NOVA SCOTIA HOUSE OF ASSEMBLY
Wednesday, June 6, 2012
Office of the Auditor General
May 2012 Report
Printed and Published by Nova Scotia Hansard Reporting Services
Public Accounts Committee
Hon. Keith Colwell, Chairman
Mr. Howard Epstein, Vice-Chairman
Mr. Clarrie MacKinnon
Mr. Gary Ramey
Mr. Mat Whynott
Mr. Brian Skabar
Hon. Manning MacDonald
Mr. Chuck Porter
Mr. Allan MacMaster
[Ms. Becky Kent replaced Mr. Howard Epstein]
[Mr. Gary Burrill replaced Mr. Brian Skabar]
[Mr. Andrew Younger replaced Hon. Manning MacDonald]
[Mr. Keith Bain replaced Mr. Chuck Porter]
[Hon. Christopher d’Entremont replaced Mr. Allan MacMaster]
Mrs. Darlene Henry
Legislative Committee Clerk
Mr. Gordon Hebb
Chief Legislative Counsel
Office of the Auditor General
Mr. Jacques Lapointe, Auditor General
Mr. Alan Horgan, Deputy Auditor General
Mr. Terry Spicer, Assistant Auditor General
Ms. Ann McDonald, Assistant Auditor General
Ms. Evangeline Colman-Sadd, Assistant Auditor General
HALIFAX, WEDNESDAY, JUNE 6, 2012
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Hon. Keith Colwell
Mr. Howard Epstein
MR. CHAIRMAN: Good morning. I’d like to call the meeting to order. I’ll start the meeting by asking everybody to introduce themselves.
[The committee members and witnesses introduced themselves.]
MR. CHAIRMAN: Good morning, welcome everyone. I’d like to start our proceedings this morning by asking Mr. Lapointe to make a presentation.
MR. JACQUES LAPOINTE: Thank you. As you know, my Spring report was tabled with the Chief Clerk in the House of Assembly last week. It was my second report in 2012 and covered audit work completed by my office in late 2011 and the early part of this year. I am pleased to have the opportunity to discuss it with you today.
With me today are Deputy Auditor General Alan Horgan, and Assistant Auditors General Terry Spicer, Ann McDonald, and Evangeline Colman-Sadd. Ann and Evangeline were each responsible for certain chapters in the report. I’m sure that among us we can answer any questions that you may have.
Before we begin I want to acknowledge the valuable work, the dedication and the professionalism of all my staff. Their efforts make it possible for us to provide assurance to the House of Assembly on the operations of government. I also thank the many public servants in departments and agencies whose co-operation was vital to the success of our audits.
There are five chapters in the report in addition to the introduction. We make 77 recommendations, all intended to improve departmental and agency efficiency and effectiveness. I’ll briefly mention the topics covered. In Chapter 2 we follow up on the implementation status of recommendations made in our reports from 2005 to 2009. We found little progress has been made on improving overall implementation rates in spite of government commitments to do so.
Chapters 3 to 5 provide the results of audits completed at boards and agencies of the Department of Health and Wellness. We found that the Addiction Services program in the Annapolis Valley was well managed overall; prescription drug monitoring processes should be strengthened; and infection prevention and control practices, particularly at Cape Breton Health, need to be significantly improved. We also concluded that the department needs to improve its oversight and direction of health services.
The last chapter describes our audit of the activities of the Office of Public Trustee for which we make some recommendations for improvements.
Mr. Chairman, just before we begin, we do have one point of clarification on one of the audits and if you don’t mind, I’ll ask Ms. Colman-Sadd to make that point.
MS. EVANGELINE COLMAN-SADD: Last week one of the members asked whether we knew if Cape Breton had contacted both of the patients that had been involved with the scopes that may not have been cleaned and disinfected properly. I just have a bit of an update on that. At the time I said that only one of those patients had been contacted and I have some additional information. I understand Cape Breton has made efforts to contact that second patient, as well, but apparently have had a lot of difficulties in actually getting hold of the person. I just wanted to make sure the members were aware of that.
MR. CHAIRMAN: Great, thank you very much. We’ll start questioning with Mr. Younger. You have 20 minutes.
MR. ANDREW YOUNGER: Thank you, I appreciate that update. I was actually going to ask you right off the top whether there was an update on that particular issue.
There’s a whole lot of ground here to cover and I doubt we’ll cover everything today so I guess the departments come back later when you do your planning. There are a number of issues in here, especially in Chapters 3 to 5, or thereabout, talking about the oversight of the department over the district health authorities. One of the things is there are some comments about whether the department is meeting its legislative requirements and responsibilities and some commentary about that. I wonder if you could just elaborate a little bit on where you see the department is not meeting its legislative requirements to oversee the district health authorities.
MR. LAPOINTE: It does come up in a number of our audits. We’ve made comments on this before in individual chapters in different reports, which is why we thought we should try to clarify that a little bit in this report. It's not a simple question, because the delivery of health services in the province is in fact decentralized and it's government policy in legislation to have a delivery of services through district health authorities. But the question then becomes, where is the division of responsibilities between those authorities and the government or the department?
We believe that the legislation is stated in a way - and we believe it's government policy as well - that the central role of the department has not been fully delegated to the authorities, but that in fact the department has a responsibility to ensure that the delivery of services, through the authorities to Nova Scotians, is fairly equivalent across the province, that appropriate services are delivered, that government policies are followed, and to make some overall decisions about delivery of services.
The role of government becomes not just to delegate down or to provide guidelines, but to in fact monitor what services are delivered and how they are delivered, to provide not just guidelines but standards - and providing standards means making some attempt to see whether those standards are actually applied in service delivery, and then to ensure that authorities comply with those standards. So it's a more active role than we often find is the case, and these particular audits are kind of an example of some of those roles and the ways in which we feel greater action needs to be taken by government to take on that role.
MR. YOUNGER: One of the areas - and maybe I'll table this because I'm going to speak to this as it works its way around - the Health Authorities Act governs, and your report talks about this, the role of the health authorities versus the role of the department, and when we talk about the issue of infection control and even some of the things that we see in Annapolis around addiction control, all of which sort of pointed to this, who is sort of watching over things, it appears - and I'm wondering whether you looked into this - that the minister's office has split the reporting of capital and business plans, despite the fact that the Act specifically disallows that.
One page I've tabled is the Act, which says that the business plan has to include the capital plan, as well as a number of other things, then the other is from this year's business plan for Annapolis, which says that each health authority is required to prepare a capital plan under the Health Authorities Act, but the minister has established an alternate process and timeline for submission.
The reason I'm asking about this is because when you go through the report and you look at things like infection control and so forth, it seems that despite the Health Authorities Act saying that the business plan and capital plan need to be together for a reason - for example, to figure out the oversight and so forth, I assume - the minister has gone outside the Act and chosen to split that, and I'm wondering whether, in your audit, you looked at that role?
MR. LAPOINTE: I have to say that when we are conducting audits like this we are looking very specifically at particular programs and even certain aspects of those programs, so the type of issue you are talking about is not one that has come up in the audits we're looking at, so we're not really competent to really comment on that side of it.
We look at, for instance in the addictions services, the standards that government has set for the delivery of services and whether they monitor, whether those are actually being complied with or not, but we don't look beyond the issue that we're specifically auditing so I don't really have a lot I can say about it.
MR. YOUNGER: No, that's fair, I'm just trying to see where we start with the breakdown. In terms of the oversight, you had stated last week or your staff had stated last week that the department is setting rules or guidelines or standards for health authorities to meet, so, for example, let’s look at Addiction Services in Annapolis, which was one of them, but then it appears that nobody is actually walking up to Annapolis and making sure that they’re following those guidelines. Am I understanding that correctly?
MR. LAPOINTE: Yes, I think that’s a fair representation. They provide standards, but then the question becomes, to begin with, are they voluntary or are they mandatory? There are mixed messages that go out; they’re called mandatory standards but put out as voluntary and the authorities consider them to be voluntary targets. They consider them, but they don’t feel compelled to comply with them. As well, the department doesn’t actually get any information as to whether these standards are, in fact, applied, and what’s true in Annapolis will be true across the province.
MR. YOUNGER: So what’s needed to fix that, in your view?
MR. LAPOINTE: I think it’s very simply a more active role by the department in all of these areas. I know that they have referred to a framework that they’re developing with DHAs to work with them, to establish the rules, and that’s fine. I think that’s one way to go about it - not necessarily the only way. But if that’s what they want to do, then they need to, in those agreements with the authorities, clearly establish a more active role for the government and the department in monitoring and assisting the operations of DHAs.
MR. YOUNGER: Does it seem strange to you that there would be a lack of clarity around whether a standard is mandatory or voluntary?
MR. LAPOINTE: It’s not a question of whether it seems strange or not, but I think it’s just an approach that has evolved over the years. If the department has taken a very hands-off approach to delivery of health services and DHAs, and they produced documents like this and just simply have drawn back from detailed involvement in the organizations, I think that’s something that has evolved over time.
MR. YOUNGER: This seems to cross over both in terms of a number of these areas - infection control and also with addictions; you’ve almost found the same things, two different services and found the same things. One of the things you just mentioned is that it sounds like they have a plan to try to work towards fixing this. I also note that when we look through the recommendations, I think they pretty much agree with all your recommendations and say, we’re going to do this, but they’ve said that in the past. Other departments have said that in the past and part of your report is the abysmal results in terms of compliance with the audits. What hope do you have or what level of optimism do you have that despite the fact they’re saying they’re going to be done, that things will actually be done? Your report also points out that things that were said would be done in the past haven’t been done yet.
