Public Accounts Committee — Department of Health — 21 June 2017

2017-06-21

Newfoundland and Labrador — Committees

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June

21, 2017

PUBLIC ACCOUNTS COMMITTEE

Pursuant to Standing Order 68, John Finn, MHA for Stephenville Port au Port,

substitutes for Scott Reid, MHA for St. Georges Humber.

The

Committee met at 9:15 a.m. in the House of Assembly Chamber.

CHAIR (Brazil):

(Inaudible) 48th session of

the House of Assembly's hearings. The hearing today is with Health and Community

Services.

I'll

introduce myself and then I'll ask Members of the Committee to introduce who

they are and the district they represent. Then I'll ask the witnesses and the

Auditor General's staff to introduce themselves. Then I'll ask the Deputy Clerk

if she'll do the swearing in of the witnesses.

So I'll

just introduce I'm David Brazil; I'm the Chair of the Public Accounts

Committee and I'm the Member for the District of Conception Bay East Bell

Island.

MR. BRAGG:

Derrick Bragg, I'm the

Vice-Chair of the Public Accounts Committee and MHA for Fogo Island Cape

Freels.

MS. P. PARSONS:

Pam Parsons, I'm the Member

for Harbour Grace Port de Grave District and a Member of the Public Accounts

Committee.

MR. KING:

I'm Neil King; I'm a Member of the Public Accounts Committee and the MHA for the

historic District of Bonavista.

MR. FINN:

Good morning, John Finn, MHA

for Stephenville Port au Port. I'm substituting for Scott Reid today.

MS. ROGERS:

Good morning, I'm Gerry

Rogers and I work for the good people of St. John's Centre, and I am a Member of

the Public Accounts Committee.

MR. PETTEN:

Barry Petten, MHA for

Conception Bay South and also a Member of the Public Accounts Committee.

CHAIR:

Okay, I can start here.

Michelle.

MS. JEWER:

Michelle Jewer, ADM, Corporate Services, Department of Health.

MR. ABBOTT:

John Abbott, Deputy Minister, Department of Health and Community Services.

MS. TUBRETT:

Denise Tubrett, Assistant Deputy Minister of Regional Services with the

Department of Health.

MS. WADDLETON:

Deena Waddleton, Health Consultant with the Department of Health.

MS. BATSTONE:

Angie Batstone, Director of Medical Services, Department of Health and Community

Services.

MR. PADDON:

Terry Paddon, Auditor General.

MS. RUSSELL:

Sandra Russell, Deputy Auditor General.

MS. KEATS:

Trena Keats, Audit Principal of Performance Audit.

CHAIR:

Okay, welcome to everybody.

I'm

going to ask Elizabeth now if she'll do the swearing in of the witnesses,

please.

Swearing of Witnesses

Ms.

Michelle Jewer

Mr.

John Abbott

Ms.

Denise Tubrett

Ms.

Deena Waddleton

Ms.

Angie Batstone

Mr.

Terry Paddon

Ms.

Sandra Russell

Ms.

Trena Keats

CHAIR:

Thank you, Elizabeth.

Just to

start off the process here, we're looking at the issue identified by the Auditor

General, particularly as it pertains to Health and Community services. In

principle, what we're doing here is really having six hearings in one day. It's

a fairly ambitious agenda. Some of it may be very easily answered and the

questions may be poignant and direct, then the answers are good.

We've

done it in a format where, from our assessment, we feel the first two or three

items may be easier to get through, and then the more contentious ones, or ones

that need more explanation, where there may be more questions asked, would take

a little bit longer.

So I do

ask that when you're asking a question if it's already been asked, fair enough,

if we can move for the expedient process; if you're answering a question, if you

could keep it to the point as much as possible for relevance purposes. Also,

with that being said, we're not going to confine anybody from not asking

questions if they have some issues of clarification they need, nor for the

witnesses having an opportunity to actually explain exactly what they're doing

to be proactive of this.

Periodically, maybe more often than not, we will be asking the Auditor General

for an opinion on certain things and for his and his staff's view on specific

issues that have been shared with us. It's an opportunity for us to ask

questions as a committee and for the line department and officials to explain

exactly how you're moving forward, your proactive approach to addressing the

issue outlined by the AG.

The

first process is that I turn it over to Mr. Abbott, as the deputy minister, to

have some introductory remarks.

MR. ABBOTT:

Thank you, Mr. Chair.

certainly appreciate this opportunity. Again, what we will be able to report I

think as a result of the Auditor General's report and our initial responses,

through the course of each one of these items, we will give you an update as to

where we are since June of 2015, as well as November 2016.

Needless to say, we've obviously taken each of the report items seriously. We're

working closely with our key stakeholders, and each of these pretty well has

been either the regional health authority or the private operators that they

oversee.

There's

been a lot of progress over the time since the reports have been issued, and

we'll be more than happy to speak to those as we go through.

CHAIR:

Okay, thank you; we welcome

that.

The

normal process that we're going to use today is that we'll give five minutes to

each of the speakers to ask their questions. You don't necessarily have to take

the whole five minutes. Some of them maybe easily answered if the question is

relevant to one or two particular issues and it's answered, then we can move on

to that. I'll start with Mr. Bragg and we will start with the first heading,

sorry, the Prescription Drug Program.

MR. BRAGG:

Thank you very much and

thank you, guys, for coming out this morning.

Actually, I won't be too long with you because I just reviewed, the last couple

of days, the report you guys gave us and the top two headings are the ones I

think we'll look for more of an update on, the progress of these. I may be wrong

in how I pronounce this; would it be the Medigent system, refill business? You

were saying anticipated in March you are going to have some action on that.

MR. ABBOTT:

Yes, that's the Medigent.

For the 10 recommendations that have been identified, I think it's fair to say

that of those 10, nine have been fully implemented and we can speak to those.

The one that you're referring to, Recommendation 1, is partially implemented.

I'll

ask Michelle Jewer to speak to the specifics, but we feel that we're not going

to be able to, I guess, concur with the Auditor General's recommendation really

because of technical issues with that applying the rules under Medigent to our

program.

Maybe

I'll get Michelle to speak to the specifics of that.

MS. JEWER: The

refill business rule that was referred to in the report, we did review that with

the vendor and it was determined there are limitations with the rule. There are

implications for pharmacies from an operational point of view. It would be a

delay in the pharmacies potentially, and that would mean beneficiaries would

have delay in getting their prescriptions. So that was one big one for us.

There were also issues with being able to track the

original prescription number because of change in processes. Right now,

pharmacists are able to extend prescriptions. So that would mean a prescription

refill might not get tracked the same way as if a physician would put a

prescription in the system.

There are certain limitations with it, that we decided that

business rule, we can't implement; but, what we are doing, we are doing

post-payment audit of refills. So that would check if there's misbilling for

refills. In addition, part of the recommendation was to look at other courses of

action in case this business rule didn't work.

So it's partially implemented because we are currently

working with the vendor to determine if there's another business rule that we

can put in place that could prevent misbilling of refills.

MR. BRAGG:

Okay, thank you.

I guess that's the same thing for the second part of that,

the second recommendation, is it, a similar answer?

MR. ABBOTT:

Well, the second one, in fact, has been fully implemented.

MR. BRAGG:

Okay. It says not implemented here when you guys gave it to us. It was to

reduce the risk of unauthorized claims and payments of inappropriate

professional fees .

MR. ABBOTT:

Yes, okay.

So, again, Michelle Jewer will respond.

MS. JEWER: So

we're saying fully implemented for this one because the recommendation said:

The Department should determine whether modifications to the Medigent system

can reduce the risk of unauthorized claims and payment of inappropriate

professional fees for compounds and prescription splitting.

We have determined that rule put in Medigent will not

prevent inappropriate professional fees for prescription splitting or compounds.

And a reason for that is because the Canadian Pharmacy Association develops

claim standards to provide orderly and efficient online processing of

prescription claims. Part of those standards does not take into account

compounds, and the different ingredients for compounds. Because that isn't in

place, it's very difficult for us to put a rule in. So that's one reason.

Another thing, there is a FPT,

federal/provincial/territorial group, a director, a pharmacy director forum,

that has this issue on its agenda to look at the claim standards and revise it

for compounds. So that's one thing that's still in process.

Prescription splitting, again, is something that we can't track by a rule in

Medigent. Again, it's the quantities that cover products dispense must be in

accordance with prescription to maximize of 90 days' supply, and there are some

exceptions to that. So we can't put all the exceptions in as a rule, but what we

are doing to ensure that we are paying appropriate claims for compounds and

prescription splitting is we are doing a post-payment audit of those claims that

come in.

MR. BRAGG:

Okay, thank you.

I'm

good, Mr. Chair.

CHAIR:

Good there, okay.

Mr.

Petten, questions on this heading?

MR. PETTEN:

The questions that Derrick

had was pretty well all I had on that section. It appears everything else seems

to be implemented.

CHAIR:

Okay, perfect.

Ms.

Parsons.

MS. P. PARSONS:

I don't have anything on the

Prescription Drug Program.

CHAIR:

Okay.

Ms.

Rogers.

MS. ROGERS:

Thank you, and thank you so

very much for being with us here this morning.

When we

look at some of the findings of the Auditor General, it seems that perhaps it

indicates an audit sector that is somewhat overwhelmed when we look at the

finding that 58 per cent of the audits outstanding as of September 30, 2014 had

been in progress between three and eight years.

I'm

wondering if staffing is one of the issues in being able to do the work that's

required.

MR. ABBOTT:

Thank you, Ms. Rogers.

I guess

the simple answer probably is that was not sort of the issue, but what we have

done since this report is looked at our audit process and have revised it. I

think we are now starting to see and what, I guess, the Auditor General was

really looking at is that we have a much more effective audit program.

So what

we've been doing over the past year or so is really being more aggressive with

our existing staff complement; having more organized audit process for this.

Now, for instance, in the department we audit numerous programs MCP being the

largest.

MS. ROGERS:

Yes.

MR. ABBOTT:

So, in essence, we've taken

our lessons and best practices from how we do those audits and now applying that

to our pharmacy program.

We've

had to, under legislation, put the regulations in place, which we have now done.

So it was really a large process issue for us. As a result over the past year or

so, we have looked at quite a number of audits. Michelle Jewer can speak to the

specifics of those, if you wish.

MS. JEWER:

Prior to September 2016, we

didn't have regulations in place to be able to do audit of NLPDP, so that was

something that was put in place in September 2016. As well, there's a provider

guide for pharmacists that bill through NLPDP and there wasn't an audit section.

That's also in place as of September 2016. Since that date, we've been able to

more aggressively audit, as John has mentioned.

Since

September 2016, we have audited approximately 470 pharmacists or pharmacies,

about 3,500 original prescriptions and about 13,000 claims in to NLPDP.

MS. ROGERS:

Great. So staffing is not an

issue.

MS. JEWER:

No.

