Public Accounts — Issue No. 7 — Wednesday, March 12, 2014 (HTML)

Present: Bruce Ralston, MLA (Chair); Sam Sullivan, MLA (Deputy Chair); Kathy Corrigan, MLA; Marc Dalton, MLA; David Eby, MLA; Simon Gibson, MLA; George Heyman, MLA; Vicki Huntington, MLA; Greg Kyllo, MLA; Norm Letnick, MLA; Mike Morris, MLA; Linda Reimer, MLA; Selina Robinson, MLA; Shane Simpson, MLA; Laurie Throness, MLA

Others Present: Russ Jones, Acting Auditor General; Greg Gudgeon, Executive Director, Corporate Compliance and Controls Monitoring Branch, Office of the Comptroller General

1. There not yet being a Chair elected to serve the Committee, the meeting was called to order at 10:05 a.m. by the Deputy Clerk and Clerk of Committees.

2. Resolved, that Bruce Ralston, MLA, be elected Chair of the Select Standing Committee on Public Accounts. (Simon Gibson, MLA)

3. Resolved, that Sam Sullivan, MLA, be elected Deputy Chair of the Select Standing Committee on Public Accounts. (David Eby, MLA)

4. Resolved, that the Sub-committee on Agenda and Procedure be appointed and be comprised of the Chair and Deputy Chair. (David Eby, MLA)

5. The following witness appeared before the Committee and answered questions regarding the Public Documents Committee Retention and Disposal Applications.

6. Resolved, that having examined the retention and disposal applications made by the Public Documents Committee, the Public Accounts Committee recommends Resolutions 1 - 16 and 18 - 19 to the Legislative Assembly. (David Eby, MLA)

7. It was moved by David Eby, MLA, that Resolution 17 be amended to require provincial retention of all listed records related to Riverview Hospital.

8. Resolved, that the Committee adjourn debate of the motion. (George Heyman, MLA)

10. The following witnesses appeared before the Committee and answered questions relating to the Auditor General’s Report Striving for Quality, Timely and Safe Patient Care: An Audit of Air Ambulance Services in B.C. (March 2013)

• Jan Butler, Corporate Director, Quality, Safety, Risk Management and Accreditation, BC Emergency Health Services

11. On behalf of the Committee, the Chair acknowledged the upcoming retirement of Josie Schofield, Manager of Committee Research Services, and expressed appreciation for her years of service in support of the Select Standing Committee on Public Accounts.

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

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
PUBLIC ACCOUNTS


CONTENTS
Page
Election of Chair and Deputy Chair	267
Adoption of Agenda	267
Election of Subcommittee on Agenda and Procedure	267
Public Documents Committee Role and Records Retention and Disposal	267
G. Mitchell
Auditor General Report: Striving for Quality, Timely and Safe Patient Care: An Audit of Air Ambulance Services in B.C.	274
R. Jones
P. Nagati
P. Thorpe
D. Blackie
J. Butler
Other Business	291

K. Ryan-Lloyd (Deputy Clerk and Clerk of Committees): Good morning, everyone. My name is Kate Ryan-Lloyd, and I am the Clerk to the Select Standing Committee on Public Accounts. As this is the first meeting of the Select Standing Committee on Public Accounts for the second session of this parliament, there has not yet been a member elected to serve as Chair of your committee. So the first item of business is the election of Chair. As such, I would like to open the floor to nominations.

K. Ryan-Lloyd (Clerk of Committees): Excellent. Thank you very much. Any further nominations?

K. Ryan-Lloyd (Clerk of Committees): Seeing no further nominations, I'll put the question.

B. Ralston (Chair): The next item, then, is the election of the Deputy Chair. Are there any nominations?

D. Eby: Yes, Mr. Chair. I nominate Sam Sullivan, the member for Vancouver–False Creek.

B. Ralston (Chair): Any further nominations? Any further nominations? Any further nominations?

B. Ralston (Chair): There is an agenda before us, and we haven't formally adopted the agenda. Just for the record, then, is there a motion to adopt the agenda as circulated?

B. Ralston (Chair): The appointment of a subcommittee on agenda and procedure. Kate?

K. Ryan-Lloyd (Clerk of Committees): Yes, the appointment of a subcommittee on agenda and procedure is a pro forma matter of business that the committee turns its mind to once per session. By practice, this committee has elected its Chair and Deputy Chair to serve in that capacity with respect to identifying meeting dates and setting agendas on a go-forward basis.

Is there a motion to appoint a subcommittee on agenda and procedure for the present session, or are there any questions on that?

S. Gibson: If a subcommittee is not appointed, then the Chair and vice-Chair would just assume that responsibility. Is that my understanding?

B. Ralston (Chair): Procedurally, though, I'm advised that we do appoint a subcommittee. I think that is consistent with the rules of order as they apply to this committee. But practically speaking, that's what will take place. I'd prefer a formal motion, just for the record.

D. Eby: I move the appointment of a subcommittee consisting of the Chair and the vice-Chair.

B. Ralston (Chair): We'll now turn to the next item on the agenda. I'm going to turn to Mr. Mitchell, who is the provincial archivist.

We will deal with some resolutions to follow. But I've asked him, and he's prepared to offer a brief overview of the role of the Public Documents Committee. Members will be given an opportunity to pose questions should they have any.
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G. Mitchell: As you realize, the Public Documents Committee is established under the Public Documents Disposal Act, and the committee is required to review a retention schedule proposed by government agencies into the preservation, maintenance and long-term value of the records that they create as agents of the Crown.

What I'd like to first say is that the Public Documents Committee consists currently of three members: myself, the comptroller general and a barrister and solicitor from the Ministry of Justice. What we do is, when we are given these proposed schedules, we evaluate them in terms of their long-term value to the government and to the society in which we serve.

Those values would include long-term legal values — for instance, beyond the standard contractual term; evidentiary value — i.e., whether it documents the formulation, the establishment, the implementation and the use of government programming; long-term legal values — i.e., protecting the rights of citizens to their government and, of course, the rights of government to their citizens; and lastly, the historical value — what it would mean to future societies in the presentation of the information.

Now, I think it's important to let you know that these schedules are guides to the women and men that work in the public service as to how records they create must be protected. So rather than, in the traditional…. Well, not traditional, really. In the long-term keeping prior to 1985, to be honest, most government offices would keep records — one approach fits all. The current approach is, by establishing and letting people know what the long-term values of records are, they can keep records, according to their values, to higher or lesser degrees of security.

For instance, the office of the comptroller general many years ago implemented their financial accounting system. They set forth proposed schedules where we have now separation of financial records by value. Certain records are kept in more secure areas than others. And now these schedules, when they're proposed by the ministries and agencies, are set out to do that very thing.

Now, the key is, of course, they are reviewed by my committee of senior public servants. We recommend to this committee that an action be taken, and traditionally we have only sent ones that we recommend approval of. Those that we don't recommend — the ministries wisely return and redraft them.

Upon approval, if your committee recommends to the whole House and it's voted upon, then these records have standing within the public service, and they are adhered to as if they were a regulation of the government.

We have 19 resolutions from 19 agencies to cover the records that they create and protect on behalf of the people, and these records set out how long they are to be maintained within an actual government office, the period of time that they will be held in secured, off-site storage, and then what will happen to them at the end of those two periods — i.e., they'll either go for confidential destruction, or they will be transferred to the archives of the government.

When they're transferred to the archives of the government, the women and men that work at the archives will prepare them for public accessibility for this generation and successive ones.

B. Ralston (Chair): Thank you. I did notice that in the Riverview resolution, some documents were going to be sent to the City of Coquitlam Archives. So there is that as an alternative. Other agencies can receive the records as well. Is that correct?

G. Mitchell: Yes, Chair. Part of the final disposition can include what we would term as alienation from the Crown — that is, we would propose to the committee and the assembly that these records have continuing community or local value and they should be transferred to that area. But all interest within the provincial area has ceased.

S. Robinson: I have a couple of questions. Those that get returned back to the public agencies because they're not deemed by your committee to be ready for disposal or they don't fit the criteria…. Do you make recommendations about why they were rejected so that that public service can then perhaps have more stringent criteria?

G. Mitchell: To be polite, yes, we do. Sometimes not so polite. Typically what happens is that the agency is either…. At the local level some areas have not experienced, say, a corporate-wide or a specific incident — one, for instance, being children that are placed in harm or who have been injured. They have a legal right under Canada law to initiate legal proceedings when they reach the age of majority. Rather than, traditionally, records being kept ten years after an incident, they'd have to be kept ten years after they reach majority.

So on little things like that — where some of your agencies do not experience that very often — the committee recommends they return and redraft the document to ensure that legal protection is there.

S. Robinson: So the committee provides a bit of an educational role, as well, in terms of helping to develop better standards.

S. Robinson: Great. The other question I have just has to do with maintaining records electronically. In this day and age, given how much a little tablet can hold, do we find that our ability to hang on to records longer…? Because we're beyond paper, we're beyond microfiche, and we're now into electronic recordkeeping, is there a capacity or a desire to hang on to records longer because storage is not as big an issue?

G. Mitchell: Let me answer that in two ways. Firstly, the schedules that are proposed will apply to any format of technology. Simply because a record is born digital does not change its value to the society we serve.

That being said, I think, on the issue of storage I say yes, storage is cheap, but if you take all of the government storage in aggregate, it's a very expensive proposition. The ministry responsible for records — Technology, Innovation and Citizens' Services — is moving towards an electronic platform for all of the government to use. But that will require — because, of course, it's so easy to create and maintain — a very disciplined approach to how you entitle documents, so that you can find what's there.

Before records management was created, a formal program, government kept a great many documents. In fact, they kept warehouses full. And if it weren't for the senior public service staff, they would actually never have found anything. Now this process allows them to keep better recordkeeping and better finding tools so that they can find what they're keeping.

The other thing about keeping information beyond its value date is that it does create liabilities for the service and the government. You're keeping records beyond…. A good example would be…. It's much easier to provide access to citizens when you know exactly that the records you're keeping have long-term value and where they are, rather than having no system and having people be told: "There's just too many records to search through to find your answer."

D. Eby: My question is around transfer of documents to third parties. The example that the Chair used, of Riverview, is exactly where I'm focused. In terms of the documents that'll be transferred to the city of Coquitlam or other third parties, do you seek commitments from them that they will be preserving these documents? Or is it up to them to decide which documents they're going to be keeping and which they'll be putting into the shredder?

G. Mitchell: That type of difficult decision is still quite rare. It has been, in previous examples. We have transferred documents alienating them from the government because of a special request from that agency. Records are not transferred to any public sector body that has not met the requirements of a proper archive. For instance, we would not transfer to an agency that had no formal archives because, of course, then the information would not be accessible to the public they're serving.

Upon transfer there are some cases where we have required that if the agency cannot look after the records, they are required to contact the creating agency — i.e., the ministry, in this case — for the right of first refusal prior to disposition.

D. Eby: So if this committee approves the transfer of documents — again, using the example of Riverview — to the city of Coquitlam, can we take comfort that the documents will still be available on request to the public in the event of litigation or historical research? Or do we not know what's going to happen to them?

G. Mitchell: To be truthful, our recommendation is that the records have no longstanding value to the government, the provincial sector. Therefore, we're transferring them to Coquitlam primarily for historical reasons, with the understanding that they will be kept as long as that agency can keep those records and make them publicly accessible.

There is no requirement in the recommendation for the archives at Coquitlam to return them to the provincial government sphere if they find either the continuing historical value is not there or find they can no longer maintain their archives. They have no value to the province, and we would not seek their return.

M. Dalton: Documents that you store. Are they all hard copy? If not, if it's more than just hard copy and the electronic copy…. My question also relates to the electronic copies, because the technology changes.

I know that with many archivists and archives there is a challenge in ensuring that the documents that are stored are kept on disks or cards or whatever and then ensuring that that is being kept up. Otherwise, those documents can be lost because we don't have the technology even to recover certain documents. Is that a situation that you encounter?

G. Mitchell: That's correct. The technology…. For instance, our area has a small collection of foreign digital records. That's true. You have to keep the platforms current. It is a challenge within the Canadian archival system that we're to find a platform that is common enough across all of the jurisdictions to ensure that public accessibility is maintained.

