Health — Issue No. 5 — Wednesday, March 26, 2014 (HTML)

Present: Norm Letnick, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Dr. Doug Bing, MLA; Katrine Conroy, MLA; Sue Hammell, MLA; Linda Larson, MLA; Richard T. Lee, MLA; Jane Jae Kyung Shin, MLA; Michelle Stilwell, MLA

1. There not yet being a Chair elected to serve the Committee, the meeting was called to order at 9:04 a.m. by the Clerk to the Committee.

2. Resolved, that Norm Letnick, MLA, be elected Chair of the Select Standing Committee on Health. (Dr. Doug Bing, MLA)

3. Resolved, that Judy Darcy, MLA, be elected Deputy Chair of the Select Standing Committee on Health. (Katrine Conroy, MLA)

4. The following witness appeared before the Committee and made a presentation on the role of ActNow BC and answered questions:

• Arlene Paton, Assistant Deputy Minister, Population and Public Health, Ministry of Health

6. The following witnesses appeared before the Committee and made a presentation on the role of the BC Patient Safety and Quality Council and answered questions:

• Doug Hughes, Assistant Deputy Minister, Health Services Policy and Quality Assurance Division, Ministry of Health

8. The following witnesses appeared before the Committee and made a presentation on the role of the Provincial Health Services Authority and answered questions:

• Doug Hughes, Assistant Deputy Minister, Health Services Policy and Quality Assurance Division, Ministry of Health

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Election of Chair and Deputy Chair	111
Ministry of Health: ActNow B.C. Overview	111
A. Paton
B.C. Patient Safety and Quality Council Overview	120
D. Hughes
D. Cochrane
Provincial Health Services Authority Overview	129
D. Hughes
W. Powell
C. Roy
Committee Meeting Schedule	139

N. Letnick (Convener): Welcome, everybody, once again to the first meeting of the Standing Committee on Health after we've been charged with our duties.

With all first meetings — I think this is our fourth first meeting — the first job is to have an election of the Chair.

I'm the convener. My name is Norm Letnick, MLA, and I'd like to welcome everybody in Hansardland who is listening in to this committee.

N. Letnick (Convener): At this point, Susan, do you want to call for nominations?

The first order of business is the election of a Chair. Are there any nominations?

S. Sourial (Committee Clerk): So we have one nomination — Mr. Letnick. Any further nominations? Any further nominations? Any further nominations?

We'll move to item 2, election of Deputy Chair. Do we have a nomination, please?

N. Letnick (Chair): Any other nominations? Any other nominations? Any other nominations?

Arlene, great to see you again. We look forward to you presenting us…. We already have the PowerPoint. We received it before, so some of us have had a chance to look at it, but if you can walk us through.

Then for the most part, we're going to try to withhold our questions until the end. We'll write them down, and then after you've finished your presentation — roughly, around 9:30 — we'll have about a half an hour for a little back-and-forth, if that's okay with you.

A. Paton: I've actually entitled my presentation Chronic Disease Prevention: Encouraging Healthy Living, because ActNow, as a brand, was retired a few years ago. I really want to talk about what we're currently doing.

My first slide kind of gives a little bit of history about ActNow B.C. and how we've kind of morphed that into healthy families B.C. In 2005 ActNow B.C. was announced. It was intended to be a five-year strategy in the lead-up to the 2010 Vancouver Olympics and Paralympics.

A lot of great things happened during that period. We actually like to take credit in the chronic disease prevention world for seeing a lot of the incident rates for some chronic diseases starting to fall during the period of ActNow and then continuing under healthy families B.C., and certainly, premature mortality rates. We have to kind of share that credit with primary care, because there were a lot of changes in primary care over that period as well that affected premature mortality rates.

We certainly are seeing those indicators starting to shift because of some of this work, so that was good.

ActNow focused very stringently on four pillars: healthy eating, increasing physical activity, living tobacco-free and then making healthy choices during pregnancy — really focusing on reducing the rates of alcohol use during pregnancy. It was rolled out as part of great goal No. 2 — leading the way in North America in healthy living and physical fitness.

Looking back at ActNow, in 2010-2011 there was a decision to shift a little bit. I'm on slide 3 now. The goals after 2010 were similar. We wanted to make the healthy choice the easy choice, with a real focus on physical activity and healthy eating. We continue to work with communities, schools, workplaces to enhance capacity in these areas.

We're wanting to address those key risk factors across
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the board and, of course, trying to help bend that health-cost curve moving forward with an aging population, increasing population. You all know, I think, the story of health care costs increasing and the need to really focus on how we, together, work to reduce those costs going forward.

After 2010 we announced in May 2011 the healthy families B.C. initiative. The focus continued to be on chronic disease prevention and healthy living. We try and shift things to the more positive to encourage people, rather than be punitive.

There is, I think, a shift to really focus on some of those vulnerable populations. The understanding very clearly is that not everybody sees the healthy choice as the easy choice. How do we drill down and support those at lower socio-economic status, First Nations populations, recent immigrant populations? What are some of the evidence-based programming and interventions that we can make in those areas to help those populations?

I think the late Clyde Hertzman often talked about proportionate universality. We need to set the stage universally and create those healthy environments, but at the same time, we need to intensify some of our interventions with certain population groups because they have a harder time accessing some of the universal programming or where public education just isn't enough to shift behaviour.

Then we transitioned the brand from ActNow, which really was seen very much as a physical activity kind of initiative. Healthy families B.C. was seen as more inclusive of all the risk factors. We certainly looked to also pull in mental health promotion. There's a lot more research about how mental health and physical health actually go hand in hand and how important those connections are, to focus both on mental health promotion and physical health promotion.

Also, alcohol and substance use are issues that can create significant problems for people making healthy choices. It's not just tobacco, although tobacco is very important. We know that the hospitalizations that are caused by tobacco use are actually falling and the hospitalizations created by alcohol use are increasing. Soon they will actually cross over, so we want to make sure that we're creating that culture of moderation with alcohol use.

Moving on to slide 4, these are kind of the pillars with healthy families B.C. At the beginning we had a real focus on healthy start. This is another area that wasn't a focus of ActNow B.C., but in a prevention strategy and trying to set the stage for children and moms and babies, there is really lots of research showing how early, early interventions can have a huge impact on the trajectory of somebody's health over their life.

The Healthy Connection Project is the actual randomized clinical trial and evaluation of a program called the Nurse-Family Partnership that was started in the U.S. It has been evaluated in the U.S., has been brought to the U.K. and Australia and is highly successful in those evaluations as having a huge impact for the children of these vulnerable moms.

They're first-time mothers under the age of 25, usually low-income, but for whatever reason are identified as vulnerable. Through this program of intensive public nurse visiting, they connect with, sometimes, the first adult in their life who can provide them with good advice, etc., until the child is two years old. That has been seen to…. Actually, in these trials they can see the see the trajectory of the child. Sorry, Hansard can't see my arms motioning in the air. They can see that the child's progression through life ten, 20 years later is significantly different from those who didn't have that intervention.

This is a major shift in public health and maternal-child public health programming across the province. After two years of this clinical trial we'll move it so that every vulnerable mom referred to the program will get the program. It will take five years to evaluate the program, but it will, hopefully, have a huge impact. Once we see the results of this evaluation, we'll determine next steps.

In order to do that, we have changed the perinatal child and family public health service standards — there have been some shifts — so that we're not spending as much time with healthy moms who already have lots of supports around them. There are still checks, still making sure that we're focusing on some of those risks during those first few months after birth around perinatal depression, etc., but we're really starting to focus in on those vulnerable moms.

That's a healthy start — a really major kind of redesign of our maternal-child public health services.

The next pillar is healthy eating. You may have heard that we've just finished three weeks of radio ads and bus shelter ads to celebrate and inform people about Informed Dining. I'll talk more about that later.

We also had in 2012 a major initiative focusing on educating the public about sodium and trying to help reduce sodium in people's diets and other healthy eating promotions. Healthy lifestyles focused first of all on Prescription for Health, which was to engage with primary care physicians, family physicians, to actually do a healthy-living assessment of their patients who they thought maybe had some risks.

That has been highly successful as well — lots of uptake by family physicians, lots of these prescriptions. They use these prescription pads, actually talk about the different services that people can access — the dietitian services at HealthLink, the physical activity line, the QuitNow services that we have in partnership with B.C. Lung and a variety of other services that people can get assistance with in helping to get healthier.
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Then Inspire Health, which has some of those support services that some cancer patients really find helpful for them. That has also been extended throughout the province now.

Then across all of those there's a real focus, of course, on those settings, how we engage with local government. Local government has a lot of the tools to create those healthy environments that makes it easier for people to be more active, to access better food choices, to not smoke, etc. So very much trying through this pillar to link the health authority and their expertise with local government, both at the board and CEO level and all the way down to the staff level.

Similarly with schools. We know, of course, that if we can start our life well in the preschool time and then we go to school and it's reinforced again…. There's a healthy environment at school, and you're supported to be physically active and to eat healthily. There are interventions that assist students not to make some of those bad choices about maybe trying alcohol before the age of 16 or whatever. Those kinds of interventions are clearly useful in that school setting.

Then healthy workplaces. We've partnered with the Canadian Cancer Society, B.C. region, to provide some on-line services for large, medium and small businesses that help them to kind of assess their workplace and then come up with strategies to improve the health of their employees.

That's on a high level. I think the next few slides talk about some of the continuation of those pillars and how we've continued to build on healthy families B.C. as a platform over the last three years.

On slide 5 is healthy start. Not only do we have the new perinatal child and family public health service standards, the nurse-family partnership and the Healthy Connections project, but we've also really improved our parent resources.

We have Baby's Best Chance and Toddler's First Steps. I don't know if any of you are familiar with those materials, but they're quite beloved in the maternal-child world and very highly used by new parents. Now we've actually got them on line in the healthy families B.C. website, and we're hoping that eventually it'll be very easy for moms to be searching for those on their iPhones, etc.

N. Letnick (Chair): And they're in different languages as well — very important.

And the child health passport, as well…. It's easier, of course, to keep a website up to date with the latest information and what the best advice for new parents is, as things do change from time to time.

Then, for healthy eating not only do we have Informed Dining…. I should just brag a little bit that we now have 1,529 outlets fully implemented for Informed Dining across the province and over 6,000 nationally. We have about 20 national chains that have decided they were not just going to do this in B.C., but they will do it across Canada. So it's kind of exciting for us to see some of our good work go national.

I mentioned the Sodium City ad campaign in 2012. The results of that from the Ipsos-Reid poll that we did after, just to test the effectiveness of that, was very good by industry standards — particularly for moms, who were part of the target, of course. It's to get moms aware of how much salt their kids may be eating.

The other program that we launched in 2012 was Food Skills for Families. This is another program that's really focused on some of those vulnerable populations. It is run out of one of our NGO partners. I think it's the diabetes association of B.C. We've run 159 programs with them, delivering it to over 1,400 participants, which we think affects quite a few families. It teaches folks how to shop, how to cook, how to manage a budget on a low income, etc.

We connect that, then, to our new program, the farmers market nutrition and coupon project, as well. Over the summer they get these coupons that they can take to farmers markets, and it connects them to really great local food and produce. We have 54 participating communities in 2014-15 that are providing coupons to 3,600 families and over 1,000 seniors. It's a very robust program that we're starting to see some real results from.

The other new program that was started in 2012 was the expansion of Shapedown and the introduction of MEND. Shapedown was a program developed out of Children's Hospital that works with families where a child has comorbidities because of their weight. They're overweight or obese and have some other medical condition as well. It's quite a medicalized program in that you've got a psychiatrist, a dietitian. It has to be referred by a family physician. They work together with the whole family, including siblings, etc., and they have fun.

They teach or expose the families to better eating habits, why screen time can be so dangerous, physical activity. They go through a ten-week process where they're actually building connections with a group of families that are struggling with the same issues. Then they have a partnership with the Y, and they get some free access to Y programs for a period of time after.

Those families tend to bond over this period and support each other afterwards. The evaluation after a year is that usually the whole family has lost weight and has really changed their behaviour.

Based on that, that's quite an expensive program because it is using professionals to teach this, because of the comorbidity issues that are involved. We have expanded that so that every health authority has that program now in at least one site within each of the health
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authority regions.

MEND is a much more community-based program offered at rec centres and at Ys. It is free. All these programs are free to the participants. You don't need a referral from a family physician. It's essentially the same thing, but run by trained staff. MEND is an acronym for "mind, exercise, nutrition, do it." It's a program that was developed in the U.K. It has, again, very good results through evaluations showing that BMIs following the program…. After a year it continues to have impacts on those families.

We now have about 1,000 people participating in that program annually across the province. We offer it about 65 times throughout the province. We're now, over the next year, going to try to provide that through a telephony program with HealthLink B.C., our 811 number, the physical activity line and the dietitian services line, and offer it so that we can spread that out to more rural and remote areas as well.

That's kind of healthy eating, but also, physical activity gets rolled into there as well. Healthy lifestyles, of course…. I mentioned the Prescription for Health and Inspire Health. We've also entered into a partnership with ParticipACTION for $6 million, a partnership that we've had…. It's about $2 million a year that we have provided to them.

Because they're a non-profit organization, they can actually purchase media on TV, in local papers, etc., at about a 4-to-1 ratio of what government can do. Our dollar goes a lot further by flowing it to ParticipACTION. They do all the creative and come up with the national campaigns, but we get a huge bang for our buck in intensifying that coverage in B.C.

Then they also have partnered with us to do a lot of things, like Sports Day in Canada, Jersey Day in Canada and all these events — Sneak It In, is the campaign that's coming shortly. We've got the Funmobile tour that goes around to communities throughout the province and gets kids to encourage spontaneous play, how to bring back play, how to teach parents and kids again what it's like not to have structured play all the time and get them away from their television and computer screens.