MS. ROGERS:

Okay. Thank you very much.

You've

also said that we now have can we have copies of the 2014-'15 and '15-'16

annual reports of the audit section? I think that those were mentioned in the

MS. JEWER:

Yes, we can provide those.

MS. ROGERS:

Okay, great. Thank you very

much.

The

department said that a policy in the form of an audit

section for the NLPDP

provider guide has been prepared. Could we have a copy of that document?

MS. JEWER:

Yes.

MS. ROGERS:

Okay, great, thank you very

much.

There

was some talk of problem pharmacies. What would constitute, for instance, a

problem pharmacy and how would you define that?

MR. ABBOTT:

Do you want a go with that?

MS. JEWER:

I can try.

I think

it would be hard to answer that question as a problem pharmacy

MS. ROGERS:

Okay.

MS. JEWER:

There are a number of

different reasons why we find misbilling or incorrect billing, and it could be

simply a training issue. I would think the majority of them would be that.

We have

identified for example, compounds is an area that's complicated

MS. ROGERS:

Yes.

MS. JEWER:

So we've identified that as an area we would audit. Refills, again, it's

probably a difficult, complicated area. We would audit that.

There

are some areas within that pharmacists can bill NLPDP for certain, we call,

expanded pharmacy services, something like medication review, antibiotic

adherence. Those programs would probably be things that we would audit because

they're new, to ensure that they're being billed correctly.

MS. ROGERS:

Okay.

MR. ABBOTT:

If I may, Ms. Rogers, now

that we have the pharmacy network in place for all pharmacies, we'll have a lot

better information looking at utilization and then how that lines up with

claims. So we can be more proactive in looking at problem issues or problem

pharmacies, for that matter.

MS. ROGERS:

Great.

Also,

since the implementation or the discontinuation of the over-the-counter drug

program, I'm just wondering, is there any intent to track or audit any of the

rollout and effects of that? For instance, will we see a spike in prescription

drugs instead of the non-prescription drugs because the over the counter have

been discontinued? Is there any plan to look at that in your audit process, kind

of tracking some of the potential changes?

MR. ABBOTT:

It wouldn't come up in the

audit process, but I understand your question. That's why I say the Pharmacy

Network now will allow us then to start looking at all prescriptions and then

looking at trends so we can look at that because of this action, what has

happened on the other side of things. That's something we'll be monitoring

closely.

MS. ROGERS:

Great.

MR. ABBOTT:

We have been looking at the

impact on clients because there are exceptions as well. We've monitored that.

There have been few. So, again, we think the policy decision was the right one

for a number of reasons, but we are monitoring the take-up.

MS. ROGERS:

Okay.

CHAIR:

Ms. Rogers, I'm going to go

to Mr. King.

MS. ROGERS:

Thank you.

CHAIR:

We'll come back again as we

go through our process.

Mr.

King.

MR. KING:

Thank you for the detailed

package that you gave us. It's quite in depth. I've read through it several

times.

This

one I'm quite happy with. We got the update on the two outstanding items and

I've got nothing to add on this one.

Thank

you.

CHAIR:

Mr. Petten, any further

follow-up questions?

MR. PETTEN:

No.

CHAIR:

Mr. Finn?

MR. FINN:

I'm fine. Thank you very

much.

CHAIR:

Okay.

I'll go

back to Ms. Rogers.

MS. ROGERS:

Yeah, I just have one more

question.

It came

to my attention that someone had a prescription for one medication and it was, I

think something like it had to be 175 milligrams. The pharmacy then had to

break it up into three pills for the one prescription: 100 milligrams, 50

milligrams and 25 milligrams. The person was charged for three dispensing fees.

Thank you, Mr. Chair.

From

our perspective, just an overall comment on our audit of the Prescription Drug

Program; we thought the report actually was quite positive in terms of what we

had found. Some of the issues were you wouldn't call them major in the grand

scheme of things.

When I

look at the particular item that the deputy talked about that is not likely to

be implemented, I think you'll find that we framed the recommendation fairly

specifically to allow them some discretion as to how they deal with it. We knew

that there might be some issues in terms of being able to implement that, so we

framed it the department should consider, those sorts of things.

I think

based on what we've seen, subject to follow up in a couple of years, or years

from now, I think we're fairly satisfied with what we see in terms of the

implementation.

CHAIR:

Thank you, Sir.

Okay,

with that being said, if there are no further questions on that heading we'll

move into Salaried Physicians and go through the same process.

Mr.

Bragg, the opportunity to ask the first questions, please.

MR. BRAGG:

Okay, Sir. Thank you very

much.

In your

report back to us you said: The Department of Health and Community Services

should consider development of province-wide performance appraisal . That was

the recommendation, to have province-wide appraisal standards.

You

said that you were going to have standardized position description templates.

Where does this stand right now?

MR. ABBOTT:

Just bear with me for a

second.

terms of this particular report item, I just wanted to let you know, just as an

initial comment, of the eight recommendations that either the department or the

RHAs were responsible for implementing, we have fully implemented two of those

and five have been partially implemented.

terms of your question around the standards, that's one that has been partially

implemented. We have a committee established to work between the department and

the regional health authorities. What we want to do is standardize what

performance standards are put in place and that we, in fact, monitor those.

What

we've done up to now is left that to each of the RHAs to do that, and we are

realizing it isn't really working. The Auditor General has obviously identified

that. It's taking more time than we would like, but we have had a lot of

discussions over the past while. Angie Batstone can speak to some of the

specifics, but we are aiming for this fall to have this recommendation fully

implemented because we certainly agree with it, and because we think it will

benefit not only the department and the health authorities, but the physicians

themselves.

Right

now there are a lot of different rules being applied, different expectations of

what is expected of the physician working in a community or in a hospital

setting and we want to make sure whatever we have in Eastern Health, applies to

Western, Central and in Labrador.

MR. BRAGG:

Okay, because in Central, I

represent an area with two cottage hospitals and I know their challenge of

finding doctors.

MR. ABBOTT:

Yeah.

MR. BRAGG:

So would this help the

process? Because the old saying out there amongst the nurses is: We have the

doctors until we get them trained and then we move them somewhere else. That's

been said for years. I'm sure you've heard it, right?

MR. ABBOTT:

Yeah.

I don't

think this recommendation in itself is going to change that. It will help so you

know the rules of engagement when you come to a community. I think you're asking

a much larger issue. We are and right across this country struggling in

terms of getting physicians to come to rural communities.

terms of the department's approach here is that we are working with each of the

health authorities and the communities to look at what is a better response for

the long term, which is certainly developing primary health care teams, so that

a physician works with a nurse, nurse practitioners, and we're seeing some, I

going to say, early success, but actually Newfoundland is sort of behind the

eight ball when it comes to this. We're working quite aggressively now with each

of the health authorities to really push hard on primary health care teams and

services throughout.

whether it's Botwood, Corner Brook, down the Burin Peninsula, up in Bonavista,

we're seeing some early successes. So Fogo and that area actually has been well

served over time, and we want to build on that and really shore up those

services so that when a physician is interested, he or she can say, look,

actually there is some support there. They're not solo practitioners because

that sort of form of practice is really now nobody coming out of med school is

interested in really doing that, and we recognize that.

MR. BRAGG:

Okay, thank you.

I know

there are numerous questions, so I'm going to let everybody have a chance at

this one. I'm going to pass it on to the next person, Mr. Chair.

CHAIR:

Okay, thank you.

Mr.

Petten.

MR. PETTEN:

Thank you very much.

Only a

couple of questions; in your second one on my spreadsheet here actually it

referenced a lot of the department's updates. You have a steering committee in

place. Who will be part of that steering committee to oversee these

recommendations?

MR. ABBOTT:

Angie Batstone is chairing,

so I'm going to get Angie, if you wouldn't mind, respond.

MS. BATSTONE:

No problem.

The

committee is comprised of myself, the director of Medical Services, being the

chair. One of my consultants, Dan Fitzgerald, is on the committee, and we have

the director of Medical Services for each of the RHAs.

MR. PETTEN:

Okay.

MS. BATSTONE:

And actually Lab-Grenfell,

the representative is actually the VP of Medicine that's one difference Dr.

Gabe Woollam.

MR. PETTEN:

Okay.

I see

here, I guess the steering committee is going to perform regular performance

evaluations; it's going to be overseen by the steering committee. A lot of times

we see committees in government and it's a pretty common thing, what powers will

this committee have to oversee because this is a fairly substantial issue when

you look at not only the public domain with salaried physicians to the general

public

MS. BATSTONE:

Yes.

MR. PETTEN:

What powers or what will the steering committee be able to do in the event of

I know you're going to monitor, but what powers would it be in the event that

you see discrepancies or what have you? How will that be addressed?

MR. ABBOTT:

When the committee gets its

work done in terms of getting the standards in place then, in essence, in one

sense, the large part of their work gets done. Now, they will be monitoring on a

regular basis, but they will then be reporting up to myself as deputy minister;

and if there are issues, then I will engage which health authority or which CEO

to make sure there is full compliance. We'll be reporting out publicly.

Obviously, at the end of the day, the minister will be accountable for ensuring

compliance right across the system.

In one

sense, this shouldn't be as large an issue as it is because it's really a

process of how we use standardized recruiting and hiring physicians and laying

out basically their job description and what we expect of them. What has

happened over time, each RHA has going off to do their own thing, dealing with

their own and they've been scrambling trying to get physicians in place whenever

they can get them. What we've seen obviously over time is that's really not

working.

We are

the paymaster at the end of the day, so all the information has to come in to

the department for what we actually pay. So, at the end of the day, we do sort

of exert control to make sure we get full compliance; i.e., if there isn't

compliance, then we have an issue or a choice as to what we do in terms of

payment.

really, at the end of the day, the department has to ensure that this is put in

place. Again, the Auditor General has pointed out a weakness in our system that,

in fact, we fully support needs to be done.

MR. PETTEN:

So I guess when you tie

Memorial University with the regional health authorities, they will have to work

collaboratively to ensure that the value for money is being attained.

MR. ABBOTT:

Yeah. The university one is a little bit more complicated on the basis of how

they hire, why they hire and the relationship with not only their clinical

practice, which we're paying for, but also then their teaching time, which the

university pays for.

So we

have to merge basically two of our systems to ensure while that physician is

recruited that the payments, both for his or her clinical time, is what we're

responsible for, is fully identified and measured; and then likewise at the

university for their administrative and teaching time, is appropriated accounted

for.

As you

can appreciate, we have two sorts of payment systems going on; we now have to

make sure they're fully integrated.

MR. PETTEN:

So there will be like a

value for money from both ?

MR. ABBOTT:

Well, I don't know

MR. PETTEN:

Because it is the public

purse, right?

MR. ABBOTT:

Oh, yes. Well, the value is in terms of obviously the clinical time, what hours

we're paying for and that we get true value for that, and obviously for their

teaching and administrative time and that's what's the university or Eastern

Health would be responsible for.