MR. LAPOINTE: That’s true, but on the other hand it varies from department to department. There are quite significant differences if you’re comparing, say, Community Services and Education, but the Department of Health and Wellness, we’ve had discussions with them at the senior level, including the deputy. They’ve given us assurances that they actually take these recommendations seriously and agree with our findings in the area. They made commitments last year, as well, and were one of the departments that actually started to live up to these commitments. They have in the last year made a strong effort to start correcting the deficiencies that have been found in prior reports - not all of the reports. They’ve been, it looks like, primarily from the most recent ones, working back, but they have made an effort and have, in fact, talked to us several times about it. I do have some belief that the Department of Health and Wellness is serious and will make these changes.
MR. YOUNGER: You indicated just now that some departments are better than others and I think that’s probably unsurprising. The departments that you pointed out as not having as good a compliance record, why do you think that is? There seems to be more of a willingness from the Department of Health and Wellness to address these things than some of these other departments.
MR. LAPOINTE: It’s hard to say, looking at this, why this situation would arise. Let’s perhaps try looking at it a little differently, and we keep looking at our recommendations and it starts to look as if we’re just telling the departments what to do, and maybe they like it or don’t like it. But all of our audits look at a variety of programming and we have findings in each of these audits. The findings tend to be around - well to begin with our findings are cleared with departments and management; in 90 per cent at least of the cases, agrees with us that these are correct. They tend to identify deficiencies in the operations of the agencies or departments we’re looking at or in the programs. These deficiencies can identify, perhaps, inefficiencies in their operations that can cost government money, ineffectiveness that hinders a program from achieving its goals and, in some cases, points to risks to public health and safety if you look at particularly the ones we just did.
The management of these organizations, once they are aware of these deficiencies, then have the responsibility, as management, to correct the deficiencies and that’s really the issue. It passes beyond us at that point and becomes a managerial responsibility. Perhaps some management groups perceive that responsibility and perhaps some do not, that’s the only difference that I could see that would occur.
MR. YOUNGER: Last week you had talked about, and your report talks about, the fact that the Cabinet, probably unwittingly, was provided inaccurate information about the status of some of your past reports and then ultimately the public because the public got that report. That Treasury Board has refused to take responsibility for managing the system and making sure that those items are accurate and I think that potentially feeds into exactly what we were just talking about with knowing what departments are doing. Why is it important that somebody, whether it’s Treasury Board or somewhere else - I mean Treasury Board seems to make sense but it could be anybody - why is it important that somebody or some department be responsible for ensuring the accuracy of information put in the system which monitors the results of your audits and the compliance with them?
MR. LAPOINTE: Well, the issue we have with this is not that this is information which should be accurate because we use it, I think that’s beside the point. I mean, we can get our own information. The issue that we have with this process and that information on implementation of recommendations and correcting of deficiencies is gathered together by somebody and is then provided to Cabinet. I firmly believe that staff in departments have a responsibility when they provide information to the Executive Council to take some efforts to ensure that the information they are providing is accurate. In this case nobody is taking that responsibility, so that members of the Executive Council who then get this information and make decisions to act on it, like issue reports and so on, are not making decisions based on all the facts. That’s the responsibility that we’re pointing to in our report that has to be accepted by somebody in one or more of the departments.
MR. YOUNGER: You noted that in the timeframe your office looked at there were 82 deficiencies, and in fairness, some of them were things that had been done and weren’t marked done. For the sake of transparency a lot of them were ones that were marked done and not done but there were some the other way. Is it your expectation that that same finding would apply if you looked at it more broadly to other years?
MR. LAPOINTE: We have no reason to think otherwise. There were two other years - the information we looked at we were doing for the purpose of our reporting in this chapter and that one took us up to 2009. The report in question included 2010 and 2011, as well, so on the basis of if you look at the years prior to that as being a sample I think you could conclude the same percentage of errors would occur in the rest of the information so that in total there would be a lot more than 82 errors.
MR. YOUNGER: The reason I ask is I just wonder whether you had any indication that that had been corrected since that time period but you have no reason to believe that it has been corrected?
MR. LAPOINTE: At the point at which we were writing this report, I would say it's highly unlikely.
MR. YOUNGER: Okay, thank you. Back to the Department of Health and Wellness - and I apologize, I'm all over the place, we've got a lot of different areas to cover - in terms of Addiction Services in the Valley, what is the potential impact of the lack of oversight to the clients who are receiving those services?
MR. LAPOINTE: For that one, why don't I pass you over to Ms. Colman-Sadd to deal with the issue?
MR. CHAIRMAN: Ms. Colman-Sadd.
MS. COLMAN-SADD: I think to some extent it's difficult to say sort of exactly what the potential impact could be, but I think in any service the impact of a lack of oversight, particularly when you have different districts and different hospitals in which those services are delivered, you can get into situations where there are different standards in different areas. One area might have a certain level of a standard and somewhere else might have a higher or lower standard, so you can get into sort of discrepancies in exactly what services patients are receiving in terms of the quality of those services and whatnot, when there is insufficient monitoring and oversight.
MR. YOUNGER: Is it fair to say that there's the potential to put clients of this service at risk? I'm not saying at risk that they're going to die, but that they could receive improper treatment or inconsistent treatment?
MS. COLMAN-SADD: I think it's difficult to say if people could receive improper treatment, that's starting to get into the medical end of things. In terms of inconsistent, I think that potential exists when there's a lack of monitoring.
I think it's important, though, to recognize that the district health authorities have a role to pay in the monitoring of their own services, as well and in reporting that information to Health and Wellness. I mean I don't think we envisage the Department of Health and Wellness being out inspecting constantly, if you will, or anything like that, I think it's at a higher level than that, and I think the districts need to do their own monitoring and then report that information to Health and Wellness - and then I think Health and Wellness needs to check on that in some manner.
MR. YOUNGER: So in the Annapolis Valley, has the district health authority not assigned somebody, even within that health authority, to be responsible for monitoring for compliance with the guidelines?
MS. COLMAN-SADD: Towards the end of Chapter 3 there is a little section that talks about performance monitoring, and Annapolis actually does do some performance monitoring. We did have some recommendations regarding making sure they covered all programs and timelines, but they do make some effort to do monitoring of some of their programs, not all.
MR. YOUNGER: I'm aware of the section at the end there, so the issue is really they are not monitoring them all and not monitoring them on a consistent basis, and I guess also maybe they don't really know what standards they're monitoring them against - is that fair?
MS. COLMAN-SADD: The issue is that just at Annapolis all programs aren't monitored and, in terms of timeliness, there are certain steps they take with regard to chart audits in an attempt to monitor standards. We found they had done them for a couple of years, but not for a couple of other years, so that was an issue.
Also, part of the issue is that then that information doesn't get rolled up and reported to the Department of Health and Wellness, so there's that lack of oversight at the departmental level.
MR. YOUNGER: Is that essentially the same issue that you are reporting on at Cape Breton with infection control? It sounds like, when I read the two of them and I hear what you are saying, it sounds like a very similar issue, just one being infection and one on monitoring standards.
MS. COLMAN-SADD: It is largely a similar issue. There's not a specific section in infection control that relates to performance monitoring and I don't know that there's as much of as formal a process for monitoring going on in the infection control area as there was at addictions in Annapolis, but it is, in terms of the department and the departmental oversight, it's certainly a very similar issue in that there's a lack of that knowledge in the department of what is going on out in the districts at a detail level.
MR. YOUNGER: I guess what worries me is that it seems you have two areas on opposite ends of the province and . . .
MR. CHAIRMAN: Order, please. Mr. Younger, your time has expired.
HON. CHRISTOPHER D'ENTREMONT: Thank you very much, Mr. Chairman, and thank you very much to the Auditor General’s Office for being in today.
I want to start basically with the follow-ups of performance on recommendations. Last week your office identified 82 errors in the provincial update. Through the media and here in Public Accounts you mentioned some mistakes that were simply that recommendations hadn’t been upgraded. Can you explain some of the recommendations or all the recommendations that were found to be erroneous outside the simple mistakes?
MR. LAPOINTE: Yes, I’ll ask Ms. McDonald to answer that question.
MS. ANN MCDONALD: There were 19 recommendations of the 82 that we found were actually complete once we sort of started looking in more detail, despite what was first provided in the TAGR system to us. That’s good news. Some of that related to - there is sometimes a misunderstanding perhaps on what the recommendation is getting at. If it’s referring to an ongoing process, sometimes the department might think it actually could never be complete because it’s an ongoing process and we say, no, you’ve done the work to address the recommendation and you might have to look at it on an annual basis but for now it’s complete.
We also saw there were about 40 recommendations where the status was downgraded from complete to some other level and then the other recommendations they would not have been complete but the status that was reported was inaccurate. The range of explanations as to why they were downgraded from complete to some other level sort of varies from the information that was in the system when we looked at it, it really wasn’t complete, it didn’t provide the full implementation of the recommendation.