Those have been very welcome in communities. For Sports Day in Canada, we actually had a record 244 community events taking place last year.

We're also developing a cross-sectoral physical activity strategy, which ParticipACTION is helping us to fund here. We've got a leadership council with a whole bunch of different sectors — academics, local government, health authorities and others — to participate in what would make sense for us, moving forward, in physical activity.

Then I also talked a bit about tobacco cessation. Our QuitNow line is very successful; 69,000 individuals are reached annually to support them in trying to quit smoking. And of course, our smoking cessation program, which is hugely successful. We've got about 155,000 people to date who have accessed that program to get free nicotine patches or gums or prescription drugs to help them to quit. In the last year our smoking rate fell by a whole percentage point, so very impressive. We think it's that combination of programming that is making a big difference.

Then healthy communities. There, again, these are the settings in trying to bring all of the pieces together — tobacco, alcohol, physical activity, healthy eating, mental health promotion — in these different settings. With our local government partners — B.C. Healthy Communities Society and UBCM — we have launched PlanH at UBCM in the fall, just last fall. That is a website where all local governments and First Nations can access tools that can help them to look at how to mobilize their communities for healthy living. We've got over 60 municipalities currently actively working with health authorities on healthy living strategies, strategic plans.

With Healthy Schools B.C., we've had over 4,000 physical activity and healthy eating workshops in the schools, with over 76,000 participants as of the end of 2013. Action Schools B.C. is a great partner that does a lot of work to improve the health of schools.

We've got our school fruit and veggie nutrition program that brings fruit and vegetables from local producers 13 times a year to schools and in some places exposes kids that may never have eaten a red pepper before. So it's kind of exciting, the stories they tell.

We also have a farm to schools program where 91 schools are currently participating, which really brings the local farmers, connects them to the school. School gardens are put in place, salad bars, etc. — another piece that intensifies, particularly in some of the rural schools and some of the lower-income schools, that connection to good food.

Then WellnessFits is our workplace wellness initiative with the Canadian Cancer Society, B.C. and Yukon region. They have over 380 businesses involved in that, and it continues to build.

Those are some of the key programs that have been going on and that we've been focusing on. But I do want to mention, on slide 9, that we also have a very strong brand now with healthy families B.C., and social media marketing has been highly successful. We're right up there, actually, with our metrics with the National Health Service in the U.K.'s metrics, with the Heart and Stroke Foundation of Canada's metrics and with Michelle Obama's Let's Move! initiative. We like to compare ourselves to those kinds of sites and see, with our population, if we are getting the kinds of results that we want.

With Facebook, Twitter, YouTube they're really ranking very high. We've had 1.4 million page views. About 35 percent of the traffic returns to the site. They spend about three minutes on the site, which is way above the
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one-minute average for websites, for the industry standard. We've got about 20,000 web-registered community members who have actually taken the time to register with us. So we continue to grow that piece.

Certainly, the other success, I think, is just seeing a tightened relationship between health authorities, small business, local governments and schools of setting pieces and how important it is for health authorities and those settings to have that capacity to talk to each other, to understand some of the evidence about what a difference it can make, not only for health but also for those other goals that those other sectors have — so better productivity for employees, if you're physically and mentally healthier.

Students learn better. So we're trying to kind of align our goals in the health world with the goals of our partners. In the school system it's about health, but it's because if you're healthy and engaged in your school community, you actually end up with better academic results. Changing our language a little bit so that we're actually speaking the language of our partners is very important — and similarly, with local governments.

Next steps, on slide 10. We continue to evolve the strategy and build piece by piece. We know from tobacco and the success that public health has had with reducing tobacco use that it takes time for society to move, and we have to take it step by step. We continue to work with our partners over time to continue to build those healthier communities and to support the population to embrace those healthier choices.

Certainly, working with health authorities and NGO partners to identify those areas that have the best impact is kind of always the next step. What are the next things we should do? We try to make sure it's very much based on evidence, what other jurisdictions have done. However, I think B.C. is doing so well that often we are finding that there's not a lot out there that we're not already leading the way on.

We will continue to build that capacity and try to get people excited to make those changes in public policy, both at the local level in schools and workplaces and at the provincial and federal level, to become a healthier population for all British Columbians.

N. Letnick (Chair): Thank you, Arlene. Half an hour right on the button. Excellent. Well done.

L. Larson: Just two things that maybe you can answer. When you talked about the smoking decrease versus for hospitalization, the hospitalization for people with smoking-related diseases was decreasing, but with alcohol it was increasing. Is that also in the same low-income vulnerable groups, or is that a general statement across all people in the population?

A. Paton: Yes, every risk factor is a little bit different — right? It's interesting. It's not necessarily always that the unhealthiest population is the lowest-income population. For example, in overweight and obesity for men, it's actually in the higher-income levels that we're having more problems.

For low-income people, they actually don't start smoking as much, so that's better. Higher-income people might start smoking more, but they quit more. But with lower income, if they do start, they don't quit as quickly. So we've got to have different strategies for different populations.

The good news is that some of the programming that we've got in the schools, etc…. The latest McCreary foundation survey, which goes and surveys about 30,000 12- to 18-year-olds in schools, is showing that for first initiation of alcohol and cannabis, the age is increasing, so that's good news. People are delaying trying and experimenting with alcohol and cannabis. But what we're finding is binge drinking in the 18-to-30 age group is really increasing — and particularly with females.

Looking at what is happening there, the liquor review — there was lots of discussion in those consultations. We were quite pleased to see at the beginning a very strong focus on public safety and health.

What we've found in many jurisdictions across Canada, including B.C., is that the liquor industry is tending to focus on, of course, younger people, because they do tend to purchase alcohol. Certainly, their advertising has had a bit of a focus on Skinnygirl and things that attract young women.

Definitely, some of the conversations that we've been having with finance and through the liquor review are looking at that pricing. We're very pleased that government is going to move on how alcohol is priced, because currently high-alcohol-content drinks can sometimes be priced at a much lower rate than lower-alcohol drinks.

L. Larson: Could you give me the list of the 54 communities that are providing the B.C. farmers market coupons? I'd just like to know which ones are in my riding that do have that coupon program for farmers markets.

A. Paton: Why don't I give you this document? I don't know why I thought that question would come up, but I have the farmers market nutrition and coupon program results. Now, this probably is for last year. This is the 45 community partners for last year, so I can give you that.

L. Larson: That would be great. Then I'd know who was in my riding. Thanks.
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A. Paton: This also has the website on it so that you can actually look about what's happening for this year.

N. Letnick (Chair): What is the website, Arlene? If you'd like to put it in the record….

When you're tracking the percentage of people that are involved with the smoking cessation program, do you do follow-up to see how many actually stay quit — I don't know if that's the right word — or that don't start smoking again? Is there any percentage there?

A. Paton: We're actually just trying to do that evaluation. It is just through our administrative records, to see if we can tease that out. After they've done the patch for three months, can we tell from their physician, from the MSP records, whether they then stayed quit?

On average, I think the statistic is it takes usually nine to ten tries before people stay quit. But the fact that our smoking rate went down by a full percentage point, and a lot of that was about…. There were about 30,000 people between the ages of 45 and 65, which was a bit of a focus. You know, if you don't quit before 50, then the impact of smoking just continues to increase. Every decade that you have quit is a huge plus to your trajectory of health.

We saw 30,000 quit from one year to the next — I think that was from 2012 to 2013 — in that particular age group — about 55,000 overall. We can't necessarily directly attribute that, and we can't necessarily assume that all those people will stay quit. We don't know if that full 55,000 all took advantage of the smoking cessation program, but we're trying to tease that out through the evaluation, which we're hoping will be done by this summer.

It is a difficult thing to actually evaluate at this point. We don't have good data to track that.

K. Conroy: I'd also like to know where the Funmobile tour went, if you have that. You could get that information back to us — to which communities that had been to. That's not my question. That's just follow-up for you.

You talked about partnerships with the healthy communities partnerships. You talked about communities, schools, workplaces. I just wondered with local government. You talked about the partnerships with local government. Does this program provide funding for the local government, or is it expected that they'll be part of the program with funding on their own?

Along that line, I know that schools have initiatives and have funding to ensure that kids are involved in the programs. I know the child care sector quite well, and the early childhood sector does not have a lot of money for these kinds of programs. Are there any funds from your program to make sure that those programs are implemented in the preschools and child care programs in this province?

A. Paton: We have focused on schools and local government. We do have some grant programs that have been assisting local government, in particular, to convene community meetings and to start working on healthy-living strategic plans.

With schools, there is funding through Action Schools B.C. and DASHBC. There are a certain number of different organizations that work with the schools. I think that's where we've seen some robust changes and action and investment in thinking about these things and what the key priorities for each school or each school division and each community are.

For the preschool area, you're right. That is a gap that we have. We're certainly looking at what we could be doing to be more effective there. We have recently invested a little bit of money in assisting after-school daycares to look at what their programming looks like and if they are making healthy eating choices in after-school programs. We're trying to kind of build out from the school. But the preschool area is an area that we would like to move into next, for sure.

K. Conroy: Can we get a list of the local communities that have gotten grants, how much they were and if you know what they were for?

R. Lee: My question is on the budget. I'm not sure about the budget in terms of the four objectives — healthy start, healthy eating, healthy lifestyles and healthy communities. What are the allocations of the resources? What's the total?

A. Paton: When healthy families B.C. was announced in May 2011, it was a $68.5 million announcement. Of that, a lot of it was looking at the healthy start program — looking at revamping, essentially, maternal-child public health programming — and shifting some of the health authorities' work to really focus on those communities, schools, workplaces and connecting them more fulsomely. Then a component of that is paying physicians to do the healthy-living assessments.

I'm just thinking. Inspire Health is full cost recovery, so the patients pay for Inspire Health. That wasn't an additional cost to the program.

The healthy eating had a certain budget associated within it of the $68.5 million. The healthy lifestyles had that component for MSP. The healthy communities — there are these grant programs that are run
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through B.C. Healthy Communities society and through Action Schools B.C. Then there was a grant to the Canadian Cancer Society, B.C. and Yukon region, for the WellnessFits.

It is spread across those four pillars in different amounts. Then, of course, there was also just the building of the website and the social media and the marketing piece, as well, as part of that.

N. Letnick (Chair): It sounds like that's probably the best way — with the actual dollars. That would be appreciated.

D. Bing: Thank you, Arlene, for your presentation. It's great to see all the positive things we're doing to encourage healthy living.

I was concerned…. Well, not concerned. You mentioned how they've got a campaign to reduce sodium. I thought: "Well, that's a great thing." One thing that we haven't done, really, is talk about sugar. I only know American numbers, but I think the average American consumes 150 pounds of sugar per year. Of course, a lot of it is because we process food. We beat the taste out of food, so we have to add sugar and salt to make it palatable for people.

I know in our high school, they had Coca-Cola vending machines because they gave a certain portion of the profits to the parent advisory council and this sort of thing. It was very difficult to get them to stop that, because we felt…. Every bottle of Coke had 12 teaspoons of sugar in it, and we didn't think that was good for our children. Yet there was an incentive, because of the financial reasons, to keep this there. It was a real struggle to get these kids to drink juice and water and healthier things.

I was wondering. Is there a chance that you could have an anti-sugar program and get people to be aware of what they're consuming in terms of sugar? I mean, it's obviously too much, and I think there's more and more evidence that there are negative health effects of sugar.

A. Paton: Yes, and definitely we do on our website talk about sugary drinks and the need to monitor that, particularly for parents with their kids. In the schools we do now have our school guidelines for food and beverages that are quite stringent in what is allowed now to be sold in vending machines. It's mostly supposed to be water and milk and some juice — but trying to be very careful about what is allowed.

Certainly, no sugary drinks are allowed in elementary school or in high school. That might have changed since you were working with the school system.

But I think that it's also important…. Certainly, the advice we get from our dietitians is that it's important not to just focus in on one item — sugar, salt, fat. I think we've found that people just, as you say, replace one for the other, because of the taste. Really, what we're trying to focus on again is to have a diet that is varied. Make sure you're not getting too much of any one thing. We're trying to make sure that we're focusing on that balanced approach in the advice that we're giving to people about what is a good diet.

That's kind of how we've been approaching it to date. There are certainly materials on the website about sugary drinks, but we haven't done the full media campaign, if you like, about sugar — possibly because we're still kind of waiting to see what some of the evidence is as well. It's been pretty recent that some of the newer evidence about sugar and its impact on cardiovascular disease has come forward.

D. Bing: Yes, new studies, certainly. It's just basically education and awareness. I think we need to take advantage of this opportunity you're having here with encouraging healthy living to make that one thing that you do focus on as well.

J. Darcy (Deputy Chair): Thank you for an excellent presentation. I wanted to ask you about the program — you touched on it a couple of times — to reach out to vulnerable moms and vulnerable children. I wonder if you could just talk a bit more about how that program rolls out. Who does it? How do they assess who are the most vulnerable moms? What's the point of entry to that process? Some of the most vulnerable moms are probably not attached to a family physician, aren't seeing a practitioner on a regular basis.

If you could talk more about that program, then I have a couple of more questions, if the Chair will allow.

A. Paton: The nurse-family partnership is a public health program, so it's run by specially trained public health nurses in all five regional health authorities.

We are, of course, working very closely with family physicians to ensure that they know about the program and are referring vulnerable moms who meet the criteria. The criteria is pretty simple. It's under the age of 25, first-time mom, and then usually it's an income measure. But often the family physician…. If somebody is maybe new to the province, doesn't have the social supports around them, feels like they may be struggling through
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this pregnancy…. So it's not necessarily tightly bound in an income range or whatever. It's kind of an assessment like that.

It's also if public health nurses are aware of moms that are struggling. It doesn't necessarily have to be referred by a family physician, either. We're trying to get the word out to any groups that are working with young women so that they can learn about the program.

