MR. ABBOTT:
Thank you, Ms. Rogers.
I guess
the simple answer probably is that was not sort of the issue, but what we have
done since this report is looked at our audit process and have revised it. I
think we are now starting to see and what, I guess, the Auditor General was
really looking at is that we have a much more effective audit program.
So what
we've been doing over the past year or so is really being more aggressive with
our existing staff complement; having more organized audit process for this.
Now, for instance, in the department we audit numerous programs MCP being the
largest.
MS. ROGERS:
Yes.
MR. ABBOTT:
So, in essence, we've taken
our lessons and best practices from how we do those audits and now applying that
to our pharmacy program.
We've
had to, under legislation, put the regulations in place, which we have now done.
So it was really a large process issue for us. As a result over the past year or
so, we have looked at quite a number of audits. Michelle Jewer can speak to the
specifics of those, if you wish.
MS. JEWER:
Prior to September 2016, we
didn't have regulations in place to be able to do audit of NLPDP, so that was
something that was put in place in September 2016. As well, there's a provider
guide for pharmacists that bill through NLPDP and there wasn't an audit section.
That's also in place as of September 2016. Since that date, we've been able to
more aggressively audit, as John has mentioned.
Since
September 2016, we have audited approximately 470 pharmacists or pharmacies,
about 3,500 original prescriptions and about 13,000 claims in to NLPDP.
MS. ROGERS:
Great. So staffing is not an
issue.
MS. JEWER:
No.
MS. ROGERS:
Okay. Thank you very much.
You've
also said that we now have can we have copies of the 2014-'15 and '15-'16
annual reports of the audit section? I think that those were mentioned in the
MS. JEWER:
Yes, we can provide those.
MS. ROGERS:
Okay, great. Thank you very
much.
The
department said that a policy in the form of an audit section for the NLPDP
provider guide has been prepared. Could we have a copy of that document?
MS. JEWER:
Yes.
MS. ROGERS:
Okay, great, thank you very
much.
There
was some talk of problem pharmacies. What would constitute, for instance, a
problem pharmacy and how would you define that?
MR. ABBOTT:
Do you want a go with that?
MS. JEWER:
I can try.
I think
it would be hard to answer that question as a problem pharmacy
MS. ROGERS:
Okay.
MS. JEWER:
There are a number of
different reasons why we find misbilling or incorrect billing, and it could be
simply a training issue. I would think the majority of them would be that.
We have
identified for example, compounds is an area that's complicated
MS. ROGERS:
Yes.
MS. JEWER:
So we've identified that as an area we would audit. Refills, again, it's
probably a difficult, complicated area. We would audit that.
There
are some areas within that pharmacists can bill NLPDP for certain, we call,
expanded pharmacy services, something like medication review, antibiotic
adherence. Those programs would probably be things that we would audit because
they're new, to ensure that they're being billed correctly.
MS. ROGERS:
Okay.
MR. ABBOTT:
If I may, Ms. Rogers, now
that we have the pharmacy network in place for all pharmacies, we'll have a lot
better information looking at utilization and then how that lines up with
claims. So we can be more proactive in looking at problem issues or problem
pharmacies, for that matter.
MS. ROGERS:
Great.
Also,
since the implementation or the discontinuation of the over-the-counter drug
program, I'm just wondering, is there any intent to track or audit any of the
rollout and effects of that? For instance, will we see a spike in prescription
drugs instead of the non-prescription drugs because the over the counter have
been discontinued? Is there any plan to look at that in your audit process, kind
of tracking some of the potential changes?
MR. ABBOTT:
It wouldn't come up in the
audit process, but I understand your question. That's why I say the Pharmacy
Network now will allow us then to start looking at all prescriptions and then
looking at trends so we can look at that because of this action, what has
happened on the other side of things. That's something we'll be monitoring
closely.
MS. ROGERS:
Great.
MR. ABBOTT:
We have been looking at the
impact on clients because there are exceptions as well. We've monitored that.
There have been few. So, again, we think the policy decision was the right one
for a number of reasons, but we are monitoring the take-up.
MS. ROGERS:
Okay.
CHAIR:
Ms. Rogers, I'm going to go
to Mr. King.
MS. ROGERS:
Thank you.
CHAIR:
We'll come back again as we
go through our process.
Mr.
King.
MR. KING:
Thank you for the detailed
package that you gave us. It's quite in depth. I've read through it several
times.
This
one I'm quite happy with. We got the update on the two outstanding items and
I've got nothing to add on this one.
Thank
you.
CHAIR:
Mr. Petten, any further
follow-up questions?
MR. PETTEN:
No.
CHAIR:
Mr. Finn?
MR. FINN:
I'm fine. Thank you very
much.
CHAIR:
Okay.
I'll go
back to Ms. Rogers.
MS. ROGERS:
Yeah, I just have one more
question.
It came
to my attention that someone had a prescription for one medication and it was, I
think something like it had to be 175 milligrams. The pharmacy then had to
break it up into three pills for the one prescription: 100 milligrams, 50
milligrams and 25 milligrams. The person was charged for three dispensing fees.
Is that something that you track? Is that unusual?
MR. ABBOTT:
I wouldn't say it's unusual,
but it will happen.
MS. ROGERS:
Yes.
MR. ABBOTT:
We monitor that and if that
is onerous to the client, then we can address that. But it's done based on
depending on how the prescription is written and in the judgment of the
pharmacist how that should in fact be put in the hands of the patient.
MS. ROGERS:
Right.
MR. ABBOTT:
That's monitored fairly
closely. I mean we will have some discussions with and, again, sometimes with
the claims that had come in, they're the kinds of things we will be looking for
to make sure that it's done appropriately.
MS. ROGERS:
Okay, thank you very much.
MR. ABBOTT:
Thank you.
CHAIR:
I'll just intercede on one
and just ask the Auditor General if he has any opinion or concern. Or does he
feel this moves forward on addressing particularly the recommendations that he
made?
MR. PADDON:
Thank you, Mr. Chair.
From
our perspective, just an overall comment on our audit of the Prescription Drug
Program; we thought the report actually was quite positive in terms of what we
had found. Some of the issues were you wouldn't call them major in the grand
scheme of things.
When I
look at the particular item that the deputy talked about that is not likely to
be implemented, I think you'll find that we framed the recommendation fairly
specifically to allow them some discretion as to how they deal with it. We knew
that there might be some issues in terms of being able to implement that, so we
framed it the department should consider, those sorts of things.
I think
based on what we've seen, subject to follow up in a couple of years, or years
from now, I think we're fairly satisfied with what we see in terms of the
implementation.
CHAIR:
Thank you, Sir.
Okay,
with that being said, if there are no further questions on that heading we'll
move into Salaried Physicians and go through the same process.
Mr.
Bragg, the opportunity to ask the first questions, please.
MR. BRAGG:
Okay, Sir. Thank you very
much.
In your
report back to us you said: The Department of Health and Community Services
should consider development of province-wide performance appraisal
. That was
the recommendation, to have province-wide appraisal standards.
You
said that you were going to have standardized position description templates.
Where does this stand right now?
MR. ABBOTT:
Just bear with me for a
second.
In
terms of this particular report item, I just wanted to let you know, just as an
initial comment, of the eight recommendations that either the department or the
RHAs were responsible for implementing, we have fully implemented two of those
and five have been partially implemented.
In
terms of your question around the standards, that's one that has been partially
implemented. We have a committee established to work between the department and
the regional health authorities. What we want to do is standardize what
performance standards are put in place and that we, in fact, monitor those.
What
we've done up to now is left that to each of the RHAs to do that, and we are
realizing it isn't really working. The Auditor General has obviously identified
that. It's taking more time than we would like, but we have had a lot of
discussions over the past while. Angie Batstone can speak to some of the
specifics, but we are aiming for this fall to have this recommendation fully
implemented because we certainly agree with it, and because we think it will
benefit not only the department and the health authorities, but the physicians
themselves.
Right
now there are a lot of different rules being applied, different expectations of
what is expected of the physician working in a community or in a hospital
setting and we want to make sure whatever we have in Eastern Health, applies to
Western, Central and in Labrador.
MR. BRAGG:
Okay, because in Central, I
represent an area with two cottage hospitals and I know their challenge of
finding doctors.
MR. ABBOTT:
Yeah.
MR. BRAGG:
So would this help the
process? Because the old saying out there amongst the nurses is: We have the
doctors until we get them trained and then we move them somewhere else. That's
been said for years. I'm sure you've heard it, right?
MR. ABBOTT:
Yeah.
I don't
think this recommendation in itself is going to change that. It will help so you
know the rules of engagement when you come to a community. I think you're asking
a much larger issue. We are and right across this country struggling in
terms of getting physicians to come to rural communities.
In
terms of the department's approach here is that we are working with each of the
health authorities and the communities to look at what is a better response for
the long term, which is certainly developing primary health care teams, so that
a physician works with a nurse, nurse practitioners, and we're seeing some, I
going to say, early success, but actually Newfoundland is sort of behind the
eight ball when it comes to this. We're working quite aggressively now with each
of the health authorities to really push hard on primary health care teams and
services throughout.
So
whether it's Botwood, Corner Brook, down the Burin Peninsula, up in Bonavista,
we're seeing some early successes. So Fogo and that area actually has been well
served over time, and we want to build on that and really shore up those
services so that when a physician is interested, he or she can say, look,
actually there is some support there. They're not solo practitioners because
that sort of form of practice is really now nobody coming out of med school is
interested in really doing that, and we recognize that.
MR. BRAGG:
Okay, thank you.
I know
there are numerous questions, so I'm going to let everybody have a chance at
this one. I'm going to pass it on to the next person, Mr. Chair.
CHAIR:
Okay, thank you.
Mr.
Petten.
MR. PETTEN:
Thank you very much.
Only a
couple of questions; in your second one on my spreadsheet here actually it
referenced a lot of the department's updates. You have a steering committee in
place. Who will be part of that steering committee to oversee these
recommendations?
MR. ABBOTT:
Angie Batstone is chairing,
so I'm going to get Angie, if you wouldn't mind, respond.
MS. BATSTONE:
No problem.
The
committee is comprised of myself, the director of Medical Services, being the
chair. One of my consultants, Dan Fitzgerald, is on the committee, and we have
the director of Medical Services for each of the RHAs.
MR. PETTEN:
Okay.
MS. BATSTONE:
And actually Lab-Grenfell,
the representative is actually the VP of Medicine that's one difference Dr.
Gabe Woollam.
MR. PETTEN:
Okay.
I see
here, I guess the steering committee is going to perform regular performance
evaluations; it's going to be overseen by the steering committee. A lot of times
we see committees in government and it's a pretty common thing, what powers will
this committee have to oversee because this is a fairly substantial issue when
you look at not only the public domain with salaried physicians to the general
public
MS. BATSTONE:
Yes.
MR. PETTEN:
What powers or what will the steering committee be able to do in the event of
I know you're going to monitor, but what powers would it be in the event that
you see discrepancies or what have you? How will that be addressed?
MR. ABBOTT:
When the committee gets its
work done in terms of getting the standards in place then, in essence, in one
sense, the large part of their work gets done. Now, they will be monitoring on a
regular basis, but they will then be reporting up to myself as deputy minister;
and if there are issues, then I will engage which health authority or which CEO
to make sure there is full compliance. We'll be reporting out publicly.
Obviously, at the end of the day, the minister will be accountable for ensuring
compliance right across the system.
In one
sense, this shouldn't be as large an issue as it is because it's really a
process of how we use standardized recruiting and hiring physicians and laying
out basically their job description and what we expect of them. What has
happened over time, each RHA has going off to do their own thing, dealing with
their own and they've been scrambling trying to get physicians in place whenever
they can get them. What we've seen obviously over time is that's really not
working.
We are
the paymaster at the end of the day, so all the information has to come in to
the department for what we actually pay. So, at the end of the day, we do sort
of exert control to make sure we get full compliance; i.e., if there isn't
compliance, then we have an issue or a choice as to what we do in terms of
payment.
So
really, at the end of the day, the department has to ensure that this is put in
place. Again, the Auditor General has pointed out a weakness in our system that,
in fact, we fully support needs to be done.
MR. PETTEN:
So I guess when you tie
Memorial University with the regional health authorities, they will have to work
collaboratively to ensure that the value for money is being attained.
MR. ABBOTT:
Yeah. The university one is a little bit more complicated on the basis of how
they hire, why they hire and the relationship with not only their clinical
practice, which we're paying for, but also then their teaching time, which the
university pays for.
So we
have to merge basically two of our systems to ensure while that physician is
recruited that the payments, both for his or her clinical time, is what we're
responsible for, is fully identified and measured; and then likewise at the
university for their administrative and teaching time, is appropriated accounted
for.
As you
can appreciate, we have two sorts of payment systems going on; we now have to
make sure they're fully integrated.
MR. PETTEN:
So there will be like a
value for money from both ?
MR. ABBOTT:
Well, I don't know
MR. PETTEN:
Because it is the public
purse, right?
MR. ABBOTT:
Oh, yes. Well, the value is in terms of obviously the clinical time, what hours
we're paying for and that we get true value for that, and obviously for their
teaching and administrative time and that's what's the university or Eastern
Health would be responsible for.
So, as
I said, we have a couple of parties involved here and we're talking roughly 95
to 100 positions at the university. We're fortunate because we're able to
attract the physician because it's a teaching hospital, but part of that them is
having sort of two contracts that we have to administer.
CHAIR:
Mr. Petten, I'm going to go
to Ms. Parsons.
Mr.
Parsons.
MS. P. PARSONS:
The regional health
authorities, in Recommendations, should conduct performance appraisals in
according with their internal policies. And of course in your response in
January 2017: Performance appraisals of salaried physicians have been ongoing
since the Auditor General's report.
Can you
provide some progress on that?
MR. ABBOTT:
Well, we have made sure that
one has been fully implemented. The RHAs have reported now to us that in fact
they have put those in place for each of their physicians. The process around
that, they've put in some reporting templates. So we're quite satisfied that
they've achieved what the Auditor General has set out for them.
MS. P. PARSONS:
Thank you.
CHAIR:
You're good?
MS. P. PARSONS:
Yes.
Thank
you.
CHAIR:
Okay, Ms. Rogers.
MS. ROGERS:
Thank you.
When we
look at some of the issues that the Auditor General did raise, for instance,
there were no procedures for basic policies such as detailed workload
requirements for salaried physicians; they identified a need for an
accountability system to track the level of service provided by salaried
physicians; the department and RHAs not following their own
Salaried Physicians Quick Reference
Guidelines when hiring; no formal evaluation of hiring of physicians
provided to the department from RHAs or MUN and no effective assessment of
performance.
The
department is saying that we're working on that. That's a lot of work and some
of it very complex, I imagine.
MR. ABBOTT:
Yes.
MS. ROGERS:
For this not to have been
done over a period of time, I come back to that issue. Is this a staffing issue?
When we see that we've seen 96 managers laid off recently, how will all this be
accomplished? Is there a staffing issue here?
MR. ABBOTT:
Again, I'll have to say no.
Really what this demonstrates is I mean it's a basic human resource management
issue.
MS. ROGERS:
Yes.
MR. ABBOTT:
Over time or since time,
take your choice here we put physicians over here and everybody else over here
in terms of their practices.
What
we're doing now is bringing the physician community in to standardized,
well-accepted human resource practices. That's all we're doing. In essence,
we're bringing in 375 physicians into our larger management practices.
It's
been identified and supported by the managers within the system. The Auditor
General pointed out, yeah, you need to finally get on with it. We have committed
then to putting in processes and procedures to get that done. The committee that
we've established is doing that and they're focused on it. We will either have
these recommendations completed this fall, some of them; the others will be into
the winter.
So I
assume the next time we report on this we will be fully compliant. We've been
talking how we do that, obviously, with existing resources. Yes, all the
departments obviously have seen a reduction in their management and other
staffing levels, but we've been able to streamline some of our processes to make
sure we get this done.
MS. ROGERS:
Do you anticipate that there
will be any problem because of staffing levels?
MR. ABBOTT:
No, not related to this.
MS. ROGERS:
Okay.
The AG
identified twenty before I get on to that; John, how do we do in relation to
other jurisdictions, other provinces in this area?
MR. ABBOTT:
I would say it's variable
right across the country now. We have a high percentage of salaried physicians
more so than other jurisdictions, and because our physicians have been really
though, specialists are included in this relying on that for international
medical graduates and what have you, have come through salaried. Because they've
been sort of outside the mainstream, we just haven't focused on it to the degree
we need to.
Saskatchewan would be
probably somewhat similar in some of their challenges because they have a lot of
international medical graduates in their system, probably even more than we do.
MS. ROGERS:
If we see more of a movement
towards integrated primary health care facilities, will that mean more salaried
physicians?
MR. ABBOTT:
The trend is in that
direction.
MS. ROGERS:
Yes.
MR. ABBOTT:
So absolutely, yes.
MS. ROGERS:
Okay. So then we really have
to get on top of this.
MR. ABBOTT:
Yes.
MS. ROGERS:
Yes. Great.
The Auditor General also
identified 22 physicians in fact, it was approximately half of the 45 doctors
that the Auditor General examined working without an employment contract. How
does that happen? I'm curious. It seems to be quite, I would think, a major
issue.
MR. ABBOTT:
Yes.
MS. ROGERS:
Are there any legal
ramifications or implications for the RHAs or for the department having doctors
who don't have a signed employment contract?
MR. ABBOTT:
Well, again, the fact they
didn't have them speaks to poor human resource management practices as it
applies to that particular group of employees, because they are employees in
essence.
MS. ROGERS:
Yes.
MR. ABBOTT:
But, again, we've had them
on a separate track than all other employees. So now we'll bring them in, and
that's certainly been put in place.
In terms of the liabilities,
well, only when they run into a problem.
MS. ROGERS:
Yes.
MR. ABBOTT:
Then who can sue whom, as it were, without a contract.
Yeah, I
think the health authorities and government in essence, their liability
increases as a result.
MS. ROGERS:
Do we currently have now any
doctors working without an employment contract?
MR. ABBOTT:
Well, I would like to say absolutely not, but I don't know that I can say that
with 100 per cent certainty. They are to have them in place. That's part of the
committee's work now is to make sure we have a reporting system to ensure that
is the case.
MS. ROGERS:
So you don't have any idea
of how many there may be currently without a contract?
MR. ABBOTT:
No, I don't know. Angie, any sense ?
MS. BATSTONE:
No. Like John said, that's part of the work of the committee, is not only those
22 that were found not to have contracts, that in fact there are contracts
drafted. On a go forward, everyone that's hired has to have a contract signed.
MS. ROGERS:
Do we still have 22 without
contracts?
MS. BATSTONE:
They've been working on that, so I don't have the exact number right now.
MS. ROGERS:
Do you have a ballpark
figure?
MS. BATSTONE:
No, I'd have to go back to the regions for that.
MS. ROGERS:
Could we get that
information?