For example, perhaps regulations we recommended be updated to a particular Act and that hadn’t been completed yet. There are a variety of reasons, there’s not sort of an overall comment to be made. We looked, in detail, at all of the recommendations with particular emphasis on those that are complete to find out whether the information that supported that recommendation had been implemented.
MR. D’ENTREMONT: When the provincial update is coming out with errors of this nature, can we trust that the province is updating us correctly on the progress? It’s a trust issue - to me it looks like - is it a miscomprehension of how the system works or is it simply that they can’t be bothered with the recommendations as they’re getting them? What’s your feeling on that or what do you see? For either, I guess.
MS. ANN MCDONALD: I’m not sure we can make an overall comment on how departments are dealing with the recommendations. We certainly found in the Department of Education that the information in the system was sometimes incomplete. There was actually nothing in the system. There would be the recommendation, the status at whatever it was noted to be at that time, often noted as being complete, and then literally no information to support that status. We would do some more digging around and find out that in fact it wasn’t complete or perhaps it was complete.
I’m not sure that we can make an overall comment about departments and their commitment to updating the TAGR system, but certainly the information that ultimately made its way to the public, there were sufficient deficiencies that we had thought we had to report it.
MR. D’ENTREMONT: You mentioned in a couple of the other answers to my colleague here, some departments have superior recommendation implementation records, others not so much. Education, as we just mentioned, seems to be one of those that hasn’t kept pace with that pact. The Department of Education apparently, from the documents, have completed 14 per cent of the recommendations in 2010 and 13 per cent in 2011. Why such a low record and how are we going to work with the Department of Education, for example, to try to bring that average up a little better?
MR. LAPOINTE: It is hard to say why any one department would have a very good record of dealing with the deficiencies and one not. The facts with Education are that when we pointed out last year the low level of implementation in Health and Wellness and in Education, senior management at Education told us that they would make it a priority to make a change in this. For whatever reason it might have happened in the past - sometimes it could be inattention, we don’t know - but they decided they would make it a priority and deal with it.
Since that time, virtually nothing has changed. I don’t know then why the dynamics are as they are in that department, that they, apparently, don’t take these recommendations seriously or take seriously the deficiencies behind them that we’re pointing out.
MR. D’ENTREMONT: A lot of the recommendations we see are, in some cases, issues of public safety, like ensuring child abuse registry checks and criminal checks are completed for hiring the employees in our schools. Some of the recommendations are essentials like that one that just do not seem to be getting done. Is it a problem of delineation of whose responsibility it is because I know we hear a lot that it’s the responsibility of the school board and not the responsibility of the department. So is there a problem between the oversight of the department and the actual workings of the school system at the more ground level?
MR. LAPOINTE: I suppose that there is a possibility that - and this is yet another decentralized department in which agencies are delivering the services - so, it could be that that is one of the factors adding some complexity to say who takes responsibility for some of these things. But I wouldn’t say that could be the sole reason, it might be one of the factors playing into it.
As I mentioned earlier, once deficiencies are pointed out in the operations of a department or its agencies that might affect either efficiencies, costs, effectiveness or public safety, then from a managerial point of view, and a governance point of view, it’s the responsibility of the senior management to deal with the deficiencies regardless of who points them out, it could be their own staff. What’s not happening here, for whatever reason and I can’t speculate on that but for whatever reason, the senior management in this department doesn’t appear to have accepted that responsibility, that I believe they have, to correct weaknesses in their own operations.
MR. D’ENTREMONT: I think we’ve talked a lot about the communication, informational request experience with the department. I think you’ve talked about how that’s gone on or not gone on with that department. The Auditor General has just said there is issue with maybe taking responsibility for these changes so when one avenue doesn’t work there is a way to get out a bigger stick and, of course, that’s working with the central part of government, there are managers for those managers which in my estimation is Cabinet Treasury Board and those outfits. Is there a role for them to play in not pushing down on the department but at least ensuring that departments take these recommendations seriously?
MR. LAPOINTE: I think there can be, certainly. You are hampered, I believe, to some extent by the very decentralized nature of the Westminster-style of government that does actually make all departments equal. There is no head office in our style of government, and it’s not just here but you’ll find in other provinces that can be a hindrance in driving change from the centre, what department can tell other departments what to do. That is certainly one of the complicating factors but it’s still possible to provide direction from the centre. I wouldn’t presume to say exactly how that should occur or what the driving force should be, whether it’s through Treasury Board or anywhere else. That is, I guess, a management decision.
MR. D’ENTREMONT: I understand that all departments are sort of created equal yet I had the opportunity to sit at a Cabinet for a number of years and knowing full well how those discussions go and knowing full well the bigger stick that the Premier holds or the Minister of Finance holds or other folks in there when it comes to your funding or what have you in that, is there a mechanism that you could suggest that could provide a better - I mean we have a tracking system but the tracking system is only as good as the data that goes in it. Is there a suggestion that you would have or maybe an experience from another province that they deal with the true implementation of the recommendations that you bring to government?
MR. LAPOINTE: I don’t think I can point out one particular way that it has to be done. I think if the change has to be done it certainly needs some direction from the centre in what way that occurs really is not for me to say. But I know that some direction from some central group that maybe authorized to do so can certainly have an impact.
More importantly, I suppose, is a need for a bit of a cultural change throughout all the departments and agencies, that they simply begin to accept more of a managerial responsibility to correct weaknesses that are pointed out to them.
MR. D'ENTREMONT: Do you find - and maybe this is the recommendations, again, having not been implemented, or at least we're not sure - are they not implemented, from your experience, because of funding issues or is it just, again, an issue of not understanding the importance of putting these things in place? I remember a lot of discussions that sometimes there are costs to be bound by these recommendations - do you find them that way or not?
MR. LAPOINTE: I doubt that it's significantly a cost issue. It might be in some cases, and in that case we're prepared to accept that and understand it if, you know, the explanation for something still being in progress is that it's hard to find money for it.
I admit that there are some times which we say, as we've said for instance in infection control, that some money must be spent because you don't have enough staff involved to make this work, so you do, in fact, have to have more staff - well where does the money come from for that?
That's not the primary issue in most cases. Most of the recommendations we make, I would venture to say, don't have really significant cost implications and, in some cases, the benefits that you get from them will outweigh the costs.
The infection prevention and control issues, for instance, the medical belief on these issues that we've seen written down are that the cost of allowing hospital-acquired infections to occur is much greater than the cost of putting in measures to prevent them. So where we might have short-term spending of some money of these things; in fact, the end result is to save money. And that, to my mind, is almost an ideal recommendation - one that in the long term saves money and also has efficiency.
The issue that I point to would not be cost, but simply a commitment to accepting responsibility in making the change.
MR. D'ENTREMONT: Moving up a little bit in the recommendations, there were 29 recommendations in Infection Prevention and Control in Cape Breton, and 13 recommendations when it comes to Addiction Services. Some of them do revolve around public and patient safety and some of them are more control issues and trying to realize whether we're getting a good service or not.
Do you feel, moving over to the Department of Health and Wellness, now that we've spent some time on education, do you find that they are providing enough oversight to the district health authorities when it comes to implementation of these recommendations?
MR. LAPOINTE: The infection prevention control issue?
MR. D'ENTREMONT: Yes, pick one.
MR. LAPOINTE: Well no, certainly what we were concluding was that the oversight in that area was too limited, particularly if you look at the group that was established, as an example, at the department to oversee infection prevention and control. They appear to be a very effective group; they seem to know what they're doing, but there are only two of them and the mandate that they were given was really quite large. If they were to actually go out and attempt to provide support to districts that have outbreaks, to provide guidance to them, to provide direction and to monitor what is occurring across the province, as a starting point, they are not able to do that. So, clearly, the department, if that's the mechanism they are using to provide oversight in that particular area of infection prevention and control, they simply are not doing it.
MR. D'ENTREMONT: Two people taking care of nine district health authorities, plus the IWK, in my mind would be not enough. We know that each district health authority would have their own infection control people, yet trying to monitor across the province, especially looking at the travel of patients from one district to another or coming to Halifax for tests, for a ream of different reasons why you would have the transfer of those patients, what do we see as maybe an alternative to that recommendation? You know we've got two people - what would the recommendation be? I mean ultimately it's probably to get a few more people in there or change their role just a little bit.
MR. LAPOINTE: I would say that their role was properly developed. The mandate they were given and the description of what they were meant to do would certainly be effective if it was put in place. So our feeling with that one is that the group as it was developed and mandated needs to be given the capacity to do, as a starting point, what they were mandated to do. I think that alone would have a major impact. If the department wants to look at doing more later they can, but at the very starting point, let the group that they have created have the capacity to do the job it’s meant to do.
MR. D’ENTREMONT: Did it seem that the district health authorities didn’t accept that oversight, I guess is what you maybe would call it, or they don’t like Halifax intruding in their day-to-day business?
MR. LAPOINTE: I wouldn’t say that we’ve run across any such feelings that came out in our audit. We have nothing documented that would show there are these kinds of tensions in the areas that we looked at.
MR. D’ENTREMONT: When looking at - and this is sort of continuing on that a little bit - when hearing from senior management in the Department of Health and Wellness that they have plans to improve that district accountability, whether it’s mostly in infection control, for instance, they want to have signed accountability agreements. Does that change anything or does that just sort of give you another piece of paper that might look good in the end but is more of trying to solve it with a hunk of paper rather than actually doing something?