We're trying, actually, to currently identify them at about 16 weeks. But as you say, sometimes young women, if they are in quite difficult circumstances, may not be touching the health care system, so we are trying to get the word out to some of those groups that may be serving those vulnerable populations and might know about it. Then they can refer them to a clinic or a doctor and ask them to ask about the program.

J. Darcy (Deputy Chair): You had mentioned earlier…. I think you mentioned a number, and I missed it. Do you have an estimate on how many young moms are now being touched by the program?

A. Paton: We're trying to get 1,000 into the program. Unfortunately, this is actually a licensed program out of the States. In order for us to bring it to B.C., we have to do a randomized clinical trial, because we're the first jurisdiction in Canada to have this program. It has been run in Australia, and it's across the U.K. now, and their evaluations are very positive. We're pretty sure it's going to be positive in Canada as well, but the requirement for us is that we have to do this randomized clinical trial.

SFU has been contracted to do that. We need 2,000 women enrolled into the randomized clinical trial; 1,000 would be the control group that we would track for five years, and 1,000 would receive the program. After two years we can open the doors and all the women can come into the program.

Not all of the province could we randomize in that way, so we have some process evaluations happening in the smaller areas. In the north there just wasn't the population base to do the randomization. We're just doing process. Anybody who meets the criteria for the program can come into the program in more rural parts of the province.

J. Darcy (Deputy Chair): Second question. I don't know if I should admit this, but mainly I eat in the legislative dining room. I wonder if you could talk a little bit more about the Informed Dining — what it is, the restaurants that have signed on and what it is they've signed on to do.

A. Paton: We've actually had quite a few conversations with the Legislature dining room. I think they're almost at the point where they won't use Informed Dining's logo, etc., but they will provide the nutrition….

J. Darcy (Deputy Chair): That wasn't a criticism of the legislative dining room. I want to be very clear.

A. Paton: Informed Dining. Everyone who signs on to the program — any restaurant, independent or a chain — signs on to a legal agreement that they will use the logo so that people get used to seeing this logo wherever they go.

I have a few little gifts. Here are some little Post-it Notes with Informed Dining's logo on it for you. I hope this is okay.

What you can do, then, is ask for all the nutritional information at the counter, if you're ordering, or at the table when you're ordering. The waiter or the server should have a document that lists off all of the nutritional information: calories, sodium, how much iron, how many carbohydrates, what kinds of fats are in every single item on the menu.

It is voluntary, so it's pretty exciting that the industry has really come to the table on this and understands that people actually want this information. I'd encourage all of you to go to those restaurants and ask for the information. They have to sign up, in the legal agreement, that they will have it available, but they also have to have prominent signage in every restaurant so that people can see: "Oh, this is a participating-in-Informed-Dining restaurant."

J. Darcy (Deputy Chair): I will be sure to seek one of those restaurants out when we leave the precinct, as they say.

Third question. You touched briefly on mental health earlier in your presentation, but it didn't arise anywhere in the rest of it. I wonder if you could talk a little bit more about that — other programs related to mental health that are part of these initiatives.

A. Paton: Really, we're trying to make sure that it is understood in those settings. When we're talking with schools about physical activity and healthy eating, that there's also…. You know, there can be a lot of stigma related to being overweight or obese, particularly in schools. We're trying to make sure that there's an understanding that this isn't about…. We're trying to get away from stigma.

We're trying to support everybody to be healthy, regardless of their BMIs, and to also realize that sometimes people are making unhealthy choices because of mental health issues, because of bullying, etc. — so really tying the healthy-living message in with, for example, the ERASE program in the schools, which is the anti-bullying initiative, and expanding that to really supporting people. How do you connect socially within the school? How do we make sure that kids aren't isolated? How do we create those mentally healthy environments?
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The recent survey that McCreary Foundation has just released shows that students actually feel really safe. It's a huge increase over the last few years of how safe they feel in their school environment, both outside, in the corridors, in the classroom, etc. — huge increases. It's really exciting to see what a huge change has occurred there. But they still are showing that they are being bullied, because it's the cyberbullying that's still happening. How do we then…?

We've got one program that's worked really well, but what else needs to happen to make sure that kids do feel safe and that that mental health in the schools and in their families then connects them to healthier life choices as well? It's not like it's a separate pillar, I guess, that we're working on, but just trying to make sure that people understand that your physical health and your mental health are connected. We need to have strategies there.

In the workplace, WellnessFits…. We've got a module now that's about mental health promotion in the workplace, how you ensure that you don't have bullying and harassment in the workplace and how to assess that in the workplace. A lot of it is kind of those assessment tools that we're trying to make sure people are aware of and that it's all part of healthy living.

N. Letnick (Chair): Good, thank you. Seeing no other speakers, I'll pose a few questions, if I may, to bat cleanup.

Before I do, actually, in the legislative dining room if you order the salmon burger and hold the burger, it's really good. In other words, just the salmon fillet — no bread, no nothing — with cooked vegetables. It's an awesome meal.

M. Stilwell: I'd like to add, too, that we can now get smoothies and other healthy choices — and gluten-free options.

J. Darcy (Deputy Chair): We have gluten-free options too. Yes, we're very happy about that.

N. Letnick (Chair): We're almost there. All we need now is B.C. meat in the legislative dining room, and we'll have a home run.

Since we're divulging our secrets, MyFitnessPal, which I have on my iPhone, over the last 120 days has brought me from 160 down to 148. An excellent tool, and I think as more and more of us end up with smart devices with all these different tools on them, we're going to see a much healthier population.

Just a few questions. One is that you talked about the curve coming down for smoking and going up for alcohol. Could you provide us with any research that you have on that? That'd be great.

N. Letnick (Chair): Someone brought up the issue — I think, Doug — about sugar and the issue of vending machines and how they've changed stock in the schools.

Some of us, as MLAs, have been approached by the vending machine folks, who are wondering whether it's actually made any difference. They believe kids are actually just going out to the 7-Elevens of the world, getting their sugar drinks anyway, and it's having a negative impact on their economic viability in the vending machine business.

Could you provide us with any research you have on that as well that would argue one way or the other on that — that they're not going out to the 7-Elevens of the world, that it's actually making a measureable difference in the consumption of the students?

The other two points I'd like to get some clarification on…. The Shapedown program that we have, basically, from what I understand, is helping in a holistic way, in a multidisciplinary team, young people and families to reduce their weight.

One question I've always had is: how much of obesity is due to lifestyle choices versus due to something else — genetic or whatever else — that can't be that easily changed? Maybe that's something you have an answer to or not, and you'll have to get back to us on that as well.

Are we saying that everyone out there that's obese at a young age is because they're making wrong choices with their families, and everyone potentially can be helped with this program? Or are we saying there's half of the people out there that can be helped with this program if we modify behaviours? Is there an answer to that that you can share now? If not, you can get back to us on that.

A. Paton: For the vast majority it's about our environment — right? — and of how difficult it is, actually, to be healthy when we're surrounded by processed food and screen time and those lifestyle choices.

I think it's always dangerous, though, to talk about it. It seems like, "Well, if everybody just made better choices," kind of blames the individual. Sometimes it is part of that, but it is also that we're surrounded by a lot of…. It's easier to sit and watch TV than to get out and go for a walk. It's easier to drive your kids to school than it is to walk your kids to school. Time is such a big issue in people's lives when everybody's working.

I think it is fundamentally not a…. Given the changes over the decades that we've seen in the increase of people's weights, we can see that it's not just about
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people's metabolism or some kind of underlying physiological issue.

N. Letnick (Chair): The last question. I wouldn't presume to guess for everyone what their life goals are, but I imagine most people's goal is to square the curve. As we get older, we tend, over 50, 60 or 70 years, to have more and more health issues. Usually we curve down to eventual death for all of us. But I would think that one of the goals that we have is to square that curve so that we stay healthy as long as we can for a nice, ripe old age and then at that point, we come off the cliff, right?

I understand that there are some places in the world that have actually figured out how to do that over generations and millennia — some places in Italy, I believe, some places in the Pacific. I think they're called blue areas. Are you familiar with them?

Can you share some of that information with us — maybe not today but by a response — so we can understand what commonalities we have in those blue areas? So we can, as we proceed with our mandate — which is to look at the sustainability and improvement of the health care system over the long term, the next 25 years or so — keep that in the back of our minds as to the ultimate goal, which is to square the curve. If we can achieve that, then we will have a much healthier system as well.

N. Letnick (Chair): Perfect. Thank you very much for coming. We really appreciate your presentation.

We'll take a minute or two to switch presenters. If you want to fill your mugs or plates, that would be great. We'll call a short recess of the Standing Committee on Health.

N. Letnick (Chair): Thank you very much for coming. We have Doug Cochrane, chair, B.C. Patient Safety and Quality Council; and Doug Hughes, ADM, health services policy and quality assurance division, Ministry of Health; who are going to be presenting.

N. Letnick (Chair): Okay. If you would have a look at the clock, it's ten after ten. We have half an hour to listen to your presentation, and then we'll have half an hour of questions and answers, if that's okay with you.

If it turns out that it takes a little less, that's fine, but don't feel like you have to finish any earlier than half an hour. Take it away, gentlemen.

D. Hughes: Thank you for giving us the opportunity to come and talk about the B.C. Safety and Quality Council. It's a piece of work that the Ministry of Health is extremely proud to be associated with, with the council and Dr. Cochrane's work and the work that's taken place. It's a real pleasure that we get the opportunity to come and talk about this. It's a great initiative underway.

Some background on the quality council is that it was established in the fall of 2008 through a throne speech commitment. The commitment was that it would enhance patient safety, reduce errors, promote transparency and identify best practices to improve patient care.

The council's authority to operate is based on the minister's prerogative, meaning there's no legislation relating to the council. Several other Canadian provinces have quality councils, although each is just slightly different in its mandate and its governance structures. Since November 2010 the council has received $3.5 million in annual funding. This funding comes from the Ministry of Health via the funding envelope of the Provincial Health Services Authority.

The mandate, on the slide that's up there, is that the council's overarching vision is a sustainable health care system built on a foundation of quality. The council's mission is to provide systemwide leadership through collaboration with patients, the public and those working with the health system in the relentless pursuit of quality. The council's arm's-length nature from government and its in-depth knowledge of front-line service delivery enhances its credibility among all stakeholders. It makes it uniquely suited to fulfilling this mission.

The council's purpose is twofold. First is to provide advice and make recommendations to the minister on matters related to patient safety and quality of care in all health sectors. Secondly, it brings health system stakeholders together in a collaborative partnership to promote and inform a provincially coordinative, innovative and patient-centred approach to patient safety and quality improvement in British Columbia.

Next slide. There are our pictures. This gives you the structure of the reporting relationship. While it operates at arm's-length from government, it's ultimately accountable to the Minister of Health.

The council is led by Dr. Cochrane, who is both the chair of the council and the B.C. safety and quality officer. Dr. Cochrane is appointed to this position by government. We are in the process of renewing his appointment as chair for another three years as well as renewing his contract as the B.C. patient safety and quality officer. Dr. Cochrane has led the council since its inception.
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The council's board includes Dr. Cochrane and four other voting members. An ex officio member from the ministry — that's currently myself — is part of the board. The executive director of the council is Christina Krause. She's sitting over here at the side. And that's Teri Collins, who is my executive director, sitting here as well. Christina is responsible for the day-to-day operations of the council, and she reports to Dr. Cochrane. The council has 19 positions, including clinical advisors, quality leaders, communication experts and administrators.

The objectives of the council. Under the terms of reference, the council has four main objectives, the first one being providing a provincewide perspective on safety and quality improvement activities; the second, facilitate building capacity in capacity for quality capability and capacity for quality improvement; support service delivery partners in achieving quality improvement; and improve health system transparency and accountability to patients and the public regarding safety and quality.

As you can see, the council's objectives relate primarily to creating the conditions under which effective quality improvements can occur, and the council aims to provide their service delivery partners with the knowledge and tools they need to make change happen. At the same time, the council aims to keep patient perspectives at the centre of all efforts to improve quality and safety.

The roles and responsibilities. The council strives to achieve their objectives through the following roles and responsibilities. They lead and coordinate the systemwide development and implementation of guidelines, protocols in quality and safety initiatives.

They assist the ministry in developing quality and safety performance indicators, including developing processes to define, measure, implement and sustain optimal clinical practices; organize education and professional development opportunities to front-line health care workers and managers; engage with the public to improve communication; enhance the patient role in developing quality improvement programs; and provide advice to the ministry regarding legislation and strategic planning to advance the safety and quality improvement agenda.

Overall, the council is able to make a more direct, hands-on quality improvement than would be possible for the ministry to undertake itself, while still maintaining a provincewide perspective — a critical role.

Council staff are experts in the field of safety and quality. As such, the council is a valuable resource for the health services delivery operations in British Columbia.

I'm going to hand it over to Dr. Cochrane for the next part of the presentation.

D. Cochrane: I, too, wish to thank you for the opportunity to come and to present information about the Patient Safety and Quality Council and to answer any questions that you might have.

This slide gives you sort of a more operational view of what is being done inside the council to try and achieve the roles and the goals of the council as laid out by the Minister of Health.

Our principal focus has always been to try and support the system to improve care to patients and clients. One of the key cardinal areas, the foundational area, has been improving care in very specific areas.

I'll talk about these as the presentation goes on, but I think we recognized shortly after the council came into existence, and maybe even a little bit before, that in British Columbia we did not have a great number of individuals who knew how to improve the health care system. We had many, many — tens of thousands of individuals — who were highly engaged, wanting to do the best for patients and clients, but the how to do it was generally missing.

In fact, when the council began, there were perhaps one or two people in each of the health authorities who had such capabilities and that could actually take an issue, define it, organize it and make a change.

One of the key foundational aspects for us was to create an opportunity for learning in the health system so that individuals could take issues and improve care as a result. That's our capability and capacity-building initiative.