That being said, currently the records that are covered by the schedules and within this provincial jurisdiction have policies and procedures that dictate how they must upgrade platforms, and they use the schedules to go through and ensure that the records that are identified as having long-term value are protected, first and foremost.
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Then they make decisions about records, either in the active office or in government off-site storage — whether or not those records need to be, with the time frame remaining in their life cycle.

M. Dalton: Just to follow up, as far as the hard copies of documents, are the majority of them kept in hard-copy form or is that a minority?

G. Mitchell: Well, for the interim period from about 1900 till most recently, we asked that all records that would have long-term historical value that were designated by the schedules were hard-copied or microfiched, put in microform. The ministry responsible is moving towards a full electronic platform, but they have put in good security safeguards so that they have backups and that the backups are regularly regenerated.

I think for the future it will all be electronic and handled by the technology. For the interim period, they are continuing to microfiche or digitize those records so that we protect the value of the information.

S. Robinson: Actually, this isn't a question. It's just some information for David over here, who was curious about Coquitlam's capacity to maintain the records. They've just hired an archivist. I know that the city is very excited about being able to have those records in perpetuity so that there's a record, locally based, about Riverview.

S. Gibson: I guess I don't want to get too philosophical here, but how do you know what's important in terms of the bigger picture?

A little anecdotal story. I have relatives that live down in California. They've hidden these time capsules in this town — Corona, California. They've hidden tons of them, and they can't find them. They can't find the time capsules.

My question is — I know that's kind of a frivolous introduction: how do we know what's important, looking back? Again, somebody must sign off on this. There must be a checklist. "Okay, this is boring. This is meaningless. Blah, blah, blah" — the stuff that we would do. I come out of a city council experience, right?

S. Gibson: But how do we know? Is there a checklist? I guess that is what I'm asking, Mr. Mitchell.

G. Mitchell: Well, the committee, when we get these presentations…. The ministry comes forward and makes a presentation, and my colleagues and I have that checklist.

We review for the evidentiary value. Does it document how a program operates, and what does it provide the citizenry? The audits and checks for all of that.

We have the foundation documents, and the policy decision documents are protected, because the society requires that.

We look at the long-term legal values, ensuring that individuals primarily but the collective as a whole are protected in the long term. We look at the long-term financial documents; i.e., will these records carry a long-term financial commitment by the government and the society?

Then lastly, we look at the historical value. That is, will these records over the long haul tell the future something about the society that we operate in and how well or not so well we've conducted ourselves to give them guidance?

We do have that checklist that we look at — all of these things — to ensure that the core of this information is maintained. By having ministries go through this process, they themselves begin to realize that records have differing value and have to be treated differently.

L. Throness: Mr. Mitchell, you appear here every year, and you bring forward a new list. How does this list differ from last year's list? What different thing are we being asked to decide today?

G. Mitchell: Well, it's longer. Each year when we bring resolutions forward, by and large we're covering a different element of government. The ministry or agency has, for want of a better word, matured to the point where they need to standardize and codify these records, and we bring them forward.

Sometimes there is a major amendment, if there's been a shift in government policy or, actually, a shift in law, and they are required to come forward and change these schedules. Once they pass through your committee, then they basically become the records law for the agencies, and they maintain them until they're altered again through this process. We never see them bringing forward an amendment unless there has been a major legal or statutory or process change.

S. Sullivan (Deputy Chair): Now, you had mentioned that there are three members of your committee. I do have an e-mail saying, I guess, that there are three members and three…. There's a provincial archivist, the comptroller general and three other persons appointed by order-in-council. So it sounds like there are supposed to be five members of your committee.

I'm a major consumer of the archives, and I thank you for the archives that you maintain. Mostly I'm interested in historical things. Certainly, the issue of being searchable is a big issue. You say that you're carrying a lot of them on microfiche. A lot of current documents are being put on microfiche?

G. Mitchell: Yes, we continue to use that format because it remains eye-readable.

As an example, the government of the United States, in the early 1990s, ordered its agents to begin using electronic records-keeping only. Therefore, they almost destroyed the microfilming industry. As you can imagine, in the aftermath of 9/11, when they realized their power grid was destroyed, they could not find any eye-readable documents that told government where their utilities structures or their power grid were.

After they got back on their feet, by presidential order they reinstituted a microfilming or a microfiching program that would ensure that all key elements were in eye-readable format, to save them from that type of catastrophe.

We've maintained that, as do most of the jurisdictions. We provide access to electronic records, but for key documents, we still prefer them to be microfiched and secured off site so that we have them.

S. Sullivan (Deputy Chair): Sometimes when I look at old documents on microfiche, they're unreadable because of the quality. Has that been improved, then?

G. Mitchell: The technology has improved. What we have done is that if the records are still extant, we are refilming them. It's more difficult. Some jurisdictions, including our own, destroyed some of the records after they were filmed.

S. Sullivan (Deputy Chair): The other issue is searchable. If they were scanned, I guess they could be searchable?

G. Mitchell: When we do it, we title each document with key words. So yes, within our system you'll be able to find them down to a key document and sometimes key phrase.

Depending on the system used within the greater government, that may or may not…. We'd have to see what the detail of access would be. We certainly could get to the document level.

S. Sullivan (Deputy Chair): But you couldn't do it on line, then. You would have to go in and look at a microfiche.

G. Mitchell: To be candid, there's no point in digitizing it if we can't provide on-line access in the short to medium term. Clearly, we are moving in that direction. I believe that the government's records management group is moving in that direction, also, for the overall government system.

V. Huntington: As you know, last year, I think, or the year before we had quite a discussion about what the records were that were actually being discussed. I wonder if you could just give some examples of what's included in resolution 2, for instance, the business and contract management ongoing records schedule, and No. 3, the CVSE operational records classification system. What types of records are we looking at there?

G. Mitchell: Well, primarily, in all of the resolutions we're looking at the foundation documents that support how that program operates. There are the policy procedure documents, and we're looking at types of case files or program files or incident files — so how the program has related to each incident or each client or each project.

At times, depending on the resolution, we're looking at how they would handle, say, a complaint to a public service or how they would handle different types of specialty treatment within a service. Particularly in the Ministry of Health, they look at different testing incidents, etc.

The schedules, overall, handle the entire life of that agency, right from when you, a client or a citizen, come into their office till they shut the program down. It includes everything that they need to operate as a viable entity.

V. Huntington: So when we're agreeing to the management of the retention and final disposition, you have listed somewhere, I'm assuming, which of those files are being disposed of and which of them are being retained. What are your criteria for that decision? Those are some pretty important files that you've talked about.

B. Ralston (Chair): If I might intervene, just to be fair to Mr. Mitchell, we were circulated about 140 pages describing in some detail the basis for the decision. I wouldn't want the record to reflect that we haven't been provided with some of the background and supporting documentation.

G. Mitchell: No, but just to follow up, before the ministry comes and presents to our committee, they have gone through a legal review with their barristers and solicitors at the department of Justice, right? And the corporate government — the people who look after the central records program — also do their review to ensure
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that the corporate policies and guidelines are being met.

So when they come and present to the committee — the fact that they're there — we are assured that they have gone through that. Then we apply our corporate value-taking — like, evidentiary and legal — because we have that experience that sometimes our younger colleagues don't. If there are questions, then we have them return, or we make the amendments right there and then.

V. Huntington: Thank you. I just thought that might be important to put on the Hansard record, just so that people who might want to read them understand how the process works.

D. Eby: Chair, a procedural question. I don't know about my colleagues around the room, but resolution 17, relating to the Riverview Hospital historical collection and ongoing records schedule, is of particular interest to me.

I wasn't sure whether the proposal would be to deal with all the resolutions in a group or to break them out. That's simply my question. If it is our intention to deal with them all as a group, if we could break out No. 17 for a separate discussion, I would appreciate that.

B. Ralston (Chair): That, indeed was my intention, but given your interest, my proposal, then, would be to deal with Nos. 1 through 16, 18 and 19, and leave 17 for a separate discussion.

If there are no further questions, the resolution that I'm advised is appropriate is this: having examined the retention and disposal applications made by the Public Documents Committee, the Public Accounts Committee recommends resolutions 1 through 16 and 18 and 19 to the Legislative Assembly.

B. Ralston (Chair): For discussion, move a similar resolution, then, I'm presuming, David, for resolution 17?

B. Ralston (Chair): So it's been moved in the same form of wording on resolution 17, and then you wanted to address that.

D. Eby: Yes, Mr. Chair. My concern in relation to this is that there is currently some discussion — certainly, in civil society and a little bit within the MLA group — about re-opening a Riverview-like institution in British Columbia and centralizing people with mental health issues in one large facility.

It seems to me that this historical collection of meeting minutes and other documents assumes a larger importance in such a context in that — if we're even considering such a move, or if the government would be — we would want to know what was done in the historical Riverview context — what mistakes were made, what was done properly and what the processes were and so on.

I appreciate my colleague from Coquitlam-Maillardville's comments that Coquitlam has hired an archivist and is interested in this. I certainly would want to know that they were retaining these meeting minutes and that they were retaining the documents and not shredding them, because they do assume this additional importance.

In addition, I note that the records in this schedule date from 1872 to 2005. With respect to the destruction of patient intake photos, for many people who were at Riverview, these photos may be the only photographs that exist of these people in the whole world. They may have spent their entire lives at Riverview and died at Riverview.

The Freedom of Information and Protection of Privacy Act allows disclosure for people who have been dead 20 or more years. It's quite possible that family members seeking to learn more about relatives or historians interested in particular people would very much seek to have photographs of these people, and they may be the only photos anywhere. So the suggestion that we would destroy intake photographs of patients also raises concerns.

Those are the two branches of concern. One is: what level of confidence can this committee have that the critical meeting minutes and documentation of Riverview remain available if we are looking to re-establish such a facility in the province of British Columbia? The second: the historical value of the intake photographs of patients and why these are suggested for destruction, given what I think is a fairly significant historical value, especially for the older photographs.

B. Ralston (Chair): Technically speaking, I wouldn't…. Archivists wouldn't participate in the debate. But I'm just wondering if you have any comment that might guide the debate.

G. Mitchell: Well, no, Chair. What I could do is I could return and ask the ministry responsible to provide answers to the Clerk on the reasoning why the decisions were made. Upon that, I could return.

B. Ralston (Chair): Well, given that response, I don't know what the view of members is. Perhaps what would be wise would be simply to table this resolution and in-
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vite Mr. Mitchell to make those inquiries and return, either in person or with further advice to the committee.

D. Eby: If it's helpful to the committee, I'm prepared to put down in a letter to Mr. Mitchell exactly what my concerns are so that he has something to take to the ministry, if that's easier for everybody.

B. Ralston (Chair): Perhaps if you could direct that letter to me, I could circulate it to all members so everyone is on the same footing in terms of what's being requested.

L. Throness: I'll just point out that as a one-time PhD candidate, a treasure trove of information like that would be very valuable for historical research purposes.

S. Sullivan (Deputy Chair): As someone who spent a lot of time researching a health facility in Britain — 1905 records…. I couldn't get them released, and I worked very hard on it. It was very important to our family to know what happened. So I'm very supportive of what you're saying.

B. Ralston (Chair): Procedurally, then, I'm just going to ask someone to move to table this resolution, adjourn debate. If we do that, that will give us the procedural avenue to have Mr. Mitchell return with some responses. Would someone just like to move that we adjourn debate on this resolution?

S. Gibson: May I be permitted to ask one additional question, if my may, of Mr. Mitchell?

S. Gibson: Once you said that we were in transition, going from low-tech to high-tech. Once everything is morphed into electronic versions, will this essentially be redundant, be an anachronism?

G. Mitchell: Well, philosophically, I believe that paper will always be used to continue to document key events or key policy decisions and key agreements. I actually don't think that's going to change much. I think what you will see is that the women and men of the next generation of public service have a great comfort level dealing with material on screen and that much of the background work will continue to be done in electronic fashion, as will most of the electronic records-keeping.

