Public Accounts — Issue No. 17 — Monday, Feb 11, 2008 a.m. (HTML)

2007 Legislative Session: Third Session, 38th Parliament
SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS
MINUTES AND HANSARD

Present: Rob Fleming, MLA (Chair); Joan McIntyre, MLA (Deputy Chair); Harry Bains, MLA; Iain Black, MLA; Guy Gentner, MLA; Randy Hawes, MLA; Mary Polak, MLA; Bruce Ralston, MLA; John Rustad, MLA; Ralph Sultan, MLA; Diane Thorne, MLA; John Yap, MLA

Officials Present: John Doyle, Auditor General; Cheryl Wenezenki-Yolland, Comptroller General

2. The Committee met in-camera to consider its recommendation for its review of the Audit of Treaty Negotiations in British Columbia: An Assessment of the Effectiveness of BC’s Management and Administrative Processes.

5. Resolved, that the Committee’s report to the House be adopted as amended, with final text to be approved by the Chair and Deputy Chair.

6. The Committee considered the Auditor General’s Report entitled Follow-up of 2004/2005 Report 2: In Sickness and in Health: Healthy Workplaces for British Columbia’s Health Care Workers.

7. Resolved, that the Committee endorse the overall conclusion contained in the Auditor General’s Report Follow-up of 2004/2005 Report 2: In Sickness and in Health: Healthy Workplaces for British Columbia’s Health Care Workers.

8. The Committee considered the Auditor General’s Report entitled Infection Control: Essential for a Healthy British Columbia.

9. Resolved, that the Committee endorse the recommendations contained in the Auditor General’s Report Infection Control: Essential for a Healthy British Columbia.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
PUBLIC ACCOUNTS



CONTENTS

		Page

Auditor General Report: Audit of Treaty Negotiations in British Columbia: An Assessment of the Effectiveness of British Columbia's Management and Administrative Processes		353

Auditor General Report: Follow-up of 2004/2005 Report: In Sickness and in Health: Healthy Workplaces for British Columbia's Health Care Workers		355
	J. Doyle
	M. Sydor
	B. de Faye

Auditor General Report: Infection Control: Essential for a Healthy British Columbia		365
	J. Doyle
	M. Sydor
	B. de Faye
	T. Dorran
	D. Cochrane

Chair:	* Rob Fleming (Victoria-Hillside NDP)
Deputy Chair:	* Joan McIntyre (West Vancouver–Garibaldi L)
Members:	* Iain Black (Port Moody–Westwood L) * Randy Hawes (Maple Ridge–Mission L) * Mary Polak (Langley L) * John Rustad (Prince George–Omineca L) * Ralph Sultan (West Vancouver–Capilano L) * John Yap (Richmond-Steveston L) * Harry Bains (Surrey-Newton NDP) * Guy Gentner (Delta North NDP) * Bruce Ralston (Surrey-Whalley NDP) * Diane Thorne (Coquitlam-Maillardville NDP) * denotes member present


Witnesses:	Dr. Doug Cochrane (Provincial Health Services Authority) Bob de Faye (Ministry of Health) Dr. Thomas Dorran (Ministry of Health) John Doyle (Auditor General) Morris Sydor (Office of the Auditor General) Cheryl Wenezenki-Yolland (Comptroller General)

R. Fleming (Chair): Good morning, Members, and welcome back to Victoria and to the Public Accounts Committee. Our meeting is going to start now. There's a member waiting to arrive, but if I could have a motion to approve the agenda, we can get underway.

R. Fleming (Chair): The agenda is before you. We have a couple of items that take place in camera before we go to the public section of the agenda.

Auditor General Report:
Audit of Treaty Negotiations in
British Columbia: An Assessment of the
Effectiveness of British Columbia's
Management and Administrative Processes

R. Fleming (Chair): Just to confuse Hansard even more, we're in open session again, on the item around the treaty report.

J. McIntyre (Deputy Chair): Thanks for that, Chair. I don't mean to get us off on a little bit of an unusual note there.

I did want to make some comments regarding the recommendations because it's a bit of an unusual situation. As the Chair just explained to us, it's been some time since we entertained the report, since we heard the report from the Auditor General and since we heard from the ministry on their progress. Also, of course, there's been quite a bit of time elapsed since the report. I note that the report was in November '06.

Certainly from my perspective, we find ourselves in a little bit of a situation because much has happened since then. I think that we had wonderful success this fall when we introduced the Tsawwassen treaty and then, of course, the five Maa-nulth-related treaties.

Since this report was written, we have had success on the treaty front. And of course we've had a number of economic arrangements and agreements that have also, I think, been very successful, including a resolution of the land on which the Legislature sits — and the Musqueam — which helped to resolve some litigation.

In my own riding I've seen the results of things like the land use agreements for the Sea to Sky accommodation, for the highway. I see the progress we're making on the new relationship in that regard.

As this time has elapsed, as I said, we find ourselves in a bit of an unusual situation, where I think some of the successes have flown in the face of some of these recommendations, particularly recommendations 1 and 2. We've seen that focusing on the lead tables has actually now produced treaty, and it still makes sense — certainly, I think the government's response made sense — to focus some of the resources on those situations where we think we will have success and where the first nations, obviously, are keen to move forward.

Then the other recommendation, the first recommendation, says that some of these economic arrangements and agreements are perhaps hampering the treaty process. I think we've seen success on that front as well.

I just thought that what I would like to do today is make a motion. I want to acknowledge the work, certainly, of the Auditor General. I'd like to move that the committee accepts the recommendations by the Auditor General's office but at the same recognizes the progress made by the ministry to date.

Just to repeat the motion, it's that the committee endorses the recommendations, which we would then….

J. McIntyre (Deputy Chair): I'll read it again, if you'd like, Chair. "The committee accepts the recommendations by the Auditor General but at the same time recognizes the progress made by the ministry to date."

B. Ralston: Just as a technicality, shouldn't the recommendations then be recommended to the Legislative Assembly? Beyond accepting them, then we recommend them to the…. I accept the comments that there has been progress made. I think that's self-evident.

R. Fleming (Chair): I think it's implicit that by this committee accepting the recommendation, we are putting that opinion towards the House and would do so in our report on the committee's activities. That would be consistent with all the other audits that we have considered. That is in your draft report there. In terms of a consistent formatting of language, I think that by accepting it here, we are in fact recommending it to the Legislative Assembly.

J. Schofield: I think that if you added, Deputy Chair, "accepts the recommendations by the Auditor General and recommends the same to the Legislative Assembly," and then a new line: "At the same time, the committee recognizes the progress made…."

That would be consistent with the rest of the report. That's all I'm trying to point out.

J. McIntyre (Deputy Chair): I know. I appreciate that. But I think that in my words in the preamble…. I did think about this carefully, and I actually chose the word "accepts" rather than "endorses" or "recommends" for the very reasons that I said.

I think we find ourselves in a little bit of a situation where, as time has passed, as I said, some of the successes have flown in the face of those recommendations. We've had success with breakthrough tables. We've had success with economic arrangements. The ministry had said pretty clearly that one size doesn't fit all, and I think history is starting to prove that.

I just think this is an unusual case — from some of the other things that we have dealt with.

J. Schofield: Yes, there's no doubt about that. All I'm saying is that as the committee is delegated to review this report on behalf of the House, if you're accepting the report's recommendations, then that has to be conveyed back to the House. The way it has been done in the past is to say that the committee accepts the recommendations and recommends that the assembly does the same. That's just sort of a procedural step, if you like.

J. McIntyre (Deputy Chair): Okay. That's fine. I don't want to make a meal of it or belabour it.

M. Polak: I just wanted, I guess, to focus us on the challenge at hand — right? If we're going to be determining that we recommend…. It is a challenge, as the Deputy Chair has acknowledged. You're faced with recommendations that are based — at least on two counts — on determinations by the Auditor General that history has proven to be wrong. How do you then endorse and recommend action that really has proven out to be in quite the opposite direction in terms of success?

I mean, the challenge that we face is if one is going to say that we, then, recommend this to the House in that sense. In particular, I'm challenged to look at, for example, the issue of breakthrough tables. When the Auditor General says that it's going to be a holdup and that it's going to cause more problems…. In the end, one could argue that it was the movement to breakthrough tables that saw a breakthrough.

I think we're challenged, perhaps, to deal with a standard wording. Therefore, it probably behooves us to take on a motion that is not necessarily our standard. It is a unique circumstance.

R. Fleming (Chair): Fair point. I think the audit is really about two decades' worth of commitment to this process. On balance, it's an audit of $250 million of spending at that table for this province. If one were even just to look at April…. I take the member's point about the two treaties that have been achieved, but there's also been one that has been voted down, so there's a balance sheet there that would show that many of the audit's key findings are in fact valid for the province as it tries to achieve more treaties.

J. Rustad: I am a little confused about it, in terms of recommending it to the Legislature. In particular, I've got a problem with number 3: "The Minister of Aboriginal Relations and Reconciliation should report annually on the status of negotiations, the barriers to success and the efforts it has made to overcome those barriers."

Any time you're in a negotiation, where you're going through a process, there can be delicate issues and there can be barriers or other things that need to be overcome, but by airing them in public, so to speak, you could actually create more problems than you can solve. I find it a challenge to be able to recommend that to the Legislature.

R. Fleming (Chair): If you go back to the central audit, though, it's not asking that things be disclosed, like what compensation or specific resource agreements are being discussed. It's talking about progress, I suppose — what stage of agreement they are at, at the negotiating table. I think the point of the audit was that there isn't regular reporting back to the Legislature, and right now there is no standing committee on aboriginal relations and reconciliation that does that either. If that addresses the member's concern that this kind of reporting could be harmful in any way….

Okay, we have a motion before us. If there are no more speakers…. I haven’t seen any hands. Deputy Chair, do you want to read the motion again?

J. McIntyre (Deputy Chair): Yes. It's that the committee accepts the recommendations by the Auditor General but at the same time recognizes the progress made by the ministry to date.

R. Fleming (Chair): If I could have a motion for the committee to return back in camera for consideration of the report.

R. Fleming (Chair): A motion to adopt the report as amended, subject to final edits by the Chair and Deputy Chair.

R. Fleming (Chair): A five-minute recess while our witnesses arrive and then set up their presentations.

R. Fleming (Chair): Okay. Committee will come back to order. I think we have the technology worked out now. Believe it or not, we're actually ten minutes ahead of our original agenda, so let's try and keep it that way. It's been a very rigorous morning for all of us.

We'll move on to item 4, which is a follow-up report entitled In Sickness and in Health: Healthy Workplaces for British Columbia's Health Care Workers. I see we're now joined by our Auditor General, Mr. John Doyle. I'll ask him to introduce this item, and then we'll hear from some witnesses from the government side.

Auditor General Report:
Follow-up of 2004/2005 Report:
In Sickness and in Health: Healthy
Workplaces for British Columbia's
Health Care Workers

Chair, Deputy Chair and Members, we're pleased to present a follow-up report In Sickness and in Health: Healthy Workplaces for British Columbia's Health Care Workers. With me today is Morris Sydor. He is the assistant Auditor General who was responsible not only for the original report but also for the follow-up process.

The original report reported in June 2004, and it examined how well the health authorities were managing the workplace to create a healthy work environment. That audit found that although there were building blocks in place to create a healthy work environment, there were also a number of gaps. Fifteen recommendations directed to each health authority were included in the 2004 report. Morris will now highlight the status of those recommendations.

I'll start just by going over the time lines for this particular review. Again, as we've just indicated, the report was issued in June 2004, and the Public Accounts Committee reviewed that particular report in November of 2004. Then about a year later we asked for follow-up information. That would have been as of December '05. We received the information during the spring and summer of 2006, at which point we carried out our follow-up review of the information and issued our follow-up report in February of 2007.

Again, the purpose of the original report was to determine how well the health authorities were managing the workplace to ensure a healthy work environment for the province's health care workers. We focused on whether the health authorities were providing leadership in establishing and maintaining a healthy work environment, whether they were promoting a healthy work environment and whether there was monitoring and reporting on the health of the employees in the work environment.

We concluded that the health authority leaders needed to focus more attention on creating a healthy work environment for their employees. The five geographically defined health authorities had some of the building blocks in place to create a healthy work environment. However, the ability to sustain and build on these was constrained by a lack of directed funding, a lack of focus and a lack of integrated information about all aspects of employee health and the work environment. As well, managers had been unable to devote sufficient attention to understanding and addressing employee needs.