So, as

I said, we have a couple of parties involved here and we're talking roughly 95

to 100 positions at the university. We're fortunate because we're able to

attract the physician because it's a teaching hospital, but part of that them is

having sort of two contracts that we have to administer.

CHAIR:

Mr. Petten, I'm going to go

to Ms. Parsons.

Mr.

Parsons.

MS. P. PARSONS:

The regional health

authorities, in Recommendations, should conduct performance appraisals in

according with their internal policies. And of course in your response in

January 2017: Performance appraisals of salaried physicians have been ongoing

since the Auditor General's report.

Can you

provide some progress on that?

MR. ABBOTT:

Well, we have made sure that

one has been fully implemented. The RHAs have reported now to us that in fact

they have put those in place for each of their physicians. The process around

that, they've put in some reporting templates. So we're quite satisfied that

they've achieved what the Auditor General has set out for them.

MS. P. PARSONS:

Thank you.

CHAIR:

You're good?

MS. P. PARSONS:

Yes.

Thank

you.

CHAIR:

Okay, Ms. Rogers.

MS. ROGERS:

Thank you.

When we

look at some of the issues that the Auditor General did raise, for instance,

there were no procedures for basic policies such as detailed workload

requirements for salaried physicians; they identified a need for an

accountability system to track the level of service provided by salaried

physicians; the department and RHAs not following their own

Salaried Physicians Quick Reference

Guidelines when hiring; no formal evaluation of hiring of physicians

provided to the department from RHAs or MUN and no effective assessment of

performance.

The

department is saying that we're working on that. That's a lot of work and some

of it very complex, I imagine.

MR. ABBOTT:

Yes.

MS. ROGERS:

For this not to have been

done over a period of time, I come back to that issue. Is this a staffing issue?

When we see that we've seen 96 managers laid off recently, how will all this be

accomplished? Is there a staffing issue here?

MR. ABBOTT:

Again, I'll have to say no.

Really what this demonstrates is I mean it's a basic human resource management

issue.

MS. ROGERS:

Yes.

MR. ABBOTT:

Over time or since time,

take your choice here we put physicians over here and everybody else over here

in terms of their practices.

What

we're doing now is bringing the physician community in to standardized,

well-accepted human resource practices. That's all we're doing. In essence,

we're bringing in 375 physicians into our larger management practices.

It's

been identified and supported by the managers within the system. The Auditor

General pointed out, yeah, you need to finally get on with it. We have committed

then to putting in processes and procedures to get that done. The committee that

we've established is doing that and they're focused on it. We will either have

these recommendations completed this fall, some of them; the others will be into

the winter.

So I

assume the next time we report on this we will be fully compliant. We've been

talking how we do that, obviously, with existing resources. Yes, all the

departments obviously have seen a reduction in their management and other

staffing levels, but we've been able to streamline some of our processes to make

sure we get this done.

MS. ROGERS:

Do you anticipate that there

will be any problem because of staffing levels?

MR. ABBOTT:

No, not related to this.

MS. ROGERS:

Okay.

The AG

identified twenty before I get on to that; John, how do we do in relation to

other jurisdictions, other provinces in this area?

MR. ABBOTT:

I would say it's variable

right across the country now. We have a high percentage of salaried physicians

more so than other jurisdictions, and because our physicians have been really

though, specialists are included in this relying on that for international

medical graduates and what have you, have come through salaried. Because they've

been sort of outside the mainstream, we just haven't focused on it to the degree

we need to.

Saskatchewan would be

probably somewhat similar in some of their challenges because they have a lot of

international medical graduates in their system, probably even more than we do.

MS. ROGERS:

If we see more of a movement

towards integrated primary health care facilities, will that mean more salaried

physicians?

MR. ABBOTT:

Are there any legal

ramifications or implications for the RHAs or for the department having doctors

who don't have a signed employment contract?

MR. ABBOTT:

Well, again, the fact they

didn't have them speaks to poor human resource management practices as it

applies to that particular group of employees, because they are employees in

essence.

MS. ROGERS:

Yes.

MR. ABBOTT:

But, again, we've had them

on a separate track than all other employees. So now we'll bring them in, and

that's certainly been put in place.

In terms of the liabilities,

well, only when they run into a problem.

MS. ROGERS:

Yes.

MR. ABBOTT:

Then who can sue whom, as it were, without a contract.

Yeah, I

think the health authorities and government in essence, their liability

increases as a result.

MS. ROGERS:

Do we currently have now any

doctors working without an employment contract?

MR. ABBOTT:

Well, I would like to say absolutely not, but I don't know that I can say that

with 100 per cent certainty. They are to have them in place. That's part of the

committee's work now is to make sure we have a reporting system to ensure that

is the case.

MS. ROGERS:

So you don't have any idea

of how many there may be currently without a contract?

MR. ABBOTT:

No, I don't know. Angie, any sense ?

MS. BATSTONE:

No. Like John said, that's part of the work of the committee, is not only those

22 that were found not to have contracts, that in fact there are contracts

Okay.

CHAIR:

Mr. King.

MR. KING:

Thank you.

I can

certainly speak to the success of primary health care teams. We've had those

established, I think, in Bonavista for a better part of a year and a half now.

It seems to take wait times down. It's been successful, so I just want to

congratulate you guys on that.

One of

my first meetings I had was with David Diamond on that issue because we lost

four doctors in the span of two months, I think, in 2015.

Getting

back to this, your steering committee is set up. Is it just for salaried

physicians or are you looking okay, you're looking at just for this individual

topic.

MR. ABBOTT:

Yeah.

MR. KING:

Going back to bullet point

2, I think, it's: RHAs will be required to manage attendance productivity to

ensure value for money.

What

ramifications are in place, or you're going to put in place, if there are

attendance productivity issues?

MR. ABBOTT:

Well, the role then of the vice president of medical services in each of the

RHAs is really to hold each of those physicians accountable for basically what

they have signed on for. Part of this review will so we will have a contract

definitely in place, we will have performance standards in place, how many

patients we expected to see, et cetera, those kinds of things. If that physician

is not producing, then it's the VP's job to have that conversation and make

sure the work gets done.

MR. KING:

Okay.

MR. ABBOTT:

If it's not, and if there is not compliance, then there's a choice of: All

right, we'll work with the physician to improve or we would have to move to

terminate if that's not the case. Again, it's a new way of doing business.

It's

generally accepted right throughout the health system that we have these

performance standards in place for all staff. Now we're just applying it to this

particular group of providers. We're working with the LMNA and others as well.

So everybody is onside. It's just a matter of now really getting this work done.

MR. KING:

Going back, and I know this

is relatively new, you guys got the audit report back in, I think, November. So

it seems like you've been working pretty hard to get everything up to standard

based on the recommendations, but looking back here in the point, you're

currently reviewing the benefit of re-establishing the salaried physician

approval committee. Why was that dissolved in the first place, and why are we

looking at going back to that?

MR. ABBOTT:

I think it just flittered away. We've had a number of discussions over the

winter sort of bemoaning that that in fact this happened, because some of the

problems we see now are a result of that.

Now,

that being said, we tried to in terms of the health authorities give them as

much responsibility and flexibility to meet their staffing needs; but, in this

case, because we control the funding at the department, we sort of dropped the

ball over time and we realize that that's something we have to reclaim

responsibility for. Because we now, if we're again, moving in towards family

health care teams, we want to ensure the physicians that are coming in meet the

needs for that community or for that region.

It's

not one of, because there happens to be a vacancy that day or that week. We

really now want to make sure we've got the right mix of physicians in the right

communities, using Bonavista as an example. So when we go out to recruit in the

future, we want somebody that in fact now will meet the needs for that community

that can work in a team setting, et cetera.

So the

rules of engagement are starting to change and we want to take more of a direct

hand in what is happening, but working obviously with the RHAs.

MR. KING:

I note the Kaizen method was used for the Bonavista Peninsula Health Care.

MR. ABBOTT:

Yes.

MR. KING:

Are you looking at using

that in other areas in the province?

MR. ABBOTT:

Absolutely, and it's because of what we've learned in Bonavista. We're now down

on the Burin Peninsula, sort of taking what we learned there, modifying it for

the Burin Peninsula area. We were out in Botwood; we were out in Corner Brook,

out in Grand Falls, Gander, right around the province.

MR. KING:

Thank you very much.

CHAIR:

nutshell, to sum it up, there should be a top-level salary cut off for any of

those salaried physicians or whatever their profession. If they reach that by

just in the hospital, we'll say, or in a combination of that and academic,

shouldn't that be the cut off? Would there be some guidelines put in place to be

able to monitor it that way? Wouldn't that be the most simplistic?

MR. ABBOTT:

If I understand your question, the clinical time is funded in one way. Their

teaching time would be funded separately and then combined. Then their employer

costs may be on top of that.

They're

indifferent arrangements at the university. Some have shared salary with their

colleagues and how that gets done. So it is a very complicated bit of business

at the university, because we are bringing all those payments together under one

contract. It's not typical in, really, any other profession that I know of that

you would do it this way but it works for us. It's just that we haven't managed

it as well as we should.

MR. PETTEN:

Thank you.

CHAIR:

Mr. Finn, any questions?

MR. FINN:

Thank you, Mr. Chair, and

thanks, folks, for being here this morning.

I'm

just kind of flicking through some of it and, as I mentioned early on, I'm

substituting today for Mr. Reid on short notice. But just having gone through

some of this just this morning, I can certainly appreciate and understand the

challenges from the Department of Health and Community Services, some 40 per

cent of our provincial budget being accounted for and I guess the complexities

with respect to three different health authorities, in particular, and every

health authority operates a little bit different.

Mr.

Abbott, you made a statement in the beginning there around just HR; you said,

essentially, they were all physicians being here and everybody else was here.

MR. ABBOTT:

Yeah.

MR. FINN:

And that's kind of like, I

guess, just a philosophical look at that's the big statement on the problem

essentially, and each health authority then operating a little bit differently

in terms of the practices.

MR. ABBOTT:

Yes.

MR. FINN:

Some of the documentation

there reflecting performance appraisals, some being done in Western are going to

be this number is lower than what was being done in Lab-Grenfell. So I guess you

guys have the task of pinning it down to the RHA level and finding the problem

there.

MR. ABBOTT:

Yes, right down to the individual level, yes.

MR. FINN:

Right.

With

respect to some of the appraisals and the workload requirements that aren't

detailed, I'm wondering, I'm just musing, if I'm a health authority and we have

the ability to hire a new physician, they must just be excited. Yay, we have a

new physician. So they don't jump into some to the nuances. Is that kind of ?