MR. LAPOINTE: Well, it has the potential, of course, always to just be another piece of paper, but I don’t think that’s the case. I think it could be quite helpful for the department and the districts to have these discussions and to put down on paper clearly their respective roles so that in those documents, once they’ve written them and agreed on them and signed off on them, it clearly outlines common agreed responsibilities and including in there the expanded - if you could put it that way - role of the department in terms of oversight and monitoring. I think that could only help the situation.
MR. D’ENTREMONT: I know I’m getting close to my time on this one so I just want to move to the issue of the Valley and, more specifically, Recommendation 3.3. It recommends “The Department of Health and Wellness should revise its addiction services standards so that standards are measurable where possible.” So my question is, are general statistics maintained for patients in the health care system or what do you see as being adequate statistics being kept?
MR. LAPOINTE: If you don’t mind, I’ll ask Ms. Colman-Sadd to speak to that.
MS. COLMAN-SADD: This recommendation deals specifically with Addiction Services standards so I’ll respond in terms of those. Many of the existing standards are really not measurable or leave out portions of the population. For example, 80 per cent of patients should be seen within X days and then it never speaks to when the other 20 per cent should be seen, so presumably they could never be seen and the standard could still be met. We wanted to make sure that standards are measurable and just that standards are - that they take a look at Addiction Services standards and make sure that they have the best possible standards that they can have because some of them are quite, as I said, limited in terms of covering the full population and whatnot.
So there are some statistics available on Addiction Services, wait times, who is seen within what time periods and whatnot. But all of the standards are not measurable and it may not be practical that every standard be measurable, but as many as possible, if they could be, would be helpful.
MR. CHAIRMAN: Order, please. Mr. d’Entremont’s time has expired. Mr. Ramey.
MR. GARY RAMEY: Thank you very much, Mr. Chairman, and thank you all for coming in this morning. I’ll probably focus my questions around Chapter 2 and perhaps Chapter 4, depending on how we do on time here. I had a look at the recommendations specifically for the Department of Health and Wellness, and it looks to me like more progress has been made since 2009 on the 2009-2011 recommendations than there was between 2005 and 2009. I'm wondering if I have that correct and if you could comment on that, please.
MR. CHAIRMAN: Ms. Colman-Sadd, Ms. McDonald.
MR. RAMEY: I'm working my way down the line here.
MS. ANN MCDONALD: We didn't do any work on the 2011 recommendations, our chapter covered 2005 to 2009, so I can speak to that by saying that certainly what we found is that the recommendations that the Department of Health and Wellness were responsible for in the later years, so 2009, that there was a higher implementation rate than of the earlier years. So in 2007 and 2008 there were a couple of prominent audits in long-term care and in home care. We found the implementation rates there were not good and we've suggested and recommended that efforts be made to improve those implementation rates.
With respect to 2005 to 2006 recommendations, from last year we noted that only four additional recommendations had been implemented. We concluded overall for all departments that those recommendations in 2005 and 2006 that have not been implemented to date that there is a failure to implement at this point in time.
MR. RAMEY: Okay. I understand that the Department of Health and Wellness has implemented 20 per cent more recommendations since your last review, is that accurate or inaccurate?
MS. ANN MCDONALD: That's accurate. Their rate last year was 36 per cent and increased to 56 per cent.
MR. RAMEY: Okay. I think I heard this commented on before but I'd just like some clarification on it and I'm switching now from the Department of Health and Wellness to the Department of Community Services. Was I correct in understanding that the Department of Community Services has the highest rate of implementation for recommendations? If that is correct, could you comment or someone comment as to why you think that is?
MR. LAPOINTE: The Department of Community Services has the highest rate at overall 85 per cent and that's fairly consistent with the approach in that department that we've seen in prior years.
You are right about the Department of Health and Wellness, as I guess I mentioned earlier, having made some efforts to start implementing recommendations but starting with the more current years and I guess working backwards, we have had discussions with them about that and they do intend, as I say, to continue working on this.
As to the motivations behind this and specifically why any one department would be different in a rate from another department, we have no way to know that. All we can do is report what we find and not try to speculate as to why the management in Community Services and Health and Wellness would be different in their results.
MR. RAMEY: Okay. I'm switching now a little bit off that topic to Chapter 4. Minister Maureen MacDonald set up a Patient Safety Committee in 2010, I believe the first and only kind, to provide central oversight. Could you comment on what role you think that committee maybe played in bringing the C. difficile outbreak under control?
MR. LAPOINTE: I'll ask Ms. Colman-Sadd to speak to that.
MS. COLMAN-SADD: I don't recall from our audit there being a significant role for that committee with regard to C. difficile in Cape Breton. That's not to say that they didn't play some role but I don't recall anything from our audit files dealing with the role that that committee might have played.
MR. RAMEY: Okay, well I guess that perhaps following along in that vein then, in the Spring session of the Legislature our government introduced the Patient Safety Act. I guess the follow-up would be, do you think this legislation is a step in the right direction, in terms of what we've been talking about here?
MS. COLMAN-SADD: I think certainly anything that speaks to patient safety and whatnot and that looks at greater oversight is a step in the right direction. I think there's significant work that remains to be done, in terms of the department's oversight of the district health authorities.
MR. RAMEY: I know we were talking about DHAs and the control they have over their own destiny, and Mr. Lapointe was commenting on the parliamentary system and how some of these things work. The Patient Safety Act sets clear outlines and requires DHAs to do regular inspections so, because it does, do you think that is an improvement in the overall scheme of things?
MS. COLMAN-SADD: I think so. I think it’s important as well then that there is oversight by the department to make sure the districts are complying with that Act and that the districts are doing the inspections and that the results of the inspections, if they’re not acceptable, that something is happening to move things in a better direction if there are issues as a result of those inspections. So I think it’s important that things get reported up to the department, at the end of the day, out of those inspections at the district health authorities.
MR. RAMEY: So based on your answer to that, I think I know your answer to this - but I’ll ask you anyway: Do you think we need to have one standard across the province for training levels and infection control?
MS. COLMAN-SADD: There are many different sources of best practices in infection prevention and control - they tend to be 70 or 80 per cent similar and then there are small differences between. So I think it’s possible to have slight differences from one district to the next and still meet the overall basic standard. I think someone needs to look at what that overall basic standard should be and say at a minimum – and there may be more than one training program that meets that minimum, it may be that there are a few different training programs that meet that minimum - I think it’s important that centrally somebody like IBCNS say, for example, here’s sort of the bare minimum of what an infection prevention control practitioner should have.
MR. RAMEY: I know I have a number of colleagues who are also interested in asking questions, so I think I might pass it over to my colleague, Mr. Whynott, with the chairman’s permission.
MR. CHAIRMAN: Mr. Whynott.
MR. MAT WHYNOTT: Thank you very much, Mr. Chairman, and thank you for being here today.
I want to go into Chapter 3 a little bit, around Addiction Services at the Annapolis Valley District Health Authority. We all know that addictions services is something that’s so crucial in the way we deliver care to people. While you were doing your audit we saw a gathering of information to come up with a strategy around mental health and addictions services for people in Nova Scotia. Did you see any of that work taking place while you were conducting your audit?
MR. LAPOINTE: Well, like I say in terms of timing, that occurred after we were doing the work, so this would be subsequent to what you see in here.
MR. WHYNOTT: Okay, thank you. Good clarification, I appreciate that.
In your review of Addiction Services down in the Valley, did you find any examples of policies or programs in place in our system that were actually best practices, that we can learn from and kind of implement across to other district health authorities across Nova Scotia?
MS. COLMAN-SADD: With regard to Annapolis Valley and potential best practices, one area that I think Annapolis - although there’s still room for improvement - they were at least doing some performance monitoring of their services, which I think is excellent. Timeliness and completeness in terms of doing all services was a bit of an issue, but at least they were making some efforts in that regard. I think that’s an area that’s important.
Another interesting area that I know Annapolis feels is sort of on the leading edge of things is their Opiate Treatment Program and how they’re implementing it. Opiate treatment is often long-term treatment, and there are often huge wait lists to get into it and they’re hoping to engage family doctors. I think it’s too early to say if it’s a best practice yet, but on a go-forward basis I think that program will help to illustrate whether that model or the typical model is what is maybe the best practice in that area.
MR. WHYNOTT: Did you find evidence that people with addictions in the Valley had to wait an undue amount of time for treatment?
MS. COLMAN-SADD: No.
MR. CHAIRMAN: Mr. Lapointe.
MR. LAPOINTE: I’ll ask Ms. Colman-Sadd to comment.
MS. COLMAN-SADD: Generally speaking, people were seen - I think 89 per cent is the statistic in the report - within the wait time standards. There are three different categories of patients and there’s a standard for how quickly each category should be seen, so some might be in emergency who are supposed to be seen within a 24-hour period. Generally speaking, they were seen within wait time standards. There were some that fell outside of it.
MR. WHYNOTT: I think, in one of our standing committees, we saw a presentation on that. I can’t quite remember the standards in the three categories - are you able to clarify that for folks?
MS. COLMAN-SADD: Emergency priority is to be seen the same day; urgent priority is within a week; and general priority is within three weeks. It’s on Page 51, in Paragraph 29 of that chapter.