MS. BATSTONE:
Sure.
MS. ROGERS:
I think that would be good
to have.
MS. BATSTONE:
Yeah, no problem.
CHAIR:
Ms. Rogers, I'm going to go
to Mr. King there now and come back.
MS. ROGERS:
Okay.
CHAIR:
Mr. King.
MR. KING:
Thank you.
I can
certainly speak to the success of primary health care teams. We've had those
established, I think, in Bonavista for a better part of a year and a half now.
It seems to take wait times down. It's been successful, so I just want to
congratulate you guys on that.
One of
my first meetings I had was with David Diamond on that issue because we lost
four doctors in the span of two months, I think, in 2015.
Getting
back to this, your steering committee is set up. Is it just for salaried
physicians or are you looking okay, you're looking at just for this individual
topic.
MR. ABBOTT:
Yeah.
MR. KING:
Going back to bullet point
2, I think, it's: RHAs will be required to manage attendance productivity to
ensure value for money.
What
ramifications are in place, or you're going to put in place, if there are
attendance productivity issues?
MR. ABBOTT:
Well, the role then of the vice president of medical services in each of the
RHAs is really to hold each of those physicians accountable for basically what
they have signed on for. Part of this review will so we will have a contract
definitely in place, we will have performance standards in place, how many
patients we expected to see, et cetera, those kinds of things. If that physician
is not producing, then it's the VP's job to have that conversation and make
sure the work gets done.
MR. KING:
Okay.
MR. ABBOTT:
If it's not, and if there is not compliance, then there's a choice of: All
right, we'll work with the physician to improve or we would have to move to
terminate if that's not the case. Again, it's a new way of doing business.
It's
generally accepted right throughout the health system that we have these
performance standards in place for all staff. Now we're just applying it to this
particular group of providers. We're working with the LMNA and others as well.
So everybody is onside. It's just a matter of now really getting this work done.
MR. KING:
Going back, and I know this
is relatively new, you guys got the audit report back in, I think, November. So
it seems like you've been working pretty hard to get everything up to standard
based on the recommendations, but looking back here in the point, you're
currently reviewing the benefit of re-establishing the salaried physician
approval committee. Why was that dissolved in the first place, and why are we
looking at going back to that?
MR. ABBOTT:
I think it just flittered away. We've had a number of discussions over the
winter sort of bemoaning that that in fact this happened, because some of the
problems we see now are a result of that.
Now,
that being said, we tried to in terms of the health authorities give them as
much responsibility and flexibility to meet their staffing needs; but, in this
case, because we control the funding at the department, we sort of dropped the
ball over time and we realize that that's something we have to reclaim
responsibility for. Because we now, if we're again, moving in towards family
health care teams, we want to ensure the physicians that are coming in meet the
needs for that community or for that region.
It's
not one of, because there happens to be a vacancy that day or that week. We
really now want to make sure we've got the right mix of physicians in the right
communities, using Bonavista as an example. So when we go out to recruit in the
future, we want somebody that in fact now will meet the needs for that community
that can work in a team setting, et cetera.
So the
rules of engagement are starting to change and we want to take more of a direct
hand in what is happening, but working obviously with the RHAs.
MR. KING:
I note the Kaizen method was used for the Bonavista Peninsula Health Care.
MR. ABBOTT:
Yes.
MR. KING:
Are you looking at using
that in other areas in the province?
MR. ABBOTT:
Absolutely, and it's because of what we've learned in Bonavista. We're now down
on the Burin Peninsula, sort of taking what we learned there, modifying it for
the Burin Peninsula area. We were out in Botwood; we were out in Corner Brook,
out in Grand Falls, Gander, right around the province.
MR. KING:
Thank you very much.
CHAIR:
Mr. Petten, any further
questions?
MR. PETTEN:
(Inaudible) I want to go
back the main thing that stands out to me with these salaried physicians is
the fact that they're working in MUN, they're teaching academically at MUN,
they're also in the hospital as salaried physicians. How do you determine a work
week? Something that I've always questioned is what's the work week for salaried
physician to be able to hold down two of those duties and to do merit, to do
justice to both of those what is a work week for a salaried physician?
MR. ABBOTT:
Well, again, I will say they
are paid based on a five-day work week, for the typical case. They will then
divide their time and that's negotiated between their clinical practice. So the
time they will be in practice and dealing with patients and their administrative
time, and then their teaching time, all that is documented.
We will
have cases where we will move some of their clinical time into teaching time and
vice versa so that each one of that gets negotiated. Those discussions generally
take place between Eastern Health and the dean with the School of Medicine and
they work that out for each physician. Then we meet our obligations as a result
of those contracts that they enter into.
MR. PETTEN:
So there's not like a clear
guideline. There's no real, you can look straight at it and find out what your
requirements are?
MR. ABBOTT:
As I said, it's going to
vary by each physician. So if you take a psychiatrist who may come in, he or she
is going to be seeing patients, so they'll allocate so much clinical time during
the week and, in that, he or she will see so many patients. We're not involved
to that degree, at this point, as to how many patients they will see, then it
will be their teaching time, which they negotiate with the dean of medicine, and
then they're given some administrative time as well to manage their office.
MR. PETTEN:
There are cases where and
the Auditor General pointed out they were overpaid based on their salary
package by upwards of 14 per cent, I know one case I was reading there.
MR. ABBOTT:
Yes. We are looking at that
and part of that is how their employer costs are attributed, depending on again
when they were initially hired to where they are now, the salary increases have
changed, how those things should be calculated. Again, those contracts were not
structured, in our view, appropriately so we have now to go back and work with
the physicians, and in consultation with the NLMA and the health authorities, to
basically rewrite some of those contracts.
MR. PETTEN:
Right. So I guess in a
nutshell, to sum it up, there should be a top-level salary cut off for any of
those salaried physicians or whatever their profession. If they reach that by
just in the hospital, we'll say, or in a combination of that and academic,
shouldn't that be the cut off? Would there be some guidelines put in place to be
able to monitor it that way? Wouldn't that be the most simplistic?
MR. ABBOTT:
If I understand your question, the clinical time is funded in one way. Their
teaching time would be funded separately and then combined. Then their employer
costs may be on top of that.
They're
indifferent arrangements at the university. Some have shared salary with their
colleagues and how that gets done. So it is a very complicated bit of business
at the university, because we are bringing all those payments together under one
contract. It's not typical in, really, any other profession that I know of that
you would do it this way but it works for us. It's just that we haven't managed
it as well as we should.
MR. PETTEN:
Thank you.
CHAIR:
Mr. Finn, any questions?
MR. FINN:
Thank you, Mr. Chair, and
thanks, folks, for being here this morning.
I'm
just kind of flicking through some of it and, as I mentioned early on, I'm
substituting today for Mr. Reid on short notice. But just having gone through
some of this just this morning, I can certainly appreciate and understand the
challenges from the Department of Health and Community Services, some 40 per
cent of our provincial budget being accounted for and I guess the complexities
with respect to three different health authorities, in particular, and every
health authority operates a little bit different.
Mr.
Abbott, you made a statement in the beginning there around just HR; you said,
essentially, they were all physicians being here and everybody else was here.
MR. ABBOTT:
Yeah.
MR. FINN:
And that's kind of like, I
guess, just a philosophical look at that's the big statement on the problem
essentially, and each health authority then operating a little bit differently
in terms of the practices.
MR. ABBOTT:
Yes.
MR. FINN:
Some of the documentation
there reflecting performance appraisals, some being done in Western are going to
be this number is lower than what was being done in Lab-Grenfell. So I guess you
guys have the task of pinning it down to the RHA level and finding the problem
there.
MR. ABBOTT:
Yes, right down to the individual level, yes.
MR. FINN:
Right.
With
respect to some of the appraisals and the workload requirements that aren't
detailed, I'm wondering, I'm just musing, if I'm a health authority and we have
the ability to hire a new physician, they must just be excited. Yay, we have a
new physician. So they don't jump into some to the nuances. Is that kind of
?
MR. ABBOTT:
I think you're
MR. FINN:
Do you know what I mean?
MR. ABBOTT:
That's, I think, part of
this
MR. FINN:
Yeah.
MR. ABBOTT:
is that they spend a lot of time on recruiting, somebody does say I'm
interested and then it's sort of like, all right, don't forget that you have
these processes that you need to follow. A lot of times the paperwork just is
pushed aside; it doesn't get done.
MR. FINN:
Okay.
MR. ABBOTT:
As I said, part of this is
how it is managed within the health authority. The approvals are usually done
through the VP of medicine and then the CEO. A lot of times the human resource
department would not even be directly involved. They may process payments at the
end of the day, kind of thing, but aren't, as I said, bringing in their
practices to say where's the contract; where are the terms and conditions of
employment; where are the standards, what have you, that they would have for all
their other employees, but not for these.
MR. FINN:
Sure.
MR. ABBOTT:
But the way you described it
is exactly how it sort of plays out in real time and we have those
conversations. I get a call: We've been fortunate, we've got a specialist that
we've been looking for now for two years, but can we sort of break some rules
here to get the individual in place?
MR. FINN:
Get him started, yeah.
MR. ABBOTT:
We'll have a discussion as
to what the rules are, but we are insisting on documentation, we are insisting
that we have a discussion and that we apply the existing policies and payments
for any new salaried physicians, whether it's a GP or a specialist. If there are
exceptions, then they would have to come into the department and be approved by
the minister.
MR. FINN:
Right, yeah. That's kind of
what I was musing, right?
MR. ABBOTT:
Yeah.
MR. FINN:
The approval process, to
question the fact that we're approving the hiring of a doctor, I mean, my God,
if there's a doctor that wants to come, let's open our arms. I can understand
some of the work there, so that's kind of what I was musing at.
MR. ABBOTT:
Yeah.
MR. FINN:
One other small question,
and I don't know if it's directly stated there, but with respect to we have
salaried physicians and we have fee for service as well. Some are availing of
both in that regard. Is there
?
MR. ABBOTT:
I'm not sure if I
understand.
MR. FINN:
Salaried physician at the
hospital and also does fee for service in clinic as well.
MR. ABBOTT:
Again, there are different
payment plans and maybe this is what you're getting at. There are payment plans
where in fact they will pool, for instance, their fees and then they will so
that's a group. At the university that happens quite often where a group will
pool their fees and then they will draw a salary from that. But that's
different from, dare I say, the salaried physicians.
Then we
have approved payment plans in place, which is sort of negotiated and it's
similar to a salaried physician construct, but in fact, again, they're a fee for
service. So, basically, it's a blend there.
MR. FINN:
Sure, okay.
MR. ABBOTT:
There's a certainty of payment in place. So we would have Angie, correct me if
I'm wrong here.
MR. FINN:
Like a hybrid model.
MR. ABBOTT:
In some cases where we have specialists, but the volume of work wouldn't allow
them a reasonable salary. So some of our pediatric surgeons, for instance, the
work they would do and on and on. So we will come up with a payment plan for
them to meet their a salary requirement based on their profession, but it's
built off a fee schedule.
MR. FINN:
Okay.
MR. ABBOTT:
Yes, so there are a lot of nuances throughout that.
MR. FINN:
Sure.
CHAIR:
Okay. I'm going to go to Ms.
Rogers now.
Ms.
Rogers.
MS. ROGERS:
Thank you very much.
In your
report, you were saying that performance appraisals of salaried physicians have
been ongoing since the AG report. How is that going?
MR. ABBOTT:
As I said, they put them in place. Some were doing them anyway and they had the
mechanisms to do it.
In a
lot of the medical staff bylaws for Eastern Health authorities, they would be
doing that or a version of it in any event for their fee for service. Now they
would bring that same process into the salaried. It should have been happening
and it wasn't, but there hasn't been any resistance to doing this. I think, as a
matter of fact, it's been encouraged. We meet regularly with the vice-president
for medical services for each of the health authorities. They are really pivotal
to making sure this gets done because they oversee that process in each of their
authorities.
MS. ROGERS:
If you can help me
understand a little bit, John. So a performance appraisal for a fee for service,
is that just around billing?
MR. ABBOTT:
No, no. It would be around what patients you are seeing, what your
MS. ROGERS:
Outcomes.
MR. ABBOTT:
Ideally outcomes; but, to be honest, it wouldn't be getting there at this stage.
That's somewhere, obviously, we would like to for all our physicians.
It
would be looking at attendance in clinic, how you're utilizing resources of that
health authority, those kinds of things, and I guess any complaints that might
come in from patients and how they get addressed.
MS. ROGERS:
So who would do this, and
how would it be done? Is there a standardized process across the province, or
?
MR. ABBOTT:
As I said, in the medical
staff bylaws you will see the processes and we would make sure that they would
be following that, but it is. Basically, at the end of the day, it is the VP of
medicine, or his or her designate, who would sit down with the physician, at
least on an annual basis ideally you would do it more than that to review
their performance. There would be a standardized performance appraisal document
that you would use.
MS. ROGERS:
Okay.
I know
you cannot reveal or release specific appraisals about specific doctors that
have been done, but can we have some information vis-ΰ-vis how many have been
done since the Auditor General's report, how many should have been done and how
many you've been able to accomplish.
MR. ABBOTT:
Sure.
MS. ROGERS:
And then also, are you
seeing any trends at all? Again, I appreciate that personal information cannot
be released, but really what are you finding in these appraisals?
MR. ABBOTT:
Fair enough. Yeah, I
understand your question. We'll follow up on that.
MS. ROGERS:
Okay, great.
Thank
you.
I also
have just a few other questions. The Department of Health and Community
Services, Regional Health Authorities and Memorial University of Newfoundland
should develop an accountability system to track the level of service provided
by salaried physicians.
We see
that we have the provincial steering committee. When did the steering committee
start meeting? What has been accomplished so far? Who is the steering committee
reporting to? Is there a reporting mechanism? Are there written reports from the
steering committee meetings or minutes? How is that going?
MS. BATSTONE:
We started work on the
steering committee and I'm new to the position as well. We started work in
February with respect to our terms of reference, our mandate, et cetera. We had
a meeting set for May which had to be cancelled, so we met early June. But this
group of directors I meet with outside of this steering committee as well. So
we've been having ongoing conversations since the report came out.
The
steering committee ultimately reports to the deputy. We do keep notes of the
meeting, high-level minutes of the meetings and action items.
MS. ROGERS:
The steering committee has
only met once then, has it?
MS. BATSTONE:
Met formally once, yes.
MS. ROGERS:
And that was this month?
MS. BATSTONE:
Yes, early I forget the
exact date.
MS. ROGERS:
Okay. This is based on a
report from November '16, the Auditor General's, so here we are. Okay. This
steering committee has really just been pulled together.
MS. BATSTONE:
Just met formally, but
multiple conversations since I would say February, since I came into this.
MS. ROGERS:
Yeah, so the whole steering
committee having a meeting conversation together?
MS. BATSTONE:
Having a conversation, yes;
informal conversations, because I connect with the directors of medical services
in the regions on a regular basis.
MS. ROGERS:
Okay.
So that
would be individual ones, not as a committee.
MS. BATSTONE:
Sometimes a conference call
if there are a number of issues, and this may have been discussed at some of
those meetings.
MS. ROGERS:
Okay.
MS. BATSTONE:
Sometimes we'd be pulled
together as a group to discuss whatever the issues of the day are.
MS. ROGERS:
Okay.
How
often do you anticipate this committee meeting?
MS. BATSTONE:
We committed to meeting
monthly. That's what in our terms of reference.
MS. ROGERS:
Okay, and you're hoping to
be able to complete the work that you need to do by this coming January?
MS. BATSTONE:
January or winter, we're
yeah.
MS. ROGERS:
Oh boy, that could be a long
time with our weather.
MS. BATSTONE:
That's true. If it was
summer it would be short, yes.
MS. ROGERS:
It would bring you right
into May and June, who knows.
Okay,
thank you very much.
MS. BATSTONE:
You're welcome.
MS. ROGERS:
The GFT physicians
CHAIR:
Ms. Rogers, do you have many
left on that?
MS. ROGERS:
No, I don't.
CHAIR:
Okay.
So I'll
let you complete that and then see if there are any other (inaudible).
MS. ROGERS:
Okay, great.
MUN and
the department indicated that GFT physicians receive additional remuneration
because of the work they do, both clinical and academic. I think Barry was
getting at a little bit of this. So the GFTs have higher expectations for job
performance and output I understand this to be very complex, I really do and
are therefore required to work in excess of hours specified in their job
descriptions; however, our testing found that GFTs were not required,
contractually, to work longer than full-time clinical physicians.
You may
have addressed that in various questions. Do you anticipate a change in that?
MR. ABBOTT:
I'm not expecting there will
be much change because each one of these sort of gets negotiated on a
case-by-case basis. What we want to ensure is there is a template that each is
used that we accept, and then there is a contract in place and that all parties
abide by that.
What
happens from time to time, despite having some of this in place, other
arrangements are getting made that we at the department are not aware of.
Eastern Health may not be aware of what Memorial is doing. Memorial may not be
aware of what Eastern Health is doing. So part of this exercise here will be to
ensure that this should not happen going forward.
MS. ROGERS:
Right, but we may still be
in the same position that, contractually, GFTs will not be expected to work
longer than full-time clinical physicians.
MR. ABBOTT:
But at the end of the day,
Ms. Rogers, whatever is in that contract is what we have to hold them and all
parties
MS. ROGERS:
Yes, I understand that.
MR. ABBOTT:
And that hasn't been documented appropriately in all cases.
MS. ROGERS:
So you're looking for
something that's more of a uniform expectation rather than ?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, great.
And
then back to the 14 per cent for the salary in lieu of benefits for the GFTs.
MR. ABBOTT:
Yeah.
MS. ROGERS:
So we see in the Auditor
General's report that 14 per cent is paid although those benefits are provided
through the MUN contract. Is there an intention to address that?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay. What is that
intention?
MR. ABBOTT:
We've done some work on that. We've done some calculations. We now have to
engage the university and, most likely, NLMA, but we will be going forward to
amend those contracts for those payments on a go-forward basis.
MS. ROGERS:
Okay. I understand the
complexities of attracting physicians for different speciality areas, different
parts of the province and I understand, yes, the complexities and challenges
there.
Thank
you for answering all these questions.
MR. ABBOTT:
Thank you.
CHAIR:
Mr. Bragg.
MR. BRAGG:
I have one more question.
If you
have fee-for-service and salaried doctors in the same clinic, is there a
standard where the salaried physician would be expected to see a certain number
of patients, or would it be a case where the fee for service takes everything
away from the salaried person?
MR. ABBOTT:
Well, it can work some days and it could be a challenge another. Really, what
we're getting at, whatever arrangement we have with the salaried physician would
be through their contract and their performance standards that we'll put in
place, the expectation of how many patients they will see, whether it will be a
day, a week, a month, whatever makes sense.
We have
no control around the fee for service, how many he or she sees. If they are
seeing appropriately and bill appropriately, that's really the extent of the
discussion there. So at times, and it may not be in the same clinic, but they
may be in different parts of the community, where that sometimes works as a bit
of an issue.