I think there will be a continuing need, regardless of how it's protected in a format, for retention and disposal authorities to be present and not get trapped in allowing the technology to dictate how long information should be kept. I think that will be a great challenge for the next generation of public service, because I think it's just too easy.

It's much more difficult to walk into a room this size and see filing cabinets stacked up on the walls. You will realize you have a records-keeping problem. As you know, on your laptops or computers or tablets, it's very difficult to come to that conclusion — that you have an unorganized cache of information. I think that will always be a challenge.

I do think that technology will be used more and more, and probably my successor's presence here will be virtual.

B. Ralston (Chair): Thank you. Just before you go, Mr. Mitchell, I understand in conversation that you're proposing to retire this June. Up until the debate on that last resolution was adjourned, it was thought that this might be your final appearance before the committee.

I do wish to note that you have been the provincial archivist since 1998, and you'd previously served as the deputy provincial archivist. In the event that you aren't able to return or we don't arrange that, I want to thank you, on behalf of the committee, the Legislature and the people of British Columbia for your years of service in this important role: preserving and thinking about the records that form the basis for so many important aspects of the preservation of memories of human society and culture in British Columbia.

May I, again, offer to each and every member the opportunity to come and visit your archives and to get a better sense of what we protect and make accessible on behalf of the people of British Columbia.

It's a longstanding offer. May I remind you that once you are within the precinct of the archives, we can neither confirm nor deny your presence. You have a safe haven, for at least a period of time.

B. Ralston (Chair): We'll now turn to the consideration of a report of the Auditor General entitled Striving for Quality, Timely and Safe Patient Care: An Audit of Air Ambulance Services in B.C. The publication of the report dates from March 2013.

I'm just going to briefly introduce the officials that are here: Russ Jones, the Auditor General; Sheila Dodds, the assistant Auditor General; and Peter Nagati, who's a director.

For the government: Peter Thorpe, who's the interim chief operating officer, B.C. Ambulance Service; Jan Butler, corporate director of quality, safety, risk management and accreditation of B.C. Emergency Health Services; and Doug Blackie, who's the director of critical care programs from B.C. Ambulance Service.

Welcome to everyone, and I'd invite the Auditor General to lead off with a brief presentation.

Auditor General Report: Striving for
Quality, Timely and Safe
Patient Care: An Audit of
Air Ambulance Services in B.C.

R. Jones: Good morning, Chair, Deputy Chair and all members. I am happy to be here this morning to introduce our report, Striving for Quality, Timely and Safe Patient Care: An Audit of Air Ambulance Services in B.C. This is a report that we did put out last March.

Air ambulance services are a key component of our provincial health care system, and they contribute to two very positive patient outcomes by focusing on two key aspects of patient care: quality of care provided by paramedics and the timeliness of that service.

Ensuring that quality care is provided involves matching patient needs with best-response expertise, by both aircraft and paramedics, and appropriate treatment. Ensuring timeliness means arriving at the scene or hospital quickly and transporting the patient promptly in a safe manner. All of these services are provided in a province that is large and has many remote communities — no small task or easy task for air ambulance services.

We undertook this audit to examine whether the B.C. Ambulance Service was monitoring its performance in providing quality, timely and safe patient care. We have concluded that the B.C. Ambulance Service is unable to demonstrate that it is providing quality, timely and safe patient care, and we've provided three recommendations to help them move from an efforts-driven focus to a focus that looks at actively managing performance in being patient outcome–driven.

Before I turn it over to Peter to take you through our presentation, I would like to also mention that while we found a number of areas where improvements can be made, there are also many examples noted in our report of good processes currently in place at B.C. Ambulance Service that support quality care, timeliness and the safe transport of patients. You can find those on a number of different pages in our report.

As the Chair has mentioned, with me today I have Sheila Dodds, who's assistant Auditor General in our performance area, and Peter Nagati, a director in our performance area.

I will turn it over to Peter to take you through the recommendations and just a brief overview of what we have in the report today.

P. Nagati: Thank you for this opportunity to present a brief overview of our audit of air ambulance services provided by the British Columbia Ambulance Service. The audit was conducted in accordance with section 11(8) of the Auditor General Act and the standards for assurance engagements established by the Canadian Institute of Chartered Accountants. For brevity, I'll be referring to the British Columbia Ambulance Service as BCAS.

Air ambulance services provide emergency life-saving treatments and transport patients to the necessary level of care. Air ambulance services contribute to patient health outcomes. As such, air ambulance services are a critical component of the provincial health care system. BCAS integrates its air ambulance service with its ground ambulance service, providing one of the largest emergency medical services in North America.

Air ambulance services include responding to pre-hospital emergencies, such as motor vehicle accidents. Services also include transferring patients between health care facilities to and from higher levels of care. About 90 percent of the nearly 8,000 annual air transports are between health care facilities. Most air ambulance services are provided by dedicated air carrier companies that operate under long-term contracts.

We carried out this audit to determine whether BCAS's air ambulance services contribute to the best possible patient outcomes by providing quality, timely and safe patient care. We did this by assessing whether BCAS has defined and is meeting relevant service standards for quality of care, timeliness and patient safety and, also, whether it is providing paramedics and aircraft based on an assessment of patient needs.

While air ambulance is part of an integrated health care system, our audit focused exclusively on the air ambulance services and their contribution to patient outcomes. Because BCAS influences patient outcomes through the quality of care, timeliness and safety of its air ambulance services, we expected to find that BCAS is actively managing its performance in those areas. Specifically, we expected to see performance information being provided to management and staff so that they can
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identify issues, improve performance and report results to stakeholders.

We concluded that BCAS is unable to demonstrate whether it is providing quality, timely and safe patient care through its air ambulance services. It has not clearly defined its objectives or measures, and it does not assess its own performance to find out how well it is doing or ways to improve. We also concluded that BCAS has not undertaken an overall assessment of its service demands to ensure that paramedics and aircraft are located and dispatched to best meet the needs of patients.

We found that BCAS does have initiatives in place to promote quality, timely and safe patient care and respond to issues as they arise. For example, it has implemented its autolaunch program to get high-risk patients to care quickly. It also makes on-call medical advisers specializing in emergency medical transport available to paramedics by telephone, as needed. It's also adopted a system to manage complaints.

However, BCAS does not track its performance for air ambulance services with respect to quality of care, timeliness and safety. While medical staff may review individual files to assess quality of care, general clinical activities are not tracked and monitored to identify systemic issues and inform decision-making. BCAS's efforts to track the timeliness of its air responses are early in development, and they do require improvement. Measures are not yet fully developed or understood by staff, and the data it does have has limited reliability.

Finally, we found that safety is a priority for BCAS staff. The paramedics we interviewed are proud of the safety of their service. But BCAS does lack a comprehensive safety program that would analyze and evaluate safety issues and incidents over time, and it does not conduct audits of the safety systems and operations of its contracted aircraft carriers.

We found that BCAS is responding with paramedics and aircraft based on its understanding of patient needs. For example, it awards contracts for aircraft based on known business requirements, and it dispatches staff and aircraft with consideration for patient needs. However, we found that BCAS has not fully assessed whether its paramedics and aircraft are in the right locations to best meet the needs of patients.

We also found that BCAS does not adequately review whether aircraft and paramedics are being dispatched effectively.

We made three recommendations to ensure that BCAS take steps to ensure that it is providing patients with the best air ambulance service possible with the resources that it has available — specifically, that BCAS (1) actively manage the performance of its air ambulance services to achieve desired service standards for quality, timeliness and safety of patient care; (2) that it periodically review whether the distribution of its staff and aircraft across the province is optimal for responding to demand for air ambulance services; and finally, (3) that it regularly identify and review a sample of its air ambulance dispatch decisions to ensure that resources are allocated with due consideration for patient needs and available resources.

The Office of the Auditor General notes that BCAS has accepted these recommendations. I'd like to thank the staff at BCAS for their outstanding cooperation throughout this audit. We look forward to following up with them in 2014 regarding the implementation of the recommendations.

B. Ralston (Chair): Just before I turn to the Air Ambulance Service, you mentioned 2014. It's been a year since this has been published. Has there been any formal follow-up evaluation in an attempt to assess whether your recommendations that have been accepted have been acted upon?

P. Nagati: We just recently received an update from BCAS regarding the actions it's undertaken in response to the recommendations. We're in the process of looking at it and deciding whether further assessment is necessary.

B. Ralston (Chair): I'm now going to call on representatives of the Air Ambulance Service to present, and then I'll open it to questions from members.

P. Thorpe: My name is Peter Thorpe. I'm the interim chief operating officer for the B.C. Ambulance Service. I've been asked to start the meeting, Mr. Chair, by passing on the apologies of Mr. Wynne Powell, the board chair for PHSA, and also Mr. Carl Roy, for their inability to be here today. There is myself. There's Doug Blackie, who's our director of the critical care program. We also have Jan Butler from our quality, safety, risk management and accreditation and a corporate director for the BCEHS. I'm also accompanied today, behind us, by Mr. Paul Bouchard, who's our manager for aviation services.

I'd like to just give a quick overview of the BCAS in relation to, then pull it together with, the critical care program. As you can see, we cover the whole of the B.C. province. We have provided Canada's only fully integrated emergency medical service since 1974. I'm sure as you can see, the area is rather large, as you know.

For us, we are an agency of the B.C. emergency health services, which oversees all the emergency health services in B.C. That in turn is a part of the Provincial Health Services Authority.

Just to give a view of the size and the scope, lots of figures there, but maybe just one to pull it together. If you look at the number of road ambulances versus the number of road calls that we do, each ambulance will cover
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maybe, approximately, 1,000 calls. You see the air ambulances themselves covering over nearly 750 calls each year. As you can see, it's a very busy service covering the whole of B.C.

The critical care program overview. The reason we provided this is that the critical care program, which is what the air ambulances come under, covers not just the air ambulances but also the infant transport teams. Sometimes patients are carried by road as well as by air. There are approximately 70 clinical staff that work within the critical care program. About 50 of those work regularly on the air ambulances and the remainder with the ITT, the infant transport team, who may transfer by ambulance or by air.

It provides a specialized pre-hospital and interfacility treatment by the use of five dedicated jet and turbo prop aircraft. As you can see, we are based throughout B.C., and I've just listed the bases there.

The critical care paramedics are trained in ways well in advance of what I was when I worked as a paramedic. They perform the advanced medical interventions that allow physicians to transfer critically ill patients between facilities safely, using monitoring and ventilation equipment, in conjunction with the physicians at those facilities. The common sort of feeling is that those units do act as mobile intensive care units.

Just to break down the call volume, we dealt with about 6,700 patients by air in '12-13. The majority of those were transported by airplane — just over 70 percent — and the rest by helicopter. I'm reliably informed that 2.1 million is 12 times around the world, but I don't really know. Just take it as read. But they fly a lot, and I don't get frequent-flyer miles from them.

What I'd like to do, with your indulgences, is pass over to Doug — to Blackie. As I said, he's our director for the critical care program. I'd like him to run through the recommendations and the actions that we've taken today in progressing towards the actions that the Auditor's office generally pointed out to us in the report.

D. Blackie: Good morning, Mr. Chair, Deputy Chair and members of the committee. Thank you, Peter.

What we'll do is we'll just walk through the recommendations and be able to provide you with some response of how the B.C. Ambulance Service has begun to implement the recommendations that have been provided by the Auditor General.

In recommendation No. 1, the Auditor General recommended that we focus on defining our goals and objectives, measuring and monitoring the timeliness and quality of our care, strengthening our safety systems and communicating our results internally and externally.

I want to just focus first on quality of care. Last week we achieved accreditation from the Canadian Medical Association for our critical care paramedic training program. We're now the second jurisdiction in Canada to have this level of accreditation, and it was quite an accomplishment. It is nice to be recognized for that.

What that means is that we're training some of Canada's most well-trained and qualified critical care paramedics, who work on our air ambulance system. We've also created a position of a quality leader within critical care programs, which also works with the air ambulance side to develop and drive our patient care and operational quality initiatives.

Thirdly, we've created a critical care quality committee, which is made up of management as well as physicians, our partners within B.C. emergency health services — the B.C. Patient Transfer Network as well as B.C. Ambulance dispatch, which partner with us on the air ambulance dispatching — as well as paramedics.