MR. ABBOTT:

MR. ABBOTT:

As I said, part of this is

how it is managed within the health authority. The approvals are usually done

through the VP of medicine and then the CEO. A lot of times the human resource

department would not even be directly involved. They may process payments at the

end of the day, kind of thing, but aren't, as I said, bringing in their

employment; where are the standards, what have you, that they would have for all

their other employees, but not for these.

MR. FINN:

Sure.

MR. ABBOTT:

But the way you described it

is exactly how it sort of plays out in real time and we have those

conversations. I get a call: We've been fortunate, we've got a specialist that

we've been looking for now for two years, but can we sort of break some rules

here to get the individual in place?

MR. FINN:

Get him started, yeah.

MR. ABBOTT:

We'll have a discussion as

to what the rules are, but we are insisting on documentation, we are insisting

that we have a discussion and that we apply the existing policies and payments

for any new salaried physicians, whether it's a GP or a specialist. If there are

exceptions, then they would have to come into the department and be approved by

the minister.

MR. FINN:

Right, yeah. That's kind of

what I was musing, right?

MR. ABBOTT:

Yeah.

MR. FINN:

The approval process, to

question the fact that we're approving the hiring of a doctor, I mean, my God,

if there's a doctor that wants to come, let's open our arms. I can understand

some of the work there, so that's kind of what I was musing at.

MR. ABBOTT:

Yeah.

MR. FINN:

One other small question,

and I don't know if it's directly stated there, but with respect to we have

salaried physicians and we have fee for service as well. Some are availing of

both in that regard. Is there ?

MR. ABBOTT:

I'm not sure if I

understand.

MR. FINN:

Salaried physician at the

hospital and also does fee for service in clinic as well.

MR. ABBOTT:

Again, there are different

payment plans and maybe this is what you're getting at. There are payment plans

where in fact they will pool, for instance, their fees and then they will so

that's a group. At the university that happens quite often where a group will

pool their fees and then they will draw a salary from that. But that's

different from, dare I say, the salaried physicians.

Then we

have approved payment plans in place, which is sort of negotiated and it's

similar to a salaried physician construct, but in fact, again, they're a fee for

service. So, basically, it's a blend there.

MR. FINN:

Sure, okay.

MR. ABBOTT:

Rogers now.

Ms.

Rogers.

MS. ROGERS:

Thank you very much.

In your

report, you were saying that performance appraisals of salaried physicians have

been ongoing since the AG report. How is that going?

MR. ABBOTT:

As I said, they put them in place. Some were doing them anyway and they had the

mechanisms to do it.

In a

lot of the medical staff bylaws for Eastern Health authorities, they would be

doing that or a version of it in any event for their fee for service. Now they

would bring that same process into the salaried. It should have been happening

and it wasn't, but there hasn't been any resistance to doing this. I think, as a

matter of fact, it's been encouraged. We meet regularly with the vice-president

for medical services for each of the health authorities. They are really pivotal

to making sure this gets done because they oversee that process in each of their

authorities.

MS. ROGERS:

If you can help me

understand a little bit, John. So a performance appraisal for a fee for service,

is that just around billing?

MR. ABBOTT:

No, no. It would be around what patients you are seeing, what your

MS. ROGERS:

Outcomes.

MR. ABBOTT:

Ideally outcomes; but, to be honest, it wouldn't be getting there at this stage.

That's somewhere, obviously, we would like to for all our physicians.

would be looking at attendance in clinic, how you're utilizing resources of that

health authority, those kinds of things, and I guess any complaints that might

come in from patients and how they get addressed.

MS. ROGERS:

So who would do this, and

how would it be done? Is there a standardized process across the province, or ?

MR. ABBOTT:

As I said, in the medical

staff bylaws you will see the processes and we would make sure that they would

be following that, but it is. Basically, at the end of the day, it is the VP of

medicine, or his or her designate, who would sit down with the physician, at

least on an annual basis ideally you would do it more than that to review

their performance. There would be a standardized performance appraisal document

that you would use.

MS. ROGERS:

Okay.

I know

you cannot reveal or release specific appraisals about specific doctors that

have been done, but can we have some information vis--vis how many have been

done since the Auditor General's report, how many should have been done and how

many you've been able to accomplish.

MR. ABBOTT:

Sure.

MS. ROGERS:

And then also, are you

seeing any trends at all? Again, I appreciate that personal information cannot

be released, but really what are you finding in these appraisals?

MR. ABBOTT:

Fair enough. Yeah, I

understand your question. We'll follow up on that.

MS. ROGERS:

Okay, great.

Thank

you.

I also

have just a few other questions. The Department of Health and Community

Services, Regional Health Authorities and Memorial University of Newfoundland

should develop an accountability system to track the level of service provided

by salaried physicians.

We see

that we have the provincial steering committee. When did the steering committee

start meeting? What has been accomplished so far? Who is the steering committee

reporting to? Is there a reporting mechanism? Are there written reports from the

steering committee meetings or minutes? How is that going?

MS. BATSTONE:

We started work on the

steering committee and I'm new to the position as well. We started work in

February with respect to our terms of reference, our mandate, et cetera. We had

a meeting set for May which had to be cancelled, so we met early June. But this

group of directors I meet with outside of this steering committee as well. So

we've been having ongoing conversations since the report came out.

Yeah, so the whole steering

committee having a meeting conversation together?

MS. BATSTONE:

Having a conversation, yes;

informal conversations, because I connect with the directors of medical services

in the regions on a regular basis.

MS. ROGERS:

Okay.

So that

would be individual ones, not as a committee.

MS. BATSTONE:

Sometimes a conference call

if there are a number of issues, and this may have been discussed at some of

those meetings.

MS. ROGERS:

Okay.

MS. BATSTONE:

Sometimes we'd be pulled

together as a group to discuss whatever the issues of the day are.

MS. ROGERS:

Okay.

It would bring you right

into May and June, who knows.

Okay,

thank you very much.

MS. BATSTONE:

You're welcome.

MS. ROGERS:

The GFT physicians

CHAIR:

Ms. Rogers, do you have many

left on that?

MS. ROGERS:

No, I don't.

CHAIR:

Okay.

So I'll

let you complete that and then see if there are any other (inaudible).

MS. ROGERS:

Okay, great.

MUN and

the department indicated that GFT physicians receive additional remuneration

because of the work they do, both clinical and academic. I think Barry was

getting at a little bit of this. So the GFTs have higher expectations for job

performance and output I understand this to be very complex, I really do and

are therefore required to work in excess of hours specified in their job

descriptions; however, our testing found that GFTs were not required,

contractually, to work longer than full-time clinical physicians.

You may

have addressed that in various questions. Do you anticipate a change in that?

MR. ABBOTT:

I'm not expecting there will

be much change because each one of these sort of gets negotiated on a

case-by-case basis. What we want to ensure is there is a template that each is

used that we accept, and then there is a contract in place and that all parties

abide by that.

What

happens from time to time, despite having some of this in place, other

arrangements are getting made that we at the department are not aware of.

Eastern Health may not be aware of what Memorial is doing. Memorial may not be

aware of what Eastern Health is doing. So part of this exercise here will be to

ensure that this should not happen going forward.

MS. ROGERS:

Right, but we may still be

in the same position that, contractually, GFTs will not be expected to work

longer than full-time clinical physicians.

MR. ABBOTT:

But at the end of the day,

Ms. Rogers, whatever is in that contract is what we have to hold them and all

parties

MS. ROGERS:

Yes, I understand that.

MR. ABBOTT:

And that hasn't been documented appropriately in all cases.

discussion there. So at times, and it may not be in the same clinic, but they

may be in different parts of the community, where that sometimes works as a bit

of an issue.

Some of

what you will hear, but there is no particular evidence to support either side

of this, some will say that salaried physicians aren't as productive as fee for

service, and some will argue that fee for service are over-seeing patients

because of the way that payments system works.

Now, we

don't have any evidence that says one is better than another. Our job is to make

sure that all patients get seen when they need to be seen. We have to make sure

we have the physicians, nurse practitioners and others in place to meet that

demand.

At the

end of the day, we will move dollars from one budget to another to meet where

people are. As I said earlier, we are seeing a trend that newer physicians are

more comfortable to meet what they want out of life and moving towards some

salary or equivalent type of payment. So they want certainty and they want to be

able to practise their full scope. But we have a generation of fee for service

that they're happy with that and we will continue to continue with that system.

MR. BRAGG:

Thank you.

actually answered the second question I had, so thank you.

CHAIR:

Mr. Petten, further

questions?

MR. PETTEN:

No, I'm good on that topic.

Thanks.

CHAIR:

Ms. Parsons.

Ms.

Rogers.

MS. ROGERS:

I'm fine. Thank you very

much.

CHAIR:

Mr. King.

Mr.

Finn.

MR. FINN:

That's what I was referring

to with the fee for service that I had brought up and the salary at the same

time. I can understand the pros and cons matrix of either getting paid by the

hour or getting paid by task done in said hour. That's the challenge, I guess,

there.

MR. ABBOTT:

Yes. Again, the issue is

played right out across the country. There's no right answer.

legs and that, if you need to make a call or go to the washroom. We'll come back

here let's say a 13-minute break at 10:35 a.m., please.

Recess

CHAIR:

We'll start now, and I'll

start with Mr. Bragg. You can start with any questions you may have or, as you

noted, an observation.

MR. BRAGG:

Okay, thank you very much.

On the

nutrition of long-term care facilities, I guess I have a broad question. I know

the AG came in and they had four objectives in mind. Since the AG came in, how

much has nutrition improved; and two-part question if I visit any long-term

care home tomorrow, would I be able to view my grandmother's or my mother's file

on the type of food they're eating?

MR. ABBOTT:

Good question.

Just,

if I may, as a start, of the 10 recommendations that were in the report, two

were obviously specific to our department and our mandate, and then eight were

specific to the regional health authorities. I just want to let you know where

we are of the two recommendations that are specific to us, and then I'll get to

your question.

One has

been partially implemented, related to the operational standards review I'll

speak to that in a minute and one has not been implemented yet to date, and

that's in terms of the performance indicator benchmarks.

For the

RHAs, five have been fully implemented, and three partially implemented by

Eastern Health; and for Western Health, seven have been fully implemented, and

one partially implemented.

terms of your question on has nutrition improved. I can't answer that, to be

honest. What we're looking at is the processes around to ensure that the quality

that is expected is there. So that's as far as I think I can go on that. Now,

Deena Waddleton can speak to some more specifics.

terms of looking at what a resident would be, in terms of the menu, then within

this review, we looked at that. I think where the health authorities are,

they're certainly prepared to put up the daily and weekly menus, but not the

longer term menus that were suggested.

So yes, you should be able to as a family member going in

and one, you should see what obviously is on the menu. You can

obviously encourage and question as well, as many of us have done in that

situation.

The department is, again, working closely with the health authorities and Deena

Waddleton is leading some of the work here on the department with the health

authorities. Again, we have a committee in place that is actively working on

finalizing and upgrading the standards. Then we're also developing a monitoring

framework so that, ideally, I should be able to answer that question better the

next time around.