Some of
what you will hear, but there is no particular evidence to support either side
of this, some will say that salaried physicians aren't as productive as fee for
service, and some will argue that fee for service are over-seeing patients
because of the way that payments system works.
Now, we
don't have any evidence that says one is better than another. Our job is to make
sure that all patients get seen when they need to be seen. We have to make sure
we have the physicians, nurse practitioners and others in place to meet that
demand.
At the
end of the day, we will move dollars from one budget to another to meet where
people are. As I said earlier, we are seeing a trend that newer physicians are
more comfortable to meet what they want out of life and moving towards some
salary or equivalent type of payment. So they want certainty and they want to be
able to practise their full scope. But we have a generation of fee for service
that they're happy with that and we will continue to continue with that system.
MR. BRAGG:
Thank you.
It
actually answered the second question I had, so thank you.
CHAIR:
Mr. Petten, further
questions?
MR. PETTEN:
No, I'm good on that topic.
Thanks.
CHAIR:
Ms. Parsons.
Ms.
Rogers.
MS. ROGERS:
I'm fine. Thank you very
much.
CHAIR:
Mr. King.
Mr.
Finn.
MR. FINN:
That's what I was referring
to with the fee for service that I had brought up and the salary at the same
time. I can understand the pros and cons matrix of either getting paid by the
hour or getting paid by task done in said hour. That's the challenge, I guess,
there.
MR. ABBOTT:
Yes. Again, the issue is
played right out across the country. There's no right answer.
MR. FINN:
Yeah, exactly.
CHAIR:
Thank you.
I would
ask the Auditor General again if there are any comments he'd like to make.
MR. PADDON:
No, Mr. Chair.
CHAIR:
(Inaudible) from the
responses.
MR. PADDON:
No, I'm happy. I don't think
there's anything I need to add at this point in time.
CHAIR:
Okay, perfect. Thank you.
I think
if everybody is good with it, we'll take a 10-minute break. You can stretch our
legs and that, if you need to make a call or go to the washroom. We'll come back
here let's say a 13-minute break at 10:35 a.m., please.
Recess
CHAIR:
We'll start now, and I'll
start with Mr. Bragg. You can start with any questions you may have or, as you
noted, an observation.
MR. BRAGG:
Okay, thank you very much.
On the
nutrition of long-term care facilities, I guess I have a broad question. I know
the AG came in and they had four objectives in mind. Since the AG came in, how
much has nutrition improved; and two-part question if I visit any long-term
care home tomorrow, would I be able to view my grandmother's or my mother's file
on the type of food they're eating?
MR. ABBOTT:
Good question.
Just,
if I may, as a start, of the 10 recommendations that were in the report, two
were obviously specific to our department and our mandate, and then eight were
specific to the regional health authorities. I just want to let you know where
we are of the two recommendations that are specific to us, and then I'll get to
your question.
One has
been partially implemented, related to the operational standards review I'll
speak to that in a minute and one has not been implemented yet to date, and
that's in terms of the performance indicator benchmarks.
For the
RHAs, five have been fully implemented, and three partially implemented by
Eastern Health; and for Western Health, seven have been fully implemented, and
one partially implemented.
In
terms of your question on has nutrition improved. I can't answer that, to be
honest. What we're looking at is the processes around to ensure that the quality
that is expected is there. So that's as far as I think I can go on that. Now,
Deena Waddleton can speak to some more specifics.
In
terms of looking at what a resident would be, in terms of the menu, then within
this review, we looked at that. I think where the health authorities are,
they're certainly prepared to put up the daily and weekly menus, but not the
longer term menus that were suggested.
So yes, you should be able to as a family member going in
and one, you should see what obviously is on the menu. You can
obviously encourage and question as well, as many of us have done in that
situation.
The department is, again, working closely with the health authorities and Deena
Waddleton is leading some of the work here on the department with the health
authorities. Again, we have a committee in place that is actively working on
finalizing and upgrading the standards. Then we're also developing a monitoring
framework so that, ideally, I should be able to answer that question better the
next time around.
MR. BRAGG:
Okay.
I guess the other thing I would ask is if they're looking for a hot meal, would
they expect it to be hot and a cool meal to be cool, at the end of the day?
MR. ABBOTT:
Yes.
MR. BRAGG:
I have some experience I never worked there, but my wife is a manager into a
facility out in Central. I know there have been some great changes, and I think
this might have come up a couple of years ago over the can of spaghetti, I
think, was the issue.
You may have someone in the facility where that is what they want every day of
the week, so how do you sort of deviate from that if that's what someone wants.
MR. ABBOTT:
Yes.
MR. BRAGG:
Okay, thank you very much.
CHAIR:
Mr. Petten.
MR. PETTEN:
Thank you, Mr. Chair.
I have a couple of questions and mine are probably under general form as well.
Nutrition in long-term care facilities, a lot of people are kind of familiar
with it, especially if you had a loved one that had spent any time in one of
those facilities.
The question that comes out to me and it's from a personal perspective I
experienced it over a number of years. My mother-in-law passed away with
dementia. My wife went every day for 2½ years, I never ate supper with her
because she went over and fed her mom and several other residents their supper
or their lunch, mostly supper.
I still know people that go back and forth to our long-term care facilities and
I'd like to be able to say that things have improved but, unfortunately, that
still exists not maybe across the board everywhere. There are certain areas
I'm sure that's fine, but that is still a real problem. Whether it's staffing
levels; is it the most vocal family that gets the most attention. Then that all
ties to the quality of the food.
So I know that it's good that the AG has brought this up because that jumped out
at me on a personal level when I saw it. I was glad to see it was addressed. I
don't know how far along, how much improvements we've actually made to make that
better because I do know staffing is still a problem when it comes to that sort
of thing. You have meal times and certain ones are independent. There are a lot
of them that are not independent. You get in line and there are only so many
hands to go around and some take longer to eat.
Derrick
just pointed out the hot meal being hot and the cold mean being cold. It's a
question, and I don't know if you can add anything to that to explain it, to
address what improvements have been done?
MR. ABBOTT:
Mr. Petten, how we would
look at that and answer the question is that we have obviously ongoing
conversations with the health authorities, particularly around this area in
terms of the long-term care facilities looking at all aspects the nursing
care, which oversees this area as well. We have the dieticians, we have the
nurses, we have the LPNs and the other attendants that are there.
We have
not had any representation to the department that I'm aware of, certainly since
I've been there in the past year, around staffing levels and around meal times,
but I understand what you're saying because I've observed it.
The
conversations we then have with the managers around long-term care is that in
terms of how they manage their staff and staffing levels, do they have the right
positions in place. We are funding them to ensure that they have the staffing
levels. We have not touched those budgets at all.
It
boils down to how those facilities are managed. So we think by going back to the
standards that we expect and putting in the monitoring framework and the
benchmarks that we will be in a better position to identify where the weaknesses
are and if staffing turns out to be a weakness through that, then we'll have no
choice really other than to support a budget increase to allow that to happen
all things being equal.
Again,
this is an issue that takes place at least three times a day, 365 days a year in
each home. We need to ensure that the administrators are staffing and supporting
that daily activity. There is no really strong reason why they can't and
shouldn't be doing that.
Again,
the Auditor General has pointed out a weakness there and I think the
professionals involved here, the dieticians and the nursing staff, have to make
sure and be held accountable to ensure that the service is delivered as
expected. In my view, there is no reason why that isn't the case.
Now, it
may and I've seen it myself. If there was a family member in, so they can
and that's a positive thing. Obviously, if you're calling on volunteers in the
community that needs to happen, but, at the end of the day, the administrators
need to make sure the meals are served hot when they're supposed to be hot, cold
when they're supposed to be cold, in the time frames that have been set for that
facility.
One of
the things we are hearing more of, which is how to support individuals who want
to have their meals at different times, in their rooms as opposed to the dining
room, things like that, and their choice. So there's a bit of a balancing act
there as well, but the administrators are handling that quite well we think.
As the
residents are going in now, they are more informed. They're stronger advocates,
either themselves or their families. So we are seeing sort of a change happening
in the delivery of that aspect of nursing care. We think with the work we're
doing now, that we should see improvement in the process, as I said. The
nutritional side of this will always be challenged as to sort of resident
choice, but in terms of the quality of their food and how it is prepared, those
standards will have to be followed and we'll be certainly monitoring those very
closely.
CHAIR:
I'll go with Ms. Parsons.
MS. P. PARSONS:
Thank you very much.
Yes, I
want to elaborate as well on nutrition, because obviously when we're talking
about long-term care facilities nutrition is the main topic of priority.
I want
to reflect back on a conversation I had with a professional living in my
District of Harbour Grace Port de Grave who is working at the long-term care
facility in Carbonear. The new implemented facility which replaced the Harbour
Lodge and, again, this is a concern with food temperature. She used a
hard-boiled egg as an example, and she expressed her displeasure, of course,
with the quality or lack of. Her words and I quote: When those eggs come and
they're to be served to our residents you can literally take them like balls and
bounce them. That's a main concern of course. Nutrition keeps coming up a lot. I
wanted to elaborate on that.
Based
on the review here in Nutrition in Long-term Care Facilities for 2015, it
states: The Eastern RHA and Western RHA should provide meals to residents in
accordance with their prescribed meal plans and at the appropriate temperature.
Of course this, again, relates back to the hard-boiled egg story.
MR. ABBOTT:
Yes.
MS. P. PARSONS:
In response in January 2017,
I see here working groups reviewing policies and establishing audit processes,
exploring medical directive for diet orders and finalize policy by June 2017.
From what I understand, this was to be finalized by June '17. So can you
elaborate on that?
MR. ABBOTT:
Okay, and maybe I'll ask Deena.
MS. WADDLETON:
In terms of the audit process question that related to that, Eastern and Western
have implemented audit processing around food temperature, in one case. The
policies that you're referencing, we're meeting actually in a week or so to
approve those, finally. There's a couple that need final approval and will be
implemented provincially. So that is on track.
Those
policies will really outline what the RHAs need to do. They are already doing,
in practise, some of this work around auditing, but it will clearly define what
they all need to do. That will include also Lab-Grenfell and Central Health,
because it's a provincial working group that we have. Then we will be as John
mentioned earlier establishing a monitoring framework, and they will have to
report to the department on the outcome of their audits. So that will help
address some of that.
MS. P. PARSONS:
Okay, thank you.
Also,
on another topic here, and it's mentioned by my colleagues, how essential and
paramount it is that we follow the Canada Food Guide and that we have a
registered dietitian, of course, to monitor regularly these menus. You
mentioned, as well, dialogue, even with residents to inform them about
nutrition. I can't emphasize enough how important this is. I guess it's more a
comment than a question.
That's
all from me now. Thank you.
MR. ABBOTT:
With that, about what the AG said and your comments, I think the role of the
dietitian has to be given higher recognition in each of our health authorities.
We had some internal discussions as to some thoughts on how that needs to work
better.
Though
I will say, just as my personal comment, in relation to one that you made, is
that if there's anybody working in the system manager or whatever and the
example you use, we definitely encourage, and I say the onus on them is to bring
that issue that's really a complaint, and that needs to be brought forward to
the administrator and needs to be addressed because that should not be
happening.
We have
systems in place and that's a brand-new facility. There should be no reason why
something like that is happening more than the one occasion. Because once it's
identified, then it obviously needs to be addressed.
MS. P. PARSONS:
How was the flow of
communication with, say, front-line staff, such as professionals who are
first-hand caring for residents, to take these concerns, I guess, to the
appropriate positions?
MR. ABBOTT:
Yes.
MS. P. PARSONS:
How is that dialogue? I
mean, I can't emphasis enough how important it is to have a free dialogue, to
eliminate any fear of being punished or for bringing complaints forward because
it's all about communication. Again, this is the quality of life of our seniors.
MR. ABBOTT:
Yes. Again, we would, based
on our encourage that, I mean it is front line. They have their supervisors
and there's that process for those that are unionized, and there's also that
process to bring to their shop steward because it's a quality issue. We're all
responsible.
MS. P. PARSONS:
Yes.
MR. ABBOTT:
We now have patient safety
legislation, which these kinds of issues now will be picked up as well. We will
have more obligations on each of our health authorities to identify and report
true incidents, and our nursing homes will be captured by that legislation.
MS. P. PARSONS:
Thank you.
CHAIR:
Okay, thank you.
Ms.
Rogers.
MS. ROGERS:
Thank you very much.
Again,
this is such a complex issue in terms of the whole issue of care for seniors. We
know the research that has been done shows that the majority of seniors want to
age and stay in place at home, and many of them, that's not possible because we
don't have a fully, publicly administered and delivered home care program. So,
consequently, many seniors have no choice but to go into a long-term care. We
all know that, and we all know how tough that is. We also know for some seniors
perhaps that's the best solution.
We're
also dealing then with seniors who are far, far away from family and community.
So, even the issue of family helping with nutrition is not a possibility because
some people are so far away from their families and their communities, even
volunteers don't really quite address this issue.
We know
how important nutrition is, not only for the physical health of a person but the
psychosocial health of a person as well. We have such a high rate of depression
among our seniors in long-term care facilities, and that too needs to be
addressed. When we think of depression, that also really affects appetite. So we
have a real complex problem here.
I would
hope that we would be able to be because of our small population which
provides extreme complications, but also provides opportunities. Why in God's
name can't we be a centre of excellence in how we take care of seniors who have
built this province?
We also
know that so many of our seniors live in poverty, particularly women. We have
the highest percentage of seniors living on GIS and OAS, and a lot of women who
were of that generation didn't have paid work outside the home. So they're very
vulnerable, we all know that. They're extremely vulnerable.
I'm
wondering, when the Auditor General found a number of RHAs that were examined
did not even follow the Canada's Food Guide, how can we explain that? When we
spend so much money in health around prevention and encouraging people to eat
properly for health benefits, for prevention, yet we're not providing that in
our institutions where we have complete control. Is there any explanation as to
how that could possibly be?
MR. ABBOTT:
Ms. Rogers, in terms of what
the Auditor General has pointed out, I think part of this is, as I said, the
role of the registered dietitian in the planning and I think we may need to make
sure his or her role is given more prominence in the planning. So it isn't based
on what's in the shall we say, what's in the cupboard, what's in the freezer,
what the budget says we can or cannot do.
We
believe they should be following much closer the Canada's Food guidelines, no
doubt about that, but the dietitians, that's their job and their professions
their own right. They have to insist on making sure the menus and the food
preparation is complaint. So we have to encourage that.
I think
what has happened again, over time with the best intentions, is people have
deviated for their own particular reasons within any one facility. As a
department, we have not gone back to make sure they are meeting those guidelines
and any other criteria. So as part of this obviously, the Auditor General has
pointed out a significant weakness in our role in monitoring through reviewing
the standard and then particularly developing this monitoring framework, that
now we will because part of that framework will talk about adherence to the
guidelines. Now we can follow up where they've been deficient and to understand
why. Then, obviously, change that behaviour.
MS. ROGERS:
Are we ensuring there's
enough money allocated to our long-term care facilities for proper food and
nutrition?
MR. ABBOTT:
Again, as mentioned earlier, we don't think that's an issue at all. We're
roughly spending $10,000 per bed, per month, for the facilities. That's just the
large number.
If you
look at what we are spending per resident, it's roughly $16,000 a year when it
comes to the overall budget per person for food. So there's sufficient funding
in the system. Again, nobody has come to us to say because of budgetary
considerations that we haven't had the right food, the right amount of food or
ability to serve it appropriately.
So,
again, it speaks to how we're managing within each of those homes. Some are
doing it, obviously, better than others. We want those that are doing it best to
help those who are struggling.
MS. ROGERS:
And how are we going to make
sure that happens? I think, you know, to say it's up to an individual dietitian
MR. ABBOTT:
Yeah, but as I say, we're ceased on this, through this monitoring framework,
that we now have a tool to go back in, in a more objective way, to find out what
in fact is happening. We can then obviously be more proactive.
MS. ROGERS:
Is the food in all of our
long-term care facilities we have how many, I forget now?
MR. ABBOTT:
41.
MS. ROGERS:
In how many of those is the
food prepared on site?
MR. ABBOTT:
Now, I don't know if I know the answer to that one.
MS. WADDLETON:
It would be most. We have a philosophy that long-term care homes are home.
MS. ROGERS:
Yes.
MS. WADDLETON:
And food is prepared on site.
MS. ROGERS:
Yes.
MS. WADDLETON:
There could be a couple of facilities that are very close, if not attached, to
an acute care centre where food would be prepared there.
MS. ROGERS:
Understood, yeah.
MS. WADDLETON:
But in most cases, and certainly in our stand-alone facilities, food is served
on site; prepared on site.
MS. ROGERS:
Okay.
CHAIR:
Ms. Rogers, I'm going to
move to Mr. King.
MS. ROGERS:
Okay.
MR. KING:
Just going back to a
statement Mr. Petten put, and we can all certainly relate to having family
members in long-term care homes. I go back to 2002, when my grandfather was in
Golden Heights Manor in Bonavista. If we didn't have the family support there
then, I don't know if he would have eaten or not. He was at that point where he
needed an assessment.
You go
to point number 8, the first point on the second page there: The Eastern
Regional Health Authority and Western should ensure residents are appropriately
supervised during meals in accordance with the Operational Standard for Long
Term Care Facilities in Newfoundland and Labrador and applicable RHA policies.
So
getting back to that, where are we? I know you discussed it a little bit, but 15
years on from that it's shocking to see we still have that issue.
MR. ABBOTT:
I guess I would have to
agree in terms of your assessment, but the onus is on the administrator and the
nursing staff to oversee each of those dining rooms, and they are staffed to do
that.
MR. KING:
Yes.
MR. ABBOTT:
So if they're not doing it,
that's an issue.
MR. KING:
And this goes back to
actually patients that can't get out to the dining rooms and in their rooms
themselves.
MR. ABBOTT:
Yes.
MR. KING:
You have the tray put there,
they did their job to that point and the tray doesn't get opened up until 7
o'clock in the evening when a family member or someone comes in, if at all.
MR. ABBOTT:
Yes. Again, part of their
role in their job is to manage that.
MR. KING:
Yes.
MR. ABBOTT:
As I said, they're doing
this 365 days, full-time. So they have to and can figure out some process
changes to support that. In some cases it is going to be a little bit of
creative thinking on their part as to how to manage that, but then they have to
call in other resources if they need it. We will, as a department, obviously
support that. We're not getting any pressure on the department from the RHAs to
say they can't meet that requirement. Again, it boils down to the administrator
managing that operation each and every day based on these standards.
So what
we will be looking at now, much closer, is to say definitively what the
expectation is and then reporting back against that, and where we are seeing
that is not happening, then, obviously, we'll be having conversations with the
CEO to make sure those issues are addressed.
MR. KING:
Okay, thank you.