At the time of the audit, the Provincial Health Services Authority was only in the early stages of developing a unified approach to employee health and well-being. Many of their policies and programs were at the individual facility level.

The follow-up found that the health authorities had taken a number of steps to implement the 15 recommendations in the report, so obviously there was a total of 90 recommendations for the six health authorities. Looking at the results, we find that 59 percent of the recommendations had been fully or substantially implemented and the remaining 41 percent had some steps taken toward implementation.

R. Fleming (Chair): I see Bob de Faye is here with us from the Ministry of Health. There are a couple of other witnesses that were due to be here but, ironically, are sick today: Valerie St. John and Frances Kirstiens. So Bob will take all of our questions and lead the presentation today.

B. de Faye: Good afternoon Chair, Deputy Chair and committee members. Let me begin by thanking you for the opportunity to discuss the Ministry of Health's and the six health authorities' responses to the Auditor General's follow-up report on healthy workplaces.

I am Bob de Faye. I'm the chief administrative officer for the ministry. As the Chair said, I'd hoped to be accompanied today by Val St. John, the assistant deputy minister for health human resources planning, and by Frances Kirstiens, occupational health and safety consultant with the Health Employers Association of British Columbia. Unfortunately, both of them have fallen ill and are unavailable, so with your forbearance I shall do my very best to step into the breach.

I'd like to thank the Auditor General and his staff for their thorough and thoughtful work on this important issue and their continuing interest in seeing that progress continues to be made in improving workplace health. We have a complex system that is only as strong as the health providers who work within it, and skilled and caring professionals provide the backbone of our system. Our goal, of course, is to ensure that all of them are supported to use their knowledge and their skills in a challenging, supportive and healthy work environment.

Given that I'm advised I have 20 minutes to cover quite a lot of ground, I propose to go through a truncated version of a much larger and more detailed PowerPoint presentation that I believe you may have

received earlier. Today's presentation will profile the three areas identified in the Auditor General's follow-up report in highlighting the work done by each health authority in the 37 residual areas noted. I'm also going to be talking a little bit about some provincial-level initiatives and a high-level system change that's being driven through those same three categories.

Overall, I can preface my remarks by saying that we have made some good progress as a system. I'm confident that safe, healthy workplaces will continue to be a priority not only to further the interests of the health care workers but also at the same time to support and enhance patient care. Once I've done my presentation, I will do my best to respond to any questions that you may have.

Included in this deck is information regarding the review of progress in the categories of enhancing leadership, promotion, monitoring and reporting, as was set out in the original structure of the report and the follow-up. I'm going to be reviewing some data indicating workplace trends, and we're going to be reviewing provincial initiatives on a highlight basis.

I should say that rather than get into the granularity of each of the health authorities in specific initiatives, of which there are dozens, I will stick to what's happening at a system level, as the focus of the Auditor General's report was an analysis and recommendations of what needs to be done in a systemic way as a framework and a grounding for good work that needs to be done by the health authorities themselves.

A little bit, quickly, about the health system in British Columbia. The authorities, of which there are five regional ones, and the Provincial Health Services Authority, which provides for tertiary health care services, are very large employers in their own right — 126,000 employees by latest count; 9,200 physicians. The health sector constitutes fully one-third of all public sector employment in this province.

Labour, of course, is a necessary and vital part of the system. It consumes, on average across all of the various subsectors, about 70 cents of every dollar. So while health care is undoubtedly evolving to become more of a high-tech form of enterprise, it is also fundamentally a high-touch service. Again, it's the people who make the difference. A healthy workforce and healthy workplaces are absolutely vital. They are integral to high-quality patient care, and a stable and healthy workforce obviously contributes to that sustainability that I talked to earlier.

As set out earlier by the Auditor General's staff, this report that we are speaking to is a follow-up report to the original 2004-05 review that was first published in June of 2004. As said, it reports on the three categories that I spoke about earlier. The 2007 report does acknowledge that there has been substantial progress on the part of the health authorities, that there has been full or substantial implementation of 53 of the 90 initial recommendations and that 37 of the recommendations have been partially implemented. We'll talk to that in a moment.

In terms of the progress to date, further to that follow-up report, I can report that all health authorities have taken action on the Auditor's recommendations and have made improvements as a result of actions on their part. There are well-coordinated initiatives taking place across the system. Many of them are systemwide initiatives, which I'll speak to later, for the purposes of having avoidance of duplication, avoidance of unnecessary costs and the ability to have comparable data to see how all of the health authorities are doing, both individually and collectively as a group.

There is a collection of data and measured key indicators, which again I'll speak to, and a communication and a reporting to the health authority boards on workplace wellness. This has become a standing item, an important item, to focus on at a board level. There have been surveys of employees, and there has been a demonstration in many, many ways and fashions that employee health and wellness are important to organizational success.

For those of you that do have the original slide deck, I'll just sort of talk about the truncation that has taken place. In the original deck there were a number of slides, from pages 6 to 24, that actually provided highlights of each and every initiative — the work that's going on in the health authority — done to address the specific residual areas of interest: the 37 initiatives that are identified in the follow-up report. As well, slides 25 to 31 are six slides that actually dig into some of the data that is being collected. We can use that to identify trends throughout the system.

I'd like to provide a brief overview of provincial leadership activities. One of the critical features, in terms of pulling this together from a systemic perspective, is to have a body that's responsible for doing just that. That's the provincial health human resources strategy council that was put into place in the fall of 2006. That council reports to the leadership council, which is made up of the Deputy Minister of Health, Gord Macatee; the chief operating officer of the Ministry of Health, Michael MacDougall; myself, the chief administrative officer; as well as the chief executive officers of all of the health authorities.

This is a group that gathers to look at systemic issues and systemic management. Again, the issues of health human resources, workplace wellness, recruitment and retention, and supply development are all critical first-order issues of concern to the council.

Of course, there's a focus on ActNow. Everyone, I think, is well familiar with the ActNow program and initiative. That, too, is being seen as promoting healthy and active living throughout all of the health authorities.

There was an opportunity, as well, with the Conversation on Health for workers in the system to have input into that very, very large public policy discussion initiative that took place. There were 17 regional meetings that took place around the province, and in each case there was a special meeting that took place before the public meeting where health professionals and health workers and workers' representatives were

brought together. They had an opportunity to provide specific input from their perspective.

In addition, there is a joint initiative that has been taking place between the Ministry of Health and the British Columbia Medical Association sponsoring professional quality improvement days for physicians.

There is also a healthy workplace leadership charter, which was created in 2006, that has five guiding principles. I'll briefly go through those.

There is leader commitment and active and visible involvement. It needs to be people-focused. This needs to be a comprehensive approach with shared initiatives, as I said, across the system so that we don't duplicate and we can have best practices implemented. We can do it once, share best practices and save costs in implementing these things. Plus we have reproducible programming, and we have data that is comparable and reliable so we know whether, in fact, we are making those positive changes that we hope to achieve.

Accountability, of course, is critical, not only in the expenditure of public money but in the actual achievement of our goals, which are very critical to having a sustainable system and a healthy workforce.

Again, in provincial leadership and under the rubric of promotion, there has been dedicated funding for health authority health and wellness initiatives — many, many initiatives taking place throughout all of the health authorities. There is the primary care charter that focuses on primary care, which is the relationship between the patient and their general practitioner. Beyond that, this is an expanded vision of primary care that involves the use of multidisciplines working together in a teamwork arrangement to provide better care.

There are interdisciplinary learning and practice networks going on. It provides a benefit not only to the patients, but it provides a benefit to the workers themselves in terms of their knowledge, skills and ability, their interest in their work and their work satisfaction.

There is, of course, the $100 million health innovation fund that was announced as part of last year's budget, and they supported a number of key projects. I'll just give you a couple of examples: the nursing graduate orientation program; the development of integrated health networks, as I said, along the lines of the primary care charter; and some work that's been going on with respect to responsive shift scheduling and front-line leadership in the nursing field.

I'd like to go through some of the key changes. These are some of the background changes that occurred in terms of the organization of the system in the past few years, all of this in aid of positioning us better to be able to do a more effective job in this critical area.

Of course, we saw in 2001 the rationalization of the regional model from 52 health authorities into six, affording an opportunity to get better organized, more streamlined and more efficient. We saw in the period 2002-2006 some very important steps into the area of governance and accountability with the implementation of service plans — I'm not just talking about service plans for the government ministry but, as well, service plans for health authorities — and the performance agreements, which were the initial attempt at a specific accountability document between the government and the health authorities in respect of what are priorities and what are key deliverables and what are expectations.

In 2007-2008 we saw the next evolution of the performance agreement approach, which was to move into a government letter of expectation. That was, one might say, an enhanced performance agreement, but it does increase alignment and accountability, and it is, of course, supported by the health authority service plans.

The next schematic little graphic really shows the health authority planning and accountability cycle. To make sense of this, I think the best place to start is at the top arrow: government priorities for health, translated into the ministry's own service plan, and the identification of goals and objectives, which translate into the letter of expectation — providing that focus, providing that guidance.

With that come some instructions from the ministry as to how to prepare health authority plans. That's an iterative and an interactive exercise in the development of those programs. We sit down together at a senior executive level. We go through their plans until they are finalized. Then there is, of course, monitoring against critical performance indicator criteria, and there is an annual reporting out to close the evaluation cycle.

Just to speak briefly of the key indicators — and there's quite a bit more in the original deck — in 2006-07 in the performance agreement letters we had implementation of a plan for workplace staff health, including recruitment, retention, safety, injury prevention, violence prevention, psychological well-being, healthy lifestyles, leadership and change management.

In 2007-2008 those new government letters of expectations and service plan indicators speak to those critical measures of health human resource planning, looking at things like sick leave — this is a good indicator of healthy organizations — vacancy rates, overtime hours and immunization rates.

Of course, in any environment where you have people being treated, you have large patient volumes. You have people who are ill. It's very critical that employees are protected against these onslaughts of annual influenza that typically show up in the fall.

There is, of course, the participation in the health human resources strategy council that I mentioned earlier. It is very important, and health authorities have stepped up to participate actively in that council because there is a recognition that this is very important work.

I want to talk a little bit about some of the other organizations or groups that support the health authority and ministry activities, one of which is the Health Employers Association of British Columbia. The association is created by means of the statute, the Public Sector Employers Act, and it is a labour relations organization.

It is the designated bargaining agent. But in the last few years, there has been a change in the nature of

collective bargaining to include a lot more policy content, so we are seeing the creation of health policy tables. Much of that work is in fact very directly relevant to workplace health.

We've seen a provincial violence prevention strategy created, standard programs on violence prevention and response, a provincial notification and alert system, strategies for dealing with violence in the workplace, and collaboration and support in Criminal Code investigations.

There is also a public campaign with WorkSafe B.C. on violence in the workplace. In the last very little while we're starting to see — and some of you may have seen if you were in a facility recently — signs that have gone up talking about workplace violence and essentially saying that there's zero tolerance here, that people need to respect health care workers.

There is a publication of best practices in violence prevention, and there is a review process with the Nurses Bargaining Association, which is led by the British Columbia Nurses Union, where they are monitoring and working with us jointly on reviewing progress along those lines.

Another program that's very important — and it is a systemwide initiative, again — is the sick leave and disability management early intervention program. We have relatively high levels of sick leave. This was, again, negotiated through a collective bargaining process in 2006. It's a joint governance initiative.

It is focused on early intervention and letting people know that they're important in the system and that they don't get lost, that there are people looking out for their welfare and that they have an important role to play. We're wanting them to get well, get back and continue to provide the excellent services that they can. So there have been a number of employees…. As at last December, there were 3,857 employees that were referred to that program.

Another agency critical partner is what they call OHSAH, which is the Occupational Health and Safety Agency. That works with employers to develop programs for health promotion and safety practices. They pilot those programs, and they facilitate the sharing of best practices through training and research. They look into assessing program effectiveness with, obviously, the overall focus and intent, the goal, to reduce workplace injuries and illnesses.

Part of the work that's been done by OHSAH…. As you'll know, a great many health care workers suffer from musculoskeletal injuries, often a lot of back problems, because they're moving patients around. OHSAH has funded things like bed lifts so that people can be safely moved and workers do not injure themselves doing that. That's been funded at $19.6 million over three years.