MR. BRAGG:

Okay.

I guess the other thing I would ask is if they're looking for a hot meal, would

they expect it to be hot and a cool meal to be cool, at the end of the day?

MR. ABBOTT:

Yes.

MR. BRAGG:

I have some experience I never worked there, but my wife is a manager into a

facility out in Central. I know there have been some great changes, and I think

this might have come up a couple of years ago over the can of spaghetti, I

think, was the issue.

You may have someone in the facility where that is what they want every day of

the week, so how do you sort of deviate from that if that's what someone wants.

MR. ABBOTT:

Yes.

MR. BRAGG:

Okay, thank you very much.

CHAIR:

Mr. Petten.

MR. PETTEN:

Thank you, Mr. Chair.

I have a couple of questions and mine are probably under general form as well.

Nutrition in long-term care facilities, a lot of people are kind of familiar

with it, especially if you had a loved one that had spent any time in one of

those facilities.

The question that comes out to me and it's from a personal perspective I

experienced it over a number of years. My mother-in-law passed away with

dementia. My wife went every day for 2 years, I never ate supper with her

because she went over and fed her mom and several other residents their supper

or their lunch, mostly supper.

I still know people that go back and forth to our long-term care facilities and

I'd like to be able to say that things have improved but, unfortunately, that

still exists not maybe across the board everywhere. There are certain areas

I'm sure that's fine, but that is still a real problem. Whether it's staffing

levels; is it the most vocal family that gets the most attention. Then that all

ties to the quality of the food.

So I know that it's good that the AG has brought this up because that jumped out

at me on a personal level when I saw it. I was glad to see it was addressed. I

don't know how far along, how much improvements we've actually made to make that

better because I do know staffing is still a problem when it comes to that sort

of thing. You have meal times and certain ones are independent. There are a lot

of them that are not independent. You get in line and there are only so many

hands to go around and some take longer to eat.

Derrick

just pointed out the hot meal being hot and the cold mean being cold. It's a

question, and I don't know if you can add anything to that to explain it, to

address what improvements have been done?

MR. ABBOTT:

Mr. Petten, how we would

look at that and answer the question is that we have obviously ongoing

conversations with the health authorities, particularly around this area in

terms of the long-term care facilities looking at all aspects the nursing

care, which oversees this area as well. We have the dieticians, we have the

nurses, we have the LPNs and the other attendants that are there.

We have

not had any representation to the department that I'm aware of, certainly since

I've been there in the past year, around staffing levels and around meal times,

but I understand what you're saying because I've observed it.

The

conversations we then have with the managers around long-term care is that in

terms of how they manage their staff and staffing levels, do they have the right

positions in place. We are funding them to ensure that they have the staffing

levels. We have not touched those budgets at all.

boils down to how those facilities are managed. So we think by going back to the

standards that we expect and putting in the monitoring framework and the

benchmarks that we will be in a better position to identify where the weaknesses

are and if staffing turns out to be a weakness through that, then we'll have no

choice really other than to support a budget increase to allow that to happen

all things being equal.

Again,

this is an issue that takes place at least three times a day, 365 days a year in

each home. We need to ensure that the administrators are staffing and supporting

that daily activity. There is no really strong reason why they can't and

shouldn't be doing that.

Again,

the Auditor General has pointed out a weakness there and I think the

professionals involved here, the dieticians and the nursing staff, have to make

sure and be held accountable to ensure that the service is delivered as

expected. In my view, there is no reason why that isn't the case.

Now, it

may and I've seen it myself. If there was a family member in, so they can

and that's a positive thing. Obviously, if you're calling on volunteers in the

community that needs to happen, but, at the end of the day, the administrators

need to make sure the meals are served hot when they're supposed to be hot, cold

when they're supposed to be cold, in the time frames that have been set for that

facility.

One of

the things we are hearing more of, which is how to support individuals who want

to have their meals at different times, in their rooms as opposed to the dining

room, things like that, and their choice. So there's a bit of a balancing act

there as well, but the administrators are handling that quite well we think.

As the

residents are going in now, they are more informed. They're stronger advocates,

either themselves or their families. So we are seeing sort of a change happening

in the delivery of that aspect of nursing care. We think with the work we're

doing now, that we should see improvement in the process, as I said. The

nutritional side of this will always be challenged as to sort of resident

choice, but in terms of the quality of their food and how it is prepared, those

standards will have to be followed and we'll be certainly monitoring those very

closely.

CHAIR:

I'll go with Ms. Parsons.

MS. P. PARSONS:

Thank you very much.

Yes, I

want to elaborate as well on nutrition, because obviously when we're talking

about long-term care facilities nutrition is the main topic of priority.

I want

to reflect back on a conversation I had with a professional living in my

District of Harbour Grace Port de Grave who is working at the long-term care

facility in Carbonear. The new implemented facility which replaced the Harbour

Lodge and, again, this is a concern with food temperature. She used a

hard-boiled egg as an example, and she expressed her displeasure, of course,

with the quality or lack of. Her words and I quote: When those eggs come and

they're to be served to our residents you can literally take them like balls and

bounce them. That's a main concern of course. Nutrition keeps coming up a lot. I

wanted to elaborate on that.

Based

on the review here in Nutrition in Long-term Care Facilities for 2015, it

states: The Eastern RHA and Western RHA should provide meals to residents in

accordance with their prescribed meal plans and at the appropriate temperature.

Of course this, again, relates back to the hard-boiled egg story.

MR. ABBOTT:

Yes.

MS. P. PARSONS:

In response in January 2017,

I see here working groups reviewing policies and establishing audit processes,

exploring medical directive for diet orders and finalize policy by June 2017.

From what I understand, this was to be finalized by June '17. So can you

elaborate on that?

MR. ABBOTT:

Okay, and maybe I'll ask Deena.

MS. WADDLETON:

In terms of the audit process question that related to that, Eastern and Western

have implemented audit processing around food temperature, in one case. The

policies that you're referencing, we're meeting actually in a week or so to

approve those, finally. There's a couple that need final approval and will be

implemented provincially. So that is on track.

Those

policies will really outline what the RHAs need to do. They are already doing,

in practise, some of this work around auditing, but it will clearly define what

they all need to do. That will include also Lab-Grenfell and Central Health,

because it's a provincial working group that we have. Then we will be as John

mentioned earlier establishing a monitoring framework, and they will have to

report to the department on the outcome of their audits. So that will help

address some of that.

MS. P. PARSONS:

Okay, thank you.

Also,

on another topic here, and it's mentioned by my colleagues, how essential and

paramount it is that we follow the Canada Food Guide and that we have a

registered dietitian, of course, to monitor regularly these menus. You

mentioned, as well, dialogue, even with residents to inform them about

nutrition. I can't emphasize enough how important this is. I guess it's more a

comment than a question.

That's

all from me now. Thank you.

MR. ABBOTT:

With that, about what the AG said and your comments, I think the role of the

dietitian has to be given higher recognition in each of our health authorities.

We had some internal discussions as to some thoughts on how that needs to work

better.

Though

I will say, just as my personal comment, in relation to one that you made, is

that if there's anybody working in the system manager or whatever and the

example you use, we definitely encourage, and I say the onus on them is to bring

that issue that's really a complaint, and that needs to be brought forward to

the administrator and needs to be addressed because that should not be

happening.

We have

systems in place and that's a brand-new facility. There should be no reason why

something like that is happening more than the one occasion. Because once it's

identified, then it obviously needs to be addressed.

MS. P. PARSONS:

How was the flow of

communication with, say, front-line staff, such as professionals who are

first-hand caring for residents, to take these concerns, I guess, to the

appropriate positions?

MR. ABBOTT:

Yes.

MS. P. PARSONS:

How is that dialogue? I

mean, I can't emphasis enough how important it is to have a free dialogue, to

eliminate any fear of being punished or for bringing complaints forward because

it's all about communication. Again, this is the quality of life of our seniors.

MR. ABBOTT:

Yes. Again, we would, based

on our encourage that, I mean it is front line. They have their supervisors

and there's that process for those that are unionized, and there's also that

process to bring to their shop steward because it's a quality issue. We're all

responsible.

MS. P. PARSONS:

Yes.

MR. ABBOTT:

We now have patient safety

legislation, which these kinds of issues now will be picked up as well. We will

have more obligations on each of our health authorities to identify and report

true incidents, and our nursing homes will be captured by that legislation.

MS. P. PARSONS:

Thank you.

CHAIR:

Okay, thank you.

Ms.

Rogers.

MS. ROGERS:

Thank you very much.

Again,

this is such a complex issue in terms of the whole issue of care for seniors. We

know the research that has been done shows that the majority of seniors want to

age and stay in place at home, and many of them, that's not possible because we

don't have a fully, publicly administered and delivered home care program. So,

consequently, many seniors have no choice but to go into a long-term care. We

all know that, and we all know how tough that is. We also know for some seniors

perhaps that's the best solution.

We're

also dealing then with seniors who are far, far away from family and community.

So, even the issue of family helping with nutrition is not a possibility because

some people are so far away from their families and their communities, even

volunteers don't really quite address this issue.

We know

how important nutrition is, not only for the physical health of a person but the

psychosocial health of a person as well. We have such a high rate of depression

among our seniors in long-term care facilities, and that too needs to be

addressed. When we think of depression, that also really affects appetite. So we

have a real complex problem here.

I would

hope that we would be able to be because of our small population which

provides extreme complications, but also provides opportunities. Why in God's

name can't we be a centre of excellence in how we take care of seniors who have

built this province?

We also

know that so many of our seniors live in poverty, particularly women. We have

the highest percentage of seniors living on GIS and OAS, and a lot of women who

were of that generation didn't have paid work outside the home. So they're very

vulnerable, we all know that. They're extremely vulnerable.

I'm

wondering, when the Auditor General found a number of RHAs that were examined

did not even follow the Canada's Food Guide, how can we explain that? When we

spend so much money in health around prevention and encouraging people to eat

properly for health benefits, for prevention, yet we're not providing that in

our institutions where we have complete control. Is there any explanation as to

how that could possibly be?

MR. ABBOTT:

Ms. Rogers, in terms of what

the Auditor General has pointed out, I think part of this is, as I said, the

role of the registered dietitian in the planning and I think we may need to make

sure his or her role is given more prominence in the planning. So it isn't based

on what's in the shall we say, what's in the cupboard, what's in the freezer,

what the budget says we can or cannot do.

believe they should be following much closer the Canada's Food guidelines, no

doubt about that, but the dietitians, that's their job and their professions

their own right. They have to insist on making sure the menus and the food

preparation is complaint. So we have to encourage that.