Getting
back to point number one; The Department should conduct a formal review of the
Operational Standards for Long Term Care Facilities in Newfoundland and Labrador
as required. The response to this was: Working group with regional
representation has been established.
So my
first question: Who is on that working group and how did the meeting go, if it
did go, for March 21 and 22?
MR. ABBOTT:
Okay, I'll ask Deena.
MS. WADDLETON:
I'm on that committee as a
representative of the department, and there are also the four regional long-term
care directors, as well as an additional person from Eastern Health who is a
manager for long-term care and who's also a dietician.
What
we've been doing, we did hold that meeting in March where we established a plan
to have these standards reviewed and revised by the end of this fall. Each of
the people on that committee are taking a number of standards and are working on
those, bringing it back to the larger group for feedback and revision and then
to finalize the policy. So we, I think, are on track to have that completed by
the end of June sorry, end of fall, not June. That's only next week.
MR. KING:
You're pretty much on track
with the summer of 2017 into that.
Just
one more question with my time I guess, and I might have a couple after. The
department and the RHA should establish benchmarks for performance indicators;
review them on their actual financial statistical data, including performance
indictors against these benchmarks that follow up on significant variance.
The
question I have with that: What determines the benchmarks being developed and
how often will follow-up take place to establish the variances?
MR. ABBOTT:
(Inaudible) we will be
looking across the food service industry as to what are the best practices for
that. We'll look at what's happening across the country and then we'll determine
that in consultation with each of the health authorities.
Once we
have those in place, then we will start collecting the data from each of the
health authorities that report in for each of their own. Our intent is that
information would be made public for each of those facilities so if it is
families, anybody else, can then have a good sense of how that particular
nursing home is complying and operating their food services.
MR. KING:
Thank you.
CHAIR:
Good? Okay, Mr. Petten, any
further questions?
MR. PETTEN:
I just have a couple of
short ones here. Just to go back to the quality of food and the staffing and
back to one of my original questions. Ms. Rogers, you referred to a couple of
questions she asked, that you will have a mechanism, your tools in place to
review this.
Basically, in a nutshell, what quality assurance measures, checks and balances
because right now it's separate; there are two different silos. So they're given
a budget and the staffing to do these things. Who is going in to make sure that
it's actually being done to the expected level of quality and care?
MR. ABBOTT:
We haven't gotten to that
stage where we would sort of send in an auditor or an inspector to do that. We
are going to be reliant on each of the health authorities to self-report and
then we will deal with that, which is common in our health system in any event.
As I
said, we want to try and we are trying, through the patient safety legislation,
an overall reporting so when there are critical incidents, if there was an issue
in the dining room, if there was a resident who because of food had some
reaction or what have you that then will get captured and reported out
provincially.
So I
think we've upped the standard and expectation right across the system. But they
will be dependent, largely, on self-reporting, and against the monitoring
framework we'll have in place, then we will issue reports on each facility.
MR. PETTEN:
So in the event of a family
member had concerns they'd report it to the manager, or the ?
MR. ABBOTT:
Yes.
MR. PETTEN:
It's incumbent on the
manager, obviously, to address that concern or push it further. That's the
concern I have sometimes. I don't know how far up the line the concern is.
Sometimes you're given an answer, oh, it's being addressed. I guess it all
depends on individual families sometimes. Some of them just take it in their own
hands and deal with. They have so many other the stress on them in general.
Again,
it comes back to the quality assurance piece and the checks and balances. I
think that is an important feature that should be, for all our long-term care
facilities, to make sure that we have consistent care across the board for the
most vulnerable, some of the most vulnerable people in our society.
MR. ABBOTT:
I would certainly agree and we, with our CEOs right throughout our Health and
Community Services system, more or less are taking a similar approach. If there
are issues of quality, each of the health authorities has a quality department
that oversees each of their operations, including the nursing homes, including
their food service. So we're reliant on them doing their work.
In the
issues where there are complaints or concerns, each of the health authorities
has their own process as to how they receive those complaints and process that.
We're actually looking at that as a department, because we want to make sure
that is done appropriately and that the complaints aren't just pushed aside.
That if there is a formal complaint, then there is a formal response, and the
complainant, shall we say a family member, can then, if not satisfied, elevate
that concern up the line. Obviously, as far as the minister's office, if need
be, and we do that on a regular basis. But that's sort of where we are.
Our
expectation is that once we get the monitoring framework in place, we'll have
much better information, and the system will know and those that are delivering
the food service know that there is actually a concern and a responsibility by
the department to actually report out. I think that will help address, not
necessarily all the issues, but most of the ones that are there today.
MR. PETTEN:
Okay, thank you.
CHAIR:
Mr. Finn.
MR. FINN:
Yes, thank you, Mr. Chair.
Just
short notice filling in here myself; I'm just having a quick flick through and
it certainly looks like there's been some great work Western Health identified
and, on the back, within a year, most of these things have been implemented, so
it's certainly kudos there.
Just in
terms of the compliance of the Operational Standards, two things sticking our
here with me, and it could just be timing. I know the dietitians quite well in
the Western region and I know some travel constraints when you're going from
Lark Harbour to Bay St. George and then across to Burgeo
MR. ABBOTT:
Yeah.
MR. FINN:
and some of the time
constraints there, but two things stated here with respect to just timing. The
regional health authority policy requires an interdisciplinary conference be
held with a resident within 10 weeks; however, the Standards state eight weeks.
So standards being different from what the RHA is saying there.
MR. ABBOTT:
Yes.
MR. FINN:
And then further with
respect to complaints: The management requires then five days; however, the
Standards require two days. So those are just very small compliance issues but
I'm just curious, I guess it's highlighted here as something you've been working
towards in indicating the meeting did occur.
MR. ABBOTT:
Yeah.
MR. FINN:
I guess some of those have
trickled down probably already I'm assuming with small
MR. ABBOTT:
But you do point to an issue not only in how nursing homes deliver this service,
that's sort of a consistent kind of theme throughout a lot of the other services
that we're sort of funding. And under Dr. Haggie, the minister, what we are
attempting to do here with all our services is to define a provincial standard
to which then all health authorities must comply.
If they
have a policy and it's different from the now new norm, new provincial, then
they have to now follow the provincial standard. So we are going to try to apply
that right across the board, whether it's mental health, food services, what
have you.
So
there's an example here, once we finalize these standards, then each of the
health authorities, their policies have to comply with ours. They'll have some
deviations on some small points but not on the significant ones. If it's a
committee and that has to meet or report, then they will be consistent across
the province.
MR. FINN:
Right. So bringing each
health authority in line with a provincial standard is the ultimate goal.
MR. ABBOTT:
Yes.
MR. FINN:
Fair enough, that's fine.
Thank
you.
CHAIR:
Ms. Rogers.
MS. ROGERS:
Thank you very much.
We've
heard a lot here today about sort of anecdotal evidence and people's own
personal experience with seniors in their families, and I think we all hear it
too as MHAs, and all of us, across the province, we hear the stories of people
where the trays are put in front of them, their loved one, and if it wasn't for
family members or volunteers, somebody wouldn't eat.
MR. ABBOTT:
Yes.
MS. ROGERS:
The other thing that we hear
is people praise the staff in our long-term care facilities. Staff who are
attentive, staff who really care. Oftentimes, they are taking care of people
that they've known in their community. So I believe it's not simply a situation
where staff have to buck up and work harder. There seems to be a systemic
problem here and I am just wondering what's going to be done about it.
We hear
from family members that they see that the staff is working so hard, yet trays
are left in front of people, not because staff aren't working hard enough, not
because staff don't care. And people are not able to feed themselves or eat.
Perhaps there is a resource issue here.
MR. ABBOTT:
I would answer this a couple
of ways. One, the onus is on the administrator and those supervising that floor,
that dining room, that day, to make sure that every resident is fed and trays
are not left in front of a resident. That should not happen.
Now if,
at the end of the day, the result is we do not have sufficient staff, then we
will address that as a department. That is not coming forward to us.
MS. ROGERS:
Okay. So they have to
advocate for more resources then if that the case.
MR. ABBOTT:
If that's the issue.
Secondly, what we want to do here is make sure we get the evidence so that it is
documented and we'll deal with that.
Third,
if there are complaints and observations and that is happening I'm not going
to argue it doesn't happen then they have to be brought forward and we address
that. So part of this monitoring framework will be how many trays have been
left, because that information is recorded in each of the facilities. So it
would suggest to me if you know that today, how are you addressing it today?
MS. ROGERS:
Yes.
MR. ABBOTT:
So we will be and are using
that data now to go back and inquire as to how they're addressing it and then,
as I said, if there is a complaint by a family member or other, then we will
record that and then address that with the CEO and their staff as to say, look,
this is happening; why.
As I
said, all things being equal, if it's a resource issue then we have to address
that. No different than if it's an emergency room, surgery we wouldn't and
shouldn't be making any difference or distinction between the demand for service
and our ability to respond. But that is not what we are being presented with.
MS. ROGERS:
We're hearing from family
members about if there's a shortage of staff, if the night staff know that
there's going to be a shortage, someone is calling in sick for the next morning,
that's there's going to be a shortage of staff in the morning, residents who are
taken out of bed really early, between 4 and 5 in the morning because they need
to be dressed and washed because there's a shortage of staff in the morning.
So it
seems to me that a lot of the complaints that we do hear, whether they're
formally registered, really are about staffing and resources.
MR. ABBOTT:
Yes.
MS. ROGERS:
The other thing I wonder I
appreciate the issue that if people need to complain is there any proactive
measure to survey residents, survey family members about satisfaction with
nutrition, that more proactive approach?
MR. ABBOTT:
Yes, the health authorities and the individual facilities do these surveys. The
interesting thing, and that's why most of those are responses. The survey
responses, to your point earlier, they rate the service, the staff and the
accommodation, quite favourably.
MS. ROGERS:
Yes.
MR. ABBOTT:
Are we talking about 1 per
cent, 5 per cent where we need to make a difference and that's really what,
through this process, we will be able to focus because if it's the quality of
the food in facility A, then we obviously have a conversation about that; is it
left trays in facility B, then we deal with that.
MS. ROGERS:
Okay.
I'm
also curious because the Auditor General, in his report, also looks at the
social needs of residents around nutrition and I would say also the psychosocial
needs. What measures are being taken by the department to ensure that a person's
dietary needs are met? For instance, religious beliefs, kosher, halal;
Indigenous people who have been raised on country food; Asian food; folks who
are vegetarian or vegan how is that being handled or is there a plan to
address that? I believe with the current aging population that those issues may
be arising more.
MR. ABBOTT:
I would agree with you in that as our society changes that's definitely the
case. Again, we leave it to facility to identify and work with the resident and
the family as to meeting those needs, and that's where the dietician would
certainly come into play to work with the kitchen to make sure the appropriate
meals are put in place.
We
haven't, at the department, taken any particular policy direction on that,
obviously, because we support that. That, for us, is a given and as each
individual has certain, particular needs then they're addressed as well.
MS. ROGERS:
So will that be ?
CHAIR:
Excuse me, Ms. Rogers; I'm
going to go on to other Members (inaudible) then I will go back to you.
MS. ROGERS:
Could I just finish that
one?
CHAIR:
You're almost finished?
MS. ROGERS:
Just this question.
Will
there be a directive, a stated fact that that, in fact, is important?
MR. ABBOTT:
I think in the monitoring framework it's are you meeting sort of really
basically resident choice, whatever that choice may be.
MS. ROGERS:
Okay, great. Thank you.
CHAIR:
Mr. Bragg, anything further?
MR. BRAGG:
A final question, I guess.
Do you
track or monitor your complaints and, if you do, can you tell if the volume has
decreased? I'll be honest, in my two years since I've been doing this, and I
have two long-term facilities in my district, I don't hear the complaints that I
hear from Ms. Rogers. I'm not saying that that's wrong or anything, so I don't
know if one being Central and one being Eastern.
MR. ABBOTT:
We don't at the department receive those unless they actually came
WITNESS:
(Inaudible).
MR. ABBOTT:
Pardon?
WITNESS:
We do.
MR. ABBOTT:
The ones that come right into us?
WITNESS:
Yeah, the ones that come to us we try to keep.
MR. ABBOTT:
Yes, so to go there, the ones that the RHAs themselves receive, we don't track
those.
MR. BRAGG:
Okay.
MR. ABBOTT:
But the ones that come directly to the department, we would track those. Again,
from the long-term care, there are very few.
MR. BRAGG:
Yes, okay, because I'm
thinking coming to our level that the family members are probably really upset
because they've probably exhausted whatever avenue they could at the front
level.
MR. ABBOTT:
Yes.
MR. BRAGG:
Okay, thank you.
CHAIR:
Mr. Petten, anything
further?
MR. PETTEN:
No, I am good on this topic,
thanks.
CHAIR:
Ms. Parsons, you're good?
Ms.
Rogers.
MS. ROGERS:
Yes, this may seem like an
odd issue but the issue of teeth. I know that the Adult Dental Program has been
cancelled and we see more and more seniors who have lost their dentures or their
dentures have broken and they may not have the money. The whole issue of
nutrition and teeth, has that been an issue, or will we see that as a growing
issue as we monitor what is happening with our seniors who are unable to get
dental care?
MR. ABBOTT:
I'm going to say it is an emerging issue, but that may not do justice to it.
It's been an issue longstanding, really. We've had conversations with the health
authorities around dental care; we've had conversations with the Dental
Association who are advocating and certainly recognize that is as an important
health care matter as anything else. We're working on that. We haven't come up
with any particular solution yet as to how do we address that, but it's
certainly on our radar.
MS. ROGERS:
Okay.
Great,
thank you.
The
issue of weighing and any unplanned weight change, what is happening now in
terms of addressing that? It seems to me it's a crucial issue, and without that
kind of information we really aren't quite sure what's happening with some of
our folks.
MR. ABBOTT:
Again, the Auditor General
speaks to that matter and his finding that will be one of the factors in the
monitoring framework, that in fact we will now start getting regular reporting
on meeting the standard.
Deena,
I'll ask you to speak to that.
MS. WADDLETON:
There has been a policy
drafted and ready for approval on weights in long-term care. In practice, the
RHAs have been doing that since the review, but we'll have a finalized policy on
weighing residents approved very soon.
MS. ROGERS:
Okay, because this was two
years ago that this report came out.
MS. WADDLETON:
Uh-huh.
MS. ROGERS:
So we're going to see one
this June, this month?
MS. WADDLETON:
This will be done, yes,
within a month or so.
MS. ROGERS:
Okay.
Do you
have any empirical evidence as to how it has improved? How do we know that?
MS. WADDLETON:
Until we get, as John has
mentioned, the outcome of the RHA monitoring, then I can't really speak to that
right now. But that will be something that we will be asking them to report on.
MS. ROGERS:
We really don't have any
reports on that?
MS. WADDLETON:
I don't have a report on
that, no.
MS. ROGERS:
Okay, so we don't really
know.
MS. WADDLETON:
No.
MS. ROGERS:
Okay.
All
right, thank you.
How
will you ensure that this is happening? It seems to me that it's such a
fundamental practice in terms of knowing how our folks are doing.
MR. ABBOTT:
(Inaudible) to the
department on meeting. Again, we will have both standards; we'll say it needs to
be done. Now we'll know how often it is done or not done and where that is.
MS. ROGERS:
Yes.
MR. ABBOTT:
And then we will follow up
with each of the health authorities to find out if, in fact, there are cases,
whether it's weighing the resident and monitoring and, more importantly,
monitoring that resident for any issues, health or other. Then we'll now have a
database to draw on. Right now, we are working in a vacuum.
MS. ROGERS:
It seems to me it's such a
crucial
CHAIR:
Excuse me, Ms. Rogers. I'm
going to go to Mr. King and we'll come back to you.
Mr.
King.
MR. KING:
First of all, I'd like to
correct a misleading statement stated by Ms. Rogers where the dental program has
been cancelled. That's not entirely correct. The days of everyone having two
sets of dentures, one for their mouth and one for the cupboard, those days are
over. I'm sure you can attest that it's done on a case-by-case basis. So let's
get that correct.
Just
one final question: Why is Western Health ahead of Eastern Health with regard to
the full implementation of these policies?
MR. ABBOTT:
One, I guess, really their system is a bit smaller. So they have opportunity to
focus a little bit more on that because the problem is that Eastern is a little
bit larger and a little bit more dispersed, but nothing fundamentally different.
I think it's just really a timing issue there.
MR. KING:
All right.
I'd
like to thank you for all the work you do. It's come a long way. You can see the
effort the department has put into this nutrition issue, and the RHAs. It shows
quite a bit of dedication over the past two years to get it from where you were
to where you are now, and I just want to thank you for that.
MR. ABBOTT:
Thank you.
CHAIR:
Mr. Petten.
MR. PETTEN:
No.
CHAIR:
Mr. Finn.
MR. FINN:
I'm fine, thanks.
CHAIR:
Ms. Rogers.
MS. ROGERS:
Yes, going back to the weigh
I'm going to weigh in again on the weigh. It just seems to me that it's just
so fundamental. Why do you think that in a number of cases it hasn't been done,
or hasn't been done as frequently as policy would what's going on?
MR. ABBOTT:
Again, I'll go back to some of the earlier points we were making. We have within
the health authorities professionals whose jobs it is to undertake this. So we
are dependent and reliant on them doing their jobs, and their managers need to
oversee this.
The
Auditor General went in and found out what to your point, we'd assumed this
would be automatic. If you know your resident, you would know if there is weight
loss and you'd want to make sure you address what the issues are, health or what
have you.
I think
it circles back to the quality of care and the responsibility within each of the
health authorities; and, in this case, the nursing homes. It was very specific
and identified specific cases. We, at the department, don't see any reason why
this hasn't been done as required. It was certainly an eye-opener for us that a
very basic measurement tool, in terms of care, wasn't being implemented.
MS. ROGERS:
Again, I would think that
those professionals who are providing that care want to provide the best care
they possibly can.
MR. ABBOTT:
Yeah.
MS. ROGERS:
So I would raise the issue
again: Is it a resource issue? I know there is a lot of stress on our long-term
care facilities, that there are wait times.
MR. ABBOTT:
But it's a standard of care.
In any of our facilities in our health services, if a standard of care is
determined, then they are resourced to meet that standard.
MS. ROGERS:
Okay.
In
response to my colleague, Mr. King, there, can you give us just an accurate
explanation of the policy of the Adult Dental care program, just to clarify?
Thank
you.
As it
stands right now, my understanding is the Adult Dental care program is available
for people on Income Support, there are further limitations.
MR. ABBOTT:
That's right.
MS. ROGERS:
But for people who not on
Income Support, it has been cancelled.
MR. ABBOTT:
There's no funding for that.
That's correct, yes.
MS. ROGERS:
Thank you. Okay.
I have
a concern around nutrition for our seniors who are waiting to go into long-term
care who are in acute care beds. I know we have a number of them. Is that
concern under examination? Because some of them are in there for a long time.