Another interesting sidebar of the OHSAH experience is the Occupational Health and Safety director's collaborative. This actually widens the circle beyond OHSAH to include other groups to focus on health, safety and wellness. It includes partners such as WorkSafe British Columbia; the health benefits trust, which is the benefits provider to the health care system; OHSAH itself; the unions; the ministry; and even Health Canada is involved with that.

They've been organizing some very important conferences, such as innovative solutions to sustain a healthy workforce. There's another conference that's planned for 2009.

Moving forward, we are committed to continuous improvement. One of the things that we're looking at is very critical in our system. Today we have a situation where we're facing an aging population, which presents its own challenges in terms of utilization and demand growth. But we also have an aging workforce, because they too are baby boomers. We also have a diminished supply of new folks that are coming up through the school system and the college system.

So it's vitally important that we look at strategies for key occupations and how we can improve supply and how we can retain people in the system. There are a number of HR strategies that we're looking at to address all of those things: workforce demographics, attrition, recruitment, new service delivery models, tech change and changing needs.

Just to bring this to a conclusion, I will speak a little bit about some specifics, because those are some fairly general statements that we are very much committed to continuing to improve on what we're doing. But I should say that the recommendation specifically regarding spans of control for managers in the system was directed to all health authorities by means of the letter of expectation. There are organizational reviews and changes that are underway now to address this recommendation. The HHR strategy council is also addressing the recommendation regarding the determination of indicators of employee and workplace health. That will be publicly reported on a regular basis.

In addition to the recommendations made in the report, health authorities have been doing a large number of initiatives that support the recommendations. Interior Health has produced their people plan and a companion document called Healthy Workplace Portfolio Commitment. Northern Health Authority has done an employee engagement survey. Vancouver Coastal has developed a healthy workplace charter.

Provincial Health Services Authority has created the prevention, promotion and protection workplace wellness and active living program, which is probably an unpronounceable acronym.

As well, I have spoken a little bit about those workforce planning initiatives. So, with that, as it says in the last line: "Safe and healthy workplaces will continue to be a priority." That's important not only to the workers, but it also leads its way into providing enhanced patient care.

J. Yap: Thank you, both the Auditor's office and the Ministry of Health, for your presentations.

In one of your earlier slides, Bob, you had a bullet point about the health authority boards being informed and a part of this from a leadership perspective. What kind of follow-up and monitoring are the boards provided, given that this is an important area?

I would imagine that in a board meeting there would be reports on performance, on patient care, results, wait lists — that type of thing. Would this now be part of the regular reporting? What type of ongoing follow-up is happening at the health authority board level? As the chief administrative officer for the ministry, what kind of follow-up does your area do on this area?

B. de Faye: As I'd indicated, all of the health authorities are now committed to having plans, both long-term strategic plans plus annual plans. For those, there are performance indicators, and as you can see when we talk about workplace health, it's a very broad area of discussion — everything from span of control to healthy eating habits, and dealing with stress, and mental illness and violence in the workplace. So all of those critical kinds of areas of focus and initiatives are built into those plans.

There is a regular reporting that takes place by the executive of the respective health authority to the boards. As well, there is a similar follow-up with the leadership council, which is the deputy minister plus the CEOs of the health authorities. This item is a regular, tabled agenda item where we speak about our plans, we speak about specific initiatives. There is an active engagement and a very interested sharing of best practices, because if somebody is doing something well they want to copy it and not have to develop it themselves and waste the time in terms of getting on with this.

So there is a reporting out in terms of the progress that we're making, the progress on creating new seats. There were 917 new seats in terms of the allied health professions — the technologists, etc. — in the 3,000 seats in the last few years in terms of nursing. There is a structured process from the health authorities, and there is an articulation of progress and an accountability. But it's also up another level into the leadership council for the system writ large overall.

The area of health human resources is vast, to say the least. You probably could have easily filled an entire conversation on health just with that topic. Workplace health and safety and employee wellness is only one facet of that.

Certainly, a lot of progress to date. In terms of the way in which the system has adjusted to this new focus — or renewed focus or however you want to say it — do you feel confident that the rate of change will continue or improve?

B. de Faye: I do feel confident about it. I'm pleased because the lights have gone on for so many people, almost simultaneously, in terms of the challenge of the demographic that I set out.

I don't think it's telling tales out of school, but when I talk to the health authority CEOs about this issue — about the supply, the welfare of people in the system, their level of engagement, how we're taking care of them — it's their number one issue. It's what they say is their number one concern.

We are seeing this discussed in the right places. We're seeing it discussed in the Ministry of Advanced Education, in respect of supply. We're seeing it discussed in all of the health authorities, in respect of the ministry. It's a key feature at the ministry executive table discussions. It's always a feature when all of the groups get together. There is a great deal of work that's happening. Conversation on Health was a very good way to bring much-needed focus and attention to this issue.

M. Polak: Mr. Chair, I would move that the committee endorse the recommendations of the Auditor General and acknowledge the progress of the health authorities to date.

R. Fleming (Chair): Oh, yeah. People can continue to ask questions, and then there is a motion on the floor for considering later.

H. Bains: On one of the areas here, Bob, you said 37 recommendations are partially implemented and require follow-up, and you said you would talk about that later. Unless I missed it, maybe you want to make a comment on what the follow-up is and what the challenges are for not implementing fully those 37 recommendations.

B. de Faye: I have a list of all the recommendations. I can tell you that of those 37 recommendations, there is substantial progress being made in each and every one of the health authorities. The work is being reviewed in terms of the progress. The accountability for progress, as I said, is being reviewed at the board level and is being reviewed at the leadership council level. And of course, there is an annual review of progress, as I showed you in that graph, in terms of sitting down with the deputy minister and the minister. There are regular meetings with the board chairs and the CEOs, and this topic is very much one of the key areas of focus where progress is examined.

B. de Faye: We've seen, since the original report was done — the work that was published in 2004…. In the last four years we've seen substantial progress. I think the progress is actually accelerating. But with that, there are some challenges that are going to require really sustained efforts, such as the issue of recruiting.

There's still work that needs to be done on putting into place all of the pieces that we need to deal effec-

tively with a very significant challenge of violence in our health workplaces. Those systems are going into place to be able to identify people at risk. You'll appreciate that in some of the health authorities in the lower mainland, all a person who's created a problem in a workplace would need to do is literally walk across the street, potentially, to another facility. So it's very important that we have the means of tracking incidents, identifying people, having the ability to take steps to prevent problems and having people trained to deal with de-escalation of issues, etc.

H. Bains: My question was: is there a targeted time to have those 37 partially completed recommendations completed? Is there any targeted time?

B. de Faye: I do not know that from the health authorities, but my expectation is that they would be done within the next year to 18 months.

H. Bains: Some other questions. You said there are some performance agreement indicators that came in 2006-2007. One of them is sick leave as a percentage of productive hours. Can you tell us what the sick-leave percentage was before and what it is now after the implementation of these recommendations?

H. Bains: In fact, you could actually give us a rundown on all of those indicators — vacancy rates, overtime hours.

B. de Faye: …but I can tell you that in terms of the health care system, there is significantly more sick leave incurred than, for example, for all Canadian workers. The last data that we have is actually some few years old. But in 2005 the average for Canadian workers was 7.8 days per FTE per year, and the average for health care was 13.1 days per year. I would have to get you information as to whether we've been able to…. We talked about the joint early intervention program, and there are targets for trying to reduce those levels.

There are some other initiatives, of course, like responsive shift scheduling that could have, potentially, a positive effect on sickness as well. I can try and get some of that information for you.

H. Bains: In fact, if you could get the information on the other indicators as well.

R. Fleming (Chair): So, Mr. de Faye, you'll endeavour to apprise the entire committee of the questions around those performance indicators, then — on sick leave, vacancy, overtime, immunization rates?

R. Fleming (Chair): And, I suppose, with a few years of tracking since the first report was done and the subsequent follow-ups.

G. Gentner: Just very quickly, I just want to know the follow-up…. As Mary mentioned before, it's such a complex issue relative to health and the health care workers who play a role within it. We'll see it in the next Auditor General's report, I think, under infection control. Not one glove fits all, but we seem to have almost a mishmash of authorities trying to sort out their difficulties not only at the jobsite but also with the implementation of health itself.

When I look at any of these summaries on the tables, whether it be the Northern Health Authority or the Interior Health Authority, etc., there are two little recommendations that stand out that all authorities had a problem with. One was at the bottom of any of these tables: "Review the extent of manager's control and ensure that it's not beyond a limit to be effective." The Auditor General mentioned that. Every authority, including the Provincial Health as well, partially fulfilled that duty.

My question is: why is it that all the authorities under this criterion had a problem fulfilling that implementation?

B. de Faye: Good point. I think the issue speaks to the span of control that I mentioned. I think the challenge of the authorities in meeting that has to do with some of the assessments that have to take place, some of the reorganization that has to take place.

There has also been a significant amount of consultation that's been drawn upon, some of which came through the Conversation on Health, some of which came from our discussions in our joint policy committee with, for example, the B.C. Nurses Union around the importance of leadership in the workplace. There have been some funded initiatives through the policy committee with the employer and the union bargaining association, including things like front-line leadership.

Some significant amounts of money, actually, have gone into putting people into the system to meet that leadership and supervisory need that exists out there — especially so because, as you'll appreciate, when we're talking about the demographic that affects the workplace itself and with the aging of the workforce…. British Columbia has, for example, with the nurses, the oldest nurse cohort in Canada.

What we are seeing, of course, is people retiring, as they will, and new folks coming into the system. It's becoming very important, with the refresh that's happening in the next generation, for there to be active, present supervisory leadership to help people orient to the work and to help them be successful and be

practice-ready as soon as possible as they graduate out of the university system.

G. Gentner: A follow-up, because the same anomaly happens again with the last recommendation: "Determining in conjunction with the Ministry of Health Services what indicators of employee and workplace health should be reported publicly on a regular basis." Again, all of the authorities, including the provincial health service, didn't quite come up to snuff relative to the implementation.

My question is, I guess, because all of them didn't come up to the standard: would not the ministry itself take the lead in making sure that there are protocols? And what indicators? Would they not all be the same, relative to the indicators?

B. de Faye: Yes, the ministry does take leadership. Val, who is not here today, chairs that health human resources strategic council. Part of the work that they do is in defining those measures and getting consistency across the measures.

The chart that I have here of the 37 initiatives…. For that last item that you talked about, "Determining in conjunction with the Ministry of Health Services what indicators of employee and workplace health should be reported publicly," in every case there is a checkmark, which indicates that there has been substantial progress made since the 2007 report. So there is progress being made on that.

Part of the challenge as well, as you correctly pointed out, is that you do not want to have different indicators with different health authorities. You need to measure the same things. You need to have common data definitions. You need to have data that is reliable.

G. Gentner: Just a quick comment. I'm glad everything revolves around the checkmark. I'm really confident now that the health care system in the province is under due diligent care. Thank you.

R. Sultan: Mr. de Faye, I'm intrigued by the fact that we've actually got two versions of your presentation before us today. I refer specifically to the one that was transmitted to committee members — all of us, I presume — dated January 29 as opposed to the presentation you've given to us, which you have truncated under the pressures of time.

What is unique and intriguing to me is that the previous version of your presentation given to us had a lot of tabular data and bar charts. For the benefit of those who perhaps haven't had the advantage of reviewing your earlier version, let me just cite in particular four panels of this PowerPoint that particularly intrigued me.

The first is titled "WCB Injury Rate Health," and it cites statistics going back to 1997. The trend line is up through '06. The WCB injury rate peaks at around 6.3 in 1999 and improved in 2000 but is down to 4.2 in the most recent reporting period, which is almost a third lower. A remarkable improvement.

The second bar chart you distributed earlier is titled "WCB Claim Costs — Registered Nurses." Here we have '01 data plotted for us indicating costs in the range of almost $20 million and in 2006, $14.6 million.

The third bar chart shows "WCB STD" — which I suspect in this context means short-term disability, not something else — days lost by registered nurses. The numbers — again, if my failing eyesight helps me with these very small numbers….

It's 80,000 in 2001 and down to 62,900 in 2006, which is about a 20-percent or 25-percent reduction in WCB short-term disability days lost by registered nurses. I see you're nodding, confirming what the chart says.