I will point out to you that this has been quite extraordinarily successful. We had a quality forum in Vancouver, hosted three weeks ago, where we had over 700 people — international, national and from the province of British Columbia — highlighting quality improvement initiatives that are being done in this province. I must say I'm extraordinarily proud of that particular achievement.

One of the things that we also felt was important was to try and be aware of things that were unfolding. I think you heard from the previous presenter that one of the things about living healthily is knowing where those blue zones are. Where are there examples of initiatives, improvements, directions and policies that could make our health system better and that we have not yet implemented or we've not considered? That, too, is part of our job.

One of the things that I think is most telling is that the council has looked not only in the acute care sector but in the community sector. In this area in particular, the dignity of the elderly — the frail elderly, those with multiple illnesses who unfortunately are on the tailing-off part of the curve — was something that Christina, I and the council members thought was important to develop, to create an opportunity here in British Columbia for that to get some legs. That is work that is currently ongoing.

The other thing that we found highly important was that our health system, because of the way it's funded and organized, sometimes has difficulty in moving resources from a particular service line or stream or sector
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to another. Improving quality invariably improves cost. The question is: how do you actually recover those costs and put them to something else? That strategic approach to funding allocation has also been something that has fallen into our thinking.

Having said all of that though, we don't do anything directly other than some sort of thinking on these strategic initiatives. We do everything through partnerships and collaboration. I think we're blessed here in British Columbia to have many organizations, many individuals, who are working to improve the quality for patients and clients, for families and for the public in general. Those individuals have a working knowledge in particular sectors that we as a council would never have.

How do we bring quality improvement, though — a provincial-wide perspective — together? Well, it's actually by joining these individuals and collaborating with them. I suspect that in many respects we're sort of like a matchmaker. We bring together people with expertise, and we're able to build on that expertise. Then to do that, of course, we have a variety of tools, the usual ones that you might expect.

I think the first foundational achievement of the council was to create what we have as a working definition of quality. Health care quality or service quality is something that we feel, but it's really hard to define. It's something we would recognize when we're exposed to it but that we could not necessarily put words to.

Based on work that was done in other quality councils and in collaboration with those councils, we felt that it was important to define quality in a number of dimensions with respect to patients and clients and also with respect to the system. The health quality matrix is that set of definitions. It's about acceptability of care, the appropriateness of care for an individual who has a particular set of individual needs. It's about being able to access that care and have that care delivered in a safe fashion and to have that care rendered effectively.

If you look at it from a systems point of view, we have to deliver equitable care across a very diverse geographic and cultural population here in British Columbia, and there's no doubt we have to do it in a way that is efficient, that there's a value for money spent.

Our matrix looks at health care from a variety of different perspectives. It's not just the child who falls and breaks his arm, and it's not just the frail elderly patient who has multiple conditions.

We divided it up into those areas where people were staying healthy — the kind of discussion that you heard earlier — then the getting-better sector, which is generally the hospital sector and what most people see as health care. Then, of course, there's the issue of living with disability and illness — something, actually, that we all do at various times during our lives — and of course, coping with the end-of-life aspects of health care.

So we at least have a definition. This definition has been used to inform the new strategic directions from the Ministry of Health, and we have used it in a number of other sectors as a lens through which we can look and say: "Are these particular initiatives delivering quality?" No one of these dimensions is sufficient in and of itself. They are all required for a quality system and quality care to patients.

The building of capacity to improve is actually a pretty important aspect of things. If we don't know how to do the work, we actually can't improve, and we should not assume it's an intrinsic understanding of people who've come through the health care system or the health management system. So we established a quality academy, and basically, this is an internship program. Individuals come out of the workplace for a few weekends during the course of a six-month period. They run a quality project, and we teach them how to do that work.

We've been successful. We've had eight cohorts come through — 216 staff members who are now able to deliver this kind of work in their health system, whether it be the health authority sector or whether it be the long-term-care sector or the home care sector. I think this is our biggest, most effective tool for long-term change in the system, to the tune of nine out of ten people actually using this in their work. And believe it or not, there's the odd doctor who's gone through it as well.

Clinical improvement comes about in a number of different ways. The CLeAR initiative, or call for less antipsychotics in residential care, is an example of a self-organizing, voluntary system that has brought together over 40 long-term-care facilities to improve the management of elderly, or often elderly, individuals who have the behavioural and psychological aspects of dementia.

We know in British Columbia that this is an issue that has affected us directly. It has affected individuals within their own constituencies. We're not different than anywhere else, but we have a burgeoning population of individuals who require special care at the end of their lives, related to mental illness. We said: "Well, this is an issue that needs to be addressed, so let's just see what happens. How can we spontaneously organize something?" So this is collaborative.

These organizations come together with four principal goals. One is let's get rid of the polypharmacy, the add-on antipsychotics that occur in this particular population because it's a convenient chemical restraint. Let's teach organizations and people working in those organizations how to manage behavioural changes, behavioural challenges, in ways that don't always require medication.

How do we then support those people to do that work? That's actually an extraordinarily tough job. It's an extremely tough job. How do we build their culture, and how do we support the family?

Well, how do we support them? Through conscientious
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planning for the care of these individuals who are now in our care. CLeAR is, I think, the most current, best example of the health care system coming together to deliver something. What we did is sort of knit it together, and we have supported it at the end.

Clinical care management is another set of 13 areas where the health care and medical literature had good evidence for particular patterns of practice that would deliver optimal outcomes — things like hand hygiene, the control of serious infections that might result in death, aspects of surgical care, the surgical safety checklist that you may have heard about or surgically induced infections.

What we did is we said: "Let's look at these best standards of care." You can call them guidelines, because that's the term that we use operationally. Really, what it is, is a suite of actions that individuals and teams can take to effect safer care. We were successful, I think, a number of years ago in working with the now deputy but then deputy minister to get this incorporated into the original innovation and change agenda and now in the reiteration.

The council said: "Well, in order to be successful — we know what this set of information is, these tools — how do we go about it?" We helped establish a measurement system so that the health system would know that they were successful in implementing and that they were successful in achieving outcomes related to these particular areas.

We said: "We need to organize to help this system create this change." Some of the folks had already been through the quality academy, but many of these areas had not had specific focus and attention. We actually brought together groups and clinical experts to support the health system, the health authorities, in undertaking these areas of improvement.

I think there will be others that come along. Medical knowledge evolves over time. We will have a better sense of where to invest our time and effort. These are large areas of improvement that are occurring currently in the province.

As I mentioned, the council is important for supporting the implementation and supporting the measurement aspect. Then there are some technical things about helping the health system learn through webinars and networks.

Here's an example. It's one that…. We'll come back, actually, to the Legislature in a moment. Sepsis is a set of infections that actually threaten your ability to survive. You think about them as flesh-eating disease, or you think about them as C. difficile infections. These all interfere with your own body's defence mechanisms in a way that can overcome them.

The B.C. sepsis network was designed to try and help address this specific issue. We created on-line learning modules, such as the pictures you saw. We had a proclamation in the Legislature of B.C. of Sepsis Day in September last, and we established what was the 150 Lives campaign.

We know that if one delivers sepsis care correctly, if we are aggressive about diagnosing it and treating these patients, in fact, we can save their lives. We went about creating a campaign based on the mandate and proclamation from the Legislature about Sepsis Day. And what has happened? Well, I think we can be assured that 150 British Columbians are alive today who would not be alive had this concerted effort not been put forward.

Surgical interventions get a fair amount of attention, usually around the access aspect of quality. Individuals such as myself, who need one or more…. Well, I guess there'll be four major joints needed to be replaced before I hit the end of that curve.

Surgical improvement has actually been a key aspect and interest. I declare a bias. I am a surgeon, so I have not only a personal but a professional interest. As well, I think it's close to half, maybe a little more, of the resources that we currently put into health care.

We have tried to define a multifaceted strategy which we have branded through the Surgical Quality Action Network, one of our collaborative bringing together of interest groups — professionals, health authorities, Ministry of Health, some aspects of the educational institutions and some of the professional bodies as well — to deal with things.

What we were successful in doing was establishing a measurement system. We were unique in British Columbia to have a surgical measurement system. We call it NSQIP. We've adopted it from the American College of Surgeons. It actually tells us how well we're doing relative to a number of peer organizations — in fact, about 370 organizations in North America. It tells us how well we're doing for like patients. It has a process called risk adjustment so that one compares apples with apples and oranges with oranges.

We've also structured a number of learning events around key surgical improvement initiatives, and we've looked at a number of areas with regard to the benefits to the system of improving surgical care and what that actually means.

Perhaps most important, and most exciting right at the moment, is that we're coming to bring together the surgical teams so that quality care is something that we can expect — not that we assume but that we can expect — in the operating room. We're doing that through what we call the B.C. perioperative improvement project.

It has two components. One is looking at unit-based safety. That's CUSP. And one is called TPOT, which is improving efficiency in the operating room. We need interesting ways of branding these things. But actually, they're all about teamwork. They're all about communication.

For those of you who are from non-urban parts of the
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province, you'll know that in your health system, people get to know each other really well. They see themselves in Safeway, and they see themselves at, maybe, Shoppers Drug Mart. They actually do work as a team because they have to work as a team. There aren't options.

In the larger urban centres, teams are very dynamic. They're always changing. So the fundamental aspects of good teamwork to ensure quality of care when it occurs in our operating theatres is something that we need to be thoughtful about and to develop specifically.

This gives you a little idea about what the impact from surgical improvement would be. We did an analysis over a year ago looking at a number of surgical complications, specifically the impact of surgical site infection. That's the unfortunate circumstance when a patient has an infection. Then we have to cure the infection before they can actually be discharged, or we have to do it while they're at home.

It's really quite interesting. If we look at a very conservative estimate of about 3 to 4 percent of surgical operations having infection and if we were able to reduce them to about half, we would free up in the order of about 25,000 hospital days in the province of British Columbia, given the current rate at which we provide surgical services, and 25,000 hospital days is about 5,000 operations, if you look at the current hip and knee replacement length of stay.

We weren't able to quantify this in terms of dollars because of how accounting is done in the health system, but we can certainly count days. The effort to improve the quality of surgical care in a very specific area — specifically, infection — has significant benefits. We can now measure it, so we actually know where we are being successful and where we are not being successful.

That then takes us back to NSQIP. What this slide shows is that over the past year and a half, where we've had reports…. These are peer-comparable, risk-adjusted reports, so the right sort of technology around the statistics. What we found is that at the present time, from our last report, which was March '13, we have 27 institutions that have specific surgical outcomes that are in need of improvement. These are people, organizations, services and operations that are at the poor end of the scale, but that's 16 less than the previous six months.

More importantly, we have five more outstanding, at the very best of all of North America, services with specific outcomes. That's quite phenomenal. You may have heard about the honorary awards that were given to Victoria General Hospital and Lions Gate Hospital because of their outstanding achievement in surgical safety. This is by the American college.

This is really quite interesting. It simply, I think, reflects that by shining a light on an area, supporting it in the context of it being important for everyone, being able to measure it, we have got a number of health systems starting to change in ways that we have never been able to recognize them changing before.

N. Letnick (Chair): Your surgical precision works in this room as well — 29½ minutes. Perfect. Thank you very much.

M. Stilwell: I'm just wondering what you're spending most of your time and effort on. Is there one key area that you have more focus on? How are you prioritizing the needs of all the different silos that you have to focus on?

D. Cochrane: There are three areas that are particularly important and consume time: clinical care management and surgical improvement, the quality academy and the Quality Forum — so the education of individuals and the recognition of them — and then the foundational networking that is required to bring people together around any number of different issues.

I think the lesser amount of time is spent in trying to be out ahead, but we have the opportunity to link with other colleague organizations across the country. Other quality councils — we interact with them on a regular basis. We have the opportunity to attend meetings where new thoughts and new plans are coming forward. It requires slightly less time, but this is a people business. You need people, direct people interaction, and those interactions, as you know, take time.

K. Conroy: I commend you for the work in the long-term-care sector because it's desperately needed. I wanted to know if you're working with all facilities in the long-term-care sector or just those that are under the bailiwick of the health authorities, or if it's all health authorities.

I also wanted to know, when you were talking about that you recommend regulations or give advice to the ministry — one of the key issues with using less antipsychotic drugs is having the appropriate staffing levels — if one of your recommendations could be that regulations ensure that there are appropriate staff levels in all facilities across the province, not those just under the guidelines of the health authorities. Those are around the long-term-care facilities.

I wondered if with…. Can I just ask you all my questions, and you can answer them all?

K. Conroy: Okay. Well, the other…. Patient quality care persons that are in the health authorities — do they have any input into what you're doing? There are actually people that have those positions throughout all the health authorities. So I want to know that. And if you could let
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us know where the sites are that you're talking about. In the B.C. perioperative improvement projects you talk about three sites, eight sites. Are those sites throughout B.C.? Can you actually let us know where the sites are where you're working?

D. Cochrane: Sure. I can go backwards. All of the information about the participation of sites in NSQIP — the measurement system and the one about which I was reporting — is available on our website. I've provided the Committee Clerk with a copy of our strategic plan for your records, and that information is available on line. All of that is on line.

The individual performance of an institution is the health authorities' business, and you would have to be speaking with them. What I do is I bring together the information in the aggregate.

This is for 24 sites in British Columbia. The improvement that we saw in those needing to be improved, the ones at the poor end of the scale, are institutions in British Columbia. The ones that are now outstanding that were not outstanding before are here in British Columbia, and they're compared with peer organizations throughout North America. So these are B.C. places.

With regard to the patient care quality review, individuals in the health authorities do not report to us. The patient care quality review structure is a separate structure. We have recognized, through their reports and through communications with the current chair of the provincial patient care quality review board, that there are opportunities for us to learn.