MR. ABBOTT:
That's right.
MS. ROGERS:
Yeah.
MR. ABBOTT:
Well, they would fall under,
then, the food that is provided by the hospital, if they're in a hospital
setting. We haven't flagged that as a particular issue at this stage.
MS. ROGERS:
I think it might be kind of
interesting again because and in fact they are waiting for long-term care.
MR. ABBOTT:
Yeah.
MS. ROGERS:
Acute care, feeding
nutrition may be a little bit different. They're in there for a long time. I was
just curious about that.
The
department noted there is a working group that met in March. Can we get an
update on that meeting? What is happening now? Will there be a formal review?
How long will it take? Is there a report from that? What is the scope?
MR. ABBOTT:
Yes, we'll provide that
information.
MS. ROGERS:
Great.
Thank
you very much.
I don't
know if I have any other questions. I think I'm okay. I just want to look at one
more issue almost there.
I was
looking on page 210 of the Auditor General's report. It looks at the shortfalls
to Canada's Food Guide. We can see that it was inconsistent. Some of the
shortfalls are more pronounced in some facilities than in others.
It was
very interesting that milk alternatives, for instance, in the St. John's
long-term care facility; there were a lot of shortfalls there and vegetables,
fruit and grain products. Dr. Albert O'Mahony Memorial Manor seems to have fewer
shortfalls. It was just kind of interesting to see the differences there.
I would
imagine then, your standards of care that you are developing will look at that
for your monitoring framework?
MR. ABBOTT:
Yeah, and I think that's a
good indication then of the kind of reporting we now will expect. We can start
looking at that and say: All right, why the deviation from what the established
norm is and what is the authority doing to address it.
MS. ROGERS:
Okay. Thank you very much.
Again,
I know how complex this is. Wouldn't it be wonderful if we could become a centre
of excellence for how we care for our seniors? I know it's a challenge.
MR. ABBOTT:
Thank you.
CHAIR:
Okay, thank you.
If
there are no other further questions, we'll finish with the Nutrition in
Long-term Care Facilities and move on to Acute Care. I have to step out for 15
minutes but Mr. Bragg is going to take the Chair while I'm out.
The
process will be to start then with Ms. Parsons as the first line of questioning
on Nutrition in Long-term Care Facilities.
MS. P. PARSONS:
No, acute.
CHAIR:
(Inaudible) the standard is
to ask, do you have any closing comments on the previous heading that we just
talked about.
MR. PADDON:
The only comment I'd make, I
mean I don't underestimate the challenges and the complexity of this particular
issue. As some of the Committee Members have talked about personal experience,
we've all had those experiences. Fortunately, mine have been fairly positive.
I am
encouraged because anecdotally I hear within Eastern Health, just from
acquaintances and people I know, that there's been a fair bit of work occurring
to address the recommendations. That's quite encouraging to us.
At the
end of the day, all our recommendations should be designed to ensure that we
have a better system and sort of care appropriately for people who are fairly
vulnerable in society. That's really what's driving us. We're quite encouraged
by what we've seen so far and, hopefully, we'll have a better system at the end
of the day.
CHAIR (Bragg):
Okay, thank you.
Moving
on, our next heading is going to be Acute Care Bed Management. It is section 3.3
of the November 2016 report.
The
first question, I'll go to Ms. Parsons.
MS. P. PARSONS:
Thank you, Mr. Chair.
Based
on the review for Acute Care Bed Management in 2016, the recommendations,
Regional health authorities should identify and/or establish performance
indicators related to acute care bed management and ensure national benchmarks
are identified or hospital targets are established for each performance
indicator.
I would
like if you could please provide an update on the latest with this.
MR. ABBOTT:
In terms of these series of recommendations, of course, they were all sort of
addressed to the individual health authorities but we have coordinated and are
looking at how they are implementing.
In
terms of the first recommendation, for instance, Eastern Health has fully
implemented the recommendation, both Central and Western have partially
implemented and we can speak to some of that and Labrador-Grenfell has yet
to begin implementation.
The
indicators that were identified are all relevant, and depending, again, how
they've been set, and we are collecting data or the health authorities are
collecting data and reporting to us on those. Central Health, for instance,
expects to be fully compliant by the fall of 2018, and Western Health by late
fall of this year.
I think
what the Auditor General has identified in this area is an important piece of
work to help us manage our hospital costs. They are the most it's sort of the
highest cost in the country. We have now means to look at how we can manage the
beds better.
We have
over 1,500 beds in our system and, depending on how we manage those, will
determine how patients get in, move through our system and, obviously, are
released. We are operating at a very high level of capacity right throughout our
system. As a matter of fact, higher than we should ideally, and that's why it's
important that we manage the beds and the people in those beds much more
closely.
Again,
the Auditor General's report I think has been very helpful to the system in
identifying a critical management issue for us.
MS. P. PARSONS:
Could you just elaborate on
the management policies and procedures with particular regard to discharge and
admission, as well as (inaudible).
MR. ABBOTT:
Well, ideally, on admission you should have a discharge plan. So a physician,
working with the nursing staff, will say: Patient X, based on the conditions
they're presenting with, based on the care plan, we should see that patient
being released within three days, four days, five days.
That's
not always done, and it needs to be. That's a best practice right across the
country. Then you're managing against a potential date. So if a person comes in
on Monday, we're assuming they're going to leave by Thursday based on the care,
and if they're not, then why not? Has the patient gotten better or worse? Has
the care plan changed or are we just not managing that patient as closely as we
should? The physician, for instance, is available to write and support the
discharge note or notice at the time.
So it's
a lot of parts moving at the one time, but if we do this well, the patient is
better served. If the bed frees up one day earlier, that means somebody else can
come in to get in. So it really improves access if we do this right.
MS. P. PARSONS:
Right. The common concerns
we hear over the years we've heard of patients being on a bed in a hallway.
MR. ABBOTT:
Yeah.
MS. P. PARSONS:
That's a common concern.
MR. ABBOTT:
Yeah.
MS. P. PARSONS:
How have we improved in that
regard? At the same time, we hear the complaint that patients are being released
too early
MR. ABBOTT:
Yeah.
MS. P. PARSONS:
when still needing care
and still in critical condition.
MR. ABBOTT:
Yeah.
On the
first example you used in terms of beds in hallway, it's usually indicative of
overcapacity in the hospital that day. That means generally the beds upstairs,
shall we say, are full and there's no room. So they have to be managed through
the emergency room.
Part of
this whole exercise in looking at the management of the beds is to say: Are each
of the beds that are in whatever service they're in, are the patients being
appropriately cared for? Are they appropriately in those beds? Can they go home
sooner? Should they be in them there in the first place? The discharge plan on
admission helps manage that.
What
we're seeing in some successes now through other initiatives is that we are
starting to free up beds. So waiting in hallways is starting and, hopefully,
will come down. Ideally, you'd want to eliminate it, but you'll never fully
eliminate it because if you get a surge on any particular night or weekend or
what have you, then you have to manage it as best you can for that period.
In
terms of the discharge early and we hear that from time to time those
decisions are made by the attending physician based on the care needs, the
physical condition of their patient. They will make a determination on release.
They will get advice from the nursing staff and others, but that's their call at
the end of the day. There is no particular if it's after three days and
they're not ready to leave after three days, then they stay.
Now,
will the physician always get it right? Maybe not but, again, we measure that.
That is a standard of care as well through our monitoring system, because if
that patient comes back within a day or two or three, well, that means the
initial care has not been appropriate. We have processes then to review that and
review that decision so ideally it shouldn't happen the next time.
MS. P. PARSONS:
Okay. I'm good for now.
Thank
you.
CHAIR:
Mr. Petten.
MR. PETTEN:
Thank you very much.
Just
reviewing the AG's report, there are a lot of common themes that come out that
and I know that you just addressed a lot of it in having a discharge plan or the
overall planning from when you are first admitted in the hospital. I know Pam
referenced to the waiting times in the ER.
The
number, 69 per cent of discharges happening between noon and 6 p.m. 61 to 69
per cent I think everyone here can attest if you ever were in the hospital,
had a family member in hospital, if you never get discharged by Friday
afternoon, you're in for the weekend.
MR. ABBOTT:
Yes.
MR. PETTEN:
If there was nothing done by
4 in the evening, you could be rest assured you had to wait until the next day.
It usually was that the physician wasn't around to sign your discharge papers or
someone needed to write a prescription. There are a lot of variations to it.
Looking
through the AG's report, that theme went right through when we look at our Acute
Care Bed Management I guess the general question is: What is the plan? Do you
change physicians? It's really a scheduling thing in hospitals because a lot of
physicians are in the ER or in the operating room, they're performing clinics,
they don't do the rounds until 5 in the evening.
Personally speaking, I think that is one big issue when you look at our acute
beds being the discharge. There are a lot of other things involved but, to me,
that's one of the biggest issues from personal experience. I think we can all
attest, they don't make the rounds until 5 or 6 in the evening or near evening.
Is
there any plan to
?
MR. ABBOTT:
Well, as part of looking at
this particular issue, yes, the physicians have to be totally engaged in how
they also change practice to support better utilization of the beds that, in
fact, their patients are in and their subsequent patients will be in.
This is
not new. Over a number of years, the health authorities have tried different
methods to make sure that the discharge is done ideally before noon and ideally
right over the seven days. If you look at what's happening in the best
performing hospitals across the country, you will see that's in fact what they
do.
We know
what needs to be done, we know how to do it, but the piece and you alluded to
it is getting the physicians to sort of change their practice, to be
supportive. That requires the VPs of medicine to better engage with them and
with the nursing and allow, in some cases, nurses to discharge if it's if I
can use the term routine. So we need to delegate some of that authority back
to nurses and what have you to allow them to discharge when the care plan
suggests that everything is on course.
There's
a lot of work that still needs to be done on that particular piece. That's
probably one of the more difficult pieces that we're struggling with.
MR. PETTEN:
Do you have a percentage of
beds that are being occupied now by long-term care patients awaiting beds?
MR. ABBOTT:
Yes, we do.
Denise
Tubrett has
MS. TUBRETT:
It's about 20 per cent on
any given day that there are individuals in an acute care bed that is discharged
and waiting for an alternative service level, one of which could be long-term
care.
MR. PETTEN:
You say they're discharged.
If they're in that acute care bed, do the doctors still make rounds to those
individuals or are they more in the care of nursing staff? How does that work?
I'm just looking at resources.
MR. ABBOTT:
Yeah, that would be
primarily under then the daily care of the nurse. The physician would, as
required, then would attend but not on a regular basis because they've been
basically discharged.
MR. PETTEN:
When you look at those
long-term care residents or patients or what have you, they're sporadically all
throughout the hospital. There's no real there could be a long-term care
patient in with three people who had surgery or what have you.
MR. ABBOTT:
Yeah.
MR. PETTEN:
There's no actual area in any of hospitals, they just take whatever bed is
available; is that correct?
MR. ABBOTT:
It does vary. So out in Central, for instance, they have moved to bringing those
patients together.
MS. TUBRETT:
And Western.
MR. ABBOTT:
Western as well, as Denise is letting me know.
In St.
John's, they're more dispersed, and again they've tried different models here.
But that being said, St. John's is probably having the most success in recent
time of moving those patients out to either long-term care because capacity has
increased, or getting some actually to return home while they're waiting for
long-term care.
MR. PETTEN:
One other question on this
I know my time expired. You have dementia patients who tend to I know our
acute care beds are taken up with a lot of 20 per cent is used. Dementia
patients, unfortunately sometimes, tend to land wherever. A lot of times it's
probably more of a less desirable location. Granted, they're getting their meals
and their care, but where they are put I don't know if my colleagues can
attest; I can attest to it. As an elected official, I deal with it a lot of
times with families who have grave concerns with their loved one when they're
waiting to get into they can't come home.
MR. ABBOTT:
Yeah.
MR. PETTEN:
They can't look after them
at home, but there's no long-term care facility available so they're waiting for
a placement.
MR. ABBOTT:
Yes.
MR. PETTEN:
I've dealt with this
first-hand. Families have come to me; I've dealt with them, and it's been a very
stressful time. But they tend to be wherever a bed is available it may not be
where me or you would want to be, but they're put there. It is almost the least,
if you look at your A level bed to your D level.
MR. ABBOTT:
Yes.
MR. PETTEN:
I've heard from other people
as well; I've dealt with it myself. That seems to be the norm. So they get their
three squares and wherever they can put them. Someone else I guess more vocal or
I don't know what you'd call it more opinionated or more able would probably
not end up there.
My
question is, I know these people are waiting to get out into long-term care and
they are taking up an acute care bed, no matter what their issue is, but is
there any consideration given to the fact of their personal situation? With
dementia, it's pretty sad disease. Is there any priority given to make sure that
they are probably in a more stable environment?
MR. ABBOTT:
If I understand, it's in
terms of while they're waiting for placement in a long-term care, so they may be
somewhere in the hospital setting. I can't speak to anything specific on that.
The particular challenge, if I can put it that way for those with dementia,
Alzheimer's, who are in the hospital waiting for placement, there are only so
many beds that we would have in a nursing home that can take and care
appropriately for that. And there you're seeing some quote, unquote backlog.
MR. PETTEN:
Yes.
MR. ABBOTT:
Now, how they're managed in
the hospital setting, again, they are patients and they are supposed to
obviously get the appropriate care. I'm not aware of any particular cases that
have come to our attention that speak to what you've observed. So that's
something we can certainly follow up with in terms of as I understand, one of
the key points there is for those dementia patients in what we call the ALC bed,
the alternate level, do we have some additional nursing provisions to make sure
that their care is appropriate.
MS. WADDLETON:
I can speak to that.
MR. ABBOTT:
Okay.
MS. WADDLETON:
So when the individual is in
an acute care bed waiting to go to a long-term care bed, oftentimes the hospital
will look at their needs. If they're a dementia patient, then they will look at
constant care, so putting clinical staff with them or nursing staff, probably a
PCA, something like that, to protect them while they're in the acute care bed.
They'll
get as much care as they need to keep them safe and keep them well while they
wait for an acute care bed. In some cases, it's additional staffing that may be
assigned to the individual.
CHAIR:
Excuse me, Mr. Petten, I'm
going to move on to Mr. King and then we can come back to you.
MR. PETTEN:
Sure.
CHAIR:
Mr. King.
MR. KING:
Thank you very much again,
to compliment you on the work for such a short time frame. I know this came out
in November. So to see the level of detail that you guys have put into this
well, mostly the health authorities at this point.
One
major question I have is with acute care management; where does technology come
into play so with data management and you track everything and you get better
outcomes are you guys looking at technology or utilizing any technology at
this point?
MR. ABBOTT:
Well, in terms of capturing
the data, yes. Really, the conversations we're having now is how technology can
help monitor residents and patients as they leave the hospital; if they do go
home, how we can monitor and support them through remote monitoring and those
kinds of things.
We are
looking at how some of our systems, if we brought a lot of the information
together in terms of one health system or information system, we can better
deploy our resources. Taking a case of somebody who comes to the emergency and
the minister announced on Monday the Chronic Disease Action Plan within that,
we see a lot of opportunity to use technology to help patients support
themselves in the community or through support by their health authority.
That's
the kind of conversations we're having. There are a lot of applications now
being developed for just that some that are being developed locally. We're
seeing, I suspect, over the next three to five years, quite significant
investment in technology to help us deliver a lot of these services.
MR. KING:
Yeah, because technology and
trend analysis would be ideal, certainly, for tracking the outcomes of this.
MR. ABBOTT:
Yeah. We have a lot of that
in place in decisions and supports to allow that. The thing is it's really
incumbent of us to use that data then, to start informing our program changes
that we need to make.
MR. KING:
That's all I have.
Thank
you.
CHAIR:
Ms. Rogers.
MS. ROGERS:
Thank you very much.
When we
look at some of I know this is such a complex thing and it's been age old.
We've been dealing with this problem for years. I don't know if it seems to be
getting better at all or what, I'm not sure; or if, in fact, there's even a
greater demand on the system because of our shifting demographics.
The
response from the department spoke of establishing working groups from the four
regional health authorities so we can optimize acute care management and working
to strengthen existing policies and procedures, so the working groups were
established. Can you tell me: Is it one working group? When was it established?
Has there been any reporting from it at all yet?
MR. ABBOTT:
Mr. Chair, Heather Hanrahan
from our department has joined us. I'll ask Heather to speak to that.
MS. ROGERS:
Great. Thanks.
MS. HANRAHAN:
There is one provincial
working group that the department leads. We have myself and another individual
on the working group and then there's one senior representative from each
regional health authority. So we've gone through all the findings and the
recommendations.
The
RHAs have shared any indicators, any policy work, anything they've done that's
current and recent, with each other as a way to, I think, get the work done
faster and to get the work done in a more provincial and consistent fashion.
MS. ROGERS:
Heather, when did that
start, that working group?
MS. HANRAHAN:
I'm going to say December.
MS. ROGERS:
Okay, great. That was fast
to get that up and going.
MS. HANRAHAN:
Yeah.
MS. ROGERS:
Will that working group look
at factors like home care, the availability of home care, all the number of
issues that impact whether or not folks can leave a hospital or go to other
alternative levels of care facilities? What are some of the mitigating factors
that keep people in acute care beds?
MS. HANRAHAN:
So there's a major initiative, I guess, within the department in terms of Home
First and trying to have the maximized supports that we can have in the
community. I guess our working group here will pick away at these
recommendations and findings until we feel that they are complete and things are
in order as they should be.
MS. ROGERS:
Okay, thank you.
Is
there still a dedicated admission discharge manager in each hospital? I know a
number of positions have been cut. But do we still have that, a dedicated
admission discharge manager in each hospital?
MS. HANRAHAN:
Yes, there would be somebody who would have that responsibility in each health
authority.
MS. ROGERS:
Okay, and that would be a
manager?
MS. HANRAHAN:
Correct.
MS. ROGERS:
Okay, great. Thank you.
Some of
the work where we see there's been some delays around discharge records,
medication reconciliation, to name a few of them, would any of those be as a
result of under staffing or too few staff doing too much?
I can
see you smiling there, John, because I raised this issue a number of times. but
I'm just wondering because I don't think we have staff not working hard. I think
staff are working very, very hard and the demand on our health care system seems
to be growing. Are any of the problems that we're facing a result of that?
MR. ABBOTT:
Yeah, the pieces you've identified are mostly in an electronic format, in any
event.
MS. ROGERS:
Okay.
MR. ABBOTT:
It is a case of bringing
those files together within the hospital setting. We have the Meditech system,
which has the record for all interventions and required interventions on one
file. If things get missed and that does happen it may be a case of rushing
or overlooking some things but, again, we are resourced to make sure that care
plan and the needs are fully addressed.
MS. ROGERS:
Okay.
Why are
some of the issues we are dealing with so they've been going on for so long,
even the issues that seem simple, like not discharging before noon, which seems
simple from a layperson. Why are they so ingrained? Why have we not been able to
at least solve some of them?