Finally, we have the fourth bar chart showing LTD, long-term disability claims incidence rate — I presume the LTD refers to long-term disability — per thousand covered lives in acute care. We see a very sharp increase in the period 1998 through 2000, peaking at 20 per thousand. It drops down to 17 in the most recent reporting period — again, about a 15-percent reduction.

Well, these are remarkable improvements, and at the risk of annoying my colleagues opposite greatly, as a politician I'm compelled to ask: why was the health system as a place to work so much less healthy on your reported data under the previous government than it is under the present government? I think the differences are startling.

B. de Faye: As I said, I think the statistics…. And I appreciate the members reminding me of what has been removed from the original presentation, because there's a great deal of fact and there's a great deal of data involved.

I think the slides do speak to the hard work that has gone on, on so many different fronts: whether it's health and safety initiatives to prevent people from being injured or whether it's initiatives to deal with violence in the workplace or whether it's those proactive early-return-to-work programs. I think they are all having positive effects. As you can see from those particular charts, they are empirical evidence, and they're measurable.

We are putting into place the framework, the discipline, the focus, the attention and the commitment required simply to do a better job on a very, very important file.

R. Fleming (Chair): I have a couple of questions I wanted to ask as well. One is just on the scope of the audit, and maybe Morris can comment on this.

You explained that excluded from the audit were doctors and contractors. Can you tell me: would those contractors involve all staff involved with cleaning and sterilization services in a hospital that now work for contractors like Compass, Crothall and other major outsource multinational companies?

M. Sydor: My recollection is that that's right. What we were focusing on was employees managed by managers in the health authority, as opposed to contractors. It would have been that group that we didn't include in that particular review.

R. Fleming (Chair): What percent of the workforce is now outsourced in the hospital, as compared to the data that was previously kept by the government and the ministry?

One of the things that's been brought to my attention from constituents and other information I've received as an MLA who represents a constituency in the Vancouver Island Health Authority is that internal audits, if you can call them that, of these contractors — who are charged with the responsibility for the cleanliness of the hospital, the sterilization procedures, including laundry and other things, besides the physical facilities themselves, building services those kinds of things — are actually known in advance when they will occur. So there's an awareness of these dates. They're not random at all.

Then, finally, the contractors are in a self-reporting relationship where they basically audit themselves and then pass on the information to those in charge of overseeing the contract.

I wonder if Mr. de Faye could tell me if that is in fact the case and what kind of direct relationship the Ministry of Health has with that set of employees that are not directly employed by the ministry but are nevertheless employed in the facilities in this province.

B. de Faye: In terms of the two questions that you had, the internal audit issue and the fact that these are pre-announced have been discussed at the leadership council with the CEOs. That is in fact the case in some instances — not all — and that is certainly going to be remediated in those instances where in fact people get pre-notification. That practice, which was not ubiquitous but did take place, is in the process of being stopped.

The other issue about self-reporting is…. I cannot speak to every single contract, but my understanding, certainly from the Fraser Health Authority, is that they have outside people to do auditing and reviews. In their case, they are not pre-announced. They come in, they do independent audits, and they provide management with detailed audit reports based on pre-established criteria for standards of service.

R. Fleming (Chair): So is it the case, then, that the leadership council is going to be implementing that type of system where there's actual independence of the audit — it doesn't come from the company itself, and it is random?

R. Fleming (Chair): I presume there are penalty clauses in place for contractors that fail to live up to the service standards. But if they're self-reporting and auditing themselves, with lots of advance notice, presumably there would be a bit of a conflict there to avoid penalties — or material self-interest in avoiding penalties.

It would seem to me that that silly situation shouldn't be permitted at all, particularly given the link between this section of the workforce in a hospital and the overall cleanliness and control of infection, etc. So it is going to be generalized, in other words?

B. de Faye: Yes. There's going to be a re-examination. There is a structured system in place for review, audit and performance management of contracted service delivery. The two issues that you spoke about are under active engagement right now in terms of not having people get advance notice of audits so that, in fact, we can get accurate indications of performance and that these are not done by self-reporting.

R. Fleming (Chair): Another question I had on a different matter, and maybe it's for you, Mr. de Faye, to answer. There's certainly a lot of data that isn't in the presentation here and that the auditors waded through in producing their report. There's a lot of discussion in the goals of promoting a healthy workplace, which talks about work-life balance and about the problems of recruitment and retention of employees.

One of the issues that comes up in my area here, where we don't have on-site day care services — unlike Surrey general hospital and Vancouver General — is how having on-site day care services for nurses, other employees, doctors, etc., can be very beneficial in lowering employee burnout and in being able to attract employees as part of the package of what the health authority may have to offer.

I wonder if you have any indicators on that and whether there is some data that your ministry has, which would lend you to support hospitals that are endeavouring to offer those services.

I know that sometimes there are capital programs available, but if there's a subsidy involved at all in a day care operation, there simply isn't in the funding formula an ability to venture that kind of service on site.

B. de Faye: As you indicated, some health authorities and some facilities have gone down that route. I guess what I can say is that with respect to being an employer of choice, with respect to being competitive in the marketplace, employers throughout the system are looking at a whole variety of initiatives. They're not being directed out of Victoria.

They're initiatives that individual health authorities — depending on their circumstance and challenges and depending on the opportunities they have, which are geographically based in many cases…. They are looking at a whole range of initiatives.

Some of them have looked at day care. There are issues around parking. There are issues around services for folks, such as massages, and all kinds of things to try and be attractive and be a healthy workplace. These are all initiatives, but they're not being mandated out of Victoria.

R. Fleming (Chair): Thank you. I think that with the unique challenges around shift work, there may be an extra emphasis on that for people who work in this profession — for this kind of service in their workplace.

The last question I wanted to ask you was just around what your ministry does when it gets examples from other jurisdictions — provinces like Ontario and Manitoba.

The instance I want to ask you about…. If you have an initiative that may cost some money, like changing the needle sticks that are used in hospitals to a safety-engineered product that does cost a little more but is proven to lower infections and injuries in the workplace, but the health authority…. How do you get them to look at procurement across the system that might lower the cost and might actually create a change in the system? If you could comment on that example specifically or any others that come to mind, I'd appreciate that.

B. de Faye: Certainly. You've raised two important issues, one of which is technology adoption. The ministry does play a role in examining all kinds of technologies, from anything like better mechanisms for injection to high-technology imaging devices. They go through that process to examine efficacy and look at cost benefits and take all the costs into consideration before adoption of a technology.

The other issue that you raised, of course, is achieving sustainability and affordability within the system through leverage procurement. There are opportunities, and they are being pursued. Again, under the aegis of the leadership council, there is a review going on of purchasing to identify what the major types of products are that we could leverage purchase across the system and effect some savings so that those savings can be put back into patient care.

R. Fleming (Chair): Just on the recommendations, there was a question earlier from a member about time lines. Of course, your ministry was first aware of this report in 2004, so it's four years from that date. In some health authorities — for example, the Northern Health Authority — zero of the original recommendations, of the 15, have been fully implemented. You've got ten that are identified for follow-up required. Some are performing better. Vancouver Coastal only requires two in the follow-up phase now.

What is the ministry's role to induce those health authorities that haven't really taken the ball and run with it, on the recommendations, to perform better? I suppose you can be commended. The Provincial Health Services Authority, which you're most closely administering, is ahead of the others, but there are some that are just not taking the key recommendations here to heart and have shown very little progress in four years. I'm wondering how you can get them to get with it, so to speak, and begin to look at this seriously.

B. de Faye: I'm not competent to speak directly to the Northern Health Authority. I don't work there or run that health authority. But I am aware that there are quite unique challenges in the north in terms of health care organization, staffing and delivery, and it's not to in any way diminish the importance of what's being said.

To speak directly to your question, though: what are the means by which we actively encourage all health authorities to take these recommendations seriously and show positive movement on all of these files? It's done through those letters. It's done through the reviews of the annual plans that they have. It's done through the reviews of the health human resources plans at the health authority level. It's done on a regular basis at the leadership council, where the CEO of the Northern Health Authority and all of the other CEOs gather on a monthly basis and speak to a number of initiatives — but also, very much, to this initiative.

There are opportunities to ask questions about progress and what's being done and, if it's not being done, why it is not being done, and are there other means to achieve progress on that file.

R. Fleming (Chair): Thank you. We had one more hand at this point — Diane Thorne.

D. Thorne: Yeah, I'm just going back to these graphs or charts again. I think it's very interesting, looking at the numbers. Speaking about what we hear from our constituents…. I mean, what I'm hearing from my constituents — and from my constituency assistants, who do all the casework — is that there has been quite a change in the process and in the system of claims paid and adjudication, etc., since we changed from WCB to WorkSafe.

Looking at these charts, I think it's very interesting that everything started to go down after the change from WCB to WorkSafe. I'm wondering: how does the ministry…? When you're assessing how things are improving or not improving in terms of the recommendations up here, how do you account for the changes in WorkSafe and WCB?

I would venture to say, from my experience in my riding — which is probably not so different from the other ridings in B.C. — that there has been quite a difference for the people making the claims.

These are all based on claims paid, or appear to be. So they're not based on claims that come in to WorkSafe. They're based on ones they actually okay in the end.

How do you do that, when you're going back to when it was a different system and the system now? How do you account for that when you're making up these graphs?

B. de Faye: I can't tell you for sure that these are claims paid versus claims made.

D. Thorne: Well, that seems to be what most of them say in the information. In the "Registered nurses' days lost," it's days paid on claims.

Then maybe I should just say that I'd like to know if in fact these are based on claims paid. I'd be interested in knowing how many claims came in that weren't paid after the system changed to WorkSafe, as opposed to WCB. And I'm sure Mr. Sultan would be interested in that information as well.

R. Fleming (Chair): Mr. de Faye, do you want to answer that now, or will that be part of your response to the earlier…?

B. de Faye: I'll bring that response for all of the committee members, if I may.

The original report was done in 2004-2005. The follow-up report, the summary, particularly for Northern Health here, is of December 31, 2005. That's a year later, in terms of the progress.

Obviously, that's now more than two years out of date in terms of the potential progress. I'm just wondering, in terms of the 15 recommendations — particularly for Northern Health — if you have a better sense of where things are at today, as opposed to something that is more than two years out of date.

B. de Faye: I do have specific information with me with respect to Northern Health.

R. Fleming (Chair): Does anyone from the Auditor General's office wish to comment as well?

M. Sydor: We haven't done any work since we received the follow-up information, so we can't add anything as to whether there's been any further progress. It would all be in the ministry's hands.

B. de Faye: I have indications that five initiatives were, in fact, substantially complete for Northern Health at the time of the 2007 report and that the remainder of the initiatives indicate that substantial progress has been made in the north since the 2007 report.

That's including things like performance appraisals that are carried out, demonstrating in word and action that employee health and well-being is important; putting appropriate mechanisms in place to gather data; developing costing information for initiatives in the human resource and occupational health and wellness plans; ensuring, in conjunction with partner agencies, that initiatives are well coordinated to maximize both funds and efforts being directed to creating a healthy working environment; ensuring that management actions are consistent with the communication to staff; reviewing the extent of managers' control to ensure that it is not beyond the limits to be effective.

To assess the work environment for risks to staff mental health and develop an action plan; to consider ways to promote a healthy lifestyle amongst employees — these are all initiatives where substantial progress has been made. To assess the work environment for risks of violence for staff safety and security and develop an action plan to mitigate risks; to determine, in conjunction with the ministry, what indicators of employee and workplace health should be reported publicly on a regular basis.

There are a significant number of initiatives. All of the initiatives have shown substantial progress being made since that 2007 report.

R. Fleming (Chair): I'm just wondering. You're using a little bit different language than the follow-up report on the categories. So what you just said is that those indicators have been partially implemented? Or does it mean substantially implemented?

R. Fleming (Chair): Substantial progress. That could be partial, or that could be….

B. de Faye: They're still not fully implemented, but there has been substantial progress made since the last follow-up report.

R. Fleming (Chair): Do you have a number on what the follow-up has required, as far as the original report has considered?

B. de Faye: I can't, for Northern Health or for the health authorities. My intent was to try and deal with this on a large, systemwide basis. To be able to speak to specific regional health authorities like the north would have required us to fly in individuals to be able to speak to all of those, and I would have had to bring in people from all six health authorities to be ready and waiting for your questions.

What I can say is that if there are specific questions about those initiatives, I can either obtain that information and make it available to members of the committee or bring in folks if the Chair and members would wish to speak to those.