MR. WHYNOTT: Okay. Great. I appreciate that. I think it’s good for the abundance of people who are watching at home today, that it is a good thing for them to realize that there are standards and that, unfortunately, it sounds like 11 per cent of people who may not have fallen within those standards. Hopefully, with the help from the province, the health authority will be able to address those issues. It’s good to hear that it’s such a high percentage of people who are being seen and being cared for in that amount of time.
I understand that there are different challenges to maintaining and monitoring wait lists in Addiction Services - can you comment a little bit on some of those challenges?
MS. COLMAN-SADD: Some of the challenges that Addiction Services staff in Annapolis, and I guess at the department as well, identified to us is sometimes with addictions services patients when they’re on a wait list for a particular service, depending on how intensive that service might be, it may not be the right time in their personal or, perhaps, their professional life to move into a treatment program. So they may be on a wait list and perhaps are the next person in line, but maybe it’s a program that requires being off work for two weeks and that is impossible right now, or they don’t have child care - there are all kinds of reasons that could play into that, so there are some challenges in that regard.
One of the other challenges identified to us with regard to addictions clients is that it’s a population sometimes who might start service and then sometimes people stop services and they need them again in the future, so it’s that sort of having to come back to the services again later that sometimes is a challenge as well.
MR. WHYNOTT: I’m certainly not an expert in this area, but I guess my next question is around who the trained professionals are who are providing these services to Nova Scotians - are we talking specifically social workers or are we talking other types of health care professionals? Can you comment a little bit on that?
MS. COLMAN-SADD: A little bit. Our audit would have touched on that a little bit in terms of when we did our testing we would see who was providing services and whatnot. There would be a variety of health care professionals who would be involved in providing services and it would be those that you mentioned. Family doctors would be included; psychologists; psychiatrists. There are all kinds of counsellors of various kinds - it just depends on the program and what the needs of the patient are.
MR. WHYNOTT: I know some of the things that we’ve seen in reports and that sort of thing is this whole model of patient-centred care, trying to encourage the family doctors in Nova Scotia to move to this whole model of patient-centred care to allow them to open up and really have incentives to open up an office where you have direct access to these sorts of health care professionals, which I think is a good model.
Again, and not that I’m an expert, but it does seem to me that if Nova Scotians and their families are able to access that care right in their own family doctor’s office, it does makes sense. If that’s the model that we’re moving to, I think that’s a good thing. I know that it takes time in order for that switch to happen, but if people who do have issues with addictions, and even mental health issues, are able to get some sort of care within that model, then I think that's a good thing. It's a good step forward.
I think Nova Scotia is being seen as an innovator across the country when it comes to health care delivery, and I think that piece is just one part of the puzzle on how we can change that.
Ms. Colman-Sadd, you mentioned a little bit about the new Opiate Treatment Program in the Valley. I understand that treatment program was implemented during your audit - can you speak to the process that Annapolis Valley Health went through in order to implement this program?
MS. COLMAN-SADD: I don't have a lot of detail on sort of how they came to the decision, for example, that that particular program model was the appropriate model or anything - it was a gap that we identified at the beginning of our audit that we knew they were working on, and it was implemented during our audit.
We looked at what are they doing, what service are they providing, that type of thing - we didn't get involved in sort of all the processes that had led to the decision to implement that particular program versus a different type of opiate program.
MR. WHYNOTT: Okay, fair enough. So, overall, it sounds like the addictions services program is functioning quite well. I mean obviously there are always changes that can be made. You noted that their policies, programs, their staff training and communication with the public and others, adequately meets expectations and really the needs of the community - is that a fair assessment of your findings?
MS. COLMAN-SADD: It is. Our findings with regard to the Annapolis Valley Addiction Services program were fairly positive. I mean, as you say, there's always room for improvement, and there were areas for improvement identified, but overall we found those services to be well managed.
MR. WHYNOTT: Great, thank you. I think I have only about three minutes left, and I do want to ask a question on Chapter 5 around the Nova Scotia Prescription Monitoring Program, so is that Ms. Colman-Sadd as well? Yes.
How do we compare to other provinces when it comes to monitoring of prescription drugs?
MS. COLMAN-SADD: We don't look at what other provinces do when we do our audits for a few reasons. Some provinces have monitoring programs and some don't, but in terms of the comparative to Nova Scotia's program we don't have any mandate to look at those program areas. And you can't always rely on what is on Web sites and on the Internet - you don't know that it's complete and accurate information when you haven't audited it, so we don't do that comparison.
MR. WHYNOTT: Okay, fair enough. Just as a comment - I understand that a number of provincial jurisdictions have actually praised our Prescription Monitoring Program and really have taken our model and tweaked it to their own, have been able to implement their own drug monitoring program, which I think is a positive thing. As I mentioned before, having seen Nova Scotia as a leader in health care delivery I think that's a good thing - so I did want to make that comment.
I think with that, Mr. Chairman, I will leave my time and go to the second round. I appreciate that, thank you so much.
MR. CHAIRMAN: Thank you very much. The second round will be for 16 minutes and we'll start with Mr. Younger.
MR. YOUNGER: Mr. Chairman, I want to get back to something that I think all members at various points have been talking about, which is the compliance issue with various audits. When we go to, I guess starting on Page 16 or thereabouts of the main report, it talks about the different departments, and I want to talk about the different departments in the current stance in terms of compliance.
I think you mentioned, Mr. Lapointe, that some departments are better than others. I notice actually it looked like Natural Resources was pretty good, but when I go through them here it says, for example, the Department of Health and Wellness, since 2011, has only implemented four of the forty-six earlier recommendations, and then it makes the comment that the lack of action is contrary to what the department promised last year. Then there has been little or no progress by the Department of Transportation and Infrastructure Renewal or the Department of Justice on those earlier ones, and no progress by the Department of Education.
I’d like to get a sense of what departments you think are doing well to clear that backlog - I assume some are.
MR. LAPOINTE: I might get Ms. McDonald to see if she can shed some insight on that, too, but I’d say that as a general rule we were finding that we had reached almost a plateau with the really older recommendations that we were looking at, going back to 2005, 2006, and 2007, and that any good progress overall you’re probably going to find lies with the Department of Health and Wellness in the more recent.
At a certain point we simply decide that we’re not going to see more progress in the older ones and we simply - I won’t say we’ll take the view that we consider them having been failed to be implemented, we simply are going to cease tracking them. Again with that, I don’t know if we had any that specifically might have done well in the older ones - I’ll ask Ms. McDonald.
MS. ANN MCDONALD: No. I can’t say there are any departments that stand out with respect to the older recommendations - and I’m talking those in 2005 and 2006 - as having significantly improved their implementation rate of those recommendations since our review last May. The chart on Page 21 gives an overall indication of the success of implementing our recommendations by department, and certainly you’ll see there that the Department of Health and Wellness improved with respect to other departments, but there has really not been a significant change.
Some departments - I think we indicated in Paragraph 2.33, for example, the Department of Natural Resources, they improved their implementation rate. But there weren’t that many recommendations made to them in the first place, so implementing one or two actually increases their rate significantly.
MR. YOUNGER: That’s a fair comment, and I note how low the implementation rate is for the Department of Environment - it really quite stands out in that chart.
MS. ANN MCDONALD: That’s the Department of Education.
MR. YOUNGER: Oh, that’s the Department of Education, yes, sorry. It’s the abbreviations, you’re right, which is even worse in some respect - and I want to talk about the Department of Education in a second here.
I guess what concerns me about it though, and it’s fair to say that - because I’ve heard some people say, well fine, these were in 2005-06, that was the previous government and all that, but some of these, there were commitments last year by the current minister - well, ministers have changed - by the current departments to try to implement those older recommendations.
Your office refers specifically to the Department of Health and Wellness and some of the others saying, listen, we know there’s a backlog and we’re going to get at them, and then you come around here a year later and it says that nothing really happened - or very little, I guess “nothing” is too strong - very little happened since the commitment was made by the departments a year ago to try to address that backlog. Is that fair?
MR. LAPOINTE: Yes, I think I can address that.
That comment applied specifically to Education and the commitments made to us by senior management at that time. There was a commitment, I had mentioned, by the Department of Health and Wellness, and they have actually been clearly making some efforts and some that we’re aware of as well. We’re looking at this not from the point of view of which particular government might have been in power at the time the recommendations were made, but this is an ongoing issue within the management of these organizations, which is continuous whatever government changes might occur. This has been an issue for some time, certainly since I’ve been in this office, and I suppose we get a little repetitive about mentioning it. But it’s something, I think, that needs to be addressed and has been ongoing for as far back as we’re tracking here.
MR. YOUNGER: I agree with you that it’s an ongoing issue and it’s striking me in reading this report that it seems to be somewhat systematic, and I’m not sure why it’s happening. You’ve raised the Department of Education and I would like to talk a bit about that because on Page 22 of your report, Paragraph 2.40, which talks about - if I understand what you’re saying here - the response you got from the Department of Education. It sounds to me like the Department of Education was even reluctant to be co-operative with you on trying to get information on the status of doing the work, and then there were discrepancies. It says “Information requested to support statuses, as well as management agreement on changes to statuses, was not provided on a timely basis. In some cases, information finally provided did not address the issue raised and we had to seek additional support.”
I assume you are pointing that out here specific for this department because it was unique in your dealings with departments or the level at which you received resistance. I wonder, could you speak a bit about the resistance you had from the Department of Education to your work?