I know
there is some positive work being done, but what's keeping us from achieving
where we want to go and where we again, this conversation has been happening
for years. What's your assessment of that?
MR. ABBOTT:
If you look at our health
authorities and certainly in the hospitals within those, as I said, we are very
well resourced, and well-resourced relative to other systems across this
country, so it isn't a resource issue. It really does boil down to how we manage
each of those programs in each of those facilities. If you look at some of the
excellent work we do in terms of cardiac and cancer care, then we need to
replicate that.
Ms.
Rogers, you appreciate when you look at the mental health and addictions, we
know a lot of what needs to happen, we have resources. There may be, in some
cases, in that particular area where we obviously need to add, but we know what
needs to be done.
All our
staff are trained, our physicians are all accredited. All our systems are
accredited and we have resources here. So it is a management issue, at least
from my perspective. The conversations we're having with the health authorities
and each of the professions is how we can better manage the resources we have to
get the better outcomes.
That's
certainly a theme the minister has been focused on since he's come into the
portfolio is to really focus. That means challenging the department and in turn
challenging the health authorities and proprietors that we can and should be
doing better here because we have all the tools at our disposal.
So
there really isn't one thing you can point to that says it's missing, but when
you try to tease it out you realize and to your point, a lot of these are not
new issues by any stretch. So it's incumbent upon us now really to turn the
tide, to make sure we manage this and much, much more effectively.
I think
holding the administrators, both in the department and in the health
authorities, to account is I think more than appropriate.
CHAIR (Brazil):
Ms. Rogers, I'm going to go
to Mr. Finn.
Mr.
Finn, any questions?
MR. FINN:
Thank you, Mr. Chair, and
thanks for the thorough information.
You've
answered most of, I guess, some of what I've been able to flip through in my
short time here, but with respect to discharge and I can understand some of
the challenges there, but I'm curious. With the discharge planning and some of
that relating to the physician, is some of the gaps there because individuals
once discharged don't have a family physician? Is that
?
MR. ABBOTT:
That could be, from time to time, a factor in when you are doing your discharge
to whom do you discharge
MR. FINN:
To whom are you putting in (inaudible)?
MR. ABBOTT:
and if there's a follow-up
care. That will come from time to time. We have, obviously, our community health
nursing system that really then will step in to manage that, and we have nurse
practitioners now more so in the community to do that. Other than that, then
that patient would end up coming back through emergency or if there are some day
clinics at a particular hospital site for follow-up care. It's not ideal, but
that would be the backup in those cases.
MR. FINN:
Okay.
One of
the findings here and it states: three of the four hospitals examined under the
Regional Authorities did not require medication reconciliations be performed.
I'm
thinking specifically because they didn't require the medication or
reconciliation be performed, it doesn't mean it wasn't actually being done
MR. ABBOTT:
No.
MR. FINN:
but I guess to me that
would just raise a lot of questions because then we're circling folks who leave
the hospital back into emerge.
MR. ABBOTT:
Right, yes.
We
think that, one, because the health authorities are now reporting back on
implementing that particular recommendation, but now with our pharmacy network
fully in place, then we have found a mechanism with our electronic health
records system that now we pull all that data together up for that particular
patient. So this becomes much easier to do.
MR. FINN:
Sure.
MR. ABBOTT:
They just have to make sure
they monitor that report.
MR. FINN:
Okay, excellent.
Thank
you.
CHAIR:
Mr. Petten, another question
or questions?
MR. PETTEN:
Yeah, I just wanted one
follow up from my questioning from earlier; I never got to finish asking it. The
point I'm trying to get at is we have all these acute care beds, demand is on,
people waiting to get in for the surgeries and that. We have long-term care
patients that are taking these beds up.
I want
to go back to the I guess they're waiting to go into long-term care and they
have their faculties about them, they're just occupying a bed. As long as
they're being taken care of it's not a huge issue.
My
point on dementia, people with Alzheimer's and forms of dementia and I've seen
this myself; my mom was in hospital in December. The next bedroom over at St.
Clare's, the next room to her was a dementia patient. She was there, she had a
bed, but there seemed to be very little controls.
It's
twofold is what I'm trying to get at. You have some places where you have a
dementia patient in where everyone is functioning. It's a very unsafe position
for both people because they're at the mercy of whomever. Then there are
patients that are in just for regular surgery who have to tolerate what comes
with that. Like I said before, it's a sad disease.
Again,
to me, what I've observed and what seems to be when I read this report, there's
no real plan when it comes to it. That's an issue. Like what was just said, 20
per cent of the beds are occupied by various forms of people waiting to get in
long-term care. While we're dealing with that until facilities are available
where that number decreases hopefully to zero at one time that seems to be
done in a very ad hoc fashion. It's like wherever the bed is, they'll end up
going there.
I've
heard nothing here today and I've probably seen nothing that tells me otherwise,
especially when you're looking at probably what I was trying to get at is
there should be better planning when it comes to certain residents that are
waiting to get in long-term care facilities because it's more than dementia.
There are variations as you progress in life that we all have to face at one
time or another. There doesn't seem to be any real planning from the hospital
health authority point of view, other than the fact we have a bed for you.
MR. ABBOTT:
Yeah.
Again,
depending on the individual circumstance, because what we are seeing, which is
sort of the gap that we're facing, we will have patients at home before they
get to the hospital they are being managed by their family, maybe with some
home support, but get to the point that really they cannot be managed and the
family has run out of energy, resources that, from time to time, obviously, will
bring their family member to the emergency and say there's been an incident and
we can no longer have our mother and whatever come back home. Then the hospital
is obligated, obviously, to receive and treat. So then they have to find a bed
for that individual. If it's dementia or Alzheimer's, it's generally, depending
on the patient's condition, will probably be isolated in a room because the
hospital will say that they been managed there because, i.e., it won't disrupt
the two- or four-bed ward.
What we
are attempting to do, and as was announced in the budget, through a truly Home
First, is that we can identify these potential patients that are residents now
at home who are high risk, who do have dementia, may have Alzheimer's, develop a
care plan for them so that there isn't a surprise when they show up, because
they shouldn't go to emergency in the first instance.
If they
cannot be cared for at home, they should bypass the hospital system and go right
into the nursing home. So that's the approach and planning we are currently
doing. Because you do identify a big issue that each of the health authorities
are trying to address. What we at the department are now doing is sort of
viewing that as one of the key priorities for us for this year. We brought all
the senior leadership, whether it's public nursing, home care, home support, all
of those disciplines, we've brought them together for two days to map this out
so that we can actually move the patients, one, that are in, out home, if need
be, to long-term care right away. We are seeing a positive impact already that
are starting to free up the beds, because people are in hospital that should not
be.
With a
few extra dollars in terms of adding to either their home support hours or home
care hours or the nursing hours, we're able to leave them definitely in their
home where they want to be, and that's a more cost effective and certainly more
acceptable way of doing that.
If this
pans out the way we are planning it, we are seeing there will be a significant
reduction in beds for that particular population. So either those beds can close
or they're used for the two- or three-day requirements if somebody has to come
in for routine surgery, those kinds of things, then we can move them through
much faster.
So I
think you're going to see, over the next couple of years, significant change,
certainly in the Eastern region, because that's where most of these issues are
playing out here, Gander, Grand Falls and Corner Brook. So we're quite
encouraged by what we're seeing already on that front.
MR. PETTEN:
Thank you.
CHAIR:
Mr. Bragg.
MR. BRAGG:
No, I'm good.
CHAIR:
Mr. Rogers.
MS. ROGERS:
Thank you very much.
I was
surprised, John, to hear you talk about the Home First is great and that's a
great plan and great to push towards, and you were saying with some extra
dollars or hours to help people stay in their homes. Yet, what we're hearing, in
fact, is people who are telling us that some of their home care hours,
particularly homemaking and home-keeping hours have been eliminated, which is
making it harder for them to stay in their homes.
MR. ABBOTT:
Yeah. So if I can split that for the moment.
MS. ROGERS:
Yeah.
MR. ABBOTT:
The homemaking ones, again, we looked at what was happening across the country,
looked at, obviously, in terms of our overall budget situation, and
determination was made that we could do that and it would not impact on people
staying in their own home, around that particular aspect.
But
when it comes to the more nursing and related I shouldn't say nursing but
when it comes to other home supports and nursing, we are now looking at what are
the appropriate assessments to be done; how we need to change those. We are
currently looking at some training programs for our nurses and social workers to
look at how we assess and that we will be coming forward basically to say, look,
we want you to assess against the hours of care that are needed and then we will
fund that accordingly.
MS. ROGERS:
So there may be some
movement on the issue of some housekeeping hours?
MR. ABBOTT:
No, we won't be changing that aspect, but it will be the other supports that
they need to stay in place. We believe if it's one or two hours of homemaking a
day, depending on what's assessed, that will be sufficient; but if they need
other supports, which is the other two or three or four or five hours a day, we
are looking at that in a much more consistent manner and to allow people to stay
at home.
The
Home First is really looking at, one, our review of the home support program
says we need to do that. Secondly, our focus on Home First for patients with a
whole lot of complex needs, we can't confine them to three hours a day or four
hours a day necessarily; but if it takes four hours this week, five hours next
week and some other supports, OT, PT, what have you, we will put that in place.
We
certainly want to focus on palliative residents. If they want to stay home, we
want them to stay at home. We know we have to change how we do that and the
hours that are required there. So we're changing that. We had an arbitrary rule
of 28 days. Now, who knows when you've been diagnosed as a palliative care
patient our rules said basically 28 days and that's it. We said that obviously
makes no sense.
Once
you've been diagnosed, then we can put in whatever the appropriate services are
in place. Money has been put in the budget to do that, the policy direction has
been set and now we're trying to operationalize that. The federal money that's
coming in will help support that as well.
Again,
we see that as a bit of a game changer in how we deal with the program going
forward. There are going to be some bumps in the road we know. We're dealing
with the home care agencies. They have to change how they do business as well,
but they seem to be fully engaged with us on making the changes.
MS. ROGERS:
Just for a point of
clarification, I know I seem like a dog with a bone on this one, but the issue
of some of the homemaking hours. Are those gone entirely or what?
MR. ABBOTT:
Well, again, we are
assessing every resident as to their ultimate, you know, what they need.
MS. ROGERS:
Yeah.
MR. ABBOTT:
The policy direction in the
budget before last, that reduced those hours, that still stands. But we are
doing it at the same time; we are going case by case. If there are exceptions to
that, we'll deal with those.
CHAIR:
Ms. Rogers, do you have much
left on this heading, only because
MS. ROGERS:
Just one comment.
CHAIR:
Okay.
MS. ROGERS:
Again, it's been such a
long-standing, serious issue and I'm so glad that you are so committed to look
at it. I wish you every luck because it has been so intransigent. Is that the
right word for this at this point?
MR. ABBOTT:
Yeah.
MS. ROGERS:
I just want to thank you
very, very much. Good luck with this.
CHAIR:
Okay.
Before
we leave that heading, I'll ask the AG if there's any particular comment or not.
You're good on it?
Okay,
if we can break for lunch and resume at 1:15 p.m. sharp, appreciate it. We're
making progress.
Thank
you very much.
Recess
CHAIR:
Okay, ladies and gentleman,
we're going to reconvene the Public Accounts hearing this afternoon with the
Department of Health and Community Services and the health authorities.
So we've
moved to the fifth heading, Personal Care Home Regulation, and we'll start the
process with any questions starting with Mr. Bragg.
MR. BRAGG:
Okay, if we're all ready.
Hope we had a great lunch, a nice light lunch.
So I'm
just wondering, where are we with the operating standards for personal care
homes. Has there been any movement on that? Is there any listing or
?
MR. ABBOTT:
Okay. If I may, just for a second, and then to answer your direct question in
the Auditor General's report he had provided 16 recommendations specific to our
department; six targeted to the regional health authorities and eight to the
government service centres or Service NL. I just wanted to let you know of the
eight recommendations between the department and the RHAs are dealing with, six
have been fully implemented and two are partially implemented.
So with
respect then to your question on the standards, right now we have a draft of the
standards that are complete, we are currently reviewing those in the department
and we expect to have those signed off and out to the system this fall.
MR. BRAGG:
Okay.
We
talked about nutrition earlier this morning, not in personal care homes. Is that
being looked at too, or are we just looking at the overall appearance and, I
guess, the qualifications of the employees and those sorts of things?
MR. ABBOTT:
No, it would be the full gamut.
MR. BRAGG:
It would be the full gamut of
everything, right?
MR. ABBOTT:
Yes.
MR. BRAGG:
Okay. So when that's
available, I'm assuming there will be reports online?
MR. ABBOTT:
We're going to move it in that direction.
MR. BRAGG:
Yes.
MR. ABBOTT:
The government overall is moving there. We have yet to develop our plan as to
what and when we'll be putting online. These will be, but I can't tell you when.
MR. BRAGG:
Are you guys aware of any
right now that are probably operating at a level that would be considered
inferior?
MR. ABBOTT:
What I can say is there is certainly one home that is under sort of a
conditional licence and that we are working with that operator at present.
MR. BRAGG:
Okay, thank you.
All
right, I'll move on.
CHAIR:
Are you good?
MR. BRAGG:
Yes.
CHAIR:
Okay.
Mr.
Petten.
MR. PETTEN:
Thank you very much.
Personal
care homes, ironically, I have 13 in my district. A lot of what we talked about
this morning with the nutrition, I guess really Acute Care Bed Management too,
acute care beds, it all kind of goes hand in hand with our personal care homes
because they're part of the bigger system of our long-term care strategy to
various levels.
The
question I have is, there are various levels of care out of the 13 in my
district, each one of them could be rated on a different level. Yet under the
regional health authority, under Eastern Health, they're all considered to be
Level 1 or Level 2. They're all rated for various residents. What I'm
questioning is what quality assurance mechanisms do the departments or RHAs have
in place to make sure that you're getting you're going in a home that's
providing Level 1 care and they should be relatively of the same standard.
I hate
to say it but, unfortunately, they're not. I know you say you have one
unconditional licence. What checks and balances who's really policing to make
sure you have the proper nutrition, the proper environment, pretty well right
across the board? Because there is a distinct difference in the level of care
I probably shouldn't say the level of care but the combinations, the level of
service provided to various it depends on which home you go in.
MR. ABBOTT:
Yes, and particularly in your
district in Conception Bay South with the community care homes that really came
out of the Waterford program. They're required and there are certain standards
that have been set for them, and we fund them accordingly.
Each of
the RHAs then have the program and a director and managers that are responsible
with professional staff, whether it is the social workers that would visit, the
community nurse, that if there are issues and deficiencies, what have you, that
they are to report those as part of their monitoring. But we know that there are
weakness in our system. So part of the review we're doing now in developing the
standards, again, also developing and monitoring framework is that we move to
increase the quality.
In terms
of the care requirements, they are assessed by whether it's the social worker or
nurse as to the required care and the home's ability to provide that care and
manage the resident. What we are actually doing in the personal care home to
your initial comment, they are a significant player in the long-term care sector
or the community and long-term care sector. We are looking to see where we can
expand how they deliver service; can they take patients who may have a higher
level of need but can be accommodated in a personal care home.
Over the
past year or so, we have had an enhanced subsidies to allow that. At the same
time, we are supporting the personal care homes to provide them with more
resources for those residents who now need to transition into long-term care.
They've been assessed to move, but in the case where there isn't a bed, we
recognize that we also have to provide more resources to that personal care home
to allow them to take care of that resident while we're waiting.
We have
a standing committee in place with the personal care home operators and we work
with them. There have been some challenges within that sector and we're trying
to work through the issues with them.
MR. PETTEN:
Okay.
CHAIR:
Okay, Ms. Parsons, moving on
the personal
MS. P. PARSONS:
(Inaudible) I can come back.
CHAIR:
Okay, good enough.
Ms.
Rogers.
MS. ROGERS:
Yes.
Somebody
who I'm working with insisted that I bring the
Report of the Commission of Enquiry into the Chafe's Nursing Home Fire,
December 26, 1976. We all know what a tragedy that was and that was also
because of safety standards and how very, very difficult that is.
MR. ABBOTT:
Yeah.
MS. ROGERS:
In that inquiry there was a
quote: We have placed our trust in government to ensure that these homes are
controlled and supervised so that there's an acceptable standard of safety and
care. And it would appear from the evidence that has come to light during this
inquiry that this trust has been somewhat misplaced.
I'm sure
that we have really learned from that tragedy that was 40 years ago but we
still have some issues that arise because of standards and whether they're
adhered to or enforced and how is that. Again, I really understand and can
appreciate although my knowledge is somewhat limited on the extreme the
growing need for different kinds of care, whether it's seniors or people with
disabilities, and how do we meet those in this particular economic climate and
also with our shifting demographics.
The
Auditor General recommended a comprehensive review of personal care home
operating standards and the regional health authority monitoring standards every
two years. So the department's response is that these items are almost complete,
these two items?
MR. ABBOTT:
Yes.
MS. ROGERS:
So when will you expect them
to be complete? I'm not sure who answered that in a previous
MR. ABBOTT:
Yes, Ms. Rogers, we intend to
have those released this fall.
MS. ROGERS:
Will those be public
documents?
MR. ABBOTT:
Oh yes.
MS. ROGERS:
Okay, great. So we will be
able to get copies of those.
Now, the
issue of inspections of our personal care homes, we now release the results of
inspections in food establishments
MR. ABBOTT:
Yes.
MS. ROGERS:
Will the department make
public results of all inspections of personal care homes?
MR. ABBOTT:
With the standards and
putting in and monitoring framework, that's our intention to do that.
MS. ROGERS:
Okay.
MR. ABBOTT:
We have to coordinate what we
do with the government service centres because they do the physical fire life
safety monitoring and reporting. But that's the direction we intend to go.
MS. ROGERS:
Do you see any possible
objections to that, any push back at all? Is there anything that you think would
prevent that from happening?
MR. ABBOTT:
Not that we're seeing. I
mean, there may be somebody in the industry that may not be as welcoming of
that, but we are consulting, obviously, with the sector. As a policy direction
we are moving towards that public reporting.
MS. ROGERS:
Okay, great.
And the
Auditor General also recommended that all four RHAs implement, I don't want to
say surprise inspections but
AN HON. MEMBER:
Unannounced.
MS. ROGERS:
Unannounced inspections, and
the department's response was that Eastern Health will continue to do so. Will
all the other regional health authorities do that as well?
MR. ABBOTT:
I think we're going to have
more conversations with them on the specifics of that and how that is done. But
putting that aside for the moment, each of the RHAs have staff visiting in those
homes constantly, regularly, announced, unannounced; either because it's as a
community health nurse going in to do their visit with their patients and other
social workers and what have you. What we want to do is that they will have a
formal reporting. Any time they go in for whatever reason
MS. ROGERS:
Okay.