H. Bains: Just for clarification on that issue, we have this report which talks about "fully, substantially and partially completed" as of December 31, 2005, so that I understand how to read this. Then you have this PowerPoint, and it talks about a 2007 report acknowledging substantial progress. Then, underneath, it says that on 53 out of 90 recommendations, action has been taken on all of them. When you say 53 of 90, do those numbers correspond with the numbers that you're giving us in this book as of 2005, or are they updated numbers?

B. de Faye: Perhaps I should ask the Auditor General or staff to speak to the initial report, the 90 recommendations, the substantial completion and the residual 37.

M. Sydor: Right. I think you've captured a large part of it right there. For each of the health authorities, there were 15 recommendations. Obviously, that is where the 90 comes from. The way we look at the recommendations is that we do have those gradations of "fully implemented," "substantially implemented" and "partially." We also have one where no action is taken. But in this particular case, there were no recommendations where nothing had been done.

At a minimum, the recommendations that we looked at were partially implemented. When we looked at them, what we determined was that there were a number that were either fully or substantially implemented.

That's the cutoff we use to determine whether further work is needed. "Substantially implemented" suggests to us that they're on the right track. They've done enough work, and we're pretty confident that they'll probably get to the end result.

Those recommendations, I think, total 59 percent of the total recommendations. Then there were 37 that were partially implemented, and as we have been discussing, ten of those were Northern Health Authority. In fact, Northern Health Authority had made the least progress of the health authorities. They only managed to implement fully or substantially one-third of the recommendations.

In the normal course of events, based on our past practices, what we would do would be to follow up on those 37 recommendations that are only partially implemented, because to us, "partially" suggests that they may fall off the table. They may not be completed for a number of various reasons, and we wanted to see whether the health authorities were in fact making further progress.

That's what we would normally do from our standpoint. What the ministry has done is obtained more current information to give you a sense as to whether any progress has been done on those 37. Obviously, the response is not in the same way that we'd address it.

When Mr. de Faye says "substantial progress," I don't know whether that would meet our expectations of substantially implemented or not.

H. Bains: I guess my question was…. Your report here says that 53 out of the 90…

H. Bains: …are "taken action," and 37 are "partially implemented." Are those numbers similar to this report, or are they different?

H. Bains: So you're reporting on what they've done as of December 31, 2005, but you are reporting it in 2007.

M. Sydor: That's right. What we did was we established a cut-off date, and that was December 31, '05. We gave the health authorities some time to get us that information. Then, because we're dealing with six health authorities and 15, it took us some time to go through the information, go back and look at the supporting documents, because it's not just getting the information. It's getting the evidence to substantiate that they're where they say they are and doing all of that, then substantiating with the health authorities, as well, that they've provided us all the information.

In those areas where we indicated that they were only partially implemented, we would discuss that with them and say: "You're not very far along. Is this really where you are, or do you have something that you failed to provide us?" So there's a lot of discussion with the health authorities as well as looking at documents. That's why it took some substantial time between getting their response and getting the report out.

R. Fleming (Chair): Okay, committee, we have reached the end of the speakers list. There was a motion put on the floor some time ago, and I wonder if we could proceed now to the vote.

We'll give you a second to bring up your presentation there for item 5, Infection Control: Essential for a Healthy British Columbia. It's report 11. We'll just take a couple of minutes and then move into that item.

R. Fleming (Chair): Okay. It wasn't officially a recess, but it was de facto. We'll carry on with item 5, Infection Control, and I'll ask the Auditor General to begin this section of the agenda.

Auditor General Report:
Infection Control: Essential for a
Healthy British Columbia

J. Doyle: Good afternoon, Chair, Deputy Chair and members. Today we're pleased to present our March 2007 report entitled Infection Control: Essential for a Healthy British Columbia. For this audit we issued seven reports — one for each health authority and a provincial overview.

Our presentation today will focus on the provincial overview, but I have no doubt that members will be interested in all the reports. With me today is Morris Sydor, the assistant Auditor General who is responsible for this project as a whole.

The cost of poor infection control can be significant, both to individuals and to the health system as a whole. The costs are both financial and health-related. In addition, there is the reputational risk to the institution

We undertook this audit to see if health authorities had effective systems in place for preventing, controlling and tracking infections across all service delivery responsibilities. We also assessed whether the ministry provided a guidance framework for health authorities. We specifically looked to see that there were plans in place, that best practices were being followed, that information systems were in place and that there was reporting on infection control management.

Overall, we were disappointed at the state of operational infection prevention, control and management within this province. However, there were efforts underway, both at the provincial level and within health authorities, to remedy the situation. We've made a number of recommendations in the report that will be highlighted as part of our presentation.

M. Sydor: I'll start off with some background information. The issue of health care–acquired infections is a global concern and has significant implication to parents, patients, families and the health system overall. Studies in New Zealand and Britain suggest that 9 percent to 10 percent of the hospital admissions acquired infection. In the U.S., data indicates that nearly two million patients a year acquire an infection. Of those, about 90,000 die. It's estimated that treating hospital-acquired infections accounts for 2 percent of total hospital costs.

In Canada there is limited data available. One survey in 2000 reported that at hospitals with more than 80 beds, only 13 percent adequately monitored their hospital infections. The lead author of this work noted that there were more than 200,000 hospital-acquired infections annually, which resulted in about 8,500 to 12,000 deaths. The direct costs of hospital-acquired infections were estimated at around $1 billion annually.

The SARS outbreak in Ontario caused 44 deaths and about 375 probable cases, and the Clostridium difficile outbreak in Quebec that was estimated to have killed 2,000 elderly patients between 2003 and 2004 further highlights the significance of this issue.

In October 2006 it was estimated that one in nine Canadian hospital patients gets an infection. In British Columbia there is limited data available on hospital-acquired infections. However, there is some tracking within health authorities, although data quality is an issue. For example, Vancouver Coastal has determined that it costs about $6,000 per case of MRSA and VRE, whether the patient is infected or has the organism but is not infected. The authority also noted that this cost has decreased as they have improved their practices. From 2000 to 2003 Vancouver Coastal estimated that MRSA and VRE cost $24 million.

Fraser Health, using Vancouver Coastal's costing in its own data, estimated that for the period 2003 to 2005, these cost $11 million. Both health authorities, though, have made note of data quality issues within their estimates.

Provincially, 5,063 new MRSA cases were identified in 2004. The cost if treated in hospital would have been over $30 million, using Vancouver Coastal's estimates. Again, we have to be cautious because of data quality issues, plus the fact that $6,000 is based on Vancouver Coastal treatment protocols, which may not be the same in all health authorities. However, the overall message is that infections have a significant cost impact on both the individual and the health care system.

Turning to our audit. Our audit was designed to assess whether there is a provincial framework for infection prevention, surveillance and control across the continuum of care, and whether each health authority has an infection control plan in place that is integrated across the continuum of care, demonstrates best practices in infection control, provides information management support to the program, and uses infection control reports for both accountability and continuous improvement.

We concluded that there is no provincial framework in place for infection prevention, surveillance and control, except in public health, and that planning for infection management varies across the health authorities. Some authorities include aspects of infection control in their strategic and health service plans. However, none provide an integrated focus across all service areas.

At the time of our audit both Vancouver Coastal and Interior Health had identified infection control as an important issue and had action plans to move their programs forward. We also found that overall, the resources devoted to infection prevention, surveillance and control have not kept pace with changing organisms or the need to ensure best practice across the care continuum.

Moving to our findings and recommendations. As to the provincial framework, we found that the framework for public health in B.C. is provided by the Health Act and communicable disease regulations. This legislation designates the responsibilities and roles of the provincial health officer and the medical health officers in the health authorities. As well, it specifies what is to be monitored and reported to the British Columbia Centre for Disease Control. As a result, the occurrence of communicable diseases in the province is known.

However, there is no framework in place for infection prevention, surveillance and control across other care-delivery areas. We recommended that the Ministry of Health establish and implement a provincial framework for infection protection, surveillance and control and, working in conjunction with key stakeholders, establish a provincial surveillance system for hospital-acquired infections.

The health authorities are responsible for the care continuum: public health, home care, mental health, acute care and long-term care. We expected the health authorities to have an integrated plan for infection control across that continuum. However, we found no

such integrated planning, although Vancouver Coastal had a business plan and Interior Health had an implementation plan following their own internal audit. Even these plans were not integrated across all programs. We did find that Providence Health Care had a strategic plan in place.

We recommended that each health authority develop an integrated plan for infection control management across the care continuum and assess their structure to ensure that it facilitates integrated planning.

We found that the health authorities did not consistently demonstrate best practices in infection control in a number of areas. When the health authorities were formed, each facility had its own infection control manual. We found that many people in each health authority were working to create one manual for each program — that is, one for acute care, residential, long-term care — by amalgamating all of these manuals. This was taking considerable time, energy and resources that could be better used elsewhere in infection management. We recommended that a basic manual template be established which will meet the needs of all the health authorities.

At the time of our audit there existed established ratios of infection control practitioners to beds for both acute care and long-term care. We found that most health authorities did not meet these benchmarks. Vancouver Coastal and Interior Health had assessed their needs based on the ratios and had either hired new staff or were recruiting staff to meet the ratios, while B.C. women's and children's hospital surpassed it. As well, communicable disease nurses are having to administer increasing numbers of vaccines, leaving less time to manage outbreaks. Thus, they are also included in our recommendation for a formal review of staffing requirements.

Medical support is important in infection control, and we found it inconsistent across the province. Therefore, this also needs to be reviewed.

There's evidence that the built environment can influence the incidence of infections in facilities. In 2004 the province undertook a facilities condition assessment of hospitals that included areas relevant to infection control, such as the number and location of sinks for handwashing, isolation rooms and separation of clean and dirty equipment. As a result, renovations in new construction were underway in the health authorities, especially for negative pressure rooms.

However, although most health authorities have a policy in place that requires infection control practitioner involvement in construction and renovation projects, this expertise was not always as involved as it should be in order to mitigate risks.

Education for staff about infections and how to mitigate them was mostly ad hoc, and medical staff was seldom included. In addition to staff education, it's essential that infection control staff maintain and enhance their knowledge. We found that resources were not always available to allow practitioners to access ongoing education. This varied by health authority.

There's also a standard certification for infection control practitioners which is to be renewed every five years. However, even support for maintaining certification was not always available. We found that in public health, funding was available for communicable disease nurses to renew their certifications every three years.

Next we'll focus on monitoring. That's both the surveillance — the ongoing systematic collection and analysis and interpretation of data — and the direct observation and audit of practice. Surveillance of communicable diseases in the community is legislated, providing a comprehensive picture of communicable diseases in B.C. However, surveillance of diseases in hospitals or other facilities is not consistent within or across the health authorities. Without a good surveillance system, the authorities do not know if specific infections are confined to one facility or are also an issue at others.

When education about good practices such as handwashing is provided, then practice should be monitored to ensure that it improves. A good example of monitoring was at Fraser Health, where they completed a handwashing audit. Although the results were not good — only 11 percent were fully compliant in this audit — they were able to use the data to develop a comprehensive handwashing education and monitoring strategy.

There was also an extensive handwashing campaign underway at Vancouver Coastal at the time of our audit, which included an evaluation component. That is both observation at Providence Health Care and self-assessment throughout the rest of the authority. In addition, use of supplies such as soaps, hand hygiene gel and such was also being monitored.

Information systems should support the infection control program. However, we found a different reality, with the exception of public health. Yet even here, although there is a public health information system in place for the province, only a segment of Vancouver Coastal uses this system.

With regionalization, many information systems within health authorities did not interface. As a result, data is defined and collected differently by the various programs. A module specific to infection control would obviously be of benefit. At the time of our audit only Vancouver Coastal and Interior Health were in the process of actively pursuing system support for their programs.

Information management support was lacking in most authorities, although we found that in some pockets, such as women's and children's hospital and Vancouver Island's south Island area. Our recommendations focused on providing information support for the infection control programs as well as ensuring the quality of data that is collected.

We found that reporting varies by health authority and overall is not well done. Indicators that are being measured by health authorities have some similarities and many differences. Some similarities come as a result of the performance agreements with the Ministry of Health, where all collect data on influenza immunization rates using the same data definitions.

As well, all collect data on MRSA, VRE and CDAD, but it is not always at the health authority level, nor are definitions standardized within the authorities. Other indicators may be collected because that's always what has been done or because of a specific issue or request.