We get together every two months. We're looking at a number of different quality initiatives — everything from handwashing to critical medication incidents. We have conducted a number of quality reviews already, and we're well on the way of developing what I feel is a culture of quality within the critical care program.

In terms of defining our goals and objectives, I'm proud to say that we have developed an operating plan for the critical care and air ambulance system, which outlines our goals and objectives and priorities for the next three years.

At the moment this plan is in a consultation round with our front-line paramedics, who are providing direct input into the priorities and our goals. It'll be going to Peter and senior executive shortly.

In terms of timeliness, we continue to work on this. It is difficult. We do have some challenges with respect to our legacy information systems, but I believe we're making good progress here.

I did want to tell you, though, that most recently we did a Lean exercise within our patient transfer network and the dispatch centre, and we've been able to reduce the amount of time it takes to process a high-priority call from 38 minutes down to 13 minutes. Again, we continue to incrementally improve the amount of time it takes from the time a hospital or a physician calls us to the time that it's actually dispatched to an air ambulance by about 60 or 65 percent.

In terms of safety, we have now completed audits of all four of our dedicated air carriers. That is a significant completion of one of the Auditor General's findings. We have found no material issues in those audits, which were conducted by Mr. Bouchard, who is behind me, as well as two independent auditors, which formed our audit team.

Formal reviews are now underway of a number of patient safety events, in partnership with Ms. Butler's area, which is quality, safety, risk management and accreditation. These include reviews that are being done in partnership with the health authorities in specific cases that have come forward.
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Paramedic maintenance of competency, to ensure that our paramedics are practising at their highest level of qualification, is being strengthened. We're adding the infant transport team to that formalized process, but we're also putting together a proposal for what we call a professional practice leader within critical care to ensure that our paramedics are abreast of the most recent developments in critical care and air transport medicine.

We've also implemented new, strict controls on the management of narcotics and controlled substances to alleviate any concerns that had come forward in a previous audit of that matter.

In terms of communication, we have done extensive outreach with the health authorities, as well as stakeholder groups such as the Doctors of British Columbia and the newly formed Rural and Remote Division of Family Practice, among others. We continue to work closely with those groups because they are our partners as we move forward in our planning.

In terms of our next steps, we will maintain a relentless focus on patient and service quality. Our goal, as I said, is to change the culture to one that is focused on viewing everything we do, whether it's patient care or management, through a lens that supports patient care quality and safety. We will be conducting and expanding our compliance and safety audits to our charter air carriers. We have about 40 air carriers throughout the province who provide ad hoc services. We'll be working with them, starting early in the new fiscal year, to conduct compliance and safety audits with them as well.

Our first set of patient care indicators is going to be implemented in the next couple of months. These are measures that we have worked closely on with the Air Medical Physicians Association, which is a North America–wide air transport medicine group. We'll have a common dashboard of clinical patient care quality indicators that become comparable to other air ambulance systems across Canada and North America.

We continue to tie in our paramedic skills maintenance and competency with our critical care education program. We educate, through our now accredited education program, the maintenance of those skills. We're tying those two together so that we can continuously improve our education from the assessment of the paramedics' skills once they're out in the community.

In terms of recommendation No. 2, we are continuing our review of our internal decision-making tools and policies to improve how air ambulances and critical care paramedics are deployed, including revising some of our internal processes. I talked a little bit previously about the Lean project, which was able to demonstrate a 67 percent reduction in the dispatch processing time. We continue to work with our partners in the health authorities to determine the optimum placement of air ambulance resources to meet current and existing service demands.

On the screen I'll just put up an example of a study we recently did in partnership with Interior Health. This shows traffic for the Kamloops-based air ambulance, showing where they have gone to pick up patients and where they brought those patients to.

This piece of data — and, of course, the data that's behind this graphic — enables us to work with Interior Health to evaluate whether we are in fact delivering those patients to the appropriate hospital, whether in Kamloops or Kelowna. It also gives us a good sense of where that helicopter is being dispatched to, so we can work with our dispatchers and the patient transport network to make sure we are sending the right aircraft and the right crew to the right call.

It also allows us to work with Interior Health to determine where the majority of calls are going. We're finding, for example, that the Kamloops-based helicopter, just over 50 percent of the time, is bringing patients back to Royal Inland, which suggests to us that the helicopter is in the correct place.

But we will continue to monitor this, because a significant minority of the calls do go to Kelowna General. For example, as Interior Health begins to develop its cardiac services in Kelowna, we may have to continue to assess and determine whether, in fact, we have the appropriate resources. This, of course, is just confined to the Kamloops helicopter.

By establishing these clearer mission profiles, as we call them, we can ensure that the air ambulance services are provided in a consistent manner provincewide and that the most appropriate crews and aircraft are being used for patient care.

As I've mentioned a few times now, we do work closely with the health authorities to better evaluate where the air ambulances are being deployed and where patients are being transported to, which then helps us fine-tune with the health authorities their referral patterns.

We're also evaluating our program through outreach visits, surveys and working with rural physician groups to ensure that we're hearing directly from physicians and nurses and health care providers throughout B.C., especially in rural, remote B.C., to constantly improve our program.

In terms of next steps, well, once we've determined the deployment and service pressures on the air ambulance service, we will begin to implement the Auditor General's recommendation to optimize placement of the air ambulance resources to the current and proposed service demands.

For example, I mentioned the new cardiac centre in Kelowna. We're already starting to see increased air ambulance traffic to Kelowna instead of Vancouver for cardiac cases, and we've been working very closely with Northern Health to try and get a sense of the economic activity that is occurring in the northeast and the northwest and how that may impact on air ambulance services.
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As I said, this information will help guide the next round of our air ambulance procurement, which begins in 2015.

Moving along to Auditor General recommendation No. 3, I spoke earlier of the quality leader. That position is tasked with managing all patient safety events and is accountable to the critical care quality committee. The committee is now meeting, as I said, on a regular basis and has the power to investigate critical incidents. Our critical care program, the B.C. Patient Transfer Network and B.C. Ambulance Service dispatch are working together to improve information-sharing and decision-making processes to make sure we are getting to our patients in a timely manner as well as providing quality and safe services.

We review specific air ambulance calls several times a week with the B.C. Patient Transfer Network and our dispatch centre to identify areas of improvement, clarify policy and build on success. Where we see trends developing in those reviews, they are then moved to the formal quality review, which is accountable to the B.C. emergency health services board. We are in the process of making significant policy and guideline changes to continuously improve our services.

In terms of next steps on this recommendation, we'll continue to review ambulance calls on a regular basis, with the goal of improving our decision-making, reducing response times and ensuring services are provided as efficiently as possible. We are collaborating with the health authorities to review critical incidents, identifying trends and improving our working relationships so that patients are transported in a safe, timely and quality way. We are continually seeking feedback from the health authorities and a wide variety of stakeholder groups to tell us what's working and what can be improved.

P. Thorpe: Thank you very much, Mr. Chairman, for the ability to go through those details. I'd like to pass our thanks again to the Office of the Auditor General for the report that they did and for the recommendations that they made. I believe that we're making some progress in the improvement of quality, timeliness and safety of air transports for our patients and working with clinicians, the health authorities and other agencies.

We value those partnerships. We believe that they give us good feedback on the service we provide, and we obviously welcome any questions or feedback from yourself or the committee, sir.

N. Letnick: Thank you to the Office of the Auditor General and to B.C. Air Ambulance for their presentations. Much appreciated. Quality, timeliness and safety are the words that you mentioned at the end of your presentation, which is what my question is about.

As we move forward with the additional metrics that you're going to be collecting on those three aspects of your service, will they be done in such a way that they're consistent with other air ambulance services across the country and, indeed, similar places around the world that have a mix of rural and urban challenges like we have in British Columbia so that we can see how well we are doing, not only over time locally in B.C. but over time compared to other comparable jurisdictions? Nothing tends to motivate a group to do better than showing that they're not in first place compared to other non-competing but similar service providers.

P. Thorpe: With the indulgence of yourself as Chair, I'll pass that question over to Doug and the work that's been going on, on a national level, over the setting of those standards.

D. Blackie: The short answer still, I think, is yes. Through the Air Medical Physician Association, we're partners with air ambulance services across Canada — STARS, Ornge in Ontario — as well as air ambulance operators across North America to develop a standard dashboard of metrics.

We'll be able to compare, at the moment, our patient care clinical indicators. Our operational indicators are coming, in terms of our ability to manage the service in a measurable way. Those are in the works right now. We've wanted to focus on patient care first.

We will be able to directly compare those with other jurisdictions, because we're all measuring, effectively, the same thing. The difficulty with other parts of the world…. I think in Australia there are some other direct comparables. I'm looking to Jan. She's done research in terms of the Scottish air ambulance service.

That would be our goal. Definitely, when we look across the Canadian landscape and our health system and the way that we're structured, we definitely can be able to report that out, both internally — I think what you're implying is to drive some competition — but also for us to develop those benchmarks and then be able to measure ourselves over time, which is what the Auditor General has strongly recommended we do.

K. Corrigan: My question is for the Auditor General or Peter, either one. My question is: are you happy with the response from the B.C. Ambulance Service? Do you think it represents an adequate plan to move forward? Are you satisfied, with the presentation that we've received today, that good progress has been made in terms of the recommendations that the office has made?

R. Jones: Yes, I think the response that we received was a good one. The presentation we've heard today — it sounds like there's a lot of very good things going on.

As we mentioned in our presentation, we have just received the self-assessment back from B.C. Ambulance
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Service, and we will be taking a look at whether or not we should be doing a more thorough follow-up than we normally would do in this case. It might be one that we could sort of pilot in terms of looking further into what these self-assessments are doing.

In a number of cases, from what I just heard in the presentation, there are still a lot of things in progress. We will take that into account in the self-assessment as well, but it sounds like a lot of good things.

K. Corrigan: A different question. In the response from the B.C. Ambulance Service, there is a discussion about the cost per patient and whether or not it's possible to compare the cost per patient with other systems in North America. It says that in 2013, B.C. Ambulance Service will reassess whether it's possible to accurately compare cost per patient to other air ambulance providers in Canada.

I didn't see anything in the presentation about that. I may have missed it. I'm wondering if you could give me an update on that cost assessment and comparison.

P. Thorpe: I'll ask Mr. Blackie to just come in on that as well. I think he's got the answer.

D. Blackie: The answer is yes, we have done some work. Unfortunately, I don't have the information with me.

The caveat on that is that our system, as an integrated air-land-sea system, is different than most of the other jurisdictions in Canada, so we have different costs. We have different overhead structures.

We've had a real challenge, for example, comparing our service to STARS. Comparing our service to STARS, with respect, is like comparing STARS to one of our contractors, because STARS is a contractor to the Alberta system. If we compare apples to apples and compare ourselves to Alberta, then we get into a totally different structure, because they have a hybrid ambulance system.

It is extraordinarily difficult to be able to give a fair and accurate assessment of our cost per patient, comparable to other operators. I don't have the exact details with me, but I know that some work was done last year to compare our helicopter service with the STARS helicopter service, and our cost per patient was significantly less.

M. Dalton: My question is along the lines of Kathy's, on what I don't see inside the audit, and that is the value for performance, or for money. I know you made some comments right here.

Maybe this is a question to the Auditor General. Just the cost-effectiveness — is that something you've touched upon at all? Do you have any recommendations with regards to cost-efficiencies?

R. Jones: It is quite possible that we might look at that in the future. We haven't currently got it in our three-year plan, but it is something, now that you have brought it up, that we can bring forward in our continuous planning process.

M. Dalton: Right. This isn't a criticism; it's just to ensure that we're getting best value for dollars.

S. Robinson: I certainly appreciated hearing the response, because just in reading the report from the Auditor General, it was actually a little bit surprising. So I'm pleased to hear that there've been some changes.

I do have some questions. In the response from the B.C. Ambulance Service, on page 10, under "Safety," one of the responses was that any identified issues that ensure the safety of patients will be reported to management, who "work to find a solution in a timely manner." I'm just looking to understand what "a timely manner" means to the Ambulance Service.