MR. ABBOTT:
there is a report and
recorded. It's part of their normal activities. If they notice anything that
should be brought to the attention of their managers of record, then that will
then be recorded, so that I think will go a long way in addressing that.
Part of
that is also I think, looking at it from a risk point of view, which homes are
probably having challenges around care issues or food issues or life-safety
issues and making sure we, one, visit them and monitor them more closely and
obviously more unannounced.
MS. ROGERS:
Right.
MR. ABBOTT:
So in the case I mentioned that we are sort of addressing right now, we are
doing regularly, unannounced inspections to make sure that they are meeting the
terms of those conditions.
MS. ROGERS:
Yeah.
Yet,
those situations, whether it be an OT or a nurse or whatever, they have a
specific task when they go in.
MR. ABBOTT:
Yes.
MS. ROGERS:
So they wouldn't be looking
at a global thing.
MR. ABBOTT:
No, but they would have sort of a template that they can report against. When
they are there, yes, they are there for their regular business and oh, by the
way, this is what else we noted.
MS. ROGERS:
Yeah, but you'll also be
looking at doing the unannounced more global inspections.
MR. ABBOTT:
Yes.
MS. ROGERS:
Great. Thank you.
CHAIR:
Ms. Rogers, I'm going to move
to Mr. King.
Thank
you.
MR. KING:
I don't have a whole lot on
this one actually. It seems to be pretty much up to date. There are a few that
are partially implemented and one not implemented and that goes back to January
of this year.
MR. ABBOTT:
Yeah.
MR. KING:
Can you give me an update on
those? I think it would be 3, 5 and 6 on the first page.
MR. ABBOTT:
So if I can just quickly, in Recommendations 1 and 2, they are partially
implemented in terms of the operating standards will be out this fall. Reporting
results to the public, we are working actively on that and may begin reporting
as early as in the next week or two.
MR. KING:
Okay.
MR. ABBOTT:
So we're focused on that for the data we have.
Recommendations 3, 4, 5, 6, 7 and 8 are implemented.
MR. KING:
Okay.
Just one
more question, a lot of this has been fully implemented over the last two years.
So for the fully implemented recommendations from the health authorities, are
you finding a noticeable difference in the improvement of following the
regulations? Or have you had an opportunity to do the follow-up?
MR. ABBOTT:
The standards when they were written and then where we were, I think what would
happen is we sort of put the standards there and we followed them but we weren't
monitoring against them as
MR. KING:
Okay.
MR. ABBOTT:
closely as we should. I don't think there was any issue when we talked to the
RHAs in how we do that. Again, the staff and the directors and managers are
constantly meeting with the operators, visiting and those things, so there's a
process in place to do that.
Now,
we've formalized that to make sure that it's done on a regular basis according
to the standards and we now can report out with more confidence.
MR. KING:
Okay, thank you.
CHAIR:
Mr. Petten.
MR. PETTEN:
No, I'm good.
CHAIR:
Mr. Finn.
MR. FINN:
I am just curious on the
reporting of the results, which you said you were partially through. It says the
department will begin to post this is Recommendation 2 the licence status.
Are you going to get into any more specifics around that I guess back to
Gerry's point, what information other than just a licence has been ?
MR. ABBOTT:
So we'll start with that and
once we have the standards done and our monitoring framework in place, then
we'll provide more comprehensive reports on are they meeting those standards and
where they're deficient. Then that will allow you to interpret why the licence
was fully met or conditional.
MR. FINN:
Right. Because some of them
were referring to fire life safety
MR. ABBOTT:
Yes.
MR. FINN:
and some of those nuances.
It's one thing I guess to log online and see that personal care home ABC is
licensed, but it's another thing to know that it's licensed yet there was a
noncompliance with this, this or that.
MR. ABBOTT:
That's where we want to get.
MR. FINN:
Right. Okay, excellent,
that's all. It looks like great progress on all those fronts.
CHAIR:
Thank you.
Mr.
Rogers.
MS. ROGERS:
Just to pick up there where
John left off, John. The Auditor General recommends that three of the RHAs,
Eastern, Central and Labrador-Grenfell, should only license personal care homes
when they comply with the personal care home operational standards.
MR. ABBOTT:
Yes.
MS. ROGERS:
That's a self-evident
recommendation. So why do you think there were personal care homes licensed when
they did not comply? What was the reasoning ?
MR. ABBOTT:
We've had that discussion
internally from time to time. When an operator, whether it's, in this case, a
personal care home or whether it's an ambulance operator or what have you, when
they are deviating from the accepted standard, then we look at the context in
which that is happening.
If it's
a case of yes, there's a fire extinguisher not working, that's one thing
MS. ROGERS:
Yes.
MR. ABBOTT:
If it's there is no sprinkler
system working, that's a different issue. But then you get into is there a plan
in place to address that, that is satisfactory and poses no risk to the
resident. Then, thirdly, we then have to have a contingency in any event, can
we move the residents? So, in some cases, there is my term here, not the
department's term sort of a bit of a compromise to be worked out
MS. ROGERS:
Yes.
MR. ABBOTT:
because, in some cases,
there is no option to relocate the residents. So we have to work with the
operator and, in those cases, then we're in doing regular monitoring and
inspections and follow-up so that the risk is minimized, not obviously
eliminated, until the deficiency is addressed.
It's not
ideal from our perspective, but it's the reality in which I guess our system has
to operate.
MS. ROGERS:
I can't remember now going
through the documents. Are there still existing personal care home that do have
some non-compliance?
MR. ABBOTT:
Yes.
MS. ROGERS:
And do we know what they are?
Is it possible to get that information?
MR. ABBOTT:
We have those that would and as I said, there's one that is sort of very
current that we're currently working here in the Eastern region, but that is
available, yes.
MS. ROGERS:
So we can get copies of that?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, great. Thank you very
much.
The
Auditor General again recommended that Eastern Health, Central and Western RHAs
ensure that personal care home staff meets the minimum hiring requirements as
required. I think you spoke a little bit to this.
MR. ABBOTT:
Yes.
MS. ROGERS:
This report now is two years
old.
MR. ABBOTT:
Yes.
MS. ROGERS:
The department's response is
that Eastern Health is doing this. What about the other RHAs and how do we know
this?
MR. ABBOTT:
We're obviously having conversations with each of those and they're fully
apprised of this.
Two
things here; one is in terms of which requirement they need to meet. As an
example, if you're hiring a new employee, if they have been tested for
tuberculous and we do that but if the need for that individual is now on a
Friday and they haven't got that test done because it's scheduled for next week,
could or should we hire that person?
I think
the answer is I think we will. We'll take that risk as long as there's a
follow-up. Do they have first aid, those things? So it's looking at each of
those criterion and say well, what is the risk in the event of; but the goal is,
obviously, to not only meet those minimum requirements, but to increase those,
particularly as the residents are older now, they're frailer and they're having
more complex health conditions so we know we need to increase that issue.
The
reality we're facing in some areas, not all, is staffing shortage, availability
of.
MS. ROGERS:
I was just going to ask you
that, yeah.
MR. ABBOTT:
Many times the operators are left scrambling to find anybody dare I say to
fill in. That's where we have to be careful because we may be compromising, yet
on the wrong thing. So we are working with those operators for them to have some
contingencies as to their recruitment plans. But if it comes to a point they
can't, then that's another conversation that needs to take place because at the
end of the day it's the residents their needs have to be fully addressed. If
the operator cannot do that in a sustained way, then the licence would have to
be removed. There are no two ways about that.
MS. ROGERS:
I imagine as well, as you
spoke earlier, that the personal care homes that you're looking at having people
with higher level of needs, needing higher level of care, and I was going to ask
you about that I imagine that staffing is a challenge and I would imagine it's
because of demographics, but it's also because of level of pay.
MR. ABBOTT:
Yeah. That will be a factor and we're cognizant of that. If that, at the end of
the day, is the issue then we obviously have those conversations and we continue
to adjust, based on provincial need, wage levels and local wage, as needed, in
these programs. So we constantly adjust around home support and any of those
community-based programs.
Again,
it has been less an issue of pay. It's just simple availability of individuals
that are willing to do this work. It's difficult and hard work, there's no doubt
about that.
MS. ROGERS:
Yes.
What's
being done to try and address that? Because it is a growing problem, isn't it?
MR. ABBOTT:
Yes. Again, the operators are ultimately responsible for the recruitment, so we
work with them. We're working obviously with the private and public colleges to
make sure those are trained to move in this work and we do a lot of work in our
HR, human resource planning, in the health system so we know where the needs
are, where the capacity is in the training system to meet that.
We are
making sure we have sufficient subsidies provided that allows the operator to
hire appropriately and at the appropriate wage levels. So it is within health,
and there is one in two other areas where the staffing is going to be a bit of a
problem, and there's no immediate fix for some of these operators.
MS. ROGERS:
Just finish this one
CHAIR:
Ms. Rogers, I'm just going to
move to Mr. Bragg to see if he has any other questions.
MR. BRAGG:
(Inaudible) about the
personal care home that caught fire and burned, I think, right to the ground
last year out in Central. Did we learn anything from that? Because I'm thinking
like emergency plans and where to put all the residents; most of them have
closed up their houses or the family has sold their house. What would be the
contingency plan there?
MR. ABBOTT:
There are contingency plans
each operator would have. Then in the short term, obviously, is there an
adjacent home or facility that they would be back into a hospital, nursing home
or a related community facility? Obviously, talking to the family for those that
can return home for a short period of time. In this case, it worked out well.
The community came together, the adjacent communities, and we were able to
literally that evening and into the next morning have everybody located.
Obviously, this is the long-term thing, it's the only home on the Baie Verte
Peninsula, so we were able to place everybody for a longer term.
The
challenge then for those is that it's not necessarily immediately that they're
going to go back within a month or even a year. We're not sure yet. I believe
the operator may be rebuilding, but I don't know.
The
lesson learned is we just build on that. Each of our health authorities have
fairly good emergency planning systems in place that we rely on. We monitor
those and if there was a resource shortage, dollars, whatever, we'll make that
available. But, in this case, they were able to accomplish and accommodate all
of that within the region in literally less than 24 hours.
MR. BRAGG:
Okay, thank you.
One
other quick question: Capacity for these buildings, are they at full capacity
for a guess I do not know if you would have
MR. ABBOTT:
No. It varies across the
region.
MS. TUBRETT:
16 per cent vacancy.
MR. ABBOTT:
Yes (inaudible). So around 16, according to Denise's numbers here, vacancies
within that. It varies by region; Central, actually, the vacancy is a bit
higher.
MR. BRAGG:
Okay, perfect, thank you.
No more
questions for me, Sir.
CHAIR:
Mr. Petten, anything further?
MR. PETTEN:
No.
CHAIR:
You're good?
Ms.
Parsons.
MS. P. PARSONS:
I think we covered everything
that I had concerns for, yes.
CHAIR:
Ms. Rogers.
MS. ROGERS:
Back to the staffing issue, I
was in conversation with someone from labour who was saying that the majority of
people providing home care or this type of personal care are women in their 50s
and some middle-to-late 50s and that soon they won't be working and doing this
kind of work. So it really is
MR. ABBOTT:
Yes, it is how to make this
more attractive opportunity for young people, but that's true for this and home
support where
MS. ROGERS:
Yes.
MR. ABBOTT:
some of the home care
agencies would find, certainly in the more rural areas of the province, in
trying to meet the need because our seniors are staying in place; people are
moving out.
MS. ROGERS:
Yeah.
MR. ABBOTT:
So that's going to be an issue that we will have for some time to come. As I
said, we are working with the operators and the trainers to make sure, to the
degree possible, to have people in place.
So like
physicians in rural areas, we do have times when there's a shortage. We work
diligently trying to find a solution with the community. So far, we've been able
to do that, but when we project out again, it is trying to make sure we can
support people basically in the rural communities. It's not easy.
MS. ROGERS:
This is not one that can be
solved by automation.
MR. ABBOTT:
No, that's right.
MS. ROGERS:
Okay.
The
Auditor General did identify 16 critical fire and life safety deficiencies
identified in seven of the 30 personal care homes reviewed, yet the Auditor
General could not verify if these critical issues were dealt with quickly.
Several of the same issues were identified in previous year's inspection as
well.
So
what's been done since this report to ensure that this is still not the case,
that serious issues are dealt with properly and to be able to verify that,
properly, quickly?
MR. ABBOTT:
Ms. Rogers, because it's with the Government Service Centres in Service NL, I
don't know if I can answer that to the degree that you would like. We have
checked with them prior to coming here today.
MS. ROGERS:
Yes.
MR. ABBOTT:
We've been informed that those recommendations have been fully implemented by
them.
MS. ROGERS:
Okay, thank you.
The
interesting letter to the editor in The
Telegram was in August 2016 from a person who had personal experience with
personal health care homes and was critical of many of the same problems
identified by the Auditor General. One of the issues was that the inspection
process for re-licensing a personal care home did not include questioning the
residents or their families regarding their satisfaction with the quality of
care.
MR. ABBOTT:
I think one of the things we will be doing on a go-forward basis, as throughout
all our health care services, is doing more client-resident-family satisfaction
surveys.
MS. ROGERS:
Great. Okay.
MR. ABBOTT:
Because that's one of the common standards around quality, and that's
recognized.
MS. ROGERS:
Yes.
MR. ABBOTT:
So that will be in our plan going forward.
MS. ROGERS:
We'll see that as a regular
course of action.
MR. ABBOTT:
Yeah.
MS. ROGERS:
Great. Thank you.
Also,
has any consideration been given so if you are in fact doing inspections, if
inspections are being done, to include resident and family input in the actual
inspection?
MR. ABBOTT:
I do not know if the previous question and this are connected here
MS. ROGERS:
Yes.
MR. ABBOTT:
In terms of an appropriate survey, we would ask them their observations or
issues around are they satisfied with a, b, c, the physical condition
MS. ROGERS:
Right.
MR. ABBOTT:
however we phrase that, but I don't know two things: for the areas that
we're responsible for, family counts as to whether it was long-term care, if
that is the case, and their input is certainly requested and encouraged. But in
terms of actually participating in depending if I understand your question
correctly the process of inspections or monitoring, I wouldn't necessarily see
that at least from where we were.
I,
again, don't want to speak for Service NL, but I wouldn't necessarily anticipate
that they would be doing that either.
MS. ROGERS:
I guess if there are any
formulized inspections of any aspect to actively then not that they would do
that
MR. ABBOTT:
Yes.
MS. ROGERS:
but to actively reach out
to residents or families as part of that process.
MR. ABBOTT:
I think the important part here is what we find, they find, say, collectively
that there is a public report that the residents and their families are fully
apprised of the results of those reports so that then if there are obviously
issues, or as you are selecting where you want to go or your family member, then
you have that information.
MS. ROGERS:
Okay, but you are also going
to survey?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, great.
Complaints process, is there a formalized complaints process? How does that
work?
MR. ABBOTT:
Again, if there is a complaint process, it will be within the RHA and then they
would record and monitor that. We, at the department, on occasion would get a
complaint directly from a family member or a resident, but usually a family
member on their behalf. We would address that with the RHA. The requirement is
then that they would follow up with the family and/or the operator, or both,
depending on the nature of the complaint, and then report back to the minister.
MS. ROGERS:
Okay.
Do you
see what kind of role the Seniors' Advocate might have in this area, not just in
complaints but in the whole issue of personal care homes?
MR. ABBOTT:
I guess our assumption is that given that we are the department that deals
largely with the seniors' issues in terms of care and through the full gamut of
care issues that we will have a lot of engagement with the advocate. Again, the
advocate's role will be more systematic issues but these all bubble up at times
and you have a systemic issue there that we will be working closely, as we do
with the Citizens' Representative from time to time. He's making his reports
based on what is happening in the health care and we work and respond to that.
What we
find, actually that's a very useful process because it takes the subjectivity
out of it and it's fact based and it's an independent observer and recorder of
the facts. We encourage many residents and families when they're not satisfied
and they're not satisfied with our answer, we encourage them to go to the
Citizens' Representative office because then we think they will get a fair
hearing. Then it helps us with improving our processes where they need to,
rather than us trying to defend some things that probably are indefensible.
MS. ROGERS:
Okay, I'm fine.
Thank
you very much.
MR. ABBOTT:
Yes.
CHAIR:
Thank you.
Everybody good? Mr. AG, you're good?
MR. PADDON:
I'm good.
CHAIR:
Okay, good.
Thank
you, Mr. Abbott, and your officials.
Now
we'll move to our last heading under Health and Community Services and Eastern
Health which is the Road Ambulance Services. I want to welcome Mr. Wayne Young
who is the regional provincial specialist in this area. You've been sworn in, so
it's all official.
I'll
turn it over to Mr. Bragg to ask any questions, please.
MR. BRAGG:
Okay, thank you.
I have
three questions. I guess I'll start off with the training. It seems like the
further you are and I looked at the map and this is only eastern, so I'm
assuming from Clarenville east that this report was done, but it is probably
reflective for the rest of the province. It seemed like the further you are away
from the Avalon region, St. John's region, the more lenient you are to the
actual training of the ambulance attendants.
Is there
a reason for that? Is it a job with staffing or
?
MR. ABBOTT:
If I may, before I answer
your specific question, just to give you an update on the recommendations. The
Auditor General provided 12 recommendations; eight that were specific to our
department and four specific to Eastern Health. Of those 12, 11 are partially
implemented and one we have not started implementing. I think the simple answer
to the question is one of capacity in each of the health authorities and then
within the operator community to take this on.
We're,
as a department, and certainly in the direction we have from the minister, is
that we need to really focus on this aspect of the road ambulance service. We
need to engage the training system because there's a capacity issue there. We
can only train so many. I think Wayne, if I'm correct if we met exactly what
the AG is sort of suggesting or implying, which we agree with, it would probably
take us seven years or something to get where we need to go. We know that's not
sustainable in terms of what we need to achieve here.
So we
are looking at some self-regulation for paramedicine so that they can up their
game. We need to provide more training capacity within the province, and then at
a certain point hopefully sooner than later with the operators, in terms of
our service level agreements with them, that they will have to meet that higher
level of training before we will fund them.
That's,
again, easier to say because that means a lot of change is going to happen and
the operators are going to have to step up their game as well.
MR. BRAGG:
In the community groups,
would that be volunteers? I think I saw (inaudible)
MR. ABBOTT:
Well, volunteers on that so if you're in the ambulance, if you're paid or a
volunteer, you're going to have to meet a certain standard. We, relative to
other provinces, have a lower level standard of care. We are providing the
emergency service, as needed, but the ability then for the attendant to actually
provide care is minimized because they are not paramedics. We need paramedics on
all of these ambulances if we want to provide the standard of care that people
expect and we believe needs to be delivered.
So it's
a lot of change that has to happen in very short order.
MR. BRAGG:
Okay, thank you.