Some of these indicators, such as those in the performance agreements, are reported to the boards, but others may not be. We recommended that the board of directors determine what indicators they need measured and reported to fulfil their governance role.

We also found that although medical advisory committees are responsible and accountable to the board for the quality of medical practice, including managing infections, there is limited reporting to the board of directors. This is due, in part, to the fact that there is limited information going to the medical advisory committees. We recommended that the boards hold the medical advisory committees accountable for this reporting.

As well, we saw a variety of surveillance and audit reports. In some cases we found they were reviewed and used to improve practice, both at a specific site and across the health authority as appropriate. In other cases, we were not sure that the reports were used or reviewed. Surveillance and audits are a quality improvement opportunity and help mitigate future risks, so we recommended that the health authorities ensure that audit reports are available for use as appropriate.

To manage the organization, senior management needs data and reports that provide the appropriate information. When we matched what we heard was needed for infection control management to what was being received, there were gaps. Therefore, we recommended that senior management determine what information it needs in this area and put the necessary systems in place to receive that information.

Reporting to the public on infections is limited. The B.C. Centre for Disease Control issues an annual report on communicable disease in the provinces, which is accessible on its website. Reporting by the health authorities on infection control, however, is limited to Vancouver Coastal and Vancouver Island. Of these two, only Vancouver Coastal provides public access to this information through their website. So we recommended that each health authority issue a comprehensive infection control annual report and make it available to the public.

R. Fleming (Chair): Thank you, Morris. I will ask Tom Dorran and Bob de Faye to come forward for the Ministry of Health. We're just having the hard copies of the slides distributed as well.

Bob, I'll turn it over to you and Tom to present in this section and introduce anyone else who is going to present.

B. de Faye: Good afternoon, and let me thank the Chair, Deputy Chair and Members for the opportunity to discuss this complex and challenging and timely issue. It's one that's controlling the health care systems across Canada and, indeed, around the world.

As you know, I'm Bob de Faye. I'm the chief administrative officer for the ministry. With me today are Dr. Tom Dorran, executive director of patient safety at the Ministry of Health, and Dr. Doug Cochrane, vice-president of quality and safety at the Provincial Health Services Authority. Dr. Cochrane is also the chair of the B.C. patient safety task force. In addition to their respective administrative roles, both Dr. Dorran and Dr. Cochrane are physicians by training and maintain active clinical practices.

I'd like to begin the presentation by thanking the Auditor General and his staff for their thoughtful, balanced and continuing work on this particular topic. I'd also like to take the opportunity to acknowledge the various groups of health care providers involved in surveillance, prevention and control of health care–associated infections around the province.

All too often we concentrate on the shortcomings of our health system without also recognizing the fact that we do a lot of things rather well in this province too. The fact is that in the overwhelming majority of cases, a patient's journey through the health care system ends with an optimal outcome.

I want to emphasize the last point, because it's an especially remarkable achievement when one considers the sheer volume of health interventions that take place each and every day around the province. For example, last year there were close to 1.8 million visits to emergency departments throughout British Columbia. There were over 750,000 hospitalizations, amounting to over 2.8 million in-patient bed-days. Of those 750,000 hospitalizations, it breaks down into almost 470,000 surgical cases and over 280,000 medical cases.

Of course, as we all know, patients may, from time to time, suffer an adverse effect as a result of their care. In some cases, the adverse effect could not reasonably have been anticipated. In other cases, the opposite is true, and the adverse effect could, indeed, have been prevented.

Hospital-acquired infections are one of the best-known examples of an adverse effect. We're all familiar with the growing media attention surrounding MRSA, VRE and C. difficile and with the serious consequences that these and other infections have for the affected patients, for their families and also for our health care system.

International patient safety literature tells us that medical errors and adverse effects such as hospital-acquired infections can never be entirely eliminated from health care. However, through the adoption of a rigorous, disciplined and systematic approach similar to that used in other high-risk industries, we can build high-reliability systems and processes to reduce variation and therefore the possibility for errors and adverse effects. In doing so, we improve patient outcomes, and we reduce financial and other burdens to the health system.

As Aristotle so correctly observed some 2,300 years ago: "We are what we repeatedly do." Excellence, then, is not an act but a habit.

With that, I'm going to turn things over to Dr. Dorran, who will describe our provincial approach to patient safety in British Columbia and how infection

control is being addressed within the patient safety context. Dr. Dorran will then be followed by Dr. Cochrane, who will be discussing a number of activities that are underway at the health authority level that promise to make a meaningful difference with respect to this important issue.

If I could just ask our doctors to be brief so that the committee will have some time to ask you questions towards the end. I know you have a number of slides here, but if we could just pace ourselves accordingly.

T. Dorran: Good afternoon. Thank you for this opportunity. I'll try and get through my presentation in as timely a fashion as I can.

As Bob mentioned, the issue of hospital-acquired infections is truly an important and highly complex issue. I'd like to present some of the challenges that we face in order to set context for the ministry's role in the health care system and how we've strengthened that role with respect to patient safety and infection control.

As you heard earlier, it's important to recognize that hospital-acquired infections are not an issue or a problem that's isolated to British Columbia. We know that rates for some organisms, such as MRSA, are generally on the rise throughout North America.

The reason for this rise is related to the way in which we treat infections and the pressures that we place on them to adapt to what we're using to treat these. In essence, we're creating more and more virulent strains of the organisms. Unfortunately, the development of antibiotics is not keeping pace with the emergence of these antibiotic-resistant organisms.

Additionally, when one considers the impending demographic shifts that we hear so much about — an aging population with an increased burden of disease — we're faced with an increased number of people out in the community with compromised immune systems and therefore more susceptibility to infections.

Our approach to infection control in the province can be divided up into three layers. We can think of the Ministry of Health as being stewards for the health system, responsible for providing strategic direction to the health authorities, who are then charged with the business of delivering those health services within their respective jurisdictions, and then the facilities level — the hospitals, clinics and other mechanisms — that actually delivers these services. Each of these layers has a particular role to play with respect to infection prevention, surveillance and control.

The Auditor General's finding with respect to the ministry was that the ministry was not fulfilling its role, as there was no evidence of a provincial framework to guide infection prevention, surveillance and control activities within the health authorities. The end result that the report showed was that there was significant variation in terms of the manner and urgency with which health authorities were approaching infection control across the province.

As Bob has indicated, we've heard the Auditor General loud and clear on this point. This issue is a priority for the ministry. As such, we've taken a number of significant steps to ensure a provincially consistent approach to infection control in the province.

Hospital-acquired infections are generally treated as an adverse event of the health system. As such, they fall within the realm of patient safety. It is within this wider context of patient safety that the ministry is approaching this issue. Reflective of the ministry's commitment to patient safety, the assistant deputy minister portfolio for patient safety was created in March 2007. This is remarkable, because this is the only portfolio of its type in the country.

The assistant deputy minister for patient safety is also the chief nurse executive for the province and as such has quite an extensive administrative and clinical background in health care.

Patient safety initiatives were formerly handled amongst several divisions within the ministry, including infection control, and these are now essentially located within the patient safety division. As you may have guessed, I'm the executive director now for this division.

Responding to the Auditor General's report was one of the first items of business that fell on my desk a year ago when I took this job. I found that many of the problems raised by the Auditor General with respect to infection control were mirrored in the general approach to patient safety within British Columbia. While there was a great deal of good work going on around the province and a number of very significant investments had been made, there was also generally a lack of coordination within and between health authorities on safety issues.

This is perhaps understandable, because patient safety has only truly become a major focus in the country since about 2004 with the publication of the Baker-Norton report.

Given this situation, along with responding to the Auditor General's report, a concurrent project of mine was to develop a patient safety framework in British Columbia in order to establish a clear and consistent provincial approach to patient safety issues, including hospital-acquired infections. This framework is presently in the approval stages, but I can say it is based on the latest international patient safety literature. In fact, it mirrors many of the recommendations made by the Auditor General.

This framework addresses a number of core elements, all of which aim to promote a culture of safety across this province. As you can see for yourself, this is how it's all laid out.

So how does this framework support infection control? Well, with respect to the first element — systemwide leadership and coordination — there are a couple of initiatives that we can speak about that will ensure a provincially coordinated and common approach.

First is the B.C. patient safety task force, reaching the end of its intended mandate later this year. The ministry is in the process of creating the B.C. patient safety and quality council which will bring major

stakeholders together around a common table to make sure that everyone has a common understanding of the issues and a common vision for the future. This organization will make a real difference in terms of priority-setting for patient safety and reducing duplication of efforts through the health authorities.

Second, and perhaps most importantly, the provincial infection control network — PICNet. PICNet has done an incredible job since it was created in 2005, which is just before the audit started. PICNet is a collaboration of experts from the B.C. Centre for Disease Control in Vancouver, along with experts in medical microbiology and hospital infection control communities — basically, all of those people who comprise the broader community of practice surrounding infection control. These include lab techs, epidemiologists, researchers, nurses, physicians and educators. I should mention, too, that all the health authorities are members of this collaborative.

Now, this organization is one of the first collaboratives of its nature in the country and has become a model for other jurisdictions. PICNet maintains active ties with similar organizations all around the world and, in fact, has helped create a global community of practice around infection control.

PICNet's mandate is the surveillance, auditing, collection and analysis of infection control data, creating best practice in educating around issues concerning infection control. So in a sense, PICNet encompasses all the core elements that we just saw, which are elements of the patient safety framework for the province and, in fact, internationally. I should also emphasize that a major focus of their work has been on promoting coordination and standardization of the way infection control information is gathered in the province.

With respect to a regulatory environment for infection control, the ministry has adopted a non-legislative approach because we feel that we can meet our objectives using other tools at our disposal. As an example, sterilization is a major component of infection control. The ministry last summer issued a policy communiqué to all health authorities requiring that they conduct a practice audit within any facilities that sterilize or otherwise reprocess medical equipment and devices and that they address these performance gaps by September of 2008.

I'm proud to say that B.C. and Ontario lead the country in their efforts to establish a reprocessing policy, and in fact, the two provinces have become the benchmarks for a national framework, which is due for release in the next two months.

All health authorities in British Columbia also must submit to a very high-level, third-party accreditation review conducted by the Canadian Council on Health Services Accreditation — CCHSA. CCHSA will be introducing a new accreditation program later this year that emphasizes patient safety. Amongst its new requirements is a set of standards including reporting on antibiotic-resistant organisms.

With respect to the performance framework, especially that which we heard in the last presentation, each year the ministry issues a government letter of expectations in concert with performance criteria outlining key deliverables for each health authority. Within these documents is language outlining goals and targets for indicators, which include, amongst other things, patient safety and quality improvement.

As we move forward in developing this framework, health authorities will be required to develop comprehensive patient safety plans that include infection control strategies. They will also be required to participate in a number of provincial patient safety initiatives.

The ministry also continues to work with a number of outside organizations, such as the Canadian Institute for Health Information, to develop appropriate patient safety indicators and performance measures that can then be included in future performance criteria frameworks.

This point relates to measurement and evaluation of the system to determine how we are performing and where we need to focus our efforts to improve. Aside from developing appropriate indicators and performance measures, we're doing a number of things to ensure that there's a robust system for the surveillance of adverse events such as hospital-acquired infections.

PICNet, for example, has developed the surveillance of hospital-associated infections program, which will ensure that standardized surveillance methodologies and definitions are used in every health authority. The pilot for SHAIP has just now gone forward in Vancouver Coastal and Interior Health, and I should be seeing some results by about August.

The province has also just announced a provincewide rollout of the B.C. patient safety and learning system, which will vastly improve the way we monitor adverse events, hazards and near misses of all sorts — not just infections — and will also then allow for the dissemination of information about safety concerns on a provincewide basis. We will be the first jurisdiction in Canada to address the monitoring of adverse events on this scale right across the province.

However, surveillance is clearly not enough. We need to be able to respond to what the data is telling us about our system and then translate that into evidence-based practices and improvement strategies. Again, I'll remind you of PICNet and the expert work that is being done in this area. I should also mention that the patient safety and quality council and the patient safety learning system will also be key to these efforts.

In addition, the government has invested in the creation of an academic chair in patient safety at the University of British Columbia. The academic chair will work with stakeholders to determine a provincial research agenda for safety issues, including infection control.