P. Thorpe: If my colleague Janice Butler will respond to that from the quality side, that would be helpful.

J. Butler: Thank you for the question. What we have done as part of an integrated quality approach with the Provincial Health Services Authority is adopted standard review processes and response times to those reviews, as with all of the PHSA agencies.

In very general terms, at a high level, if we were to have, for example, what we determine to be a critical event, the standardized review time is 60 days from the notification of the event to the actual review and then 60 days from the development of recommendations to the implementation of those recommendations. All of that is monitored at our B.C. emergency health services board level through the quality and access committee.

S. Robinson: That's great. That's helpful. So there's a standard in terms of expectation. That's very, very helpful.

I have one other question, which has to do with the review committee, the patient care quality committee. I'm just wondering if you could tell us a little bit more about this committee and if there's a report generated and who gets that report and how that sort of feeds back into the system. That's really not clear to me how that gets played out.

P. Thorpe: Yep, okay. The critical care program's quality committee is the committee that we're talking about.
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The committee itself — I've got the terms of reference in front of me — involves quite an extensive membership. It's chaired by Dr. Steve Wheeler, who's our critical care doctor who oversees, from a medical point of view, the program. And the co-chair is Doug.

It involves the Quality Lead, members of Quality Lead and also staff and stakeholders within the program. The committee meets on a bimonthly basis, so every two months. The minutes are circulated, and they are held as formal minutes of the BCEHS.

So that would feed into the process that Jan was talking about a minute ago. That would pick up any quality issues that we may find or identify.

S. Robinson: Well, then I won't follow up, because I have one more question. If I have time for one more question.

So part of what I'm curious about is this idea of developing a culture of continuous improvement, which I think is ultimately what you're trying to do.

I'm just wondering how you will measure whether or not you have created a culture in that way and how you will know that. There will always be room for improvement. You will always be looking — that's the idea — for better, tighter, faster, safer. And how you will know that you've achieved that.

J. Butler: In January of 2013 B.C. emergency health services undertook its first patient safety culture survey across the organization to establish baseline understanding of where the culture sits.

We used a validated tool. It's also part of our process to seek accreditation through Accreditation Canada, so it's part of that process. We will be redoing this survey every four years.

In the interim the results that were generated from the survey have been shared across the various committee structures and management structures within the organization. Specifically, we have targeted a couple of key areas for focus to improve that culture — the main one being providing feedback to staff who actually report concerns regarding safety.

We're tracking that percentage of feedback on those reported issues as they are closed off, and we are reporting that percentage and tracking that percentage all the way up to our board.

M. Morris: Directed probably to Peter or Doug. I'm from Prince George, and I'm very familiar with the big, green mass that you had on your map there, because it was the same area that I looked after with respect to providing policing services, so I know some of the challenges that you face there.

I'm very curious. The Auditor brought up some issues with respect to the placement of the aircraft and whether they're located in the right areas or not. I've fielded a few complaints from time to time up in my region about the time lapse, I guess, from the time the call goes in for an air ambulance until the time that service is received.

Do we have proper coverage up there, or do we have trouble attracting the right talent up in that particular part of the world? What can we do about that?

I also understand that B.C. Ambulance Service contracts services with STARS quite a bit up in the northeast part of the province — and whether we can look at expanding that.

D. Blackie: Thank you, Member. It's a good question. The majority of our air ambulance calls are to Northern Health. Northern Health presents itself with some very significant challenges in terms of access for patients — geographic distance, weather, as well as things like gravel runways or no runway to land an air ambulance.

We've been doing an awful lot of work in the north with Northern Health. We've been looking at how they're planning and how they are intending to change the designations, for example, of some of their hospitals, then being able to assess those changes in terms of how we then deploy air ambulance.

One of the things that I think is important to mention is that the air ambulances — and you saw this in a previous slide — although they are regionally or geographically based around the province, each air ambulance has a provincial mandate.

So the north is served by all of our turboprop and jet aircraft. For example, our Vancouver jet is routinely in places like Fort Nelson and Dease Lake.

With respect to Fort Nelson, we've done some work up there with the municipality as well as with Northern Health and the physicians to try and look at different options for medical evacuation of patients by air. There have been some challenges up there, and we do contract with Alberta Health Services for both fixed-wing and helicopter services, which are provided by STARS for the northeast as well as the East Kootenays of the province.

It just makes it…. Well, there are a couple of issues. One is that Northern Health and Interior Health — patients are generally referred into Alberta because they are geographically closer. We have an agreement with Alberta to enable them to provide additional capacity to us when we're unable to go.

There have been some issues, and our biggest challenge in the north is access into those communities, as well as weather. It does pose its challenges, and we are working, as I said, with Northern Health and our contracted
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providers up there, which is Northern Thunderbird Air as well as our charter operators, to always and continuously look.

The other piece that I wanted to mention is we are planning to have a meeting with the mayor of Kitimat to discuss her vision and her concerns around some of the economic activity in the Terrace, Kitimat and Prince Rupert triangle. We do have an air ambulance in Prince Rupert, and we want to make sure that it's appropriately serving the people in that area as well as Haida Gwaii and the north and south coast.

We're very much, I guess, on the file for the north and looking at lots of innovative and creative solutions. I hope that answers your question.

D. Eby: I just wanted to say — and I'm sure this thought is shared by everybody on the committee here — thank you to the members of the Ambulance Service for the work that they do every day in keeping British Columbians safe, and also, thank you to your agency for your appropriate and responsive reaction to the Auditor General's report. Hearing about a response time reduced from 38 minutes to 13 minutes is significant and reflects the seriousness with which you take this process. It's not always the case that we hear this in this committee, so thank you for that.

My question is related to that Lean program and the 38-minute to 13-minute reduction. I just want to understand that a little bit better. When I picture air ambulance response, I'm picturing helijet. They get the call, and they could just run out to the launch pad and be in the air. I'm wondering why it's 13 minutes instead of five minutes, two minutes, and so on.

D. Blackie: The Lean exercise that I spoke about very briefly in the presentation was really looking at the time that the hospital calls the B.C. Patient Transfer Network to the point that the air ambulance is actually dispatched. They've been able to reduce that from 38 minutes down to 13. That's the call processing and dispatching time.

There's a lot of triage that is involved, a lot of communication with physicians trying to find a sending hospital for the patient to go to and then for our dispatch centre to figure out which is the best air ambulance and crew to go to get that patient.

Once it's dispatched to the air ambulance station, depending on which resource it is and where they are, sometimes…. For example, there was a drowning in Cranbrook last summer. We happened to have our infant transport team coming back from Calgary empty. They were almost overhead of Cranbrook. They were able to divert into Cranbrook, able to transport that child, and that child recovered. Those are the serendipitous moments. Otherwise, we are launching an aircraft cold from one of the bases.

The helicopters are normally in the air…. I don't want to hazard a guess in front of the committee, but we do have some standards that we're continuing to work on. But it is, in terms of an autolaunch, extremely quick. It's within eight to 15 minutes, depending on where the crew happens to be, the state of the helicopter and those sorts of things. At other times it can be immediate.

J. Butler: May I just add to that, if that's okay. In terms of the specific question around the Lean process and how that works and the complexities that the Lean process seeks to undo and to refine, when we get a call that comes through to the Patient Transfer Network, it's important to understand the number of parties that are involved in the conversation around how we move this patient. There's the sending physician, there's the receiving physician, there's the call-taker in the Patient Transfer Network, there's the dispatch group out of the patient transfer coordination centre, and there may be other physicians involved, from Alberta, for example, as part of that process.

All of those people together in one conversation can make for complication. What the Lean process sought to do was really refine that communication and get it down to its lowest point, removing as much waste, if you will, from that call-processing system as we could manage to get out. What the system focused on was the highest-acuity calls. The Lean process focused on those highest-acuity calls, obviously the most critical ones, to get the transfer plan in process as soon as we could and, specifically, to minimize the amount of additional interactions necessary in order to finalize that plan.

D. Eby: The presentation from the Ambulance Service describes accreditation of critical care paramedic education. It's not an education certificate that I'm familiar with. I'm familiar with primary care paramedic and advanced-care paramedic certifications. I'm wondering if you're creating a new paramedic certification here or whether that's shorthand for these certifications. If you could just drill down a little bit into that for me.

P. Thorpe: Thank you for that question. We have primary care paramedics and advanced-care paramedics and emergency medical responders that are employed by us.

The critical care paramedic program is doing its own training course. You would be an advanced-care paramedic, I think, for three to five years before you could apply to become a critical care paramedic. There is a separate training course for that, and as Doug mentioned, that has recently been accredited. I think it's only the second program in Canada that has been accredited in
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that way.

It is, in effect, a higher level of clinical training. What it does is allow people who previously, in my day, would have been transferred with a doctor or a nurse escort to be transferred by our clinical staff.

It is a separate clinical qualification for all intents and purposes, in answer to the question.

D. Eby: So why are all of the paramedics within this very urgent care context not advanced-care paramedics? Why would you have…? You already have emergency medical responders, for example, or primary care.

D. Eby: I understand that, but you have emergency medical responders and primary care paramedics. Why?

P. Thorpe: The way the Ambulance Service is…. What we have, when you're in remote and rural communities, is staff who are part-time, who work as emergency medical responders or primary care paramedics. They provide a medical response to emergencies or accidents.

Where we have a higher level of need in, for instance…. We have ACPs, advanced-care paramedics, around the province. So we have them here in the Lower Mainland. We have them in Kamloops, Kelowna, Prince George. They will be dispatched to calls of a higher acuity to back up, maybe, a primary care paramedic or EMR that is present.

The CCP program is a build on that, and it is to allow for this extra equipment, the ventilation, the fact that patients are ventilated, the fact that many of these patients may not be conscious, would be unconscious, as well. They're dealing with other medical equipment that your normal advanced-care paramedic wouldn't deal with.

It's a stepped process, and obviously, we have to match that to the demands of the community.

L. Throness: I found myself being frustrated as I read the audit. I want the Auditor General perhaps to comment.

We get a crack…. The Auditor General gets a crack at the BCAS maybe every ten or 15 years or so, so it's very important that the committee receive direction from the Auditor General and the government as to whether it's doing a good job, but we don't find out from this audit whether it is.

We find that there are deficiencies in information-gathering, so we recommend that they gather information. They say, "Yeah, we're going to gather information," but we still don't know stuff that's very practical.

For instance, I would like to know: what are the response times, with international and national comparisons? We don't know.

Downtime. Are planes and helicopters equipped to minimize downtime in bad weather? We don't know.

The result of this is that it's status quo. Everything sounds rosy; everything sounds great. But to me, it's kind of a surface rather than a penetrating analysis, and it doesn't give us a lot of direction. We're just not sure whether these good, well-intentioned folks are doing a good job or not.

P. Nagati: When we designed this audit, we originally intended to analyze patient outcomes. Ultimately, that's what matters. How did the patient do when they received air ambulance service?

We found that BCAS did not have that information, so we had to back off a level. We had to look at proxies for patient outcomes — timeliness of service, quality of care, the safety of the service provided. Once again, we found that BCAS did not collect the information to assess whether it was providing timely, safe or quality patient care.

We share your frustration, in that we couldn't get closer to what ultimately matters — patient outcomes — but we did what we could with the information that BCAS had available.

L. Throness: Then, may I suggest that you go back with a hard look at it, because that's a serious issue. We're talking 7,500 people dying outside of hospital in B.C. every year. How many of those could be attributed to a lack of service from the BCAS? We need to know that as public-policy-makers.

May I request that you go back with that more penetrating, harder analysis and a more critical analysis for us in the future?

R. Jones: Thank you, Member. I have noted that down. It is something…. As I mentioned before, we will be doing a follow-up. Maybe, in looking at that follow-up, as we have done with a number of other audits, we may expand it, now that we have an understanding that the B.C. Ambulance Service is getting more information and whatnot, so that we can penetrate it further. We'll put that into our plan.

V. Huntington: I'm a little bit frustrated that we have to rush at this point, because I think the audit does un-
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cover a number of issues.