MR. LAPOINTE: Yes, that was specific to this department and that’s one of the reasons why, since it stood out, we mentioned that specifically in here. As to the details, I’ll ask Ms. McDonald to tell you more about it.
MS. ANN MCDONALD: With respect to the Department of Education, our experience this year was I guess less than good. We just found that we sent requests over to get support - the way the process works is the status is indicated in this TAGR System, which we use and which government had developed, we look to that to see what the latest status is noted, we look to see what the support is for that status and then we focus on those recommendations that are noted as being complete, and we ask for the information that supports that recommendation is in fact complete.
Those requests would be sent over to the Department of Education. We were not getting responses back to our requests on a timely basis so we would have to go back to them and ask when we could expect this. Then we finally said we need this by a certain date, so we started to get some progress but it was frustrating, more than anything - it was a frustrating experience and that’s why it’s highlighted here in terms of co-operation with our requests.
I can’t comment on their commitment to implement recommendations, but certainly from the perspective of conducting this engagement it was frustrating to be constantly asking, receiving delays, and then when we did get the information that we asked - or rather a response to the question - it sometimes didn’t address the question that was raised, and then we’d have to go back. So, overall, not a great experience.
MR. YOUNGER: Did you have any indication of why there were so many delays or problems?
MS. ANN MCDONALD: No, there was no sort of overriding comments that were made to us. When we started to elevate the questions and bring in more senior staff, then they were dealt with a little bit more quickly.
MR. YOUNGER: Are there any recommendations that your office can make to solve - I mean I would hope this will never happen again, but that’s almost like it’s undermining the Office of the Auditor General and the role you’re supposed to do on behalf of Nova Scotians. I’ve said this before, but I think departments have a right to disagree with your recommendation and say, listen, we disagree with you and we’re not going to do that - and you see that sometimes and that’s fine. At least if they give the reasons, the public can make a decision, and the Legislature can make a decision on whether they agree.
This is different. This is almost undermining or thwarting your attempts to do your job, and I just wonder if there are recommendations that you can make in terms of procedural change or legislative change, anything that could help prevent that sort of thing happening in the future?
MS. ANN MCDONALD: We actually have a meeting with the Department of Education next week to discuss the results of this review and also, overall, our audit approach. Hopefully, after that meeting, if there are improvements we need to make in how we ask questions, then we’re certainly open to suggestions. Hopefully the result of the meeting though will be an understanding of a more co-operative nature for next year’s assignment.
MR. YOUNGER: Did you sense the department took seriously the importance of the work you were doing?
MS. ANN MCDONALD: I guess the frustration we experienced had to deal with getting responses to our questions, not dealing with the importance of the recommendations, so I just want to differentiate that. I can’t comment on whether they were in any way trying to thwart the process of implementing recommendations or paying less attention to recommendations, just that as we tried to get support and answers to our questions it was a frustrating process.
MR. YOUNGER: I know you’ve laid out the report slightly differently this time - personally I like it with the recommendation and then the response from the department. I think that’s very helpful, so I congratulate you on that. I hope other people like that too.
I wanted to ask something; it’s something that stands out. When we look at the Office of the Public Trustee, which I think is at the back, No. 6, their responses are very different from some of - actually any of the other responses I’ve ever seen, because not only does the Office of the Public Trustee agree with them all, and that’s fine, but they say not only do we agree but this is the timeline under which we expect to implement it, for almost all of them.
We’ve been talking about this compliance issue and this allows you - and the public - to not only measure whether they’ve done it, but whether they’ve done it reasonably within the time frame that they suggested, and the urgency that they place on a recommendation. Do you have any comment on the difference in how they’ve responded versus how you see other departments respond to the recommendations?
MR. LAPOINTE: I can talk to that issue of timelines. It is something that we have started to encourage in the responses from all the auditees for the reason that you say, that we have been asking them, particularly now that we’re putting this right into the body, whether they agree or disagree with a recommendation, but also we want to know from them whether they intend to implement the recommendation and, if so, in relatively few words, what are the main actions that they intend to take? But then we’ve also been encouraging them to start giving us timelines. You’ll see them occurring elsewhere as well, but this Office of the Public Trustee simply complied very well with our request to provide information in that way.
It does help now to be able to see what kind of action they’re going to take. Are they going to do this in the next six months, over the next couple of years? I’ve already, in fact, had a discussion with the Public Trustee about a couple of the timelines that seem to me are a little lengthy and I’ve discussed ways in which she might be able to do some of these sooner. So it’s very helpful from a very practical point of view, and I think it’s a step in the right direction.
MR. YOUNGER: I would agree because I think what we’re seeing now are recommendations from 2005-06 that somebody said, yes, we agree with, but 20 years before we get to it. And you’re right, actually I never thought of it, it allows you to comment and have a discussion with them whether you think the timeline is reasonable. It also gives you an idea of the importance that they’ve placed on each recommendation. If it’s something they’re going to do immediately, obviously they see that as critical or easy to implement; if it’s a couple years out, they obviously don’t see it as critical.
When you do the future compliance monitoring of this, do you intend to also look at not only whether they’ve done something, but the timelines in which they suggested they might be doing this? I realize this is sort of new - the Public Trustee is the first one to lay it out so completely.
MR. LAPOINTE: Yes, this is certainly something we consider in going forward. If they indicated a timeline of six months and two years later they’re still in progress, then that would be one of the recommendations we’d have to perhaps question and see what’s going on. Whereas if they tell us it will take, in fact, three years, we would not expect when we go back that it would actually be finished, so it gives us a good indication of what’s happening when we do return.
As you say, it does help us as well in immediate discussions with them in seeing whether they fully perhaps understand the recommendation. An example, with the Public Trustee, I guess it’s the final recommendation in which we recommended they put in an accounting system - I understand that this is something we found when we were actually auditing their financial statements, that they are a $9 million operation in terms of spending and they don't have a general ledger. If they were a corporation and I was their accountant, I would advise you that you simply must have an accounting system with debits and credits and general ledger, internals in a normal way of things. They've been operating with other ways of recording things that have developed over the years and . . .
MR. CHAIRMAN: Order, please. Mr. Younger's time has expired.
MR. D'ENTREMONT: I'm so interested in this response that I think I'm going to let the Auditor General continue on here.
MR. LAPOINTE: Thank you, I'll continue where I left off. When I then had our follow-up discussion with the Public Trustee - we do this in every case before we issue - when I discussed this I realized they were looking at having a big study, an analysis of what their needs were and how they might go about it, how they might fund it and it was all going to take a very long time.
I was able to explain that really what we were talking about was to simply go out and get some professional advice, perhaps, but to buy an off-the-shelf guide package, like Accpac and get some help from a good accountant to implement it and put in a general ledger. We weren't recommending a very big, complicated project but, in fact, a very simple one, the kind that I would have recommended if I had been, in my previous life, their accountant coming in to do their books.
I think they had a better understanding of what really we were talking about and they might have had a misunderstanding and not actually taken effective action if we hadn't seen that timeline there and asked why it would take so long. That little aspect was quite a benefit of the way they responded.
MR. D'ENTREMONT: Thank you. I would think that buying Simply Accounting or Accpac would be a good avenue on that one, so I thank you, that is very interesting.
I'm going to move over a little bit. There was a comment that came from the government members in this committee - it's sort of this apparent feeling that an election presses a reset button when it comes to the implementation of recommendations. I'm just wondering, what is your feeling at this point, because we sort of have this government's recommendations and that government's recommendations, does that seem to happen often, or do you see that happening here?
I know it's been echoed by the members here, but do you find that within the departments?
MR. LAPOINTE: I don't think that it's an issue of which government is in place at any particular time when we make recommendations. I know that some of these go back to a prior government in terms of when they were made, and some to the current government.
We attempt not to take that into account in the work we do and in our recommendations to the departments, and look at the work we do for them as being to the perpetual organization regardless of what might be happening at the political level. I think that what we see, too, at the departmental level is that's how they treat it as well.
MR. D'ENTREMONT: And my feeling, too, is that government is government, regardless of who is at the helm. The recommendations that come from a certain time are still up for implementation by the current government - I think that's an important standard that I think government should take.
I'm just wondering, we talked a little bit in my questioning last time with the errors in the provincial update, I'm just wondering is there going to be an updated document we could have that addresses some of the things that were laid out in your original document? You know, if we found 19 of them that were actually completed, but were shown as incomplete in the previous report, is there an update we can get of that?
MR. LAPOINTE: At the current time I'm not aware of any document that reflects changes that we're making. The timing for a second provincial update I guess is fairly soon. We don't have any knowledge of what will be done in terms of the information for that feeding into that report. What we would expect is that the findings, the changes that we made as a result of what we looked at would be changed inside that TAGR system. We will assume that they would do that, since we pointed them out to them and would expect that would be.
MR. D’ENTREMONT: I’m just wondering to the chairman, is there a way we could get a copy of the TAGR so we could see the updated version or do we have to wait for the provincial update? I’ll just leave that question for staff later on to see. If there are changes, it would be nice to see the updated version of that since our last meeting.
MR. LAPOINTE: Could I ask Ms. McDonald to provide a little more information on that too?