We also continue to invest in evidence-based programs such as Safer Healthcare Now, which is the Canadian offshoot of the highly successful campaign from the Institute for Healthcare Improvement in the States called 100,000 Lives Campaign. Through evidence-based practice and education, Safer Healthcare Now programs have led to a significant improvement in the safety and quality of care that's offered to

I will just point out very briefly here, however, that four of the ten Safer Healthcare Now initiatives centre around infection control. In fact, later this year Safer Healthcare Now will be rolling out its latest initiative, which centres around antibiotic-resistant organisms.

A coordinated patient safety strategy also emphasizes the need to ensure that the distinct body of knowledge and skills associated with patient safety and quality improvement then informs the training and education and professional development for all health care professionals. On this front, PICNet, as you can see, is actively engaged with infection control communities through several educational initiatives.

Another important issue is ensuring that there are enough infection control professionals around the province. The ministry will be working with stakeholders such as PICNet and academic institutions to ensure there are adequate opportunities for education, training and certification for all infection control practitioners.

An important component of the provincial framework for patient safety is ensuring access to accurate and understandable information, which will help the public and all stakeholders first understand the system and then take steps to participate in improving it.

One of the reasons that we've created this patient safety and quality council is to ensure we do a better job of communicating information to all stakeholders, including patients, through educational materials on personal measures for improving safety for the public, as well as mechanisms to ensure patient feedback is appropriately incorporated into any improvement strategies we embark on. These strategies will ultimately contribute to improve patient safety outcomes.

Patient safety literature also recommends that leadership at the highest levels also be engaged in safety and quality improvement. The ministry is committed to working with health authority leaders to ensure that they are fully informed about strategic plans with respect to safety and quality improvement strategies and that there's a common understanding of these.

In closing, I'm confident that we are headed in the right direction. With the increased emphasis on reducing the number of adverse events throughout our health system by application of the provincial framework that I've just described, not only can it realize significant cost savings in a number of areas, but it will also lead to improved patient care. As such, patient safety is a wise investment for, in the long run, it mitigates unnecessary costs through reduction of adverse events. When it comes to patient care, it's simply the right thing to do.

On that note, I'm going to turn over the discussion to Dr. Cochrane, who will provide insights from a health authority and operational perspective.

D. Cochrane: Thank you, Chair and members of the committee. It's a privilege for me to be here and to provide you with background information and to try and answer any questions you might have on behalf of the B.C. patient safety task force, an organization that was established in 2004 to shepherd some of the safety initiatives, including those related to infection control.

The Auditor General already this afternoon has provided us with some information about the impact of hospital-acquired infections on patients and on the stability of the health system. One of the initiatives that we've undertaken here in British Columbia is to try and understand an economic analysis of this — not in terms of dollars but in terms of the access of patients to services in British Columbia.

The best information comes from the French-speaking hospitals in Montreal. If one looks at their current infection rate of 1.8 percent, there is a significant impact on length of stay as well as engagement in the ICU, in addition to the costs that the Auditor General referred to.

Doing some translation of this information, based on current length of stays that are being generated at the Vancouver Coastal Health Authority, Vancouver Island Health Authority in some of their hip and knee operations, by changing the infection rate by only one half, it can result in a significant bed savings, which of course allows additional patients to be treated — something that not only affects our health system but also, of course, affects the individuals who might have acquired an infection.

This is a principal access strategy that the task force and others have been working to support. One of the vehicles by which that support can occur is through the Canadian Patient Safety Institute. This is a pan-Canadian organization represented by all provinces. It has undertaken, amongst other things, an initiative called Safer Healthcare Now that Dr. Dorran referred to.

The focus of this is in part on nosocomial or hospital-acquired infections. Surgical-site infections as well as pneumonia associated with long-term ventilatory support are two areas. I'd like to report to you on how B.C. is doing in these areas.

Safer Healthcare Now brings together evidence-based practice and puts it together in a specific set of standards and bundles that are applied to patients throughout our health system. The results from Surrey Memorial Hospital are indeed impressive when we look at the compliance of surgical services in creating the best environment to minimize infection, specifically related to how many patients are getting appropriate antibiotics.

If we compare ourselves in British Columbia against other western provinces in the number of patients who have had clean operations — in other words, ones where the skin has not been broken beforehand, the majority of which you would see in hospitals — our infection rate for clean, postoperative infection is, in fact, quite admirable. It actually reaches and has reached the Montreal level, and it is well below that seen in our western provincial colleague institutions.

Similarly, if we look at pneumonia occurring as a complication of ventilation — patients who have this going into our ICUs — our rates have been consistently

lower or as low as any of the other western provinces. All of this is occurring subsequent to the Auditor General's report.

We have some outstanding organizations in British Columbia that lead the country and have received national and international acclamation for the work they have done — specifically, the intensive care unit and the emergency room at St. Paul's Hospital in an aggressive approach to sepsis, resulting in substantial decrease in the mortality that these patients, who are all very ill, suffer; significant changes in their resource requirements; and, of course, significantly decreased burden on the health care system in general. This has allowed St. Paul's to accommodate the increasing volumes which they have seen related to patient demographics and other things occurring in our health system.

At B.C.'s Women's Hospital and at Children's Hospital there has been a substantial decrease in the rate of hospital-acquired bloodstream infections related to central lines. These are the kind of IVs that are used for the treatment of oncology patients and others who need long-term antibiotics. This is related directly to the Safer Healthcare Now initiative and the bundle that is applied there now.

C. difficile has been a major issue. In fact, it's a major threat to patients who are unwell. Other than our youngest, our elderly are our most fragile patients and most subject to this. Nanaimo Regional has brought together a set of undertakings related to education, contact precautions, cleanliness and regular feedback that has dropped the rate of nosocomial — in other words, acquired in hospital — infections for C. difficile and has cut it down by almost two-thirds.

This is actually quite remarkable and is the foundation upon which initiatives through CPSI, the Canadian Patient Safety Institute, and the government in Quebec are trying to address this particular issue.

All of these things have occurred and are shared through the B.C. patient safety task force, through PICNet and through the minister's innovation conference that occurred last year. The opportunities for all health authorities to participate and to achieve similar levels of achievement are in place, I think.

It's not just inside our acute care system that we need to address the issues. Dr. Dorran alluded to the fact that we tend, by way of treatment, to select out organisms and create bacterial resistance. British Columbia and the ministry in Alberta had come together many years ago to implement a public health program called Do Bugs Need Drugs?

You've probably seen the commercials on television. This is a public health and education campaign that brings the force of our children to the use of antibiotics in the circumstances of illness so that we have antibiotics available for the treatment of infections by not using so many.

The B.C. patient safety task force has a broad mandate. It covers many other kinds of adverse events, including infections. We're a collaboration of all of the health authorities and work in conjunction with PICNet to try and address issues of nosocomial infection. I think we're well on our way to doing this through a number of structured and collaborative processes.

I'll ask committee members at this time if they have questions for the Auditor General or any of the presenters from the Ministry of Health. Of course, we have six volumes to this report, so I recognize that some members may wish to ask authorities specific questions.

Auditor and ministry officials, Doctors, thank you very much for your presentations and, frankly, for your candid points of view on what is obviously a very, very sensitive part of our health care system.

I had noticed that the paper again this morning was talking about some of the antibiotic-resistant strains that are causing a big problem in Ontario. This is a bit of a moving target.

First a question and then a following remark. Is there anything in the medical science world that you see with respect to trends of these types of things that can help us in terms of planning on more of a go-forward basis — in other words, the procedures by which we respond to these new types of bacteria and these new types of infections that would help us in planning on a go-forward basis?

The approaches to this are about as varied as jurisdictions that this actually occurs in. I was at a presentation earlier this year — actually, at the Halifax 7, which is an international patient safety conference — and interestingly enough, the Netherlands more or less takes a scorched earth approach. They are very gung-ho with their antibiotics, to the point where they've got their resistance rates down to about 2 percent.

The data is still lacking, however, on the cost versus benefit, because as you can probably understand, there's a significant cost associated with having such a strict approach and a strict protocol. The question then is: by taking such a dramatic approach to it, are we inflicting less harm than if we were to take the approach that we are currently doing here in having a selective strategy? There are other approaches out there, but we've chosen to take sort of a multi-pronged approach here.

I. Black: Chair, in the interest of forming a basis for any subsequent questions, I would move acceptance of the recommendations from the Auditor General and also acknowledge the ongoing progress of the ministry.

H. Bains: A couple of questions. The Auditor General report suggested a cost to Vancouver Coastal, I think it was, of $24 million in 2000-2003 and $11 million to Fraser Health. Over at Provincial I think it was $30 million.

Is there any data available prior to that? Are we on the increase, are we staying the same, or are we actually on the decrease of the cost?

T. Dorran: I have no answer. I don't know where we are on the cusp of the curve, or if there is in fact even a curve.

H. Bains: So we don't know if any of the programs that we have are working. Is it costing more or less, or are we staying the same?

That's simply a reflection of…. As you can probably well understand, community-acquired infections are generally on the rise. Not to be pejorative, but that's just it. They're ubiquitous. They're in McDonald's; they're in bus shelters; they're in hospitals. So the prevalence of these infections is going up. What we're trying simply to do is stem the rise within our institutions and with our strategies.

H. Bains: The other one is on page 12 of the Fraser Health Authority. It talked about SARS in 2003, and the minutes of the senior executive called for development of infrastructure and program of the infection control department. A proposal was put forward for additional resources. Then in the fall of 2004 an issue of post-Caesarean surgical wound infection at Surrey Memorial Hospital resulted in an external review of the infection control management at the hospital. Recommendations were made regarding the infection control program authority-wide. Then it went on to say that in early 2005 a consulting group was hired to review the infection control program.

As a result, the infection control program was in a state of flux at the time of our audit, which is 2007. We're going back to 2003 when the minutes of the senior executive called for an infrastructure program, and in 2007 we are still in a state of flux. By going through two or three of those different stages, what's happening?

T. Dorran: I don't know of any specific details within a specific health authority. My view is provincial oversight.

What we're finding with many of the health authorities is a difference in their capacity with respect to much of what we do within the health care system — a difference in their capacity in order to make changes. What I would presume is happening in Fraser Health is…. They are organizing around their infection control strategy, and they are taking measures, but they're only going as fast as their capacity is able to unfold.

Unfortunately, we're also limited. We've got a severe shortage of infection control practitioners in the province, so we can only go forward at a certain rate, based on limited resources.

H. Bains: That's not how I read this. This report talks about: "There was call for a program and infrastructure through the minutes of the senior level management." They recognized that there's a need for it. Then there was one case that was post-Caesarean infection. Then external contractors were called in to do a program, and it says that the infection control program authority-wide recommendations were made.

So the work is being done. Recommendations are being made, and then something else comes in. And no wonder that by 2007, four years later, it says that the infection program is in a state of flux.

We're not seeing the results. They recognize that there's a problem. They recognize that we need the program and the infrastructure. Then they move on to the next target. Then they move on to something else.

D. Cochrane: I don't know that I can answer it directly, although I did author the report on Caesarean infections. What that did is it refocused the attention of Fraser Health on infection control at that time.

I think the consequences of that are the infection rate and the compliance rate that you saw for hips and knees for Fraser Health at Surrey Memorial Hospital. So although the structured program that the Auditor General may be referring to was probably still in evolution, I know that the consequence to patients was that their infection rates dropped substantially. And I think that's been seen as far as we can tell from the Safer Healthcare Now initiative data.

In 2004, after the post-Caesarean infection case, they asked for an infection control program, and it says the recommendations were made regarding the infection control program authority-wide.

H. Bains: What this says is that those recommendations were not implemented, because by 2007 they're still in flux.

D. Cochrane: I can't address that question for Fraser Health. I do know that their infection rates have fallen.

H. Bains: Can we get that information? What is happening in Fraser Health as far as those recommendations that were made authority-wide?

R. Fleming (Chair): I think there'll probably be other information for members that you can't provide today.

J. McIntyre (Deputy Chair): I guess my question is to the Auditor General. I noticed in the presentation that basically the PICNet system was just sort of getting underway at the time of the audit. My question is: in terms of what we've been hearing today and in the presentation, which I thank all of you for…. It sort of puts you on the spot, but do you feel that what

we've heard today about PICNet and some of the success in standards and in the way it's being set up is moving in the right direction in terms of some of the weaknesses that you identified earlier?

J. Doyle: Thank you for the question. Yes, I do believe we're moving in the right direction, but infection control is so important. It's so fundamental to our health care system that I propose to keep a very close watch and brief on how all the recommendations are addressed by the health authorities and the Ministry of Health.

J. McIntyre (Deputy Chair): It seems, from what you've said, that we're taking a leading role, along with Ontario, but I agree. I think everybody recognizes how important this is.

As a supplementary, I was just curious. To the ministry officials and doctors: is there some sense of the effectiveness of some of the handwashing campaigns, and things like that? I've seen some of the commercials. I've seen even in the hospitals, when I've been in Lions Gate, very big signs about handwashing before and after you leave the hospital — things that are certainly new. Do we have a sense of how they're working for staff as well as visitors?

T. Dorran: The only handwashing campaign that I can speak to was from VIHA, and unfortunately, they're just going through their remeasurement now. They took a baseline measurement. Now they're going through their remeasurement to find the effectiveness of the campaign.

B. Ralston: I have two questions. One would be to Dr. Cochrane. As the author of the report about Surrey Memorial in 2004, are you satisfied with the implementations at Surrey Memorial of the recommendations that you made at that time?

D. Cochrane: I'm satisfied. Within the health system in the acute care sector, I think they took a number of steps to try and rectify this problem, and they've been successful. I think we still have weaknesses in our community follow-up sector, which is something that PICNet is going to be working on in respect of their surveillance activities.

Patients leave hospitals so quickly that a surgical-site infection — one in a wound — may not in fact not be evident until they return to their family physician, obstetrician or surgeon. Completing that information loop becomes very important. It will be one of the tasks of the SHAIP-BC initiative.

B. Ralston: One further question. In our material, in the main report on page 3 there's an excerpt from a CBC Marketplace sequence where there was a hidden camera which followed a physician in St. Paul's Hospital who, contrary to medical knowledge for the last hundred years, didn't wash his or her hands before moving from one highly contagious patient to another.

The quote here is from Dr. Michael Gardham of Toronto's University Health Network. I'm going to ask for your comment. "'Physicians are always the worst offenders. They're the least likely to wash their hands,' a simple act that could prevent the majority of infections."

Given that statement, first of all, I'd ask you: do you agree with that? Secondly, not to direct all comment at physicians, but this seems to be a very dramatic point. What steps have you taken, either in the ministry or at the Auditor General, in terms of dealing with this apparent conduct by physicians?

T. Dorran: I don't think this is an issue that is limited to physicians. I still continue to practise, as does Dr. Cochrane, so I see firsthand what happens on the ground. I don't think this is an issue that's isolated simply to physicians.

However, I think you've actually raised an important point. It's one thing to introduce these campaigns; it's another thing to sustain the change that the campaign makes. I think that is the next challenge that faces us.

I'm sure you're going to find some wonderful results coming out of VIHA's campaign, for example, but now it's a matter of sustaining that change and making sure it's ingrained. The other steps we're taking to subtly do that is actually trying to influence medical education, believe it or not, at the curriculum level within the universities and adopting infection control strategies in education at that level so that they develop habits right from the get-go and that they continue.

G. Gentner: …and it all stemmed from swimming in a public pool, so be careful with the hot tubs.

I read it with all the different reports. There's one reference here — hopefully, PICNet can solve the problem — that cites that there's a difference in the manuals used — Fraser east versus Fraser north in the Fraser Health Authority. I'm looking for what kind of standardized infection control mechanisms we really have if, even within their own authority, they're using separate, different manuals. It leads me to comments in the Vancouver Coastal Health which also relate to a lack of standardized reporting relative to the software and computer systems between different hospitals. There is movement between different hospitals and even authorities.

That's the first question I have, and maybe you can answer it. Where are we going with this sort of standardized infection control throughout the province?

T. Dorran: Sure, I'd like to take that one. Thank you for the question. That is exactly the whole reason behind the SHAIP program, the surveillance program for health care–associated infections. What we found was that through regionalization, the way that information was collected — the data elements, the methodologies — was different all across the board and all across the health authorities. What that essentially did was made it trying to compare apples to oranges.

One thing we've done with the SHAIP program is PICNet…. The SHAIP program is a program that's been promulgated by PICNet. What they have done for their pilot is standardized the way in which information is collected — standardized the data elements, the definitions — to ensure that like information is gathered all across the province.

G. Gentner: Okay. Following that, Chair, is the oversight. The authority has the ability to go into facilities, albeit public and/or private. How often is this occurring? Does it happen annually? Do you have to notify the private facility that you're coming? How many times have the authority or authorities…? What's the percentage of doing audits on following the proper protocols?

D. Cochrane: I can only speak about our own health authority and, in particular, the Children's and Women's. Auditing is done annually, it's done unannounced, and it's done by the infection control practitioners that Dr. Dorran spoke to, who are employees of the health authority but are at arm's length to the care providers that are in that particular area.

G. Gentner: To follow up on that, all facilities are audited at least once a year, whether they're residential and/or acute facilities in the province.

D. Cochrane: I'm not able to answer the second part of your question about residential facilities.

G. Gentner: Okay, your understanding. Possibly we could get some qualification on that. How often are the residential providers of facilities audited? Hopefully, at least once a year.

I have one last question, if I may. Going back to Vancouver Coastal, we talk about…. "The health authority will select facilities." I guess it's related to the audit, and they independently conduct audits on a random or scheduled basis at its discretion. No advance notice to a health authority is required. With that, I'm hopeful that that has been the case. They could be spot-audited, or call it what you will, but there are audits independently conducted by the appropriate health authority.

R. Hawes: A couple of points, I guess, to follow up, first, on Mr. Gentner's question and comments. I had the pleasure — I don't know if I'd call it that — of travelling the province in 2001 with the Select Standing Committee on Health to look at the 52 health regions that then existed. I know that there was almost no communication between those health authorities. Really, there was no information-sharing that I'm aware of. At that time, I don't think anyone was looking at infection control at all. I'm not sure if they were, but I'm not aware that they were.

I guess I'll ask you: has the change to the six health authorities made it much easier to develop a provincewide infection control system than with the 52 health authorities that existed prior to, I think, 2002?

T. Dorran: Absolutely. Thank you for the question. I've only been in this job for a year. I can't imagine what it would be like doing a road trip and trying to take in 52 health authorities. It's enough work to try to take in the six. But you're absolutely right.

What's happened is that with the regionalization there are now very key contacts in each of the health authorities that I meet with on a regular basis. Not only do I meet with these people, but also, they belong to the PICNet collaborative. There are regular meetings going on with PICNet and with their colleagues around infection control.

Then in turn there are informal networks that are set up. For example, I meet on a quarterly basis with the patient safety and quality managers throughout all of the health authorities — again, to touch on issues which will include infection control. As well, on a higher level once a month all the CEOs from all the health authorities gather in Vancouver at leadership council to discuss issues which also will range to infection control.

R. Hawes: Okay, the second part of my question, then, is with respect to what Mr. Bains was asking. That is that in 2004 there was some indication that there may have been some concern among people within the health authorities that we should take some steps. He's concerned that they weren't fully implemented as of this report.

I'm assuming that prior to the changeover to six regions there was nothing being done with respect to developing an infection control system for British Columbia. The stats for Canada would show that probably, that was right across the nation.

Not being an expert in this, I guess I'll ask you. This is not something that you put together and develop overnight. It's an evolutionary process, I'm assuming. Is it unusual that we would start noticing something in 2004 that had not been noticed before and that by 2007, as the report indicates, we're well underway, we're making plans and developing, and things are happening? Is it unusual that we wouldn't have completed a plan and fully implemented it in three years? Is that an unusual thing?

R. Fleming (Chair): The first part was on the assumptions that infections weren't dealt with prior to this millennium, and then the second part was….

R. Hawes: No, but we didn't have a provincial plan. I know there was no provincial plan.

T. Dorran: Perhaps what I will say is that I think what's happened in the past several years is that there's been a general realization that, as I alluded to in my talk, we need to accurately measure what is happening. We need to collect baseline data. As I mentioned earlier about the SHAIP program, we need very clear-cut…. We need to know what we're measuring.

We need to know what the extent of the problem is. Once we know what the extent of the problem is, we know where we can focus our efforts, and then we remeasure. I think that is now what we're starting to get a bit more savvy on.

I have no doubt infections did exist when there were 52 health regions. What I'm saying is that I think we're getting a bit smarter in how we collect our information, how we address it now.

R. Fleming (Chair): I want to ask a quick question for Dr. Dorran related to the VIHA report here on the Island.

I realize that the fieldwork for this audit was completed, I think, in February 2006, and here we are two years later. Nevertheless, the report on almost every section of what we're discussing today suggests that all of the infection measures taken are in the early stages. Standards for infection prevention surveillance are not consistently demonstrated. Surveillance and control is weak. Reporting on prevention, surveillance and control of infections across VIHA is weak.

I appreciate the patient safety division having been created earlier this year and your role there. You've described the leadership council and how you're trying to drive change and what a huge job that is in terms of changing the culture across the health care system, regardless of how many regions there are and how local and how close to home those regions may be structured.

I want to ask you whether, in the time you've been in this position, front-line responsibilities for managing infections have become more effective. One of the disturbing findings in the audit around VIHA was that in terms of the standards of having infection control practitioners and looking at how many acute care and residential care beds…. In some cases we have 5 percent of the infection control officers on the ground doing the work. In the best-case scenario in the acute care sector we have about 40 percent of the officers that we should have.

We have these medical advisory committees that are on the ground, and they have officers reporting to them, but in some cases they are so badly understaffed that I don't think they could meet any reasonable audit standard for inspection that's annual or otherwise.

I wonder if you could tell me how you get the resources into the health authorities. I appreciate that there are a lot of competing demands on where to spend resources. I wonder if you can tell me, though, in terms of your data collection, if that's getting better. How far do we have to go?

T. Dorran: I don't think it's ever going to be enough, to be completely candid with you. In fact, believe it or not, VIHA is actually bucking the trend, because they've had some success. I'm hoping they've poached from outside the province, but they've actually been able to increase their number of infection care practitioners within VIHA itself.

I think, also, that what's happening is that they have some true leaders within VIHA. What VIHA is now emphasizing is taking it down to the front-line staff and charging each and every health care professional with the job of fighting infections.

Yes, I see the efforts every day that I turn up for my shifts, and I see the efforts in the numbers they're coming back with.

D. Thorne: Just very quickly, sort of following along with what you were talking about and looking at pages 15-17 and into 18 and 19. Almost all of us are from Fraser Health, and unfortunately, all the questions…. I did look through the other books, and there is definitely a shortage of staff.

Looking at the qualifications that people have or have to have or whatever, it's really quite a wide range of qualifications. The one thing they have in common is that there are a lot of qualifications for this job. Are you looking at all at having a specific, shorter program that might work so we could get more people on the ground, as the Chair referred to?

T. Dorran: Absolutely. This is one of the efforts we're looking into. I was going to say, just on that point, that that will be one of the key roles of the patient safety and quality council — to look at issues exactly like that, find out where the needs are, actually tack a number to it and find out what numbers we need in order to adequately address the problem.

The second part is: how do we then address that need? That's exactly what the patient safety and quality council is set to do.

R. Fleming (Chair): Committee, there was a motion put on the floor. It was to adopt the recommendations. Is there any further discussion on the matter?

R. Fleming (Chair): I want to thank our witnesses for being here today and for rescheduling after the last weather-related cancellation of this committee. I thank the Auditor General and Morris and everybody else in his office for being here today as well.

We need a motion to present the report of the committee at the earliest opportunity.

Hansard Services publishes transcripts both in print and on the Internet.
Chamber debates are broadcast on television and webcast on the Internet.
Question Period podcasts are available on the Internet.

		Witnesses
		• John Doyle, Auditor General
		• Morris Sydor, Assistant Auditor General
		• Bob de Faye, Chief Administrative Officer, Ministry of Health

		Witnesses
		• John Doyle, Auditor General
		• Morris Sydor, Assistant Auditor General
		• Bob de Faye, Chief Administrative Officer, Ministry of Health
		• Dr. Thomas Dorran, Executive Director, Patient Safety and Special Initiatives, Ministry of Health
		• Dr. Doug Cochrane, Vice President, Quality and Safety, Provincial Health Services Authority

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
PUBLIC ACCOUNTS