You've undertaken all of these good reforms over the last year. But so many of them should have been absolutely standard within the service over the last few years that I'm wondering how management is now dealing with their own training levels and their own understanding of the responsibilities that are inherent at the management level. How is that progressing?

P. Thorpe: Thank you for the question. I think it's fair to say that we recognize that there were…. Following the audit, we saw the gaps that were there. From the point of view of the management, I think what's been important for us in the last 12 months is our move into the health sector. That allows us to start to look at some of these things such as the quality.

We recognize some of the gaps that were identified during the audit around the provision of the service — the technical, the operational side. Doug and colleagues have worked very hard on that. We're continuing our transformation into a more accountable organization, an organization that works within Health. I think that's where those issues are going to be captured now.

V. Huntington: Okay. I don't know how much time we're going to have for two or three questions. Let me be really specific to follow up on one of Laurie's comments. What is the pre-hospital death rate at the moment in northern British Columbia?

V. Huntington: We have the data in the late '80s. It was repeated in 2012, but there's no update on that data. Seventy-five percent of individuals died pre-hospital in northern British Columbia versus 14 percent in the Lower Mainland.

I'd like to have an understanding at some point — maybe it can be done in the follow-up audit — of what that factor is today. And has the Air Ambulance Service come to some understanding of what role they might have played in that? Is it timeliness?

It seems to me, for instance, that even 13 minutes…. If it's a standard, an average of 13 minutes before you even think about getting the plane off the ground, is there another way that you can deal with those types of things? Where are your critical care people? Where are your top-level people?

I've seen stories where you're flying them out of Vancouver, and then they go up to Prince Rupert, and then they go on the helicopter to wherever they're going. Well, is that the best message and the best way of organizing your equipment and your personnel?

I am really troubled by some of this, and I think we do need more data. I think we do need some comparisons between the way the B.C. Air Ambulance Service works versus the STARS system. It maybe needs to have an independent analysis.

Certainly, I've been overwhelmed with individuals — one in particular that I think we all know about — talking about the difference between the services here, in Europe, in Ontario, in Alberta and British Columbia.

I need to know the information from an independent perspective — not from your perspective, not from his perspective. What is the reality here? And is there a better way that government and the Air Ambulance Service can really define what the issues are and provide us with the best-quality operation that we can possibly have?

That's not to say you're not dedicated and that the quality of the service isn't good. It's just that the audit uncovers some substantial problems. When I ask what the pre-hospital death rate is in northern British Columbia, the answer should be there — if you understand.

S. Gibson: You mentioned a term in your presentation: "controlled substances." Now, that wasn't mentioned here. I'm not sure why you mentioned that. I was just going to ask. I have two questions. What was that all about?

D. Blackie: This is a new system that we have in place to control access to narcotics and other drugs which fall under the "controlled substances" definition that the paramedics use as part of their practice. In the past the narcotics and other drugs were issued personally to the paramedics. As well, they could replenish those packs when they were at various different hospitals.

There were a number of issues that were identified through an internal audit around that. This predates my time at B.C. Ambulance. We now have a much stricter control system with biometric safes at each of the air ambulance stations, and the drugs are no longer individually given to the paramedics. They're given to the paramedics for the time of that shift.

We've just put stricter controls on things like the morphine that they use and the paralytics and other drugs that they use.

P. Thorpe: No, it was due to a change in legislation about the use and the carrying and storage of those drugs.

S. Gibson: My question is on the "Audit Results by Criteria." It has criterion 2.1: the Ambulance Service "is meeting the service according to standards of quality of care." And it says on it: "Not measurable." I might contest
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that one, possibly. Earlier on we heard that there's surveying that takes place. With my background in business and marketing, the only way you can tell the quality of service is to talk to the customers — i.e., the patients.

I was a little disappointed in that one. It's not an overt criticism, I guess. But if you're talking to the patients, you find out the quality of care is going to be revealed by the patients. Mr. Blackie mentioned a moment ago…. I picked up the word "surveys," which I circled in my notes here.

Could either one of you — either Mr. Blackie or Mr. Thorpe — or the Auditor General comment on the advisability of surveying, the validity of surveying and how useful it is to determine the quality of service? In that case, where it says here "not measurable," it would likely move into the category of being measurable. Those are my questions.

P. Thorpe: I'll refer the question over the use of the surveys to Jan Butler from the quality side.

J. Butler: Thank you for the question. It's a very timely one, and it's an issue that the province of B.C. is actually addressing through the patient-reported experience measures group, which is a provincial group that, as you may be aware, has been conducting patient experience surveys in various sectors across the province. For the first time ever, B.C. emergency health services has been invited to participate in that process.

I actually sit on the working group to develop those questions. We met as recently as last week to finalize some of the questions that will be included in the survey process, so we are actually moving down that road. The details of that are not yet quite finalized, but we are going there.

D. Blackie: If I may, internally over the last six months we've also piloted a survey of the hospital sites that our paramedics visit to transfer patients out of. We pilot-tested, essentially, a survey instrument with those sites. They sent it back in a stamped self-addressed envelope, and it provided us with some good feedback from the nurses and the doctors in those sending hospitals about our responsiveness as a system, the communication with those systems and their general assessment of the paramedics.

It was a pilot. We're evaluating right now how we maybe can improve upon it, integrate it with some other surveys that are occurring with respect to the patient experience. So, again, it was an early trial, but it actually did provide us with some good feedback just in terms of how our program is working with the hospitals and the doctors.

S. Gibson: I guess, supplementary…. Two suggestions I'd make is that it's much better to use a third party, an external party, to do the surveying. Second, to increase participation and transparency, advise participants that all raw data will be available. If there's any suspicion that it's massaged or sanitized in any way, the participation rate drops significantly. Those are just two gentle recommendations.

R. Jones: I was just going to mention that we, in a number of our reports, do use surveys as well, and it can be a very useful tool for gathering information.

Myself and the Deputy Auditor General were at a forum last week for the Pacific Northwest. It was an audit forum where we met with people from Oregon, Washington State and Alaska. One of the sessions was around surveying and the usefulness — a lot of good tips around how to get the best information. You always do have to watch what you get in a survey, but if the survey is crafted in the right manner, you can get some very good information.

Just one other point that the member brought up around the use of drugs and whatnot. I know for a fact that most of the health authorities…. In their internal audit departments right now, that is one of the key internal audits that they are doing — taking a look at drugs and the disposition of drugs and the controls around that. So it's good to see that it was looked at.

B. Ralston (Chair): I put myself on the list next. In the Ambulance Service presentation, in "Next Steps," they talked about…. That was in response to recommendation 2. It states: "Design new air ambulance contracts based on volume and referral patterns."

On page 20 of the audit, there's a review of the three long-term contracts that were signed in 2011 and 2012. There was a fairness audit of those, and there were no discernible improprieties. But I do understand, for example, that the contract with Helijet is an eight-year contract, $104 million. It runs through to April 1, 2019, with an option to renew for another four years, although, apparently, there is a provision to terminate on six months' notice.

What is meant by "designing new air ambulance contracts," given that it appears that the service is locked into three long-term contracts?

D. Blackie: Thank you for the question. A number of these contracts have the option to renew. The first of those contracts comes up in 2015. You're correct that most of them are fairly long-term contracts. That was a decision that was taken by the B.C. Ambulance Service prior to my arrival. But it does enable us, through the renewal phase and the extension phase, to be able to at least have discussions with those air carriers.

They are long-term contracts. But what we want to do is, as each of those contracts comes up for reconsidera-
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tion, to determine whether, in fact, those aircraft and crew are in the right place. We want to be able to assess that.

B. Ralston (Chair): You also mentioned a contract with Northern Thunderbird Air. There was a well-publicized crash, resulting in fatalities at YVR and involving a Northern Thunderbird Air aircraft, in 2011. What review did you undertake of your contract with Northern Thunderbird Air as a result of that? I believe there was a coroner's inquest as well.

D. Blackie: We are in receipt of the Transportation Safety Board's final report on that crash and have been in constant contact with Northern Thunderbird to understand the salient events that contributed to that unfortunate accident. The issues have been covered and investigated by Mr. Bouchard, the manager of aviation, and his audit team in their recently completed audit of Northern Thunderbird.

The audit that Mr. Bouchard and the audit team completed with Northern Thunderbird Air has demonstrated no material findings related to flight safety or maintenance of the aircraft. The findings they did have were more around recordkeeping and some minor issues.

We're satisfied that that particular unfortunate accident at YVR involving the Northern Thunderbird aircraft, which was a different aircraft by model than the ones that we currently use for the Air Ambulance Service, was in fact an isolated incident.

You can read the Transportation Safety Board report, which I'm sure you have, which outlines the contributing factors to that accident. But we're satisfied, through our audit process and our ongoing contract compliance and ongoing meetings and discussions with Northern Thunderbird, that they operate the air ambulance that they are contracted for in a safe and professional manner.

L. Reimer: My question is along the same lines as David Eby's when he was asking you who is on board these aircraft, what skills they have and what training they have.

I have come to realize that some jurisdictions have doctors on board. I'm wondering if we've looked at that and whether we've determined whether or not that might be feasible and whether that makes a difference to patient outcome.

D. Blackie: I can provide some information, but I would have to go back and provide information later with respect to the clinical outcomes of having a physician on board.

We have looked at it and have concluded that having two critical care paramedics — who are trained, by and large, equivalent to an intensive care nurse — on board the aircraft with real-time physician support from intensivists, intensive care physicians, that are part of our transport advisory team — that we have, in effect, a de facto physician on board.

Our air ambulances are equipped with satellite telephones. The paramedics are in constant contact with the transport adviser specialists, who are essentially with them throughout the entire flight should anything require their intervention.

The model that's used in some jurisdictions is to have a nurse and a respiratory therapist. Some jurisdictions in Europe, for example, do use physicians and nurses, and in the United States. But we have found that the types of patients that we are providing care for are well served by having the two critical care paramedics on board, with the physician in real-time contact.

L. Reimer: My second question has to do with data, because I have been contacted by a constituent who feels that there isn't sufficient data at B.C. Ambulance. So will you be applying what you've learned from this audit of air ambulance to the rest of the Ambulance Service in addition?

P. Thorpe: I think the answer to that one would be: yes, we will. I think it's fair to say that we accept that the data we have is probably not totally accurate. That was something that was brought up through the audit process.

We need to also agree what that data is. So as Doug has mentioned, these sorts of international standards or the national standards, which aren't there at the moment, that we're working towards — once they've been agreed on, then we will obviously keep them. One of the things we'll need to look at is the appropriate way to publish them and make them open to the public and to members of this committee.

G. Heyman: The third recommendation was to "regularly identify and review a sample of air ambulance dispatch decisions to ensure resources are allocated with due consideration for patient needs and available resources."

I have two questions. One of them is: can we get a bit more specificity from Air Ambulance Service about what has been done to meet this recommendation, and any comment the Auditor General cares to make?

There was another recommendation to "periodically review whether the distribution of staff and aircraft across the province is optimal for responding to demand."

It would seem to me that the second recommendation is pretty obviously the kind of best practice I would expect to be in place and, to a lesser extent, perhaps recommendation 3 was as well.

I'm wondering if, in responding to these recommen-
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dations, the Ambulance Service or the Auditor General has…. In thinking about the lack of this review procedure or at least an adequate review procedure in these two regards prior to the Auditor General's report, have you identified any other areas of the service that should also be subject to regular review?

J. Butler: Peter Thorpe touched on it earlier in one of the other questions, with a reference to moving the B.C. emergency health services into the health sector.

I think it's fair to say that the regular and periodic review, as recommended by the Auditor General, is certainly something that is specific in this context to Air Ambulance. But I would say, more largely, the regular review in a formalized manner of all issues raised is not specific or unique to Air Ambulance.

It's certainly a gap that existed before the OAG's audit. It's a gap that's existed for many, many years within the emergency health services, but it is a gap that we have addressed. Certainly, within the last three years we've implemented a full quality and safety program in the organization, so we have recognized that.

The other gap that exists, which was also mentioned, I think, in Peter Nagati's comments in the presentation, was that we instituted a public complaints office within the B.C. emergency health services. Again, another gap that, one could argue, you would have expected to have been filled quite some time ago. But for an organization that was not aligned with the health care sector previously, these were new pieces that were brought in.