We take information that they are able to share with us, and it helps inform our thinking about the next steps and where next steps might be. But their process is with respect to the treatment of an individual. Our job is to try and translate that into something that might be relevant for the system. They do not report to us.

D. Hughes: The patient care quality review boards — the chair reports to the minister as well. I'm looking to Teri. But we have staff who are housed in the Ministry of Health that will receive phone calls. So it operates inside of that structure.

Across the province we have individual boards that get together, as well, which I think, as MLAs, you're quite familiar with in your areas. We meet on a regular basis with all of the chairs that come together, and we review their work. We work with them to try and have the access for the health authorities that the recommendations are coming into — health authorities and the ministry that were acting upon them. Then we also look at their relationship in the communities as well.

I would say that the recommendations coming forward are then looked at: how do we improve? That's where we bring in the safety and quality council around a quality improvement piece of work. The recommendation of the care review boards would be more along the lines of saying, "This is what we're seeing. Here are some things that you should look at" — health authorities or ministry. Then we would work around a performance-planning approach, around how we are going to change so that we can get at some of the systemic issues for patients around access, around communication.

We'd look at how we can increase or do a better job with communication so that we are transparent in saying that if you go in for surgery or a procedure, then you will need follow-up. You'll need to think about care, and you'll need to look at how you're going to do that."

How do we build that plan together? That's the work we would then go back to the health authorities and say: "You need to think holistically around the person, as opposed to the procedure." There's before-work that needs to happen, and then after-work that has to happen.

That's ongoing work that we have with the review boards and through the agenda with the council.

D. Cochrane: The first two questions that you asked — I think I remember. Please correct me if I remember them in error.

One related to advising the minister about regulation and regulating the level of staffing in a particular organization. That has not been within our mandate.

The other question that you asked, though, is really quite telling, because health care in British Columbia is much more than the health authorities. When you get into the community sector, there are large aspects of private, public, mixed funding and all sorts of things. Our CLeAR initiative was open to everyone, but it was voluntary. We did not have any authority to mandate that all long-term-care facilities would participate. We made it a voluntary initiative.

And just one other question: have the people that have come to your quality academy been from the long-term-care sector, the private owner-operators, the non-profit sector? Have they also participated in that?

D. Cochrane: I can't give you percentages of people who were health authority versus not. But I know that there was opportunity, and I know that we've had participants from all sectors.

N. Letnick (Chair): When you do go back, if you do have that information readily available, if you wouldn't mind sharing it with the committee. If it's going to take
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a lot of work to put it together, then think twice. But if you do have that information, that would be wonderful for us to have.

R. Lee: I think that in some of the material I read supplied to our committee I saw a graph on the risk of life-threatening encounters. For example, one in ten million will die in an air flight — that kind of risk.

I think I saw that one in ten in the medical system will die by accident. I don't know how…. That's a U.K. study. Have you read the report, and can you comment on those figures? How does it relate to B.C.?

D. Cochrane: I don't know that I've actually read that particular study. What I can say is that medical error and the consequences of it are probably the third-commonest cause of death in the United States. I think that's probably true of Britain. I know that in…. Well, ten years ago when the study was done in Canadian institutions, some of which came from British Columbia, the numbers were about the same order of magnitude.

I know that for studies that have been done in the past, that is very true. I do know that in examples like sepsis or in stroke care or in cardiac myocardial heart attack care, British Columbia is far better with regard to the ability to prevent these things, as well as to rescue people from them when they are affected by the illness.

I would hope that our numbers, in what I believe to be a forthcoming assessment of adverse events in Canadian hospitals, will actually show an improvement, at least for B.C. But that study is in the planning stages at the moment.

J. Shin: I'm very happy about these initiatives — like CLeAR and the Sepsis Network — that have very well-defined target goals and objectives. There are quantifiable outcomes and definitive action items.

I'm curious to find out how many of these initiatives the council has championed or is involved with at any given time, given that, I think, the funding for the council is $3.5 million. I don't know if that's your operating costs, but where does the funding come from to support all these great projects and campaigns?

D. Cochrane: The funding is as it stands. We don't receive other funding from other sources. Well, I should perhaps…. That may change as our expertise is requested by other individuals, where we might choose to actually contract with them and bring more money into the council.

But the answer, I think, right now is 15. There are 13 clinical care management initiatives. I put surgery in one bucket, of which there are six individual initiatives there, and then CLeAR. So how many does that give us? It may be close to 20. We support those through a staffing model where we have physicians, we have nurses and we have quality leaders, many of whom are only working part-time for us. We've been able to make do with what we have and, I think, quite successfully.

J. Shin: I have one more question. For your programs, like the events and the campaigns and activities, is there a cluster of locations that you choose in B.C.? Is it based on needs or….? If you can comment on what the rationale is.

D. Cochrane: For clinical care management improvement initiatives, they're provincewide — all institutions, all health authorities. In an individual health authority they may not have got to implementing it in all of their institutions as yet, but it's everyone.

The quality academy is a voluntary program, but we're sold out on all of our cohorts. The Quality Forum is also a voluntary area, but we've been sold out in all three years. It's just reflecting, I think, the interest and the passion that people have in the health system.

NSQIP was limited to large and medium-sized hospitals, so there are only 24 that currently are measuring surgical outcomes using that particular set of tools. We based the decision of which ones on the fact that here were our largest surgical providers and here were our middle ones, and this is how much money we had. Then we sort of had to cut it off.

In the interim, though, the American College of Surgeons has organized a NSQIP program for rural institutions because their particular surgical needs are actually a little different, and the original methodology would not have worked for them. In the future we'd like to see it spread provincewide. We don't want to leave anyone out.

J. Darcy (Deputy Chair): Thank you very much. You've a fascinating presentation. You could go in a zillion directions here. I want to try and connect it back to the kinds of things I hear in my constituency office and the kinds of things I hear about as Health critic. I hear about problems that people have in my constituency, and they tend to come from across the province as well. These are about situations that are happening to individuals, but they also point to systemic problems, and they certainly relate to patient safety and quality.

Katrine mentioned standards in residential care, which include staffing levels. But people will come frequently and say, "My parent, my grandparent, isn't bathed frequently enough, isn't" — you know, all of the kinds of things that the Ombudsperson heard in that report.

We now have a seniors advocate who can deal with systemic issues but not individual issues.

Individual issues go in a certain place in the health authorities, and you've defined where that goes. But the individual issues don't come to you, which I understand. It's sort of: how do we make that link so that at least when…?

Do you become fully advised of the nature of, if not the individual issues and complaints…? It could be any of a number of things. It could be Royal Columbian Hospital — how long someone spends in a hallway, which is pretty current right now, or any of a number of issues. Are you made aware at least of the substance of those sorts of issues, if not the individual ones, in order to help to advise and inform the initiatives that you undertake?

D. Cochrane: That's a really interesting question, because the answer is yes, and from multiple directions.

I have the opportunity. We do have an office. We have a website. We have a phone number, and some individuals have sought me out in my role. In that circumstance I try and understand what the issue is and then make sure that they get to the right body or person to help sort that out. At an individual level, I actually am touched by people who have had experiences that have not met their needs.

I think, as well, we're informed by the ministry. We're informed by the patient care quality review boards. We're informed by the Ombudsperson's report. We're influenced, actually, by different areas within the ministry when it comes to aspects like measurement, for example.

So yes, the opportunity to be aware of many of these issues is present. It's timing; it's sequence. It's how they come together. I mean, all of those things do influence whether this becomes an initiative or a strategy. I work with the minister and the ministry to try and define our role as a quality council forum.

D. Hughes: I would just add that the patient care quality review board…. The process — individual situations would get referred to the officers in the regions to investigate and look into. If they're not resolved to people's satisfaction, they can request that the review board undertake a review.

Along that process, I know I personally would be getting involved in certain situations and being able to look at asking the questions that I'm sure would be the same questions you would ask.

D. Hughes: You can call, and I can't guarantee a resolution, but I do know that I'll ask a lot of questions around what's going on. We are not hesitant to call upon the review boards to look at a situation. If we see a systemic issue, we'll ask them to look at that.

I am quite looking forward to the seniors advocate and having discussions with her. We've had a couple of discussions already. We have been meeting with the Ombudsperson around the last report. I met earlier this week around individual recommendations and looking at where exactly we have made progress and where we need to do some more work. That's the work I'll be doing with the Ombudsperson — to come back and readdress some of the issues that were raised.

When I look at the council's role in this, for me they're significant in the quality improvement piece of the work. That's what we're trying to do — really position the council as the leader in the quality improvement work — with their position in that they have a bit of arm's length.

We'll have a situation that will come up. Recently there was a case — the review of the model on Vancouver Island — where the council was having a look at that and being able to look at that from a different perspective. So there's a way that I think we work in partnership with the council, which really positions them to give the minister good advice and give the staff good advice.

J. Darcy (Deputy Chair): Another question. I'm sort of understanding it better conceptually. Let me ask another question. It's related.

You spoke earlier about sepsis and best practices in order to reduce sepsis which develops as a result of other infections. There's a fair bit of literature that also indicates that the conditions within which an antibiotic-resistant infection develops or becomes far worse, are both about cleanliness — like handwashing.

They're also about cleanliness of the conditions of the hospital. They're also related to overcrowding and lack of space for isolation, for instance. Something like that — where would you or the council fit in? You've talked about professional development and staff training and so on. On something like that, would you undertake education, training, staff development — whatever you want to call it — in the area of best practices as far as that's concerned? It certainly has some budget implications. That one goes in many directions, I know.

D. Cochrane: If we just talk about sepsis and conditions that would predispose to that kind of life-threatening infection, there are probably three areas that come to mind immediately. First of all, in clinical care management there are three areas that specifically focus on this — one around sepsis per se. This is life-threatening sepsis, its recognition and treatment.

D. Cochrane: The second is around hand hygiene, and the third is around the appropriate use of antimicrobials. This is the whole idea that if we overexpose ourselves, the animals in the environment in which we are and so on, we won't have antibiotics that actually work against these highly adaptable bacteria. So there are three areas specifically around where that happens.

I also have been asked by either the health authority or
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the ministry — and it depends on the particular circumstance — to do focused reviews on particular aspects of things. The best example in light of the question you're asking is to review the implementation of recommendations that were made to Burnaby Hospital regarding C. difficile outbreaks.

That is another vehicle that I, perhaps in the role of the patient safety and quality officer rather than the council, have an opportunity to impact or influence but certainly to cast a different set of eyes on things.

I wanted to ask some simple questions about governance. I'm just thinking: what is the background and composition of your 19-member council? I was wondering: are they all health professionals, or are there different backgrounds? And why are just six of them voting members?

D. Cochrane: I may have miscommunicated around the membership of the council. There are four appointed council members that come from the board resourcing office. Currently we have a lawyer with past health authority board experience. We have an individual from business. We have an individual from the public sector philanthropy and social development, and we have a nurse who is involved on the nurse regulatory side. So there are actually only four members of the council in addition to Doug 1 and Doug 2.

Our staff. I think you may be referring to the fact that there are a number of staff, some of whom are part-time and some of whom are physicians. We have built the staff around…. Well, first of all, it is a multidisciplinary staff. They're not all just health care providers. We have nurses, we have physiotherapists, we have respiratory therapists, and we have physicians with the specific areas of expertise we need to move forward on a clinical improvement initiative. Those are actually staff positions rather than on the council.

S. Hammell: I'll be quite brief. My question is around voluntary versus compulsory, using the example of the long-term care facilities. I assume in the province there are many more than 40. I don't know how many there are, but I assume there's a good number. You have gone in on 40, and there's been some change. As a change-maker, you've made some change. How do you take something that is best practices or proven through experience and, through testing or through research, ensure that it actually gets implemented beyond the voluntary stage?

D. Hughes: When I saw the progress that's been made…. I think the first piece of work that was done was around the numbers that have stepped up and participated — and to really look at the approaches. I looked at the first phase as learning and looking at progress that's been made.

You're right. Now the next piece for us is to look at how we grow this so that we do say that this a solid approach that has good results. That would be some of the work that would fall inside of my team — to look at how we implement. As Dr. Cochrane mentioned, it's a complex environment, with health authorities and non-profits and private operators. There are about 26,000 facilities across the province. It's something that I think I need to take to the B.C. Care Providers Association. I think we need to look at how we can improve in that area. It's a piece of work that we'll engage in over the next period of time.

S. Hammell: It would be correct, and I would think it would be wise, that it would be largely voluntary, encouraging people to move along a path. But is there a point at which your work can become or should become compulsory that best practices do move into that area?

D. Hughes: For me, that would be taking it in and looking at integrating it around the standards.

The clinical care guidelines that were talked about earlier — that's another vehicle that we can use around looking at how we begin to look at the use of clinical care guidelines. It's one of the areas that we're actually just reviewing at this time, looking at how we can expand some of the guidelines out into the community sector, particularly into this sector with the elderly. What can we do to move forward on that? It is a work-in-progress. It's not the intent to just leave it as voluntary forever. It's to move…. I don't anticipate resistance from people.

D. Cochrane: I don't know whether there'll be resistance or not. With a voluntary effort, we pre-select people who are particularly interested in this. But small initiatives can raise everyone's boat in this world. I think that spreading it…. And that's really what you're talking about. How do we make it an expectation, that I could feel comfortable when I need that kind of service? It is a real challenge, but there are regulatory aspects that can be applied. They just need to be applied at the right time, I think.
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K. Conroy: I just wanted to add to that that in addition to the B.C. Care Providers, there's also the B.C. Seniors Living Association, and they have developed a really great system of guidelines around practices within their facilities that they're having care providers utilize throughout the province. So they also are working on a set of guidelines. Both organizations work in parallel with each other and have members in common also. They also are an organization that you could be working with.