The
other question I have is relating to response times, and I guess I'll tie this
in with I'm not really familiar with the 911 system, if the Avalon always had
it or it was just the greater St. John's area. The new 911 system province-wide,
does that speed up the ambulance response time, or does it somewhat slow it
down?
MR. ABBOTT:
Again, there's a change in what each region or your community is used to. So if
you're calling an ambulance, you can call 911, and in St. John's that's
accepted. You could call the hospital directly or you can call the operator
directly. Depending on who you call, when you call so if you're calling 911
and then they have to triage that and send it over to the operators, there's
obviously a gap in time, and depending on how sophisticated your system is. So
we are learning, outside of the greater St. John's area, how to do that better,
but it's still not perfect. Our response times then, once the call is in, if
it's to 911, the 911 to the operator, the operator then, whoever is on dispatch
receives the call, within 10 minutes that ambulance is supposed to be leaving
for the scene.
That's
sort of what we measure and we have all the statistics on that for each service
across the province, and we monitor that closely.
MR. BRAGG:
I was just curious, if you
get complaints where people are used to calling the local number and now they
call 911, they call back there and people are saying now, where I used to wait
10 minutes, I wait 40 minutes.
MR. ABBOTT:
Yes.
MR. BRAGG:
You're not hearing that are
you?
MR. ABBOTT:
No. We've heard examples of that.
MR. BRAGG:
Yes.
MR. ABBOTT:
When we do hear that, we do
go back to find out who called whom when and try to measure that. If there's a
problem in that community or region, then we're honing in on that to make sure
that the residents know exactly who they should be calling.
MR. BRAGG:
If you look at your ambulance
system overall, would you rate the best situation where anybody should go
forward with like an ambulance from the hospital, ambulance from a volunteer
group, or from a private company?
MR. ABBOTT:
I don't know in terms of which one it is are they meeting with standards that
you're setting? Do they have an efficient, high-quality dispatch? Do they have
good vehicles and do they have trained paramedics on that vehicle? They are sort
of the three elements. If you got that right, then you have a good service.
Both in
terms of the AG report but also the other work that the department has done in
terms of Fitch report,
which has been referenced; they did a comprehensive review of our ambulance
service here in the province. They've laid out a series of recommendations that
if we follow those according to their recommendations, we will have a
high-quality ambulance service throughout the province.
We are
starting the implementation of that report in tandem when looking at these
recommendations because they do go hand in glove. The first focus for us now is
on central dispatch. We have to have all ambulances coming out of basically one
system so we know exactly where all ambulances are, what they're doing and how
they're doing it. And right now, we're able to monitor where they are, but we're
still running multiple services and we have exclusive areas and things like
that. All of that has to change if we want to improve the service.
MR. BRAGG:
One final question, Mr.
Chair, and that has to do with the condition of the ambulances, overall
condition.
MR. ABBOTT:
Yeah.
MR. BRAGG:
Except for Service NL, are
there any other checks and balances to make sure the ambulances are up to code?
MR. ABBOTT:
Well, there are different inspection systems. One of the things that we do not
have here in this province, we do not have one piece of legislation that covers
all aspects of the ambulance service from the time your licensed to have it, to
monitor the vehicles, to monitor who's on the vehicles. So we are working on
drafting legislation, hopefully this fall, if not, next year, to put in-house so
we can bring all of those pieces together.
MR. BRAGG:
Thank you.
That's
it for me, Mr. Chair.
CHAIR:
Okay.
Mr.
Petten.
MR. PETTEN:
Thank you very much.
On this
issue, one broad question I'd ask: Is the funding adequate for the road
ambulance program? You hear anecdotally and we've heard over protests and
complaints.
MR. ABBOTT:
Yeah.
MR. PETTEN:
It seems to originate back to
some policy but a lot of funding issues.
MR. ABBOTT:
Mr. Petten, I don't see it that way and certainly at the department. Again, we
are meeting the needs of each of the ambulance services and operators across the
province and we negotiate on that. We've added significant new dollars under the
current agreement.
For the
hospital-based services, we work with them on their budget needs, but we are
also challenging how they can be more efficient to do things more effectively.
So as an example, in Western Health last year, and now we're moving into Central
Health and hopefully into Eastern Health in the near future, is when we are
doing non-medical transports. So why do you use the same service and attendants
for that service, when you are responding to an emergency? They're two
completely different services. They have now moved to change that. That frees up
resources and saves dollars that they can put back into the ambulance program.
Depending on how you measure this, but at the department we believe we have an
overcapacity of ambulances in this province. We can reduce the number of
ambulances and use that money to put it into training, increasing the skill
level and, obviously, payment within the system and also support having a
central dispatch system throughout the province. But that means certain
decisions would have to be made as to which ambulances and which communities
would have to change.
Again,
the bigger costs are certainly in the urban centres and their response times are
closely examined. We expect when we talked this morning about value for money
to make sure we get that in those services.
From
time to time, we do get complaints there isn't sufficient capacity on a
particular hour in a particular day, particularly in the St. John's area, but
they have systems in place to address that. They can call on the regional fire
department and others and other ambulances to support them, if need be.
It's
really measuring the risk at any point in time. As the population changes and
the communities change, we have to respond with the appropriate ambulance
service.
MR. PETTEN:
Okay.
I had
another question that was medical transport so you went two for one on that.
MR. ABBOTT:
Yeah.
MR. PETTEN:
That was a question I've
always wondered about because you're taking resources from areas and you see it
all the time, they're just transporting from one community into the hospital and
they have their staff onboard. They're taking away the vital service, what's
needed most. There has to be a way around it.
MR. ABBOTT:
Yeah.
MR. PETTEN:
So I appreciate that.
That's
all I have for now, Mr. Chair.
CHAIR:
Thank you, Mr. Petten.
Ms.
Parsons.
MS. P. PARSONS:
Thank you.
The
question I have it's a concern that's been brought forward to me by a
constituent who is a paramedic in the District of Harbour Grace Port de Grave
and working for a private or community-based ambulance. The concern brought
forward is that there's a difference in the overtime pay and the training. What
is the level of standard versus the public-private? Are they paid relatively the
same wages? Do they receive the same OT?
MR. ABBOTT:
Wayne, I don't know if you
want to respond to that.
MR. YOUNG:
There is a difference in how
various services compensate their employees. Essentially, it comes down to the
contractor and the company that they work for. We say you have to have
ambulances available, but how they compensate their employees they are a
contract company that we move forward with.
The
challenge that many of them face is there's a significant difference. I mean
everyone in the province deserves ambulance response, but we have operators that
will do many calls in the run of a day and we have many operators who do very
few calls in the run of a week. To be able to match staffing and employee
compensation is a challenge that the operators have, but that is essentially
you know, they are contractors.
MS. P. PARSONS:
Okay.
With
regard to response times and a recommendation from the last report in 2016
with electronic data-gathering technology which is yet to be determined where
are we on that? Have these devices been placed in the public vehicles where they
can be monitored with regard to response times?
MR. ABBOTT:
(Inaudible.)
MS. P. PARSONS:
So that's done?
MR. ABBOTT: And
we have started now tracking that information. We intend to use that then when
want to develop more in terms of response times. But really from a quality point
of view, are they responding on time; who's on the vehicle, because we are
paying for each element. And then we'll use that information now when we sit
down and re-negotiate the contracts with the operators beginning this fall.
MS. P. PARSONS:
This would apply to obviously community based, privately owned as well?
MR. ABBOTT: Yes.
MS. P. PARSONS:
Okay.
Just one last question for me yeah, I guess a question.
There was an incident, as we can recall back several years ago, where a patient
was being transported and had managed to escape on the Trans-Canada Highway and
unfortunately was hit by an oncoming vehicle.
It was a fatality. What have we done as a result of that
incident to prevent these further incidents? This, to my understanding, was a
patient with mental health issues. What has been done since then?
MR. ABBOTT: No,
I'm not familiar with the case.
Wayne, do you
?
MR. YOUNG: There
has been a fair bit of conversation with the paramedicine experts and the mental
health staff on the transport of patients who are under consideration for that.
We try, where we can, not to move them at night as we do, and we try and take
all precautions that we can. But it's also very much within the act and within
everything else what are the considerations for the patients themselves in the
evaluation that's done it's been a challenge.
MS. P. PARSONS:
As a result of incidents like
this one, I guess ambulance paramedics and whatnot, and even operators; do they
have sort of like a kind of speciality training when dealing with patients with
mental health? As we know, a lot of these calls are to do with mental health
issues and crisis.
MR. ABBOTT:
So again, that would be part
of the training, but to your point is as this becomes more prevalent, we have to
ensure that. We'll be building that in as we're doing now with dealing with
naloxone and things like that.
As these
issues emerge, we're sitting down with Eastern Health with the provincial
oversight for the ambulance service to develop protocols and then work with the
operators and their staff to put those in place. But it does require the
co-operation of each of the operators. Outside of the hospital basis, they're
all privately or community owned and we have to engage each of those and get
them onside.
MS. P. PARSONS:
Thank you.
CHAIR:
You're good?
Okay,
Ms. Rogers.
MS. ROGERS:
Thank you.
The
Fitch report now is four years old. That report called for a complete overhaul
of our province's ambulance system. Looking at, too, when we look at the three
issues a single agency to administer and oversee the program, a central
dispatch system, a self-regulation of ambulance professionals is it fair to
say that a number of the Auditor General's deficiencies that he found are
because the review's recommendations haven't been followed through?
MR. ABBOTT:
I wouldn't put it the way
you've raised it there.
MS. ROGERS:
Sure.
MR. ABBOTT:
But I think they are
reinforcing those findings and that we now have in front of the minister a
series of recommendations to, in fact, start implementing the Fitch report
which, again, is consistent with the Auditor General's findings and his
recommendations and how you now basically modernize our ambulance services going
forward.
MS. ROGERS:
Again, in those
recommendations, they're four years old and still are so very relevant because
we haven't followed through on those.
MR. ABBOTT: Yeah.
Now, I wouldn't
MS. ROGERS: Why
haven't we?
MR. ABBOTT: I
want to be careful. Different aspects are being implemented.
MS. ROGERS: Fair
enough, yes.
MR. ABBOTT: But
the larger system-wide ones and I would say because of timing of elections and
government change and those things, it's probably slowed down the progress. I
know the department was on this road and had to sort of just wait until the
government was able to address it with the other priorities it's dealing with.
But as I say now, the minister has a series of recommendations that he will be
dealing with going forward and we've spent a fair bit of time with briefing him
and working with him on these issues.
We think and we've talked to the operators. Again,
there's a lot of change here, so as much as we would like to say let's have it
done by X date, there's going to be a fair bit of negotiation with them and it
requires an infusion of dollars. Given the government's overall fiscal
situation, we've had to do some trade-off of dollars to find the money to put
into this service.
MS. ROGERS: Is
there any kind of guesstimate time frame around a central dispatch system?
MR. ABBOTT:
Well, as the government has already committed in
The Way Forward this is a priority. We
have to have proposals out literally in the next couple of months, and ideally
this year, to have that in place. So that's sort of the time frame we're working
on.
MS. ROGERS: So
the proposals, like the request for proposals, would be going out in a few
months.
MR. ABBOTT: Yes.
MS. ROGERS:
Okay.
There was an RFP that went out September 2015 and called
for design and implementation plan, and the closing date for that October 2015.
But we're going to see this happening again.
MR. ABBOTT: I'm
sorry; I was just asking Denise here.
MS. ROGERS:
Yeah.
MR. ABBOTT: That
proposal that you referred to was again before I joined the department.
MS. ROGERS: Yes.
MR. ABBOTT: That
was to hire a consultant to help us design.
MS. ROGERS:
That's right.
MR. ABBOTT:
Which they have done. They have submitted a report. Now we are taking the ideas
presented there and that will allow us now, assuming government agrees,
to go out with a request for proposals to put a central dispatch system in the
province.
MS. ROGERS:
Okay, so not just for design
again, but to actually implement the design that was
MR. ABBOTT:
Yeah.
MS. ROGERS:
I can't remember, has that
design been made public, the report from that proposal? And will it be?
MR. ABBOTT:
Yeah, I don't think there's
any reason why we'd now, it may be caught up in our Cabinet process, but we
will check on that.
MS. ROGERS:
Okay.
If it's
available, can we have a copy of that?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, great. Thank you.
That's
encouraging. That brings us one step further.
MR. ABBOTT:
Yeah.
MS. ROGERS:
Closer.
Then in
response to the Auditor General's recommendations on patient care reports the
department noted the process would be much more efficient with implementation of
electronic patient care reporting. Can we get a sense of where that might be?
MR. ABBOTT:
Wayne, do you have any
?
MR. YOUNG:
The electronic patient care
reporting which is essentially laptops in the ambulances ties hand in glove
to the central medical dispatch centre. Fitch, when they did their planning
project, envisioned that electronic patient care reporting be a part of the
central medical dispatch centre.
MS. ROGERS:
Okay, so there's no point in
having them if we don't have a central right. Okay.
A
question once again about the RFP for the central medical dispatch centre; the
RFP might go out this fall. When is the anticipated then, how long for the RFP
and then the actual implementation?
MR. ABBOTT:
Well, I would say from that
you're probably talking 12 to 18 months. Again, depending which options we come
with and who responds, there are those that are and there's some dispatching
going on centralizing because we have summer operators because they run
multiple services and large services in the province. Then there are those
outside who have provincial systems that they could literally parachute in here.
We'll
measure all of that once we get the responses and we'll be looking at,
obviously, which will be the most cost effective to allow us to proceed.
MS. ROGERS:
Okay.
Thank
you very much.
CHAIR:
Thank you.
Mr.
King.
MR. KING:
(Inaudible) questions here.
Rural areas are always a challenge. I look at some cases which were brought to
my attention where the one because it's all through private contract. I know
Fewers are the big name out our way.
You have
a dispatcher getting called from home, and then he has to go get his buddy,
which you drive past a house but you need to stop, too, to get his compatriot
there and then you have to come back.
Has
there been much through to providing a central location, say like Bonavista or
somewhere they can stay, be dispatched from that location and you get there in a
little quicker time?
MR. ABBOTT:
Well, I think when we get to the central dispatch and the concept we have, then
you start bringing all those issues out on the table.
MR. KING:
Okay.
MR. ABBOTT:
And you say, if you want the most efficient system and the most timely response,
then you have to do things exactly as you're suggesting.
MR. KING:
That's some feedback I've
actually gotten from some paramedics. Having a central location makes more sense
for them because they don't have to make that stop for their buddy, go back and
then go from there.
One
other thing that came to my attention very early on after I got elected is
what's being taught I believe the paramedic college is in Grand Falls or
Lewisporte I think that's a private college, but I'm not sure what was being
taught and what was being tested at the time because I think at the time we
underwent new standardization. We went by something that Ontario went through or
tested on. And what the attendants found was what they were being taught at
their college wasn't the same thing they're taught on their exam. So has that
been taken care of or something that you're aware of?
MR. ABBOTT:
I'm going to ask Wayne if
MR. YOUNG:
It's Keyin College you're talking about in Grand Falls.
MR. KING:
Yeah, I think so.
MR. YOUNG:
They've had, to the best of my knowledge, very good pass rates.
MR. KING:
Yeah.
MR. YOUNG:
I know because I deal with them. They have made some modifications to their
training program to help the students be, what they consider to be, better
equipped to do the national exam, but it's not technical medical skills. It was
how the questions were being asked and being phrased.
MR. KING:
Yeah, I believe
MR. YOUNG: I think
the first time around, they had some experience that the students were taken a
little off guard, but Keyin Tech has very good pass rates.
MR. KING: Yeah,
and that was the attendant he passed his exams, but there a little concern at
the time because there a bit of transition time. Usually when you don't hear
anything afterwards, everything seems to work out. So thank you for clarifying
that question for me. It's something I've had in the back of my mind for some
time.
That's all the questions I have. I want to thank the
department for providing us such detailed answers and listening to our concerns.
You seemed to do a very good job over the last two years getting things from
where they were to where they are today.
CHAIR: Thank
you.
Ms. Rogers, any further questions?
MS. ROGERS:
I'm fine.
Again,
thank you so very much for today. John, you've been stellar in providing all
that information for us. Thank you to all your staff.
You
certainly do have a challenge ahead of you. I feel we're probably all very much
in good hands. Good luck and thank you.
CHAIR:
Mr. Finn.
MR. FINN:
I'm fine with the questions
that have been asked by my other colleagues.
Thank
you.
CHAIR:
Gentlemen, as I think
everybody has completed and, again, I want to echo on behalf of all the
Committee all the key things that have been outlined.
As the
Chair, I always get to have the last word and normally ask questions that may or
not have been answered or not answered to our satisfaction. I had 18 questions
noted and all have been answered to my satisfaction and even in more detail than
I would have thought.
I do
have one question that I'll ask Wayne: Can you give me a little bit of a
breakdown, or us a breakdown, on the classifications from primary, secondary
ambulance services, just so we have an understanding of how that's determined.
MR. YOUNG:
You're talking about a
primary and a secondary ambulance?
CHAIR:
Yeah, exactly in the
particular community or region.
MR. YOUNG:
John, do you
?
CHAIR:
Or, John, would you
?
MR. ABBOTT:
Go ahead.
MR. YOUNG:
Okay.
What
we've done is we have 83 ambulance bases in the province. Every multiple
ambulance base has at least two ambulances that we contract 24-7 response. There
are a number of single ambulance bases and that ambulance base, obviously, is
contracted 24-7. Other additional ambulances at that base so say there was an
operator who had four ambulances, two would be considered primary and they are
to staff them 24-7 with 10-minute response.
The
other ambulances are what we class as secondary ambulances. While they are still
available for emergency response, their primary task is inter-facility transport
and go from there.
CHAIR:
Yeah. That's just the
clarification I wanted. That was my understanding but I wanted pure
clarification as to where that is.
Other
than any other questions, again, on behalf of the Committee I want to thank you
guys. It was a great opportunity for us to get some clarification. We were
impressed by the response that came back from the department, but there's always
clarification. Sometimes you guys might use lingo from a bureaucratic point of
view that, us, as mere politicians, may not understand. It's good to get
clarification because we need to keep our constituents informed.
I want
to thank the Auditor General and his staff also for being here. We look forward
to seeing the Auditor General again tomorrow; we have two more sets of hearings
tomorrow. You guys right now until we do a review in two or three years, you're
off the hook. Anyway, thank you, guys. I thank the Committee. I want to thank
Elizabeth ,too.
So we're
good, guys, tomorrow 9 o'clock here, CSSD. And while I have the Committee here,
we need to pass you're good; you don't get to vote on these minutes the
minutes from our meeting of May 18, which we reviewed which hearings we were
going to hold.
Moved by
Mr. Bragg; seconded by Mr. Petten.
All
those in favour signify by saying 'aye.'
SOME HON. MEMBERS:
Aye.
CHAIR:
Opposed, 'nay.'
Motion
carried.
On
motion, minutes adopted as circulated.
CHAIR:
Thank you.
The Committee adjourned.