I think

what has happened again, over time with the best intentions, is people have

deviated for their own particular reasons within any one facility. As a

department, we have not gone back to make sure they are meeting those guidelines

and any other criteria. So as part of this obviously, the Auditor General has

pointed out a significant weakness in our role in monitoring through reviewing

the standard and then particularly developing this monitoring framework, that

now we will because part of that framework will talk about adherence to the

guidelines. Now we can follow up where they've been deficient and to understand

why. Then, obviously, change that behaviour.

MS. ROGERS:

Are we ensuring there's

enough money allocated to our long-term care facilities for proper food and

nutrition?

MR. ABBOTT:

Again, as mentioned earlier, we don't think that's an issue at all. We're

roughly spending $10,000 per bed, per month, for the facilities. That's just the

large number.

If you

look at what we are spending per resident, it's roughly $16,000 a year when it

comes to the overall budget per person for food. So there's sufficient funding

in the system. Again, nobody has come to us to say because of budgetary

considerations that we haven't had the right food, the right amount of food or

ability to serve it appropriately.

So,

again, it speaks to how we're managing within each of those homes. Some are

doing it, obviously, better than others. We want those that are doing it best to

help those who are struggling.

MS. ROGERS:

And how are we going to make

sure that happens? I think, you know, to say it's up to an individual dietitian

MR. ABBOTT:

Yeah, but as I say, we're ceased on this, through this monitoring framework,

that we now have a tool to go back in, in a more objective way, to find out what

in fact is happening. We can then obviously be more proactive.

MS. ROGERS:

Is the food in all of our

long-term care facilities we have how many, I forget now?

MR. ABBOTT:

MS. ROGERS:

In how many of those is the

Just going back to a

statement Mr. Petten put, and we can all certainly relate to having family

members in long-term care homes. I go back to 2002, when my grandfather was in

Golden Heights Manor in Bonavista. If we didn't have the family support there

then, I don't know if he would have eaten or not. He was at that point where he

needed an assessment.

You go

to point number 8, the first point on the second page there: The Eastern

Regional Health Authority and Western should ensure residents are appropriately

supervised during meals in accordance with the Operational Standard for Long

Term Care Facilities in Newfoundland and Labrador and applicable RHA policies.

getting back to that, where are we? I know you discussed it a little bit, but 15

years on from that it's shocking to see we still have that issue.

MR. ABBOTT:

changes to support that. In some cases it is going to be a little bit of

creative thinking on their part as to how to manage that, but then they have to

call in other resources if they need it. We will, as a department, obviously

support that. We're not getting any pressure on the department from the RHAs to

say they can't meet that requirement. Again, it boils down to the administrator

managing that operation each and every day based on these standards.

So what

we will be looking at now, much closer, is to say definitively what the

expectation is and then reporting back against that, and where we are seeing

that is not happening, then, obviously, we'll be having conversations with the

CEO to make sure those issues are addressed.

MR. KING:

Okay, thank you.

Getting

back to point number one; The Department should conduct a formal review of the

Operational Standards for Long Term Care Facilities in Newfoundland and Labrador

as required. The response to this was: Working group with regional

representation has been established.

So my

first question: Who is on that working group and how did the meeting go, if it

did go, for March 21 and 22?

MR. ABBOTT:

Okay, I'll ask Deena.

MS. WADDLETON:

I'm on that committee as a

representative of the department, and there are also the four regional long-term

care directors, as well as an additional person from Eastern Health who is a

manager for long-term care and who's also a dietician.

What

we've been doing, we did hold that meeting in March where we established a plan

to have these standards reviewed and revised by the end of this fall. Each of

the people on that committee are taking a number of standards and are working on

those, bringing it back to the larger group for feedback and revision and then

to finalize the policy. So we, I think, are on track to have that completed by

the end of June sorry, end of fall, not June. That's only next week.

MR. KING:

You're pretty much on track

with the summer of 2017 into that.

Just

one more question with my time I guess, and I might have a couple after. The

department and the RHA should establish benchmarks for performance indicators;

review them on their actual financial statistical data, including performance

indictors against these benchmarks that follow up on significant variance.

The

question I have with that: What determines the benchmarks being developed and

how often will follow-up take place to establish the variances?

MR. ABBOTT:

(Inaudible) we will be

looking across the food service industry as to what are the best practices for

that. We'll look at what's happening across the country and then we'll determine

that in consultation with each of the health authorities.

Once we

have those in place, then we will start collecting the data from each of the

health authorities that report in for each of their own. Our intent is that

information would be made public for each of those facilities so if it is

families, anybody else, can then have a good sense of how that particular

nursing home is complying and operating their food services.

MR. KING:

Thank you.

CHAIR:

Good? Okay, Mr. Petten, any

further questions?

MR. PETTEN:

I just have a couple of

short ones here. Just to go back to the quality of food and the staffing and

back to one of my original questions. Ms. Rogers, you referred to a couple of

questions she asked, that you will have a mechanism, your tools in place to

review this.

Basically, in a nutshell, what quality assurance measures, checks and balances

because right now it's separate; there are two different silos. So they're given

a budget and the staffing to do these things. Who is going in to make sure that

it's actually being done to the expected level of quality and care?

MR. ABBOTT:

We haven't gotten to that

stage where we would sort of send in an auditor or an inspector to do that. We

are going to be reliant on each of the health authorities to self-report and

then we will deal with that, which is common in our health system in any event.

As I

said, we want to try and we are trying, through the patient safety legislation,

an overall reporting so when there are critical incidents, if there was an issue

in the dining room, if there was a resident who because of food had some

reaction or what have you that then will get captured and reported out

provincially.

So I

think we've upped the standard and expectation right across the system. But they

will be dependent, largely, on self-reporting, and against the monitoring

framework we'll have in place, then we will issue reports on each facility.

MR. PETTEN:

So in the event of a family

member had concerns they'd report it to the manager, or the ?

MR. ABBOTT:

Yes.

MR. PETTEN:

It's incumbent on the

manager, obviously, to address that concern or push it further. That's the

concern I have sometimes. I don't know how far up the line the concern is.

Sometimes you're given an answer, oh, it's being addressed. I guess it all

depends on individual families sometimes. Some of them just take it in their own

hands and deal with. They have so many other the stress on them in general.

Again,

it comes back to the quality assurance piece and the checks and balances. I

think that is an important feature that should be, for all our long-term care

facilities, to make sure that we have consistent care across the board for the

most vulnerable, some of the most vulnerable people in our society.

MR. ABBOTT:

I would certainly agree and we, with our CEOs right throughout our Health and

Community Services system, more or less are taking a similar approach. If there

are issues of quality, each of the health authorities has a quality department

that oversees each of their operations, including the nursing homes, including

their food service. So we're reliant on them doing their work.

In the

issues where there are complaints or concerns, each of the health authorities

has their own process as to how they receive those complaints and process that.

We're actually looking at that as a department, because we want to make sure

that is done appropriately and that the complaints aren't just pushed aside.

That if there is a formal complaint, then there is a formal response, and the

complainant, shall we say a family member, can then, if not satisfied, elevate

that concern up the line. Obviously, as far as the minister's office, if need

be, and we do that on a regular basis. But that's sort of where we are.

Our

expectation is that once we get the monitoring framework in place, we'll have

much better information, and the system will know and those that are delivering

the food service know that there is actually a concern and a responsibility by

the department to actually report out. I think that will help address, not

necessarily all the issues, but most of the ones that are there today.

MR. PETTEN:

Okay, thank you.

CHAIR:

Mr. Finn.

MR. FINN:

Yes, thank you, Mr. Chair.

Just

short notice filling in here myself; I'm just having a quick flick through and

it certainly looks like there's been some great work Western Health identified

and, on the back, within a year, most of these things have been implemented, so

it's certainly kudos there.

I guess some of those have

trickled down probably already I'm assuming with small

MR. ABBOTT:

But you do point to an issue not only in how nursing homes deliver this service,

that's sort of a consistent kind of theme throughout a lot of the other services

that we're sort of funding. And under Dr. Haggie, the minister, what we are

attempting to do here with all our services is to define a provincial standard

to which then all health authorities must comply.

If they

have a policy and it's different from the now new norm, new provincial, then

they have to now follow the provincial standard. So we are going to try to apply

that right across the board, whether it's mental health, food services, what

have you.

there's an example here, once we finalize these standards, then each of the

health authorities, their policies have to comply with ours. They'll have some

deviations on some small points but not on the significant ones. If it's a

committee and that has to meet or report, then they will be consistent across

the province.

MR. FINN:

Right. So bringing each

health authority in line with a provincial standard is the ultimate goal.

MR. ABBOTT:

Yes.

MR. FINN:

Fair enough, that's fine.

Thank

you.

CHAIR:

Ms. Rogers.

MS. ROGERS:

Thank you very much.

We've

heard a lot here today about sort of anecdotal evidence and people's own

personal experience with seniors in their families, and I think we all hear it

too as MHAs, and all of us, across the province, we hear the stories of people

where the trays are put in front of them, their loved one, and if it wasn't for

family members or volunteers, somebody wouldn't eat.

MR. ABBOTT:

Yes.

MS. ROGERS:

The other thing that we hear

is people praise the staff in our long-term care facilities. Staff who are

attentive, staff who really care. Oftentimes, they are taking care of people

that they've known in their community. So I believe it's not simply a situation

where staff have to buck up and work harder. There seems to be a systemic

problem here and I am just wondering what's going to be done about it.

We hear

from family members that they see that the staff is working so hard, yet trays

are left in front of people, not because staff aren't working hard enough, not

because staff don't care. And people are not able to feed themselves or eat.

Perhaps there is a resource issue here.

MR. ABBOTT:

I would answer this a couple

of ways. One, the onus is on the administrator and those supervising that floor,

that dining room, that day, to make sure that every resident is fed and trays

are not left in front of a resident. That should not happen.

Now if,

at the end of the day, the result is we do not have sufficient staff, then we

will address that as a department. That is not coming forward to us.

MS. ROGERS:

Okay. So they have to

advocate for more resources then if that the case.

MR. ABBOTT:

If that's the issue.

Secondly, what we want to do here is make sure we get the evidence so that it is

documented and we'll deal with that.

Third,

if there are complaints and observations and that is happening I'm not going

to argue it doesn't happen then they have to be brought forward and we address

that. So part of this monitoring framework will be how many trays have been

left, because that information is recorded in each of the facilities. So it

would suggest to me if you know that today, how are you addressing it today?

MS. ROGERS:

Yes.

MR. ABBOTT:

So we will be and are using

that data now to go back and inquire as to how they're addressing it and then,

as I said, if there is a complaint by a family member or other, then we will

record that and then address that with the CEO and their staff as to say, look,

this is happening; why.

As I

said, all things being equal, if it's a resource issue then we have to address

that. No different than if it's an emergency room, surgery we wouldn't and

shouldn't be making any difference or distinction between the demand for service

and our ability to respond. But that is not what we are being presented with.