MS. ANN MCDONALD: With respect to the 2005-09 recommendations, the details of the current status is actually on our Web site. If you look there, they’re listed in every recommendation. With respect to 2005-06 recommendations, the status is noted as failure to implement because that is where we are with those. From 2007, 2008 and 2009, the status that is noted there is the one that has been agreed upon, if you will, between us as a result of our work and the departments at the end of this review. Those are listed there by their current status and we’re hopeful that those current statuses will be updated in this system for government then to be able to use on a go forward.
MR. D’ENTREMONT: Just in the issue of clarity. In your original answers you were talking about the update or the changes in status, some of them by simply asking the question and looking for further detail into it, where some of those statuses did change. So it’s good to know and I’ll have a good look at that one.
If I switch over to more detail within it, looking at the recommendation to the Treasury Board itself, I think it was Recommendation 2.2 that read, “Treasury Board Office should implement a quality assurance process to ensure information reported on the implementation status of recommendations in the Tracking Auditor General Recommendations system is accurate and complete.”
Apparently the answer from Treasury Board was that they didn’t agree with that recommendation. I’m wondering what your thoughts are around implementation of that recommendation or failure to do that?
MR. LAPOINTE: The two recommendations that we made, as you say one was to take action to ensure the updates, that the information is accurate. The other is to set the quality assurance to make sure of that. They’re variations on the same theme. What we’re saying to them is to take some responsibility to ensure, or take some positive actions to ensure the information you’re compiling is accurate rather than leaving it for us to do later on.
The response, I guess, what appeared to me, certainly in terms of our first recommendation, yes, they agree it should be accurate but they’re not taking the responsibility to ensure that. Rather, they will work with departments and with us to see to it that it’s accurate. Well, we don’t work with them on that, to ensure it’s accurate, that’s not our job. That’s not in agreement with our recommendation which was that they should not continue to do what they’re doing now but to take further action.
In effect, the Treasury Board was saying to us, in both those responses, that they don’t feel it’s their responsibility to ensure that what the departments and agencies put in there is correct.
MR. D’ENTREMONT: So in the larger view again, we come back to that responsibility issue, who’s responsible for a lot of these things.
MR. LAPOINTE: Yes. Our view is that we don’t care who accepts the responsibility for this. Whoever is compiling the information and passing it on to Cabinet takes responsibility for passing on accurate information. It’s not a question of us telling them that if you’re going to compile this, do it right. That’s not our business. But if they’re going to pass it on to Cabinet, then somebody has to take some responsibility for what is given to Cabinet.
MR. D’ENTREMONT: Is there an opportunity for a change in some legislation to ensure that? I mean, again, we’re going on best practice, reasonable issues, but I think it shows that maybe some of these things still don’t get done even with the best effort of everybody. Should we, as a Legislature, look at a change in the law?
MR. LAPOINTE: Well I suppose you could, and I wouldn’t rule that out. My feeling is that it shouldn’t be necessary to put into law that managers of programs should correct deficiencies that they are aware of in the operations of their programs - it should be a managerial culture. There are a lot of ways of accomplishing that, and I suppose that is another one of those ways, though I’m not sure how you would draft that exactly.
MR. D’ENTREMONT: I just look back at freedom of information, I mean, even though it seemed reasonable and transparent that information should be released from departments, it took a FOIPOP Act in order to ensure that it was going to be done correctly and within certain timelines. So I’m just thinking out loud mostly that maybe a change to the AG Act might require these things to happen.
MR. LAPOINTE: Well yes, it could. I’d hate to, in this case, look at having the AG Act being coercive . . .
MR.D’ENTREMONT: No, that’s true.
MR. LAPOINTE: . . . and giving us authority to enforce recommendations on departments. I think that is probably stepping beyond the bounds of what we should do. Our job is to, once we have findings, report them to this Legislature and then to pass responsibility for taking action on them to the Legislature and I think that, theoretically, is a more appropriate route to be taking.
MR. D’ENTREMONT: Yes, and I don’t think it is the heavy hand of making sure the recommendations are implemented, it’s at least requiring that the information be updated on a regular basis and for that to done accurately.
MR. LAPOINTE: Yes.
MR. D’ENTREMONT: If I change over a little bit to the other issues of the day - and I find this one interesting when it comes to Addiction Services - we sort of ran into this one yesterday in our Community Services Committee meeting when it came to guidelines and the issue of mandatory standards, when it came to the addictions services houses - and we were talking about Talbot House, actually, yesterday. So I’m just wondering maybe some comments around the issue of mandatory standards and the control of that. I look at, more specifically, the issue of Recommendation 3.2 - how are we going to ensure that the standards that are set by the department are actually implemented by the districts and those organizations that offer that service?
MR. LAPOINTE: I think that given the topic here, I’ll ask Ms. Colman-Sadd to address that for you.
MS. COLMAN-SADD: Specifically with regard to addiction services standards, I think there is some work to be done there in terms of clarifying for district health authorities whether the department considers standards to be mandatory or not, because department staff indicate they feel they are mandatory but the standards document itself says right on the front cover that they are voluntary, so I think there is some clarification needed there so that districts understand whether or not they are required to comply with those standards. I think, going along with that, there is an obligation under the department to monitor to make sure that those standards are appropriately implemented by the district health authorities.
MR. D’ENTREMONT: Do you find that that data collection is as adequate when it comes to the patient files and those kinds of things that are happening on the ground?
MS. COLMAN-SADD: I can’t speak to specifics of data collection in patient files other than at Annapolis, because that is the only area where we did an audit, and specific to addictions files. We did do some testing in addictions files, and by and large we found they complied with policies. There was some room for improvement in terms of timely filing of patient assessments and whatnot in the files.
Addictions has its own information system - I guess you could call it - called ASsist that is out of the Department of Health and Wellness and I know there is some specific information that is gathered in that, but we also found there were a lot of empty fields in that. Some of the fields are not used by all of the districts, and we also identified an error in how the department was calculating the wait times with that system.
MR. D’ENTREMONT: I think it goes to a greater discussion when it came to the whole issue of electronic medical records, when it comes to tracking all of the patients. It’s not just the specific information on ailments or surgeries and those kinds of things but there are some data fields, I think, that we, as a province, should have an idea about when it comes to wait times or even infection and those kinds of things, so we have a better method to track all patients across the province, regardless if they’re in the Valley on Addiction Services or whether they’re in Yarmouth on something else.
I know that’s probably more of a general statement than a question, but again to the data collection issue, is there a recommendation? I mean they have their own system, should there be more of a standard across the province for all these things?
MS. COLMAN-SADD: Do you mean for all types of services?
MR. D’ENTREMONT: Absolutely, because right now you have ASsist, you have another EMR over here, you have another program for this. There just seems to be an awful lot of data collection that no one seems to have a handle on what is actually going on. Maybe it’s a general question for the AG.
MS. COLMAN-SADD: I think that’s an area where the Department of Health and Wellness would need to look at and make their decisions regarding what they feel the data standards are. I don’t think that’s necessarily for us to say what they should be.
MR. CHAIRMAN: Order, please. Mr. d’Entremont’s time has expired. Mr. Whynott.
MR. WHYNOTT: Thank you very much, Mr. Chairman. I’m going to go back to Chapter 4. My understanding from reading the chapter, you did look at CDHA, is that correct? So could you comment a little bit about some of the practices in place at Capital Health regarding infection prevention and control that are working well, and maybe compare them a little bit to what’s happening in Cape Breton?
MR. LAPOINTE: Yes, certainly, I’d ask Ms. Colman-Sadd to take that.
MS. COLMAN-SADD: Two specific areas at Capital that come to mind are presence of infection control practitioners on units and hand hygiene audits. We found at Capital Health that the presence of the Infection Prevention and Control practitioners from within Capital Health on the various patient units was quite good, they visit those units regularly.
MR. WHYNOTT: Okay, so who are those people? Are they just . . .
MS. COLMAN-SADD: They’re staff of Capital Health who are involved in infection prevention and control, so it’s their role to make sure that if there’s an outbreak, if a unit sees a higher incidence of some particular disease, then they might get involved and say okay, is there a concern here, are we doing everything we should? They’re just kind of present on the units, making sure hands are being washed, things are being cleaned and everything is running as it should.
It was very evident when we had our tours of Capital Health that staff on the units recognized those ICPs, know who they are, and realize their role and what they’re doing, whereas there wasn’t a great presence of infection control practitioners on units at Cape Breton District Health Authority.
Another area at Capital Health where we really thought they were doing a good job was their hand hygiene audits. I don’t remember the exact details from the report but hand hygiene audits talk about moments for hand hygiene, and there are basically four. It relates to kind of before-and-after patient interaction and times when staff come into direct contact with patients, so hand hygiene audits measure those moments and measure whether or not hands are being washed at those times.
Capital Health’s hand hygiene audits were more detailed, they covered many, many more moments, probably four or five times as many moments as what Cape Breton’s did. They also post the results on the units within the hospital very, very clearly on bulletin boards. As we toured around, for example, I noticed many places where hand hygiene audit results and infection rates and whatnot were posted, so they’re there for staff to see, which I think helps with awareness. But they’re also there for patients and their families to see because a huge part of infection prevention and control lies with the patient. The patient has a right to ask a practitioner, have you washed your hands? If they know they haven’t, then please wash them.
When you increase awareness of hand hygiene and whatnot amongst patients and their families, it helps as well.