There are quite a few more examples. I can certainly share them, largely, but they're probably outside the scope of this particular audit.

P. Thorpe: If I can just add to that. To be quite open, my background isn't in air ambulance; it's in ground ambulance. That's where I've come from. Just to add to that and build on the question, I hope, I think there is more that we can do about where our ambulances are and what their capacity is to respond in the future. I think we've recognized that for some time. We've worked towards it, not just in respect of the remote and the rural areas of B.C. but also in the Lower Mainland itself.

The point about, "Have we got the right vehicle, the right ambulance, in the right place at the right time?" is a valid point. It's something, now that we've made this transition, that we really need to start to look at. I think the reason it's good to do it now is because we've got the advantage of being an integral part of the health system, which I would be used to in the U.K., rather than a branch on its own. Therefore, it's not just about where we are but where other services are actually located, how we can complement them and how we work with them jointly.

B. Ralston (Chair): Thank you. I'm then going to go to people a second time around. I don’t think there are any other first-time speakers.

K. Corrigan: I also wanted to talk about recommendation No. 2: "Periodically review whether the distribution of staff and aircraft across the province is optimal for responding to demand for air ambulance services." I noticed, in terms of reporting on progress, that there's reference to ongoing review of the air ambulance resource. I know there has been a little bit of talk about some of the things that have been done, but I'm trying to get a sense of what is new and different.

Then the other question with regard to recommendation 2. The response from the B.C. Ambulance Service said that the B.C. Ambulance Service "will undertake a blank-slate review in order to determine whether our aircraft and personnel are in the best locations." The blank-slate review, I note from your presentation today, has not been undertaken.

I'm just wondering if you could go over a little more the things that have been done that you haven't already talked about, in terms of responding to the concerns about the distribution of staff and aircraft and also a little bit about the blank-slate review and what that is going to entail, and why it hasn't happened yet.

D. Blackie: Those are great questions. Thank you. I'm happy to respond to them. In terms of what’s new and different, we've focused on getting the foundation sorted out with respect to the air ambulance system, how the air ambulance system is integrated with the ground ambulance system. I'm fairly new to the Ambulance Service. I started just shortly before the Auditor General's report came down, so it was a bit of a learning curve. That's my story and not an excuse.

At any rate, what we have done, in terms of new and different, is really trying to understand our business and what it is that we actually do today, and then start building that foundation that we can then build our house on top of, so to speak — which were a lot of the great ideas that came from the Auditor General.

One of the things that we have undertaken is really trying to…. And we've talked a little bit about this — this Lean initiative that we did with our partners in the Patient Transfer Network and the dispatch office — to really say: "How can we improve what we currently do, and how can we better analyze what it is that we currently do?" So really understanding our current state better, because it is spread over several different organizations within B.C. emergency health services. I have spent quite a bit of time doing that.

Just as a point of clarification: the 38- down to 13-minute exercise was for patients who were already in a hospital that needed to be transferred to another hospital. Our response rates, in terms of the autolaunch, which is responses to accident scenes, is immediate. I just want-
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ed to be very clear about that.

In terms of understanding where the aircraft and crew are — can we optimize that or change that? — we've made some small, minor changes to when paramedics come on shift, when the aircraft come on shift — just some tweaking to see if we can actually improve efficiency.

For example, by changing the start time of our Prince George aircraft, we've actually managed to carry more patients during the day. It's just one of those funny little things, but nevertheless, it has been positively evaluated. A one-hour difference makes a world of difference. It's small changes like that.

The graphic I showed earlier with all the lines on it is the precursor to the blank-slate review. It's really trying to understand: where are the patients that each air ambulance is being sent to, and where are the hot spots, so to speak? If we have a patient in Fort Nelson, how often are we going to Fort Nelson? How sick are the patients in Fort Nelson compared to Kelowna, compared to, say, Prince Rupert or Haida Gwaii? Then understanding those patterns.

That work is underway. We have staff working on that, as we speak — again, to try and map out where the patients are, how sick they are and where they're going.

A big part of the learning and another thing that's new and different is the amount of engagement we're doing and partnering with the health authorities. I don't believe there was a lot of that previously within the Ambulance Service. It's not a criticism. It's just the way things were organized.

Being now part of the Provincial Health Services Authority has really opened up the opportunity to sit down, roll up the sleeves and get some real work done with the health authorities. We've been working very closely with Interior Health, in understanding how their referral patterns are for trauma cases, with Northern Health around how they want to establish their trauma centres, so that we can then realign our resources potentially to support that.

In terms of the bigger picture — and that's where the blank slate comes in — you really have to get the fundamentals down, understand what your business is today and then the blank slate is really saying: "If we were to build it all over again, would it look like this?" My understanding, and certainly what I've been told by my predecessor, is that the location of the air ambulances has been largely historic. It's where they've always been. I'm the person who is the new guy, who is in there saying: "Well, let's challenge that assumption."

Does it make more sense to put an air ambulance in Fort St. John? Does it make sense to put them all in Kamloops? I don't know at this point. That's where, hopefully, the blank-slate review, which would be done by a third party — it wouldn't be done internally — would help us.

We have had some preliminary discussions with an academic group that has done some work for B.C. Ferries and those sorts of organizations — FedEx — those sorts of ideas of how you manage logistics and how you move a package, essentially, from A to B. It's a level of expertise that we're going to go outside of our organization to help us determine.

In terms of my own workplan, it has very much been: let's get the fundamentals right. Let's work with our health authority partners to make sure what we're thinking about is what they're thinking about and vice versa, so that we can integrate our planning and integrate our vision of services to the north, the Interior and the Island, those sorts of things, and then be able to move forward.

We're still kind of in that early phase, I guess, but we're hoping to implement, if all goes according to Hoyle, the blank-slate review probably by the fall of this year. That's our plan at the moment.

V. Huntington: Some of my questions have been asked, but if I could go back to the blank-slate review. Have you no hypothetical numbers, no previous understanding of what the demands are on the service, say, in northern British Columbia — northwest versus northern areas, because they have had two different response- and death-rate issues over the history? Do you not have some sense of whether you've got the resources or the trained personnel necessary to service the north, for instance?

It is the critical area in terms of higher death rate, and that's a response-time indicator — not necessarily from you but for reaching trauma centres — of the certain values. There's got to be something so that you've got a sense of how you're going to serve these sectors that have lost ground over the years in terms of their ability to have an equal level of service throughout the province — understanding that if they need trauma level 1, they've got to get down to Vancouver or Victoria, because that changes within the health services.

There must be some instinct you've got in terms of locating personnel, the level of training the personnel need, rather than congregating them in Vancouver. Or is it like the Oil and Gas Commission? They don't want to live up north, so they actually live in Kelowna and Victoria.

D. Blackie: I can try to answer that question from an Air Ambulance perspective. Certainly, what you've touched on, Member, is what the Auditor General also observed, which is: it's very difficult to make decisions based on gut feel.

We have a pretty good feeling, and the feedback we get from the health authorities is that, yep, they're happy with the job that we're providing. Sure, there are some challenges. There are small communities, like Takla Landing. There's Dease Lake, for example, where there has been criticism. We're often challenged to get there in a timely
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manner, and there are many reasons for that.

Sure, our gut feel is that at the moment there's a general satisfaction, but can we do better? If we're going to do better, we have to do with evidence, and that evidence had not been forthcoming previously, in my experience. We've begun to actually collect that evidence in a way that isn't call by call by call but is more metadata that allows us to look at: where are the hot spots, and where are the patients coming from — in a very macro sense?

I think in the past the Ambulance Service has provided an on-demand service: "You call; we haul." That's what I've been told by some of the paramedics. I think that has served the agency well for many years, but now we're getting to the point where the planning and the decision-making, which the Auditor General pointed out, has to be more sophisticated.

Unfortunately, the challenges and sophistication sometimes take a bit of time when you're dealing with a lot of — say, for example — legacy data systems. As Peter said earlier, we are focusing on trying to improve our data systems. We've cracked that nut, I'm positive, to be able to answer that particular question, saying: "Our gut feel and our intuition is this, but what is it actually?"

A lot of it, too, has to do with the health authorities in terms of, as I said, being able to integrate our service with their services as well. For example, for a badly injured patient in Fort St. John, Northern Health, at the moment, would prefer that patient go to Edmonton. That actually introduces a whole series of complexities in terms of a transfer and why, for example, often a Fort St. John transfer may be contracted out to Alberta. It makes more sense to use an Alberta resource to do that.

I'd prefer a B.C. resource do it. From a taxpayers' perspective, it's a lot more cost-effective to have a B.C. resource do that transfer, but from a patient care perspective and a timeliness perspective, sometimes we can do those calls a lot faster than Alberta, and sometimes Alberta can do them faster than us. I'd like to be able to have that flexibility.

As I said, our decisions need to be more evidence-based. The critique from the Auditor General is: "You can't demonstrate that you are doing this or doing that." We know, we feel, we talk about it with the health authorities, and they're very objective, I think, in their comments to us. Some things work well; some things don't. But we have to be able to also show that. So that's been where a lot of the work and energy has gone.

V. Huntington: I'm sure glad that the energy…. I'm sure glad the work's starting to happen, because it's pretty surprising. I go back to one thing you said, a little thing. You said that increasing the start time by an hour makes a big difference. What do you mean? Are these individuals contracted on ten hours a day or 12 hours? Are they not ready to go the minute they're required to go? What is the issue here?

D. Blackie: I'm happy to clarify that. The Prince George air ambulance pilots and crew were traditionally coming on shift, I believe, at eight o'clock in the morning. Now they come on at seven. It's a small change, but that change has actually resulted in more patients being handled, because they're essentially in the queue earlier, provincially, to be able to move those patients out of Prince George or to be able to go somewhere in the north to transfer someone. It sounds like a small change, but it's actually had a fairly significant impact.

V. Huntington: What I'm flabbergasted to hear is that it's not a 24-hour service.

D. Blackie: The air ambulance service is 24 hours. The Prince George, Kelowna and Kamloops teams are all on a 12-hour shift. Then we have the province, which is essentially served by the Vancouver-based team at night. That has shown to be adequate in terms of how our call patterns are from the sending facilities.

V. Huntington: How about survival rates and patient outcomes? You don't know those answers, do you?

D. Blackie: I don’t have them at my fingertips today, because a lot of the data…. The example you gave earlier is actually coroner data in terms of people who die at the scene. I can provide you with a study that was done in the north — I believe it was last year or the year before — which looked at this very issue, in terms of survivability. I'm happy to do so. I just don't have it with me today.

V. Huntington: Mr. Blackie, I think what I’m looking for is information…. How effective is the B.C. Air Ambulance Service at moving patients and getting them to where they're supposed to be, alive? It's not a matter of looking at coroners' data about who died on scene. Just how effective are you at the job of moving critically ill people to the trauma centres?

Then there are the hospital transfers. That's another issue. I don't know how many of those would be considered critical.

But it seems to me the job of the Air Ambulance Service is to get somebody from injury point to trauma care as quickly as possible, and to know whether you're doing that effectively — i.e., patient outcome. That, to me, would be one of the most critical things that you should be knowing about the effectiveness of the service.

P. Thorpe: If I could just add, maybe, Mr. Chair, to that, because I think what….

B. Ralston (Chair): I'll ask the Auditor General to re-
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spond to the general point as well, but you go first.

P. Thorpe: It's just that, as we said during the presentation and I think the Auditor General said as well, only about 10 percent of our work is those emergencies and those trauma patients. What we find is that about 90 percent of our work is critical transfers. We talked about death out of hospital. It's a small percentage of the work that Air Ambulance does. Many of those patients are transported to hospital by ground crews. I think that relates back to the fact that we're an integrated service, unlike many others.

I think, from my experience — I was the area director in Prince George, covering the northern districts for some time — there are lots of challenges. A lot of that area is not covered by 911, so potentially, we find out too late, regardless, that there's been an accident. The fact there are great distances….