MS. ROGERS:

We're hearing from family

members about if there's a shortage of staff, if the night staff know that

there's going to be a shortage, someone is calling in sick for the next morning,

that's there's going to be a shortage of staff in the morning, residents who are

taken out of bed really early, between 4 and 5 in the morning because they need

to be dressed and washed because there's a shortage of staff in the morning.

So it

seems to me that a lot of the complaints that we do hear, whether they're

formally registered, really are about staffing and resources.

MR. ABBOTT:

Yes.

MS. ROGERS:

The other thing I wonder I

appreciate the issue that if people need to complain is there any proactive

measure to survey residents, survey family members about satisfaction with

nutrition, that more proactive approach?

MR. ABBOTT:

Yes, the health authorities and the individual facilities do these surveys. The

interesting thing, and that's why most of those are responses. The survey

responses, to your point earlier, they rate the service, the staff and the

accommodation, quite favourably.

MS. ROGERS:

Yes.

MR. ABBOTT:

Are we talking about 1 per

cent, 5 per cent where we need to make a difference and that's really what,

through this process, we will be able to focus because if it's the quality of

the food in facility A, then we obviously have a conversation about that; is it

left trays in facility B, then we deal with that.

MS. ROGERS:

Okay.

I'm

also curious because the Auditor General, in his report, also looks at the

social needs of residents around nutrition and I would say also the psychosocial

needs. What measures are being taken by the department to ensure that a person's

dietary needs are met? For instance, religious beliefs, kosher, halal;

Indigenous people who have been raised on country food; Asian food; folks who

are vegetarian or vegan how is that being handled or is there a plan to

address that? I believe with the current aging population that those issues may

be arising more.

MR. ABBOTT:

I would agree with you in that as our society changes that's definitely the

case. Again, we leave it to facility to identify and work with the resident and

the family as to meeting those needs, and that's where the dietician would

certainly come into play to work with the kitchen to make sure the appropriate

meals are put in place.

haven't, at the department, taken any particular policy direction on that,

obviously, because we support that. That, for us, is a given and as each

individual has certain, particular needs then they're addressed as well.

MS. ROGERS:

So will that be ?

CHAIR:

Excuse me, Ms. Rogers; I'm

going to go on to other Members (inaudible) then I will go back to you.

MS. ROGERS:

Could I just finish that

one?

CHAIR:

You're almost finished?

MS. ROGERS:

Just this question.

Will

there be a directive, a stated fact that that, in fact, is important?

MR. ABBOTT:

I think in the monitoring framework it's are you meeting sort of really

basically resident choice, whatever that choice may be.

MS. ROGERS:

Okay, great. Thank you.

CHAIR:

Mr. Bragg, anything further?

MR. BRAGG:

A final question, I guess.

Do you

track or monitor your complaints and, if you do, can you tell if the volume has

decreased? I'll be honest, in my two years since I've been doing this, and I

have two long-term facilities in my district, I don't hear the complaints that I

hear from Ms. Rogers. I'm not saying that that's wrong or anything, so I don't

MR. BRAGG:

Okay.

MR. ABBOTT:

But the ones that come directly to the department, we would track those. Again,

from the long-term care, there are very few.

MR. BRAGG:

Yes, okay, because I'm

thinking coming to our level that the family members are probably really upset

because they've probably exhausted whatever avenue they could at the front

level.

MR. ABBOTT:

Yes.

MR. BRAGG:

Okay, thank you.

CHAIR:

Mr. Petten, anything

further?

MR. PETTEN:

No, I am good on this topic,

thanks.

CHAIR:

Ms. Parsons, you're good?

Ms.

Rogers.

MS. ROGERS:

Yes, this may seem like an

odd issue but the issue of teeth. I know that the Adult Dental Program has been

cancelled and we see more and more seniors who have lost their dentures or their

dentures have broken and they may not have the money. The whole issue of

nutrition and teeth, has that been an issue, or will we see that as a growing

issue as we monitor what is happening with our seniors who are unable to get

dental care?

MR. ABBOTT:

I'm going to say it is an emerging issue, but that may not do justice to it.

It's been an issue longstanding, really. We've had conversations with the health

authorities around dental care; we've had conversations with the Dental

Association who are advocating and certainly recognize that is as an important

health care matter as anything else. We're working on that. We haven't come up

with any particular solution yet as to how do we address that, but it's

certainly on our radar.

MS. ROGERS:

Okay.

Great,

thank you.

The

issue of weighing and any unplanned weight change, what is happening now in

terms of addressing that? It seems to me it's a crucial issue, and without that

kind of information we really aren't quite sure what's happening with some of

our folks.

MR. ABBOTT:

Again, the Auditor General

speaks to that matter and his finding that will be one of the factors in the

monitoring framework, that in fact we will now start getting regular reporting

on meeting the standard.

Deena,

I'll ask you to speak to that.

MS. WADDLETON:

There has been a policy

drafted and ready for approval on weights in long-term care. In practice, the

RHAs have been doing that since the review, but we'll have a finalized policy on

weighing residents approved very soon.

MS. ROGERS:

Okay, because this was two

years ago that this report came out.

MS. WADDLETON:

Uh-huh.

MS. ROGERS:

So we're going to see one

this June, this month?

MS. WADDLETON:

This will be done, yes,

within a month or so.

MS. ROGERS:

Okay.

Do you

have any empirical evidence as to how it has improved? How do we know that?

MS. WADDLETON:

Until we get, as John has

mentioned, the outcome of the RHA monitoring, then I can't really speak to that

right now. But that will be something that we will be asking them to report on.

MS. ROGERS:

We really don't have any

reports on that?

MS. WADDLETON:

I don't have a report on

that, no.

MS. ROGERS:

Okay, so we don't really

know.

MS. WADDLETON:

No.

MS. ROGERS:

Okay.

All

right, thank you.

How

will you ensure that this is happening? It seems to me that it's such a

fundamental practice in terms of knowing how our folks are doing.

MR. ABBOTT:

(Inaudible) to the

department on meeting. Again, we will have both standards; we'll say it needs to

be done. Now we'll know how often it is done or not done and where that is.

MS. ROGERS:

Yes.

MR. ABBOTT:

And then we will follow up

with each of the health authorities to find out if, in fact, there are cases,

whether it's weighing the resident and monitoring and, more importantly,

monitoring that resident for any issues, health or other. Then we'll now have a

database to draw on. Right now, we are working in a vacuum.

MS. ROGERS:

It seems to me it's such a

crucial

CHAIR:

Excuse me, Ms. Rogers. I'm

going to go to Mr. King and we'll come back to you.

Mr.

King.

MR. KING:

First of all, I'd like to

correct a misleading statement stated by Ms. Rogers where the dental program has

been cancelled. That's not entirely correct. The days of everyone having two

sets of dentures, one for their mouth and one for the cupboard, those days are

over. I'm sure you can attest that it's done on a case-by-case basis. So let's

get that correct.

Just

one final question: Why is Western Health ahead of Eastern Health with regard to

the full implementation of these policies?

MR. ABBOTT:

One, I guess, really their system is a bit smaller. So they have opportunity to

focus a little bit more on that because the problem is that Eastern is a little

bit larger and a little bit more dispersed, but nothing fundamentally different.

I think it's just really a timing issue there.

MR. KING:

All right.

I'd

like to thank you for all the work you do. It's come a long way. You can see the

effort the department has put into this nutrition issue, and the RHAs. It shows

quite a bit of dedication over the past two years to get it from where you were

to where you are now, and I just want to thank you for that.

MR. ABBOTT:

Thank you.

CHAIR:

Mr. Petten.

MR. PETTEN:

No.

CHAIR:

Mr. Finn.

MR. FINN:

I'm fine, thanks.

CHAIR:

Ms. Rogers.

MS. ROGERS:

Yes, going back to the weigh

I'm going to weigh in again on the weigh. It just seems to me that it's just

so fundamental. Why do you think that in a number of cases it hasn't been done,

or hasn't been done as frequently as policy would what's going on?

MR. ABBOTT:

Again, I'll go back to some of the earlier points we were making. We have within

the health authorities professionals whose jobs it is to undertake this. So we

are dependent and reliant on them doing their jobs, and their managers need to

oversee this.

The

Auditor General went in and found out what to your point, we'd assumed this

would be automatic. If you know your resident, you would know if there is weight

loss and you'd want to make sure you address what the issues are, health or what

have you.

I think

it circles back to the quality of care and the responsibility within each of the

health authorities; and, in this case, the nursing homes. It was very specific

and identified specific cases. We, at the department, don't see any reason why

this hasn't been done as required. It was certainly an eye-opener for us that a

very basic measurement tool, in terms of care, wasn't being implemented.

MS. ROGERS:

Again, I would think that

those professionals who are providing that care want to provide the best care

they possibly can.

MR. ABBOTT:

Yeah.

MS. ROGERS:

So I would raise the issue

again: Is it a resource issue? I know there is a lot of stress on our long-term

care facilities, that there are wait times.

MR. ABBOTT:

But it's a standard of care.

In any of our facilities in our health services, if a standard of care is

determined, then they are resourced to meet that standard.

MS. ROGERS:

Okay.

response to my colleague, Mr. King, there, can you give us just an accurate

explanation of the policy of the Adult Dental care program, just to clarify?

Thank

you.

As it

stands right now, my understanding is the Adult Dental care program is available

for people on Income Support, there are further limitations.

MR. ABBOTT:

That's right.

MS. ROGERS:

But for people who not on

Income Support, it has been cancelled.

MR. ABBOTT:

There's no funding for that.

That's correct, yes.

MS. ROGERS:

Thank you. Okay.

I have

a concern around nutrition for our seniors who are waiting to go into long-term

care who are in acute care beds. I know we have a number of them. Is that

concern under examination? Because some of them are in there for a long time.

MR. ABBOTT:

That's right.

MS. ROGERS:

Yeah.

MR. ABBOTT:

Well, they would fall under,

then, the food that is provided by the hospital, if they're in a hospital

setting. We haven't flagged that as a particular issue at this stage.

MS. ROGERS:

I think it might be kind of

interesting again because and in fact they are waiting for long-term care.

MR. ABBOTT:

Yeah.

MS. ROGERS:

Acute care, feeding

nutrition may be a little bit different. They're in there for a long time. I was

just curious about that.

The

department noted there is a working group that met in March. Can we get an

update on that meeting? What is happening now? Will there be a formal review?

How long will it take? Is there a report from that? What is the scope?

MR. ABBOTT:

Yes, we'll provide that

information.

MS. ROGERS:

Great.

Thank

you very much.

I don't

know if I have any other questions. I think I'm okay. I just want to look at one

more issue almost there.

I was

looking on page 210 of the Auditor General's report. It looks at the shortfalls

to Canada's Food Guide. We can see that it was inconsistent. Some of the

shortfalls are more pronounced in some facilities than in others.