N. Letnick (Chair): In the one minute that we have left, if I may, just a couple of questions. One is the issue of overdiagnosis. There is some literature out there that says as a society we overdiagnose ourselves. We go to the doctors with all kinds of issues. Doctors send us for all kinds of tests. We find things we never intended to find in those symptoms. Does that come under your bailiwick? Do you look at that at all, as far as a quality aspect?

The second part. We can't manage what we don't measure. Obviously, you're measuring more things so that we can manage quality. At what point do we pass that tipping point, which is that we're spending so much time managing and not enough time providing the front-line service that we've gone too far?

D. Cochrane: The first topic is this whole business of appropriateness. Many patients in British Columbia do fall victim to modern imaging technology, the asymptomatic or irrelevant issue for a particular patient. I think that speaks to the issue of what is appropriate care for a particular individual.

The answer is yes. We, with the ministry, have been quite active in trying to define a process for studying appropriateness.

At a human-human interaction, appropriateness might get defined on the 19th hole of the golf course when it comes to "I'm going to have this kind of orthopedic intervention or not." I use surgery because it's really simple. Many things are much more complicated than that.

Getting feedback from patients is actually going to be the answer for this. So understanding how well a particular intervention on a particular set of guidelines, how a particular pattern of care works for individuals in the aggregate, is where I think we're going to find the answer to appropriateness.

It balances the individual autonomy that we enjoy here in British Columbia with regard to some health decisions. But it also balances what's actually going to work and what is not necessarily the new shiny object that we're sort of pursuing.

The University of British Columbia has a very active role here. The ministry does. I think appropriateness is probably, in addition to spread and sustainability, the next big hurdle.

D. Cochrane: Well, clinical care management has been a very interesting initiative because in order for us to know that the guidelines were being implemented and to know that they were working in the context of care in British Columbia, we actually do need to measure.

There's no doubt that for a period of time, you need to measure with enough detail and rigour that the Auditor General could come along and say: "My gosh. You guys are actually doing a good job."

I think, though, there comes a time when we know that the performance is sustained and ingrained and that we can actually move from measuring five things to measuring two things. That's an active process that's ongoing now for CCM.

We'll never get away from measurement. We need to do that. It holds me accountable as a provider, and it holds our system accountable.

N. Letnick (Chair): Thank you very much for your presentation. It was much appreciated.

N. Letnick (Chair): We now have the presentation from the Provincial Health Services Authority. We have Carl Roy, CEO of Provincial Health Services Authority; Wynne Powell, chair of the PHSA; and Doug Hughes is back again, ADM, health services policy and quality assurance for the Ministry of Health.

Thank you very much, gentlemen, for coming. We have half an hour to listen to your wonderful presentation, or less, but don't feel rushed to do so. Then we'll have half an hour or more of questions and conversation. Please take it away.

D. Hughes: I'll start and, just again, thank you for having interest in asking us to come to present on the Provincial Health Services Authority, which we lovingly call PHSA. We'll refer to that through the presentation.

The outline that we want to run through is to talk a bit about the structure and role within the B.C. health system, the partnerships and the initiatives, achievements in innovation and research, and then some of the challenges facing PHSA as we move forward.
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First of all, situating PHSA within the B.C. health system. It was established as a provincial health authority alongside the five regional health authorities in December 2001. PHSA has a 12-member board of directors, geographically representative of the province. The specific role in B.C.'s health care system, in concert with the Ministry of Health and the regional health authorities…. The Ministry of Health is responsible for establishing expectation target outcomes for health authorities' performance and for monitoring and evaluating health authority performance against those expectations.

The regional and First Nations health authorities are responsible for identifying population health needs, planning appropriate programs and services, ensuring that programs and services are properly funded and managed and meeting performance objectives. PHSA's role in that work is that it works with the five regional health authorities and the Ministry of Health to plan, coordinate and fund the delivery of highly specialized provincial services and is also required to meet performance objectives.

The ministry liaises with the PHSA at all levels to ensure strategic alignments and issues are monitored and managed. There's regular engagement with the ministry and routine meetings with senior executive. The ministry reviews the program proposals, staff participate in selection of steering advisory committees led by PHSA agencies and programs, and the ministry monitors delivery of provincial programs, including those led by PHSA but delivered through regional health authorities.

The ministry may request from time to time for PHSA to take on leadership roles that involve new program proposals and ensure equitable access and effective delivery, especially of high-cost specialty services, for very small patient populations.

C. Roy: Actually, we're just going to change the game plan. Mr. Powell will run through the slides.

W. Powell: Good morning. PHSA is the only health authority devoted solely to providing specialized health services in the province of British Columbia. It provides innovative, high-quality care delivered through specialized expertise with a provincial reach. It's a major teaching organization, which many people don't realize. It's a major component within the teaching of medical professionals. It's a hub for research, and it's a major system solution for delivery of non-clinical support services for the health sector.

Our brand position is: "Provincewide solutions, better health." We embody and envision that in the work throughout the province.

We directly govern and administer B.C. Cancer Agency, B.C. Centre for Disease Control, B.C. Children's Hospital, Sunny Hill Centre, B.C. Renal Agency, B.C. mental health and substance use services, B.C. Transplant, B.C. Women's Hospital and Health Centre, Cardiac Services B.C. and Perinatal Services B.C. Those are directly governed and administered. PHSA oversees nine agencies which provide these highly specialized services. They totally account for about one-third of the province's spending on health care or hospital care.

The best way to think of PHSA is as the brain which ensures patients are moved into high-level specialized care no matter where they live within the province. Our role differs depending upon the specialty and the agency. Sometimes we provide strategic coordinating roles, as Doug has referred to, ensuring health authorities have the right resources to provide specialized care. We also provide direct service to patients. We conduct research to improve specialized care, and we teach practitioners to deliver that specialized level of care.

There's one thing all our agencies, programs and divisions do, and that's establish clinical standards to ensure the delivery of safe, high-quality, effective and efficient specialized care.

You may have heard of our major agencies and divisions, but you may not have heard of 20 provincial programs which provide highly specialized services. We have listed most of them here in your presentation, and I will not repeat them, but as you can see, they start there with the Ambulance Service and end up with Trauma Services — so quite a complex list.

The provincial language services is a minor part of it, but it provides over 350 skilled language specialists providing interpretation and translation services in over 150 languages. Now, why is that important? When someone comes in for care and they can't speak the language and the practitioner doesn't speak their language, obviously correct care can't occur. That's when this service pops in, to help those very special situations, and it's very effective.

PHSA's aboriginal health program is building awareness of cultural issues. We set up a training program about the aboriginal cultural issues, and it has become, actually, regarded well across Canada as a very high-quality program. We developed an on-line cultural competency training program, which has now trained nearly 3,800 health care workers.

The provincial blood coordinating office developed iCHIP. Now, that's an information portal that helps patients with blood disorders monitor and regulate their use of infusion blood products at home and supports clinicians in providing comprehensive care. iCHIP stands for Inherited Coagulopathy and Hemoglobinopathy Information Portal. The health system is rife with these words. It's a very complex system that is put back in the acronym iCHIP. Now, iCHIP is the first of its kind in Canada.

I'm a professional accountant, and when you look at the budget, it is daunting. Around this table it's a very
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important aspect of running health care. While money is not the most important issue, the quality of health care is. It is something we have to guard carefully in order to deliver the right kind of quality health care.

Directly, we're responsible for $2.5 billion for you. We came through last year with a $782,000 surplus. We are projected to balance our 2013-2014 year-end again. We have 19,000-plus employees. Since its inception…. Except for the first year when I took this project on, we have run a balanced budget since then, for 12 years, and hopefully will complete the 13th year with a balanced budget.

To give you the significance of the direct health care costs, they're annual expenditures — and this is for 2012-13 — such as cancer care and specialized acute services. The B.C. Cancer Agency accounts for $594 million; B.C. Children's and Women's, $476 million; B.C. Centre for Disease Control, $100 million, and I'm rounding somewhat; B.C. Transplant Society, $47 million; Forensic Psychiatric Services, $62.7 million.

The number one issue we're very proud of is the dedicated staff that work, day in and day out, in those very specialized cares. As British Columbians, I think we're very blessed to have these people. They do a great job for us.

Our scope of responsibility includes B.C. emergency health services board, Health Shared Services B.C., the Lower Mainland consolidation, innovation and research. I'll just address some remarks specifically to those.

Over the years, in addition to the original core agencies and provincial programs, PHSA has assumed responsibility for a growing number of provincewide services and agencies. It makes sense, since we are the provincial-wide health authority.

Let's talk briefly about some areas like B.C. Emergency Health Services. Underneath B.C. Emergency Health Services you have three different categories. I'll talk specifically right now about B.C. Ambulance Service. That was established as a provincial service in 1974. The governance for B.C. Ambulance Service, Patient Transfer Network, first responders and B.C. trauma program is now under B.C. Emergency Health Services.

The terminology "Patient Transfer Network" is a new name for Bedline, if you're trying to match up history. This was all consolidated under PHSA under 2013. PHSA's unique mandate is to provide health care professionals and all British Columbians with access to pre-hospital emergency health services and non-emergency health services and information services. BCEHS board is made up from the board of PHSA. Operations of the commission and its services were successfully consolidated into the PHSA in April 2013. So it's a work in progress.

PHSA's mandate is to plan and coordinate accessible, effective and high-quality provincewide health care services, and that made it the logical home for BCEHS. A major operational component of EHSC is B.C. Ambulance Services. This is the largest emergency medical services provider in Canada. There are over 3,800 paramedics and dispatchers, 500 ambulances, ten dedicated aircraft including six airplanes and four helicopters — and 40 prequalified charter operators to complement that — along with 184 ambulance stations. It's a very complex system.

In 2012-13 we responded to 510,743 pre-hospital calls and patient transfers; 504,000 were by ground, 6,700 by air.

When the government announced that the Emergency Health Services Commission would transition to PHSA, it also confirmed that BCAS would remain a provincial ambulance service. BCAS was given a clear mandate and a direction to pursue opportunities to improve the ambulance service and further contribute to health services in communities throughout the province. While BCEHS is part of PHSA, unionized employees have also moved into the health sector bargaining unit.

This move is an opportunity for BCAS to solidify its role as a provincial health care provider and expand its operations with other provincewide health care agencies. We've been working for several years to better align the B.C. Ambulance Service with the delivery of health care.

We hear a lot about the unmet needs in rural and remote areas. There is tremendous support for more full-time paramedics in these areas to bridge service gaps.

Maximizing existing resources — the paramedics, the hospital-based care teams and so on — means redesigning the system to better integrate it into the health care system.

Throughout the transition BCEHS has been focused on three key priorities: strengthening quality and safety, integrating paramedics into the health care system, and increasing the numbers of full-time paramedics in rural and remote British Columbia.

By leveraging PHSA's unique network and expertise, BCEHS is making strides in improving the services and access to care for British Columbians, but it is a work under process.

Another area we assumed responsibility for is the B.C. Health Authority Shared Services Organization. This is an acronym known as BCHSSO. It began operations in February 2007 and was tasked by the government with providing non-clinical services for the six health authorities as a collective entity.

In March 2010 the health authorities decided to move the organization into PHSA as a division, and they renamed it, at that point, Health Shared Services B.C. Approximately 1,500 staff from the five regional health authorities were transferred into PHSA as a result.

Now, HSSBC retains a separate management board made up of the six CEOs, the chief administration officer from the ministry and two independent members. The goal of HSSBC is simple: leverage the buying power,
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find efficiencies and operational savings, and promote alignment and integration across the health authorities.

They have achieved impressive results. Both we and the Auditor General have trouble tracking the specific results, because it's very hard to track every single order that's placed and assessed. But our assessment for the savings negotiated by March 31, 2014, is that there's been over $230 million saved.

We have simply calculated that by taking the previous buying volumes that were done in the separate health authorities and then adding that up, at the new reduced cost we've gotten by doing group buying, and saying: "Okay. We will, in all probability, have the same volume or more, so this is the minimum savings."

Obviously, as PHSA, we're trying to put more rigour into the ability to monitor that, and that's a work in progress. But these are genuine savings. These savings are then reinvested by the health authorities back into the important clinical services.

HSSBC has also established an interprovincial supply chain working group with Alberta, Saskatchewan and Manitoba. The affect of costs on this system is profound, and we believe the potential to even achieve further economies of scale strongly exists.

PHSA is a major partner in the Lower Mainland consolidation. PHSA has assumed accountability for four areas of service: information management and technology, interpreting services underneath the provincial language service, Emergency Management B.C., and pathology and laboratory services.

Both IMITS, which is information management and technology, and interpreting services will achieve their savings target this year. With labs, we have managed to achieve savings, but there is much more that needs to be done. It's a very complex subject that we're trying to get our hands around and move that into a stronger savings story.

PHSA laboratory service did realize $7 million savings by the end of this fiscal, which includes savings from the staff transfers, so if you factor in the costs that were absorbed — the $5.3 million — then you're looking at a combined savings to date of $12.3 million for the Lower Mainland only.

There is serious money that can be saved in this area. It requires collaboration and a lot of work to get to where we need to go, but the opportunity here is tremendous. With the new legislation now before the House, we believe this will help us achieve more savings, higher quality and hopefully greater efficiencies.

In the process of developing a new strategic plan to ensure our alignment with the Ministry of Health's recently refreshed strategic agenda, which is called Setting Priorities for the B.C. Health System, what PHSA is presently doing is…. Their last strategic plan was finalized in 2010. This is all now in a renewal process to align ourselves with these new priorities for the B.C. health system. Each of our agencies is working on its own action plans and strategic plan and objectives to align overall with the ministry's plan and strategic outcomes.

Three key enablers: provincial policy, organizational capacity and partnerships. The new strategic plan reflects an evolution as a learning organization, a platform to pursue greater integration across PHSA and with the regional health authorities. It lays out how we deliver on our commitment on provincewide solutions — better health. We increased capacity in the specialized eating disorders — ten in-patients to 14 and two day spaces to six. These numbers are relatively small, but they have profound effects on those patients who need that.