The issue there over the timeliness of response is always important, and I accept that. I just wanted to take the chance to acknowledge that, but also, the perspective there is that — whilst we will get back to you with those, the report that Doug has talked about — many of those patients are secondary transfers. They're successful transfers and are transferred safely from a local hospital, where they would have been assessed by a physician after being taken by a ground crew through to the major trauma centres through the critical care transport teams.

V. Huntington: I'm interested in that 10 percent that we don't know what the outcome is.

I think, as Peter Nagati pointed out earlier, one of the things that we would like to have done was take a look at patient outcomes and the information around that.

Because it wasn't being tracked when we did the audit, we thus have our recommendation that that information should be available, that it should be tracked. That is useful information that should be reported publicly as well.

As we pointed out earlier too, we only looked at the air ambulance service, not the integrated service of all emergency health. But yes, we would love to see patient outcomes tracked and the information made available.

N. Letnick: Two questions. Both have to do with the meta-analysis that you're going to do — the clean slate of where the services are and where the customers are and if you are located in the right place.

The first question is: will all that data be available to the public to review so that when you come up with your final decision, the public can see that it's supportable for that decision? If you're talking about moving services, you're talking about a big political issue. Don't underestimate how powerful health care is when it comes to politics.

The second question, which is related, is: what process are you going to go through, through that review? What I mean by that is: who, through the different parts of it, will be the ones that are adopting the recommendations? Does that end up at the deputy minister level? Does it end up at the cabinet table? Does it end up at the CEO of B.C. Ambulance? Who, at the end of the day, will be making those decisions?

If you can just describe the process so that we're all comforted that the data is transparent and open to everyone to provide input or to comment on and that the process is also open and transparent. So when you come up with your final decision, at least people will understand how you got there.

P. Thorpe: I think I must try and pick up the transparency issue. It's fair to say that once the data in that review is done and we know the results that are on view, it will involve great involvement with stakeholders. I think all the people you've talked about there would be classed as stakeholders.

Decisions and recommendations would be made to the PHSA board and the BCEHS board, which is our governance process, but we would also need to consult with the local communities and the areas that are served. So in summary, yes.

The data. At what level? I struggle to say. We need to be clear on privacy issues and all that sort of stuff, but it's not unreasonable to assume that lots of that data will be available, although it may be in a highly summarized form.

The evidence and the types of things that have been displayed today, from the point of view of the maps and the mapping that we can look at, are something which should be part of that as well so that it's visible and people can understand it.

Then the governance process that we would follow will be through the BCEHS and PHSA board.

D. Blackie: We haven't quite laid it out yet — the process — because we're not quite there yet, but I just want to reiterate what Peter said. The process already, in terms of the understanding — the demand mapping that has been shared with the health authorities…. The health authorities obviously are a huge partner in this, but also, our employees would be impacted by any potential changes.

I do take your point regarding the need to engage with communities, as well as at the political level. I think our experience from our colleagues in Alberta with respect to this very issue has been some good lessons learned for us. We've been working with them very closely just to understand some of the challenges they've had to try
[ Page 290 ]
and change their deployment of air ambulances and some of the problems that's caused —so some lessons learned from our neighbours to the east and taken under advisement.

N. Letnick: A supplementary, if I may. Then, are you saying that the PHSA board will make the final decision on the distribution of services for B.C. Ambulance? Or is the B.C. Ambulance going to do it? Or is the Minister of Health going to do it?

P. Thorpe: Sorry if I wasn't clear about that. I think what I'm saying is that there's a governance process in all these decisions. Whatever the review comes up with would go through the BCEHS board, through to the PHSA.

It would be fair to say at this moment in time…. You've mentioned it also. There would be political interest in that, and I think there would have to be consultation with all the stakeholders, which would include everybody that you've mentioned, prior to any changes being made.

The other bit here, just for clarification. Obviously, there are only so many places you can run these services from in B.C. There needs to be the infrastructure around it, even in a process that identified that it might be better to put an air ambulance in a certain location. From the point of view of the time it would take, if there are no facilities there to support it….

There are lots of different factors we'd need to look at, but from the point of view of who makes the final decision, that would have to be made in consultation with the whole group of stakeholders that you've mentioned.

M. Morris: One of the comments you made earlier is that the Northern Health is a fairly big user of the air ambulance service that we have in the province here.

Prince George is geographically centred pretty much in the centre of the province.

Prince George has some great facilities there. But I would think that having your 24-hour service centred in Vancouver…. Most of the trips would start in Vancouver, go inland, upcountry, perhaps north of Prince George and around, pick up the individual and all the way back to Vancouver again. That, of course, delays…. You know, you're looking at an hour's flight time to Prince George and beyond.

Would it not be better to locate a 24-hour service in the centre part of the province, and they can take off from there and head south, perhaps, and pick up whoever needs to go and continue on? It cuts your response time down significantly and provides a higher level of service to the people in the interior of the province that require those services.

I know that Prince George has an ELS system. It's got all the new modern types of systems that we need to land at night and in inclement weather and whatnot. From my perspective, I think it'd be a big step in providing an enhanced level of service for all of B.C.

P. Thorpe: My first city when I arrived was Prince George, so I have a tie to it.

I think, in answer to your question, the short answer is that that may be one of the things that the blank-slate review shows us — that we should do things like that.

Doug mentioned previously that the position and the hours of operation are based on demand. I think the Auditor General has clearly outlined that we need to look at that periodically and review it.

We are going through that review process from the current…. Again, I don't want to keep on referring back to one slide but the slide that Doug showed from the Kamloops and Kelowna area…. I think that part of the review is: have we got the right vehicles in the right place operating at the right times?

There are always different factors involved in this as well, Mr. Morris, and one of them is about when physicians want to transfer people. We’ve talked about how the majority of these calls are transfers. The health service system in B.C. — the same as it is in the U.K. — is reluctant to transfer people overnight. The level of clinical cover available in some cases — I'm not saying every case — is not there to accept patients.

Part of the process that we go through with the Patient Transfer Network — we talked about the emergency physicians that are involved in that — is what the best time is. Sometimes the best time is two o'clock in the morning, and we have a vehicle, an air ambulance in Vancouver, that's willing and able to meet that. We've talked about the timelines and everything.

If a decision is found that there needs to be a change in that, then obviously, we'll need to respond to it. But we just need to be cognizant of the other stakeholders that we've talked about and what their needs are.

B. Ralston (Chair): I have a question myself. You mentioned STARS in Alberta, and there are some reports that it's a very effective service. I understand — at least, I've been advised — that STARS in Alberta has been considered so successful by the provinces of Saskatchewan and Manitoba that there's a proposal to amalgamate the three services across those three provinces.

Is that in fact the case? If so, are you aware of that? Finally, do you have any comment on that?
[ Page 291 ]

D. Blackie: We're not aware of any discussions around the prairie provinces amalgamating STARS services. We're in fairly constant contact with our colleagues at STARS and Alberta Health Services, and they've never mentioned that. So I'm not sure. That could very well be the case. The underlying reasons for it I can't really comment on.

I used to live in Alberta for a number of years. STARS is very high profile. They provide an excellent service for the people of Alberta and, most recently, Manitoba and Saskatchewan.

It is important to note, though, that they are a helicopter-only service, and they provide a very limited range of services — primarily trauma responses.

Again, it's the comment I made earlier. It is difficult to compare our fixed-wing and rotary-wing integrated service with a relatively small player like STARS, which operates a handful of aircraft in very specific mission profiles. I won't deny that they're extremely successful in the prairie provinces.

B. Ralston (Chair): The other thing that I was told about — it's a technical detail that I may be wrong on, but I'll venture the question nonetheless — is that Alberta helicopters are able to carry two patients at once, and that's not the case in British Columbia. Is that in fact accurate or not?

D. Blackie: That is not accurate. STARS has implemented…. I don't work for STARS, so I'm only taking this second hand, from my conversations with my colleagues at STARS. They have recently implemented a new helicopter, which is physically larger than their previous helicopters. Their previous helicopters comfortably can carry one patient and uncomfortably two. The new helicopter is designed for one but can carry two.

The Sikorsky S-76C+, which we operate through our helijet operator, and the Bell 412, which is our Kamloops-based helicopter, can both carry two patients at a time, or one incubator. It's arguable that we can carry two incubators, but there's an issue of access for the paramedics. Nevertheless, we can carry, if needed, two patients. The fixed-wing aircraft can also carry up to two patients.

B. Ralston (Chair): Thank you. Those are all the questions I have. We're just about near the time.

I did want to note that reference has been made to some follow-up that you'd undertaken, Mr. Thorpe and Mr. Blackie, to provide. The Clerk will be in contact with you. That will come to the committee and then be distributed to all members.

Auditor General, did you have any closing comments that you wish to make? I think we've had a pretty thorough canvass of the issues here.

I did note that the public account hearings into the air ambulance service in Ontario went on for at least 18 months. We've obviously accomplished it in much speedier time. Better Chair, perhaps. Thank you very much.

Before members leave, there's one other item that I want to address briefly. Perhaps we'll let Mr. Blackie and Mr. Thorpe pack up, and then I'll address that final issue just before people go.

B. Ralston (Chair): I did want to note for the committee that many of you will know Josie Schofield. Unfortunately, she couldn't be here today. She has worked with the parliamentary committees office since 2000 and has served as the researcher in support of the Select Standing Committee on Public Accounts since 2007. She has prepared, over that time, 11 reports of the Select Standing Committee on Public Accounts.

She will be embarking on a very well-deserved retirement at the end of this month, and as such, this will be the final Public Accounts Committee meeting for which she acts in her capacity as a researcher. She's a dedicated observer of the Public Accounts Committee, as many will know. I'm sure that none of us would be surprised to see her in the gallery at a future meeting.

I just want to ask members to join me in conveying our appreciation and thanks to Josie for a job well done over those many years.

V. Huntington: Just under other business, I wonder if others on the committee would be interested in a discussion of management letters and our right to review these management letters with the Auditor General and under what circumstances. I wonder if that could go on the next agenda or the next appropriate agenda — not in two years.

B. Ralston (Chair): Sure. Thank you for that. I know that's a concern that you've raised before. Perhaps what I can suggest is that the Deputy Chair and myself can discuss that, and we'll get back to you about how we might tackle that issue or whether we want to bring it to the committee as a whole or whether it's something we can deal with in another way. That's noted, and we'll get back to you.
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V. Huntington: That would be fine, Mr. Chair, except that I really feel that it's an issue that the committee as a whole could discuss quite appropriately, in camera if you prefer. But I for one would like a clear understanding of why there is this problem of us seeing management letters and whether or not we should have access to them.

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Chair:	* Bruce Ralston (Surrey-Whalley NDP)
Deputy Chair:	* Sam Sullivan (Vancouver–False Creek BC Liberal)
Members:	* Kathy Corrigan (Burnaby–Deer Lake NDP)
	* Marc Dalton (Maple Ridge–Mission BC Liberal)
	* David Eby (Vancouver–Point Grey NDP)
	* Simon Gibson (Abbotsford-Mission BC Liberal)
	* George Heyman (Vancouver-Fairview NDP)
	* Vicki Huntington (Delta South Ind.)
	* Greg Kyllo (Shuswap BC Liberal)
	* Norm Letnick (Kelowna–Lake Country BC Liberal)
	* Mike Morris (Prince George–Mackenzie BC Liberal)
	* Linda Reimer (Port Moody–Coquitlam BC Liberal)
	* Selina Robinson (Coquitlam-Maillardville NDP)
	* Shane Simpson (Vancouver-Hastings NDP)
	* Laurie Throness (Chilliwack-Hope BC Liberal)
	* denotes member present
Clerk:	Kate Ryan-Lloyd
Committee Staff:	Ron Wall (Committee Researcher)
Other Staff:	Greg Gudgeon (Office of the Comptroller General)

Witnesses:	Doug Blackie (B.C. Ambulance Service)
	Janice Butler (B.C. Emergency Health Services)
	Sheila Dodds (Office of the Auditor General)
	Russ Jones (Acting Auditor General)
	Gary Mitchell (Provincial Archivist)
	Peter Nagati (Office of the Auditor General)
	Peter Thorpe (Interim Chief Operating Officer, B.C. Ambulance Service)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
PUBLIC ACCOUNTS