It was

very interesting that milk alternatives, for instance, in the St. John's

long-term care facility; there were a lot of shortfalls there and vegetables,

fruit and grain products. Dr. Albert O'Mahony Memorial Manor seems to have fewer

shortfalls. It was just kind of interesting to see the differences there.

I would

imagine then, your standards of care that you are developing will look at that

for your monitoring framework?

MR. ABBOTT:

Yeah, and I think that's a

good indication then of the kind of reporting we now will expect. We can start

looking at that and say: All right, why the deviation from what the established

norm is and what is the authority doing to address it.

MS. ROGERS:

Okay. Thank you very much.

Again,

I know how complex this is. Wouldn't it be wonderful if we could become a centre

of excellence for how we care for our seniors? I know it's a challenge.

MR. ABBOTT:

Thank you.

CHAIR:

Okay, thank you.

there are no other further questions, we'll finish with the Nutrition in

Long-term Care Facilities and move on to Acute Care. I have to step out for 15

minutes but Mr. Bragg is going to take the Chair while I'm out.

The

process will be to start then with Ms. Parsons as the first line of questioning

on Nutrition in Long-term Care Facilities.

MS. P. PARSONS:

No, acute.

CHAIR:

(Inaudible) the standard is

to ask, do you have any closing comments on the previous heading that we just

talked about.

MR. PADDON:

The only comment I'd make, I

mean I don't underestimate the challenges and the complexity of this particular

issue. As some of the Committee Members have talked about personal experience,

we've all had those experiences. Fortunately, mine have been fairly positive.

I am

encouraged because anecdotally I hear within Eastern Health, just from

acquaintances and people I know, that there's been a fair bit of work occurring

to address the recommendations. That's quite encouraging to us.

At the

end of the day, all our recommendations should be designed to ensure that we

have a better system and sort of care appropriately for people who are fairly

vulnerable in society. That's really what's driving us. We're quite encouraged

by what we've seen so far and, hopefully, we'll have a better system at the end

of the day.

CHAIR (Bragg):

Okay, thank you.

Moving

on, our next heading is going to be Acute Care Bed Management. It is

section 3.3

of the November 2016 report.

The

first question, I'll go to Ms. Parsons.

MS. P. PARSONS:

Thank you, Mr. Chair.

Based

on the review for Acute Care Bed Management in 2016, the recommendations,

Regional health authorities should identify and/or establish performance

indicators related to acute care bed management and ensure national benchmarks

are identified or hospital targets are established for each performance

indicator.

I would

like if you could please provide an update on the latest with this.

MR. ABBOTT:

In terms of these series of recommendations, of course, they were all sort of

addressed to the individual health authorities but we have coordinated and are

looking at how they are implementing.

terms of the first recommendation, for instance, Eastern Health has fully

implemented the recommendation, both Central and Western have partially

implemented and we can speak to some of that and Labrador-Grenfell has yet

to begin implementation.

The

indicators that were identified are all relevant, and depending, again, how

they've been set, and we are collecting data or the health authorities are

collecting data and reporting to us on those. Central Health, for instance,

expects to be fully compliant by the fall of 2018, and Western Health by late

fall of this year.

I think

what the Auditor General has identified in this area is an important piece of

work to help us manage our hospital costs. They are the most it's sort of the

highest cost in the country. We have now means to look at how we can manage the

beds better.

We have

over 1,500 beds in our system and, depending on how we manage those, will

determine how patients get in, move through our system and, obviously, are

released. We are operating at a very high level of capacity right throughout our

system. As a matter of fact, higher than we should ideally, and that's why it's

important that we manage the beds and the people in those beds much more

closely.

Again,

the Auditor General's report I think has been very helpful to the system in

identifying a critical management issue for us.

MS. P. PARSONS:

Could you just elaborate on

the management policies and procedures with particular regard to discharge and

admission, as well as (inaudible).

MR. ABBOTT:

Well, ideally, on admission you should have a discharge plan. So a physician,

working with the nursing staff, will say: Patient X, based on the conditions

they're presenting with, based on the care plan, we should see that patient

being released within three days, four days, five days.

That's

not always done, and it needs to be. That's a best practice right across the

country. Then you're managing against a potential date. So if a person comes in

on Monday, we're assuming they're going to leave by Thursday based on the care,

and if they're not, then why not? Has the patient gotten better or worse? Has

the care plan changed or are we just not managing that patient as closely as we

should? The physician, for instance, is available to write and support the

discharge note or notice at the time.

So it's

a lot of parts moving at the one time, but if we do this well, the patient is

better served. If the bed frees up one day earlier, that means somebody else can

come in to get in. So it really improves access if we do this right.

MS. P. PARSONS:

Right. The common concerns

we hear over the years we've heard of patients being on a bed in a hallway.

MR. ABBOTT:

Yeah.

MS. P. PARSONS:

That's a common concern.

MR. ABBOTT:

Yeah.

MS. P. PARSONS:

How have we improved in that

regard? At the same time, we hear the complaint that patients are being released

too early

MR. ABBOTT:

Yeah.

MS. P. PARSONS:

when still needing care

and still in critical condition.

MR. ABBOTT:

Yeah.

On the

first example you used in terms of beds in hallway, it's usually indicative of

overcapacity in the hospital that day. That means generally the beds upstairs,

shall we say, are full and there's no room. So they have to be managed through

the emergency room.

Part of

this whole exercise in looking at the management of the beds is to say: Are each

of the beds that are in whatever service they're in, are the patients being

appropriately cared for? Are they appropriately in those beds? Can they go home

sooner? Should they be in them there in the first place? The discharge plan on

admission helps manage that.

What

we're seeing in some successes now through other initiatives is that we are

starting to free up beds. So waiting in hallways is starting and, hopefully,

will come down. Ideally, you'd want to eliminate it, but you'll never fully

eliminate it because if you get a surge on any particular night or weekend or

what have you, then you have to manage it as best you can for that period.

terms of the discharge early and we hear that from time to time those

decisions are made by the attending physician based on the care needs, the

physical condition of their patient. They will make a determination on release.

They will get advice from the nursing staff and others, but that's their call at

the end of the day. There is no particular if it's after three days and

they're not ready to leave after three days, then they stay.

Now,

will the physician always get it right? Maybe not but, again, we measure that.

That is a standard of care as well through our monitoring system, because if

that patient comes back within a day or two or three, well, that means the

initial care has not been appropriate. We have processes then to review that and

review that decision so ideally it shouldn't happen the next time.

MS. P. PARSONS:

Okay. I'm good for now.

Thank

you.

CHAIR:

Mr. Petten.

MR. PETTEN:

Thank you very much.

Just

reviewing the AG's report, there are a lot of common themes that come out that

and I know that you just addressed a lot of it in having a discharge plan or the

overall planning from when you are first admitted in the hospital. I know Pam

referenced to the waiting times in the ER.

The

number, 69 per cent of discharges happening between noon and 6 p.m. 61 to 69

per cent I think everyone here can attest if you ever were in the hospital,

had a family member in hospital, if you never get discharged by Friday

afternoon, you're in for the weekend.

MR. ABBOTT:

Yes.

MR. PETTEN:

If there was nothing done by

4 in the evening, you could be rest assured you had to wait until the next day.

It usually was that the physician wasn't around to sign your discharge papers or

someone needed to write a prescription. There are a lot of variations to it.

Looking

through the AG's report, that theme went right through when we look at our Acute

Care Bed Management I guess the general question is: What is the plan? Do you

change physicians? It's really a scheduling thing in hospitals because a lot of

physicians are in the ER or in the operating room, they're performing clinics,

they don't do the rounds until 5 in the evening.

Personally speaking, I think that is one big issue when you look at our acute

beds being the discharge. There are a lot of other things involved but, to me,

that's one of the biggest issues from personal experience. I think we can all

attest, they don't make the rounds until 5 or 6 in the evening or near evening.

there any plan to ?

MR. ABBOTT:

Well, as part of looking at

this particular issue, yes, the physicians have to be totally engaged in how

they also change practice to support better utilization of the beds that, in

fact, their patients are in and their subsequent patients will be in.

This is

not new. Over a number of years, the health authorities have tried different

methods to make sure that the discharge is done ideally before noon and ideally

right over the seven days. If you look at what's happening in the best

performing hospitals across the country, you will see that's in fact what they

do.

We know

what needs to be done, we know how to do it, but the piece and you alluded to

it is getting the physicians to sort of change their practice, to be

supportive. That requires the VPs of medicine to better engage with them and

with the nursing and allow, in some cases, nurses to discharge if it's if I

can use the term routine. So we need to delegate some of that authority back

to nurses and what have you to allow them to discharge when the care plan

suggests that everything is on course.

There's

a lot of work that still needs to be done on that particular piece. That's

probably one of the more difficult pieces that we're struggling with.

MR. PETTEN:

Do you have a percentage of

beds that are being occupied now by long-term care patients awaiting beds?

MR. ABBOTT:

Yes, we do.

Denise

Tubrett has

MS. TUBRETT:

It's about 20 per cent on

any given day that there are individuals in an acute care bed that is discharged

and waiting for an alternative service level, one of which could be long-term

care.

MR. PETTEN:

You say they're discharged.

If they're in that acute care bed, do the doctors still make rounds to those

individuals or are they more in the care of nursing staff? How does that work?

I'm just looking at resources.

MR. ABBOTT:

Yeah, that would be

primarily under then the daily care of the nurse. The physician would, as

required, then would attend but not on a regular basis because they've been

basically discharged.

MR. PETTEN:

I know my time expired. You have dementia patients who tend to I know our

acute care beds are taken up with a lot of 20 per cent is used. Dementia

patients, unfortunately sometimes, tend to land wherever. A lot of times it's

probably more of a less desirable location. Granted, they're getting their meals

and their care, but where they are put I don't know if my colleagues can

Yes.

MR. PETTEN:

I've heard from other people

as well; I've dealt with it myself. That seems to be the norm. So they get their

three squares and wherever they can put them. Someone else I guess more vocal or

I don't know what you'd call it more opinionated or more able would probably

not end up there.

question is, I know these people are waiting to get out into long-term care and

they are taking up an acute care bed, no matter what their issue is, but is

there any consideration given to the fact of their personal situation? With

dementia, it's pretty sad disease. Is there any priority given to make sure that

they are probably in a more stable environment?

MR. ABBOTT:

If I understand, it's in

terms of while they're waiting for placement in a long-term care, so they may be

somewhere in the hospital setting. I can't speak to anything specific on that.

The particular challenge, if I can put it that way for those with dementia,

Alzheimer's, who are in the hospital waiting for placement, there are only so

many beds that we would have in a nursing

Document details

Collection	Newfoundland and Labrador — Committees
Citation	2017-06-21
Type	committee
Volume / chapter	committees standingcommittees publicaccounts ga48 2017-06-21pacdepartmentofhealthandcommunityservices
Language	en
Format	html
Source	PROVINCIAL
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