In a functional cancer imaging program at the Cancer Agency, we doubled capacity from 3,100 patient scans to 6,200. We have reduced wait-lists in a number of areas. I'll give you several examples. Using the child life specialist to prepare children for an MRI scan — that simple change through our Lean program has reduced the number of children who used to be sedated for an MRI scan. That in itself reduced the wait-list.

Using a new computer-based scheduling system has reduced the number of patients who receive fewer than seven days' notice of chemotherapy appointments by 58 percent and decreased the number of wait-list patients by 84 percent. I'm sure you'll have a number of questions. It's such a complex and large system. I'm just giving you several anecdotal examples this morning, but we have hundreds of them. It gives me joy as chair because I've seen such significant improvements to patient outcomes by these changes.

So 346 transplants were carried out by B.C. Transplant in 2013. I don't know if any of you have had family members that need such a transplant. One of my distant family members needed a lung transfer, and that lung transfer saved her life. Can you think of the effect on that family by that one life-saving gesture?

Last year we did 346 of those, where we improved the family outcomes and, in all probability, made the system more sustainable because we lowered costs for their care. Transplanted patients have less cost. So it's a win-win all around. We did 40 more than in 2012, so that was encouraging. Part of our challenge, of course, is to have donors. That's where the system can help us to raise more donors.

This year included the 400th heart transplant, in December. The first was only in 1988, so you can see how far we are coming in health care. A highly successful promotion campaign and improved measures and protocols are some of the reasons for this success.

I want to talk for a moment a little bit about research. An important part of PHSA mandate is to improve the health of British Columbians by advancing research and using research findings to inform decision-making and health care planning. According to our PHSA 2012-2013
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research metrics report, PHSA-based research has attracted $128 million of outside money in research funding in 2012-13. That's an important economic driver, but more importantly, it's an important driver to improve the sustainability and the quality of health care.

Multiple PHSA agencies are involved in this research. In 2012-13 the combined total of these agencies' publications that were accepted by the professional journals was 1,598, which I think speaks to the professional opinions of the research outcomes. And 96 percent appeared in peer-reviewed journals. To any of you that understands the peer review process, that's a very high score indeed.

We recommended through research that the gynecologists remove fallopian tubes in women undergoing hysterectomies or tubal ligation. This reduced deaths caused by ovarian cancer by 30 percent, according to our BCCA records. All found through research — we couldn't have done it without that research data to back it up.

We found two existing screening tests are accurate in diagnosing development delays in children and could be incorporated in the family practice setting, leading to earlier treatment at the B.C. Children's Hospital and providing better outcomes.

A breakthrough study improved influenza vaccine protection in infants and toddlers, and it increased the antibody protection by 30 percent, according to our data from B.C. Centre for Disease Control. Again, these are only anecdotal, small examples of the research, but if any of you would like to tour any of the research facilities, I would welcome you to tour. I think you'll be very impressed at the dedication of the staff. We're blessed with the expertise that wishes to help us, and we're fortunate that PHSA is helping them raise the money in order to do the job on behalf of British Columbians.

PHSA prides itself on an uncompromising effort to achieve the best patient outcomes. I have done this task for you since the very beginning, in 2001. I do it for $1 a year. I do it because I care about the patients. On your behalf, I want to drive the very best patient outcomes in the system and the best value for British Columbians.

Renewed efforts at preventing health problems. We have to work harder at keeping people out of hospitals and, when they do require hospitalization, we need to restore them to optimum health as soon as possible. That remains our absolute focus.

I have Carl Roy here, our president and CEO. He's also president of the BCEHS, and we would welcome any questions that you have. Thank you for the opportunity for this morning's presentation.

N. Letnick (Chair): Thank you, Mr. Powell and colleagues, for a very good presentation.

J. Darcy (Deputy Chair): I will need to leave at 12 because the lab reform bill that you mentioned may or may not be up this afternoon, and I need to be prepared for that. Thank you for your presentation.

I have to take the opportunity. This is not a question; this is a pitch. I need to take the opportunity. You're familiar with the issue of pediatric cancer survivors, which has been the subject of a private member's motion and considerable discussion in the House. I want to take the opportunity of you being here to encourage you.

I know you've established a task force, and I look forward to hearing about the proceedings and discussions there, because I really do think this is an opportunity for us to address a need that has not been understood. Medicine is coming to understand it much more but has not historically…. It is absolutely about coordination, not fragmentation.

I'm going to just leave that one there. I know you're not in a position…. Well, maybe you're in a position to respond to that. I'm not sure.

W. Powell: The only response I would provide is that we're looking forward to the task force's outcome. Because of our focus on improved health care, we'll be very passionate about seeing what the answers are and how we can help improve.

J. Darcy (Deputy Chair): Thank you so much. I've met with many of those folks and their families across the province, and there is a need that's not being met at the present time.

Shall I put out all of my questions? Then I understand that there may be many others that have to come.

You mentioned the issue of the integration of paramedics into the health care system, and I wondered if I could ask you a question about where the consideration is at, at the present time, about the model of community paramedicine that has been looked at in some other jurisdictions. I understand that it's complicated and that there are people who do other jobs in health care and overlapping issues and so on, but I wanted to know where that was at.

W. Powell: Of the current assignments that you've asked PHSA to tackle — or the government has asked PHSA to tackle — and my personal drive to try to help, the ambulance system is probably one of the most challenging ones.

The board has tasked the management, through Carl Roy, being president, to review best practices right across North America — and beyond, if we need — in order to help redesign our system. These are early days, and we know that we're getting challenged by a variety of stakeholders as to: are the right decisions being made, and are the right issues being thought about?

I can assure you as a committee that we as a board are very emphatic that we want to improve what is occurring
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on a provincial basis on paramedic care and ambulance care. We have union contracts that we have to honour, obviously.

W. Powell: You know from working with me in the past that I'm very optimistic. I always go into these…. When there's such a compelling need, hopefully, we can all roll up our sleeves and find a way to make it actually happen.

We are looking at additional medical oversight in order to perhaps expand scope, and we're going through some of the regulatory issues there. But it's very much a work in progress.

We currently have some personnel matters that we're dealing with at the management level that I cannot talk about today. But they are well underway, so there will be some outcome from that review in due course.

C. Roy: I would just add that our community paramedicine and other enhanced roles for paramedics has been something that I've personally been interested in for some time. The Ministry of Health has been very clear that as part of the rural and remote strategy, there's a huge opportunity to contribute paramedic skills. What we're really after is to….

We have to be attentive to the 911 pressures, the emergency pressures that paramedics have to respond to. But especially in rural and remote B.C. there is such a huge opportunity to integrate paramedics and their skill sets into the interdisciplinary health care team, and to do that in a manner that's acceptable to all of the interests.

We've had some experience, albeit limited, over the past three years working with Northern Health, in particular, at pilots. But again, we look forward to some enabling policy and a strategy around community paramedicine to be able to really take that large leap forward. There's no question that it will require some investment, and we're building that into our plans. Of course, it is a matter, as you will know, that is alive and well at the bargaining table, as we try to move forward.

We are hoping that we get the right alignment of the interest to really be able to leverage the considerable skills of the paramedic profession. I'm quite excited about the potential to better serve British Columbians.

Community paramedicine is not just a rural and remote strategy. That's the primary focus, but we see its application right across the province.

J. Darcy (Deputy Chair): I'll ask the question. Maybe I can leave it with you, and it's something you can get back to us on. I know that you mentioned the Auditor General's concerns about the ability to track the savings in Health Shared Services B.C., which I presume is also a question regarding lab services. I wonder if you could just talk briefly, or you could get back to us. The Auditor General said that because, in some cases, we're talking about systems that don't speak to each other, different coding mechanisms in different health authorities, it's difficult to be precise about what those savings actually are.

My question is more one about going forward, especially since we're talking about lab services consolidation — presumably under PHSA, although that remains to be seen. That will be one of the questions I'll be asking when it's up. What are the mechanisms for being able to meet with the concerns that the Auditor General had about accurate measurement?

W. Powell: The Auditor General and I were in total alignment, but it was difficult to measure. We shared with him some of our plans for how we're going to try to measure it in the future by having closer alignment with the systems. We actually asked our external auditors to build in additional auditing procedures next year to, hopefully, start addressing some of this information.

Again, as an accountant, I like to be very sure of the figures we present to you. Today they are soft figures, because of the nature of the buying group. Before I retired, in my previous life, I used to be a CEO of a large retail group. I used to be a member of large buying organizations.

The buying groups are very effective at saving money, because you bring that scalability to it.

The Auditor General and I both agreed that the savings are really there. The problem is to track it. In your previous presentation that was happening while we were waiting here, Dr. Doug Cochrane talked about the complexity of measuring, but you need to measure to have accountability. We are trying to build that into the system.

I think if you were to have a conversation with the Auditor General, he would tell you that he's quite comfortable with the way we're approaching trying to document that.

C. Roy: Briefly, I would make a distinction between HSSBC, which currently is a shareholder model…. HSSBC presents the opportunity for savings, and then it must be implemented, or the health authorities must choose to implement to achieve those savings. Then it's in
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their financial system. Part of the system change that Mr. Powell's talking about is something we're quite interested in, to be able to track those savings, and we'll pursue that.

The distinction between HSSBC and lab, depending on the approval in the House, is that this would not be a shareholder model. This would be a model — and it's preferable, from our perspective — where, should it come to PHSA, PHSA is managing and leading that business with all of the interested parties. It does afford us the opportunity, albeit through a collaborative and engaging model, to make the decisions that are in the best interest of quality, safety, savings, efficiency, and so on and so forth.

L. Larson: Regarding ambulance, and so on, in rural areas, you manage your budgets extremely well. I'm wondering. Is there a shortage — because occasionally, that's what I run up against — of paramedics and ambulance services in the rural areas? Is it a shortage of people that want those jobs, or is it a shortage of money to hire people for those jobs?

C. Roy: A very good question. Some of this is a feature of the way the service has evolved. In very small rural and remote communities in British Columbia, the model is that we rely on volunteers in the community who are trained up and carry a pager. If they're called to provide the service, then they receive the callback pay.

What we're interested in…. This is the benefit of looking at community paramedicine. It allows us to bring in a higher-trained and -calibre paramedic to provide service. Our recruitment challenges are more a function of the current model that we offer than it is a function of the community.

The second point I would make is that industry has to meet their WorkSafe requirements. They do pay a different rate as they meet their WorkSafe requirements. They do tend to pull paramedics out of the service to work at camps and industry sites.

I'm pleased to report that through the great work of Northern Health Authority, we have had some very productive discussions with industry, which now understands that this is an issue of meeting your legal requirements but also contributing to the sustainability of the community. We are optimistic that we will be entering into a business relationship where B.C. Ambulance can provide that service.

I think that will help, along with our focus on community paramedicine and enhancing the service to the community.

R. Lee: A few questions on the emergency services. There are some issues in remote areas. It's not getting the helicopter or airlift soon enough, fast enough, to get the patients to the hospital or whatever. Are there any plans to improve those kinds of services?

There's one aspect we have to remember. A lot of my life I've lived in a little rural community as well, so I fully understand. I served 18 years with a very small fire department. I have seen what it's like in these rural communities.

We have a very large province. It's 2½ times the size of Texas. When you put that into perspective…. Fortunately, I've got strong aircraft experience, because I run an aircraft company, which is not associated with health provision in any way.

We know the equipment. We know what can be done. We're looking at the current volumes of calls. We're analyzing it, and we're trying to coordinate it better. But the reality is that with the size of the province, there will be times that we cannot reach our goals, which we all want to around this table, of providing the speed of service that we'd like to provide. It is very challenging.

C. Roy: I think this is an important question around what level of service we can provide right across the province. Presently we organize the air transport, which is the most expensive part of our system. We organize it on a geographic basis and then use private providers as required.

I would just reinforce that it doesn't matter where you live in British Columbia. When you need care, your call and your care needs are triaged using an international methodology through a provincial dispatch system. That's a unified system. So we know very clearly what your needs are, and then resources are allocated based on those needs.

Because air transport is usually reserved for folks that require critical care or higher levels of care — by that I mean that the services they need exceed the services in their local community — we will dispatch, again, some of the most expensive critical care paramedics who will work in very close contact with physicians to transport those patients by helicopter or fixed-wing aircraft.

We review every case. We understand what the time essence is, and we build that, as Mr. Powell has said, into our budget process each year to look at where enhancements can be made. Our most recent enhancement was two years ago with an additional dedicated helicopter in Kamloops.

We monitor very carefully and centrally both land and air response, but the air response gets particularly close attention due to the urgent requirements of patients that require that service.

R. Lee: The second question is on the very successful procurement and improvement. But another aspect is the inventory control — inventory control on, say, hospital usage of materials or whatever. Are there any studies on
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that aspect, on how savings can be achieved?

W. Powell: Again, I'm going to ask Carl to jump in and help. But remember, on inventory control…. When you do centralized buying and that, part of the secret sauce in regards to HSSBC is that we also manage health risk. It's not just a procurement agency. We have to manage the health risks associated with procurement, which is a slightly different outcome than just strictly a procurement process.

Take pharmaceutical medicines, for example. There can be an across-the-board, cross-Canada shortage, and there was in two particular drugs in the last year. We as a province came through in one of the best service models for our patients because we had planned for it and we had sufficient inventory.

Just-in-time inventory concepts are useful, but you have to balance that off against the potential health risks.

C. Roy: I would just add that the warehousing and inventory control process is centralized provincially through HSSBC, and the participating health authorities receive regular reports. Of course, it's a pay-as-you-go system, so there is an incentive for them to ensure that they're using their inventories appropriately.

R. Lee: The last question is on scope of practice. We know that to optimize the overall system, there is some changing of scope, say, for example, of pharmacists and nurses. Overall, are there any further studies on system optimization?