MR. WHYNOTT: You spoke about doing a tour of various units and that sort of thing, are we talking about all buildings, all Capital District Health facilities? I’m talking about Musquodoboit Harbour, Cobequid.
MS. COLMAN-SADD: No, we toured the VG and HI sites, the Dartmouth General site, and Hants. Then in Cape Breton we toured the Cape Breton Regional Hospital and Glace Bay.
MR. WHYNOTT: Okay, thank you. So you talked a little bit about some examples of CDHA, would those be simple practices and policies that could be implemented in Cape Breton?
MS. COLMAN-SADD: Yes, certainly they would be with regard to the hand hygiene audits. It’s a matter of doing more of the audits. Cape Breton had far fewer of them - far fewer of their units had had hand hygiene audits. It’s a matter of posting the results where it’s obvious to people. They post their results on their Intranet, I believe, in Cape Breton for staff. It’s a lot more obvious when it’s sitting on the bulletin board at work every day, and then patients and their families are able to see it as well. I think increasing the number of audits and increasing the extent of those audits - Cape Breton’s audits didn’t involve a lot of moments for hand hygiene, a very small number, and the more moments you can cover then the better sense of your compliance you can get.
MR. WHYNOTT: It’s interesting, I recently, for a family member, had to be at the emergency at the QEII within the last week since you’ve released your report, and I noticed probably because I read the report a little bit more, but you actually notice it because you’re aware of it - health care workers washing their hands. I couldn’t believe it actually, how many times they were washing their hands. Obviously I think it’s a good thing, but I guess my heightened awareness of that was really good.
I want to move on to Chapter 6, the Office of the Public Trustee. You note that the Public Trustee’s office has a comprehensive policy for managing client investments - can you just elaborate on that a little bit more?
MS. ANN MCDONALD: We wanted to see and test how client investments were being managed and we found that their policy covered what we would expect to see. If you look in Paragraph 6.29, it details some circumstances that might be considered when you’re looking at a client’s investments. For example, their age, so you wouldn’t expect to see that somebody who is older is being put in riskier investments, they’re looking for stability to meet their needs. Overall their policies and the way they managed investments, we were pleased with them, we didn’t find any deficiencies during our testing.
MR. WHYNOTT: Okay. Can you comment in more detail on the prudent investor approach used by the office?
MS. ANN MCDONALD: I believe that is what is outlined in Paragraph 6.28; it addresses that. I mean, we’ve commented, I think, in the past in this office about the concept of prudent investments. Certainly what is outlined in the Office of Public Trustee policy is, as noted there, generally speaking to make sure the risk has been addressed, that you’re maintaining capital for the client, and that the funds are there to meet the client’s needs as required by that client’s individual circumstances.
MR. WHYNOTT: Your report also notes that staff are following the policies and safeguarding assets when opening and closing estates - can you comment a little bit more on that as well?
MS. ANN MCDONALD: You’re referring, I think, to earlier in the chapter which deals with the opening and the closing . . .
MR. WHYNOTT: Exactly.
MS. ANN MCDONALD: . . . so that’s when the staff get the assets, when they obtain the assets from the client and they set them up in their records at the Office of Public Trustee. We certainly found that for keeping those assets and maintaining records of them, that was well done by the Office of Public Trustee.
We did identify a deficiency with at the time that the office becomes aware that they are going to be responsible for the assets, the collection process, to go to the client’s home and pick up the assets, that there was a significant deficiency there and we recommended that be improved. When the Office of Public Trustee first becomes aware that they are going to be appointed to look after a client’s estate, they will send out individuals to gather the assets, but the office doesn’t supervise that collection process, and we identify that that puts the assets and, in fact, even personal information at the client’s home in jeopardy, so we’ve recommended that the Public Trustee should assign staff to supervise that process to ensure that what they receive from the estate is complete and that therefore what they enter into their records is complete.
MR. WHYNOTT: Would that be existing staff that the office already holds - or do you think that could be done in the capacity of existing staff or would they have to hire more?
MS. ANN MCDONALD: I think that decision is up to the Public Trustee. They are undertaking a risk assessment right now. Mr. Lapointe made reference to a meeting that we held with them, and I know that they are looking at some alternatives, but ultimately the decision as to whether or not they hire more staff to implement that recommendation is their decision. Certainly, though, we think that there’s enough of a risk there, that they need to address it.
MR. WHYNOTT: I’m interested around the whole question of providing guidance to staff, making health care decisions for some of the clients - can you elaborate on that policy a little bit more? I’m just interested in that.
MS. ANN MCDONALD: Certainly. The health care decision aspect of the Public Trustee’s mandate - my understanding is that it has been somewhat informal, but that it has been more formalized lately through legislation, I believe, in 2009 in that it finally came to be that the Public Trustee Office set up a division to deal with these decisions. So we tested a few things; we wanted to see that the policies that they had developed were in line with the legislation. A policy that says, for example, that there is certain paperwork that has to be associated with the Public Trustee having the jurisdiction to make these decisions, that that policy addressed, you know, here is the paperwork that you need to see.
We also wanted to see that there was support for the decisions that the health care decision group ultimately made and we were satisfied that, through our testing, we found no serious deficiencies, and three minor deficiencies which are identified on Page 139 with respect to the decisions made. Overall, the health care decisions in that division within the Office of Public Trustee were operating well.
MR. WHYNOTT: You mentioned about testing. I forgot to ask this question earlier - how do you test that? Do you just look at what has happened in the past - how do you test those policies? Just walk me through what exactly happens.
MS. ANN MCDONALD: There are two phases; first there are the policies themselves, so we’re looking to see that the way the policy is written - and perhaps any procedural aspects of the policy - that they address the legislation. So, as I mentioned, here is the legislation, here is what paper should be in place per the legislation before the Public Trustee has jurisdiction. So how does the policy reflect the legislation? We were satisfied that the policies were well developed in that they reflected the legislation.
Then with respect to actual testing of the policies in place, we pick a sample and the sample extent that we use is based on audit methodology, and probably beyond this conversation. But we then select individual client files and we look to see what is in the file in terms of documentation is supported by what the policy said should be in the file. Again, my example of jurisdiction, so that the paperwork that should accompany whether or not the Public Trustee has jurisdiction to make a health care decision is in the file. That’s basically our testing and, as I indicated, we were satisfied with our testing.
MR. WHYNOTT: Mr. Chairman, I’m going to pass this over to Mr. Burrill for the last few minutes.
MR. CHAIRMAN: Mr. Burrill.
MR. GARY BURRILL: Just following along with these questions about the Office of the Public Trustee, I just wanted to get a clarification about the final section of your report dealing with the matter of inadequacies in financial reporting. It’s not immediately apparent from the report, to a non-specialist, exactly what it is that is lacking in the present system.
Am I right in taking the understanding from the report that the current system would allow a client, or those acting for a client, to review adequately what was being done on a client's behalf through the Office of the Public Trustee, that that part was okay, but that in aggregate, taking all of this together, there was an inadequate system for determining how the whole office was doing for the community of clients - is that the point that is being made?
MR. LAPOINTE: I think I can shed some light on that. It's actually a pretty simple point that the - looking at it now more from the point of view of their financial auditors, which we also are. When Ann's group was in there we found that in fact they keep track of all their financial operations, which any organization does, through systems that have developed over the years, and focused on keeping track of client assets. But like any standard organization, they have revenues and expenditures, have balance-sheet income statements and don't have an accounting system to track all those. So we first went into this on a practical basis. When we come to review their financial statements at the year end, deciding an opinion on it, we find that of course they have a lot of difficulty taking the records that they have, which were developed for other purposes, and extracting from that the financial information they need to produce a financial statement.
They manage it, but for instance, right now - Ann will correct me if I'm wrong - I believe they have one person on staff whom I could say really understands how they do this, to go from an effective tracking inventory system to an accounting system and to get the debits and credits you need to produce an income statement. That person can do it, has a very difficult time, our staff can understand it as well, but not only is it very time-consuming, it's not meant for that purpose. So it's really a simple matter of not having a standard accounting system that any operation of this size would have in place to do that, and that is because it has evolved in a different direction.
MR. CHAIRMAN: Order, please. Your time has expired.
Mr. d'Entremont, you requested some written information. Were you satisfied with the answer or do you want the written information? If you do, could you explain exactly what you are looking for.
MR. D'ENTREMONT: No, I'm satisfied with the answer that I got.
MR. CHAIRMAN: Great. Thank you.
With that, I'd ask Mr. Lapointe to do any wrap-up comments you would like to have.
MR. LAPOINTE: Well thank you, Mr. Chairman. In closing I'll just say that I appreciated the opportunity to discuss my report with you today, and my staff have as well. My staff and I do appreciate this committee's continuing commitment to a strong accountability in Nova Scotia. Thank you.
MR. CHAIRMAN: Thank you very much, and thank you again for your report and comments today.
We have some information supplied to the members that is on your agenda sheet today. The clerk informs me that all that information has been supplied. Our next meeting will be later this Fall, to be determined by myself and the subcommittee. Unless there's any other business from the committee, a motion to adjourn would be in order.
MR. CLARRIE MACKINNON: So moved.
MR. CHAIRMAN: It has been so moved.
We stand adjourned.
I would just say, everybody enjoy your summer. Thank you.
[The committee adjourned at 10:54 a.m.]