W. Powell: This is a very complex area in the scope of practice. I think from my sitting in the chair role, the opportunities to constantly look at scope of practice and fine-tune it would be beneficial to the system. When you look around the world, there are many professions that do more than what we are currently allowed, by process, to do in the province of British Columbia.

It takes collaboration. It takes building trust. It takes building an environment where the current professionals assigned the responsibility are willing to share or delegate.

I have to tell you: none of that comes easily. We certainly have many hours of discussion on that, and the ministry is very supportive on encouraging that. But it's not something I'd like to sit here and tell you is an instant fix, because it's just too complex.

C. Roy: I would just add that health human resource planning, which is at the heart of this question, is a priority in the new Ministry of Health plan. We're all being asked to formally look at our health and human resource planning. We know what the demographics are. We've known for almost two decades. So we do have to be fairly intentional around saying: if we don't have physicians to provide this specialty service, how do we get maximum use out of the physicians that we are able to retain?

That moves us into looking at physician assistants and other professional differentiations with different scopes of practices that exist in many jurisdictions and have for a number of years. It's just about doing that in a very disciplined, data-driven way before we hit the wall.

S. Hammell: To start off, I think the PHSA has some amazing programs — just amazing. I would start right off with the B.C. Cancer Agency. Most of us have been touched in some ways by cancer. I know I have a son who is dealing with it right now, and I can't say enough about how professional, effective and just amazing….

I see that throughout your areas. But there is one that I am particularly close to, which I'll talk to you about. You have a $782,000 surplus, and we have a situation in our mental health care system that is pretty critical, particularly. I think we have a big problem in our mental health and addictions services in the long run, because there have been dramatic changes in the last ten years that are cultural in some ways. But they are showing up as a consequence in our health care system, particularly in mental health and addictions.

We raised in it the House yesterday. I would have automatically thought this was a budget issue. But if you have a surplus, and it's not a budget issue…. You have a difficulty in the forensic hospital system. If I read my research correctly, which is obviously the Times Colonist, it's $150 an hour in our system versus $243 an hour in the federal system, plus $180 to $200 in the private system, where we're going to lose two more forensic psychiatrists who are leaving at the end of the month of March. And we have people in jail who should be in hospital. Really, for all of us it's unacceptable.

W. Powell: It's an excellent question. First of all, I'll take your kind remarks back to the Cancer Agency at the next board meeting, so thank you for identifying that. I'm going to let Carl jump in on this answer as well.

The practical reality is that on a budget of $2.4 billion, a $782,000 surplus is very, very small. If I had you around the boardroom table…. We sweat during the year because we think we're going to run into a deficit. It's very complex, and I always breathe a sigh of relief when we can come that close. We're trying to spend the maximum money we can without actually running into a deficit. I hate to say it, because $782,000 is a lot of money, but it's really a rounding thing in the size of budget we have.

Speaking specifically to forensic, I'm going to ask Carl to jump in. That is a broader question — and we
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are working with the ministry — where we need to get approval to pay higher amounts. The difficulty I have as your chair is that the issues are real, and in this particular case we are losing people and we're not competitive. We've identified that to the ministry. The ministry understands that, and we're working through it.

At the same time, if we were to react to every single one like that, we wouldn't have a sustainable system. It's a real balancing act, so we're working very collaboratively right now to try to find a solution without raising long-term issues. We are working at it because we can't tolerate losing the professionals we are in this particular area.

I've seen, over the 13 years I've done this, that from time to time you get these hits. We're getting a hit right now in forensics, and it worries me terribly. That's why we're having discussions with the ministry.

C. Roy: I would just add that first of all, we're pleased about the role we have in the important area of forensic mental health. The ministry has reinforced our role more broadly provincially in looking at the hard-to-serve in the province as well as others.

I think the point I would make about forensics…. First of all, it is being resolved. So I'm delighted about that. We've been working for some time very constructively with the ministry.

When it comes to physician rates, this becomes a matter of negotiation with the BCMA. There's a whole series of requirements that must be met. We always have to have a view of what happens when issues arise in one specialty, because we can often set a precedent that generally gets applied to others as well. Our desire always is that we resolve these matters before we get into a crisis situation.

In forensics, it's not just specialists leaving because of the workload pressures or compensation. It's that the incumbent group then has to do additional work, so the workload pressure becomes even more intense. The overall compensation, if I can say that, will be resolved, and we're all happy about that.

We're also putting a plan into place fairly immediately to deal with how we best support those incumbent and remaining specialists so that we don't have any further departures. I was involved in this issue, as were others on the team, into last evening. I'm pleased with where we'll be.

The final point I would make is that oftentimes on competitive compensation rates…. In this case what was driving it was a decision by the federal government to pay their forensic psychiatrists much higher than any other jurisdiction. You'd be surprised that we have not been able to confirm those rates. It's very interesting. And we do know that one of our greatest sources of recruitment to replace the psychiatrists that have left will be those who work in the federal system. Having increased the rates, whatever it is, they now have laid them off. We will have a pool of specialists in the federal system that we are aggressively recruiting.

S. Hammell: You were heavily involved in the agreement with Vancouver and the rolling-out of some of the new systems that you have around mental health. You have your health study, your hotel study. You have the studies that have been done in Vancouver recently. Is that a provincewide initiative, or is it just for Vancouver city?

C. Roy: The minister's announcement was for us to look at the very acute problems we were having in Vancouver. But it was with a view to doing the planning and establishing a service platform that could be scaled up to other communities. We know there's intense need in the Lower Mainland. Even though we're kind of focused on best practice for Vancouver, we're also giving thought to how that could be scaled up elsewhere in the province.

D. Hughes: : I'll just add to that. PHSA is really taking — we talked in the presentation about a clinical framework — a provincial framework around, particularly in the Vancouver situation, this subset of people who were a danger to themselves and a danger to the community. A group that we worked quite closely with is Corrections as well.

In response to the forensics issue, we are working with ADMs with Corrections to look at how we can look at capacity, look at different ways of doing the work in the forensics area as well.

In reference to the mental health going forward, we are working with the learnings from the Lower Mainland, because Fraser Health was involved in the Vancouver situation. As you know, people move up and down the SkyTrain quite nicely there.

We are really looking at the clinical piece of that, and we're in conversations with the other health authorities around looking at a framework that will go forward to try and look at the larger urban centres around this population. People are coming from Kelowna, and they're coming from Prince George, Kamloops and Vancouver Island as well. But there is work with health authorities to look at that subset of that group of people.

K. Conroy: I want to echo Sue's comments on what the different organizations under your jurisdiction do. When I look at the list, I think there are only two that our family hasn't accessed. My husband has had two liver transplants and a kidney transplant, and I donated a kidney. So we're well aware of the Transplant Society and the work they do — most of them, actually, when I look at the list. I'm glad that you're here, because I've been meaning to come and actually do some tours on some of the organizations that you've talked about.
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I do want to make a pitch for rural B.C. People have to travel to the coast when people have cancer. PET scans — the only place you can get them is in Vancouver. I know there was some discussion around the opportunity to try to do PET scans in Kelowna, to try to bring it into the Interior. I hope that discussion continues. Once you have a PET scan and you know what's going on, it saves money in so many different ways. I mean, the initial cost is expensive, and I know there's the whole issue around moving the nuclear stuff that they need to do the scans up to Kelowna and the longevity of that scan.

N. Letnick (Chair): Before you make an announcement that it's moving to Kelowna, I want to get my quote right, as the local Kelowna MLA of course.

K. Conroy: Kootenay MLA lobbies for PET scans in Kelowna. We got that on Hansard — in cooperation.

C. Roy: I'm pleased to report that Mr. Powell and the board have looked at this question four months ago and commissioned a study. At our April board meeting we'll hear from the president of the Cancer Agency around the plan for PET scanning. That will be built into our budget process going forward.

K. Conroy: I certainly hope it's a positive report for the people of the Interior, because it's much needed.

You were talking about the strategy with paramedics working in the communities. There was a pilot project done at Kootenay Boundary Regional Hospital that was very successful. There were unfortunately some jurisdictional issues, but the paramedics that were involved speak really highly of the program.

I would be only too happy to pass on their names to you, people that can speak about the program and what worked and what didn't work. It was highly successful in our area and saved people's lives. We were really disappointed when it was cancelled.

W. Powell: This is one of the exciting changes we believe we can do within the ambulance system. This is one of the exciting areas that the board is very keen and passionate about pursuing.

C. Roy: I would just say that I'm so pleased to hear you acknowledge the jurisdictional disputes. It certainly is a major focus around our implementation strategy. We're doing some good work with the licensing board around scopes of practice and some flexibility there.

Earlier I referred to the bargaining process. We do need some enablers. It always helps when we have a very clear direction from our ministry, and there's no question about that direction. But we do need some help from some of the other interests, and we're keen to get that help.

In terms of your pilot, I know about that pilot, and it is one of the few that were positive and that we're actually building on. We really do hope to change the way that paramedics view their work. Right now they view themselves as independent practitioners in the pre-hospital environment. We need them to make the shift to understand that they are skilful health care practitioners that need to work within the health care interdisciplinary team context.

I'm optimistic, having been on this file with them since they moved into the health sector. I do think the enablers I referred to are all going to be there for us to be able to move very quickly, as part of the rural and remote strategy, to have that pilot restored and, actually, a broader range of service the paramedics can provide the community.

N. Letnick (Chair): Apparently we still have quorum, so with the indulgence of our speakers, we'll continue for a few more minutes.

I wanted your opinion on mandatory organ donation and that if people didn't want to do it, they'd have to opt out. I know it's something that's been looked at by the Canadian Blood Services as well as the B.C. Transplant Society. It's an issue that people that have been involved in transplantation find most intriguing.

W. Powell: Over the years, we have had a variety of discussions — both the ministry and different ministers. When you look at the European system, for example, it has what they have called a negative out, where you have to vote your way out rather than voting your way in. I hope one day we as a society can have the courage to do that system, because I think it would help immensely.

It's got society issues and, obviously, political issues and other complication around it, but just strictly on a medical basis, if we could reach that goal, it would be extremely helpful.

N. Letnick (Chair): I'm not too sure if you're familiar with our mandate, but we're tasked to look at the next 25 years, come up with options and then measure the acceptance of those options in the public domain. That's one example of something that we could take to the public and examine.

W. Powell: If we could encourage the public to endorse that, we would improve outcomes in this province.
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D. Bing: Just a simple question. I'm just wondering if your agencies are fully funded. Like, sometimes I see some of them doing fundraising — maybe Children's Hospital or something like that.

W. Powell: Well, for example, through the support of the government and the taxpayers, we're rebuilding Children's Hospital today. That would not have occurred if it hadn't been for the tremendous fundraising initiatives of the Children's Foundation. They've raised $200 million to assist us in that cost, of which approximately $150 million is going directly to the rebuilding of the hospital, and $50 million is going to child health care, Child Health B.C., which services the whole province.

We as a society could not today function as well as we do without the kindness and the abilities of the foundations to help us raise money from the public in causes that they wish to support. We're blessed that the public will put their money towards these projects, because without that, the public purse itself would be very strained to do it.

It does make a fundamental difference. You see it in cancer care. You see it in transplant. You see it everywhere. In my travels around the province on your behalf, I make sure that I try to communicate to all those volunteers within the various foundations how important their role is to our outcomes.

D. Bing: I also see, particularly in cancer care, there are a number of organizations that try to raise awareness for their particular area that they're concerned about. It certainly is very helpful, I'm sure.

W. Powell: Part of the challenge, when you look at that next 25 years out, is that when funding is raised for a particular stakeholder's desire, you have to look at the broader system as a whole as to whether or not that money is going to be best spent in that area for the long term. It might be dealing with a particular issue of interest at that point.

Our challenge, then, as a PHSA organization, is to try to have the donors understand the broader basis of how that funding could help, versus sometimes investing only in a very unique little silo that may not prove as helpful. We do that very delicately, but we try to encourage them to think of the long-term sustainability issues.

N. Letnick (Chair): The only question I have is: when is your strategic plan going to be ready to be viewed by the public?

W. Powell: The process is well underway between us and the ministry. The ministry, as you know, is still fine-tuning their strategic plan. It's a hierarchical design. Work is well underway with us working on the underpinnings of our information we have now, but we'll be holding back on release of it until we can make sure it's aligned with the most current ministry and minister's plan.

As we go through our process, I'm quite sure that we're going to be seeing each other again, and your expertise and your professionalism is outstanding. Thank you very much for serving the people of British Columbia so well in your capacities, all of you.

N. Letnick (Chair): With that, I would just like to remind members that we have a meeting on April 9. The only item of discussion, as far as I know so far, will be our call for proposals for options to sustain and improve the health care system. We'll be talking about that on April 9. Of course, we'll circulate an e-mail, since most of us…. Well, I don't want to say who's here and who's not.

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Chair:	* Norm Letnick (Kelowna–Lake Country BC Liberal)
Deputy Chair:	* Judy Darcy (New Westminster NDP)
Members:	Donna Barnett (Cariboo-Chilcotin BC Liberal)
	* Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	* Katrine Conroy (Kootenay West NDP)
	* Sue Hammell (Surrey–Green Timbers NDP)
	* Linda Larson (Boundary-Similkameen BC Liberal)
	* Richard T. Lee (Burnaby North BC Liberal)
	* Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	* Michelle Stilwell (Parksville-Qualicum BC Liberal)
	* denotes member present
Clerk:	Susan Sourial
Committee Staff:	Gordon Robinson (Committee Researcher)

Witnesses:	Dr. Doug Cochrane (Chair, B.C. Patient Safety and Quality Council)
	Doug Hughes (Ministry of Health)
	Arlene Paton (Ministry of Health)
	Wynne Powell (Chair, Board of Directors, Provincial Health Services Authority)
	Carl Roy (President and CEO, Provincial Health Services Authority)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH