Performance Problems: 37 Health Care Issues from the Auditor General

The litany of health care problems identified by the Auditor General in her 2015 report is frightening. Here's thirty-seven of them dealing with LHINs, LTC, EMS, Rehab Hospitals, Health Infrastructure, Home Care, and Health Human Resources.

Local Health Integration Networks (LHINs): A Lot of Problems

1. LHINs have not met performance expectations. "Most LHINs performed below expected levels in the year ending March 31, 2015. In that year, LHINs on average achieved their respective local targets for six of the 15 performance areas".  Also: "Based on the provincial results that include all 14 LHINs, only four of the 11 provincial targets that measure long-term goals for LHINs were met."
2. Performance has not improved. "While province-wide performance in six of the 15 areas measured has improved between the time the LHINs were created and 2015, in the remaining nine areas, performance has either stayed relatively consistent or deteriorated since 2010 or earlier". 
3. The Auditor also found that the performance gap between LHINs has widened over time in 10 of the 15 performance areas.
4. There are bigger health care problems in northern and rural areas. The government promised to develop a health care plan in 2007 for rural and northern areas but failed to do so.  Given the ongoing problems, the Auditor General has recommended that the province develop this plan, as promised.
5. The Auditor recommends that MOHLTC "should determine how best LHINs can manage the primary-care sector." Currently, LHINs do not oversee primary care (except for Community Health Centres).The Ministry says it "accepts this recommendation and will examine ways the LHIN role in primary care can be strengthened".
6. Neither the Ministry nor the LHINs routinely verify that the information health service providers submit to them is accurate and reliable. "Without such verification, the Ministry and the LHINs cannot be certain that health services are being provided as expected, nor can they be assured that significant errors in reporting has not occurred." The LHINs show no interest in verifying the data, replying: "The LHINs and Ministry acknowledge the importance of high-quality data for decision making. Accountability for reporting accurate and timely data lies with the health service providers."
7. Processes used to plan and integrate the health system need improvement. Notably, the Auditor notes the "LHINs could do more to define system capacity (that is, how service supply meets current and future demand for service)."The recommendation is for the LHINs to"begin to collect, over a reasonable time period, the data needed to determine the existing capacity of all health services in their regions"
8. The LHINs should "identify further group-purchasing and back-office integration opportunities in the various health sectors, and implement these cost-saving practices." The LHINs say they will "support" such integration but note that that they will on clinical integration instead: "Consistent with the LHIN mandate, LHINs will continue to lead and focus on service integration (i.e., the integration of service delivery to patients, clients and residents) for the benefit of residents."
9. The LHINs don't consistently measure the cost savings achieved (or not) by mergers and integration. "Only one of the four LHINs we visited tracked the cost savings that resulted from its integration projects, and then only on merger-type projects." The LHINs response sounds like they will find a measurement system that will prove these integrations are saving money: "LHINs will work toward developing a standard framework in which to identify and measure the impact of these integrations demonstrating overall value for service providers, patients and the system."
10. The Ministry of Health and Long-Term Care should review existing LHIN boundaries. The Ministry indicated that it will review the existing LHIN boundaries to determine whether changes may be required.
11. "LHINs are not notified of funding changes on a timely basis, and in turn do not in due course notify the health service providers they fund, resulting in cases where funding originally earmarked for health service providers is returned to the Ministry." (This may help explain the tendency for the MOHLTC to under-spend its budget.)

Comment:  [A] There are significant performance problems. Despite this, the government is reducing resources for health care.  [B] There is scant evidence that the government driven integrations and mergers of health services providers are saving money.  Notably after the Harris government required hospitals to merge, significant evidence arose that this had driven costs up, not down.  [C] There is little attempt to measure the needed capacity of the health care system.  Despite this, the government is systematically reducing the resources available to the health care system, and especially hospitals. [D] The bigger problems for health care in northern and rural Ontario are no doubt connected with the failure of the government to develop a good health care plan for northern and rural Ontario, as it had promised in 2007. We need a solid plan to deal with these issues.  

Long-Term Care Quality Inspection Program: Repeated Non-Compliance

1. The Ministry of Health and LTC (MOHLTC) is not following up on long-term care "situations placing residents at risk. "Specifically two-thirds, or about 380, compliance orders due in 2014 had not been followed up within the Ministry's informal 30 day target."
2. "The Ministry’s actions are not sufficient to address the repeated non-compliance in certain long-term-care homes—We noted that homes in one region did not comply with almost 40% of the compliance orders issued by the Ministry in 2014, while homes in another region did not comply with about 17% of orders."
3. The Auditor General notes, "Ontario legislation does not require a minimum front-line-staff-to-resident ratio at long-term-care homes—Home administrators identified insufficient staffing and training as the main reasons for their failure to achieve compliance. In 2014, long-term-care homes provided an average of 3.4 direct care hours per resident per day, while the Ontario Association of Non-Profit Homes and Services for Seniors recommends four hours. Home administrators also said that the provincial funding of $7.87 per resident per day is not sufficient to meet residents’ nutritional needs (three meals plus two snacks)."

Note the ongoing problems in the homes and the connection made to under-staffing.  

Infrastructure: Inadequate hospital funding

1. Ontario funding is less than the renewal needs for existing hospitals. "The assessments of hospital facilities identified $2.7 billion dollars of renewal needs, requiring annual funding of $392 million to bring assets to what is considered good condition. However, since 2014/15 actual annual provincial funding has been $125 million and prior to that, since 2010/11, only $56 million was provided." 
   
   
   
2. Hospitals "have had to use operating funds to fund capital" projects. "In the last five years, hospitals spent on average $45 million a year of operating funds on capital and other funding needs."
3. Funding is less than needed not just for renewal of existing facilities, it is also inadequate for required new facilities. "Existing funding does not address significant pressures faced by ministries for new projects... the Ministry of Health and Long-Term Care has received submissions for 37 major hospital projects totalling $11.9 billion dating back to 2005/06. These submissions were endorsed by Local Health Integration Networks as needed projects requiring funding. However, the Ministry did not put forward these projects for approval to Treasury Board as these initiatives could not be managed from within their existing budget allocation."
4. There is a bias in funding allocations towards new facilities at the expense of renewing older facilities.

Comment: Earlier reports by the Auditor General's office have documented how privatized public private partnerships (P3s) -- the government's preferred way of developing new facilities -- are wasting billions of dollars of public money.  Now it turns out that the  government is biased towards developing new facilities at the expense of renewing existing facilities. Righting this imbalance by focusing more on renewing existing facilities would put the crimp on those P3 corporate rip-offs.   Spending too much on new P3 facilities is especially bad given that the Auditor also finds that we are not doing enough hospital infrastructure projects to keep up with needs.  With most of Ontario hospital facilities over 31 years old, that spells trouble so we certainly cannot afford to waste what we do spend on privatized P3s.

Paramedic Services ("Ambulance"): Improving response

1. A July 2015 consultants report collected data from 14 of 50 municipal delivery agents. "The consultant concluded that there were limited opportunities for operational efficiencies that would result in cost savings. This was primarily due to all municipalities using unionized staff with relatively similar wages across Ontario. However, the report also noted that improved call triaging could reduce costs overall in urban municipalities. Therefore, the consultant recommended that the province work with municipalities (especially larger urban ones) to increase the accuracy of dispatch systems’ prioritizing of calls. The Ministry is planning to address this recommendation in the Provincial/Municipal Land Ambulance Dispatch Working Group’s report, expected in fall 2015."
2. The Auditor claimed little progress on minimum service levels and promotion of efficient delivery. "The consultant noted that the Ministry’s current performance measures do not reflect the key outcomes of land ambulance services and recommended that the Ministry review the current measures. The Ministry plans to share the consultant’s report with the OAPC (the paramedic Chiefs) in fall 2015 and then develop processes to promote more efficient land ambulance services by March 31, 2017"

Comment: Improvements in dispatch protocols will help paramedics respond more rapidly to emergency calls.  The other recommendations in the consultant's review, reportedly to be released to the Chiefs in 2015, should be closely followed. 

Rehabilitation hospitals: Rising demand

1. This sector will expand as the population ages, particularly as the baby boomers turn 75. Still the Auditor notes that "approximately a third of patients admitted to inpatient rehabilitation at the two hospitals we visited with stroke programs had been assessed by an acute-care hospital as having mild functional impairment. This suggested they might have been better served in outpatient programs if these less costly services were available."
2. There is no co-ordinated rehabilitation system in Ontario.
3. "There was wide variation in the supply of regular rehabilitation inpatient beds across the province, which could mean that patients had to travel outside their LHIN for services. The number of beds ranged from 57 per 100,000 people in the Toronto Central LHIN to only six per 100,000 in the Central West LHIN. The provincial average is 18 beds per 100,000."
4. The Ontario Hospital Association reported that, as of March 2013, about 2,300 alternate-level-of-care patients who were ready to be discharged were waiting in acute care hospital beds for arrangements to be made. Of these, 25% were waiting for a regular rehabilitation bed or a complex continuing care (which includes restorative rehabilitation) bed.

Comment: With almost 600 patients waiting in other hospital beds for a rehabilitation bed, more rehabilitation hospital beds will significantly reduce alternate level of care patients in hospitals.  Most of the other patients are waiting for LTC beds -- but there is precious little sign that the government wishes to expand either LTC or Rehab capacity.

Community Care Access Centres (CCACs): Wait lists and varying service

1. Clients are still put on wait-lists and have to face long wait times to obtain personal support services.
   
2. 2. Clients with the same assessed needs still receive different levels of services depending on where they live in Ontario.
3.  CCAC funding is predominantly based on what each CCAC received in prior years rather than on actual client needs and priorities.
4. CCACs are unable to provide personal support services to the maximum levels allowed by law. 
5. Care co-ordinators’ caseload sizes vary significantly, and some exceed suggested ranges in standard guidelines
6. Clients may not receive appropriate levels of services as CCAC care co-ordinators did not assess or reassess clients on a timely basis
7. Not all care co-ordinators maintained their proficiency in, and some were not regularly tested on, the use of assessment tools
8. CCAC oversight of contracted service providers needs improvement
9. CCACs do not consistently conduct site visits to ensure service providers are complying with their contract requirements. The lack of site visits to contracted service providers by the CCACs, and the CCAC reliance on self-reporting by contracted providers, does not sufficiently mitigate the risk of under performance or billing inaccuracies. The Auditor consequently recommends the CCACs should conduct routine site visits to monitor quality of care and verify the accuracy and completeness of information reported to CCACs. The CCACs appear to be uninterested in this, noting that they see value in mandatory provincial requirements for automated reporting to the CCACs.
10. The MOHLTC should expedite diverting low-need clients from CCACs to community support service agencies. The MOHLTC supports this. A phased implementation is going ahead, beginning with four early adopter LHINs. This reform will reduce the CCAC scope of work
11. CCACs should require that all CCAC care co-ordinators comply with the minimum number of assessments per month and be tested on the use of the assessment tools each year
12. The Auditor notes that the Ministry only requires contracted service providers to annually self-declare that they have complied with the government’s $4 an hour PSW wage enhancement and so recommends that the CCACs should conduct inspections of service provider records, on a random basis, and share the results with the MOHLTC.

Comment: The Auditor’s report supports some of CUPE’s home care concerns: [1] the CCAC wait lists and the inability of the CCACs to provide the maximum care allowed supports our contention that home care is underfunded; [2] The Auditor’s concerns that the CCAC oversight of contracted providers is inadequate bolsters our contention that, given almost 20 years of CCAC contracting, it is time to consider that contracting-out for vital health care services is the problem.

Human Health Resources

1. The Auditor General had previously identified that access to health care was a problem for some Ontarians, particularly those who live in rural, remote and northern areas of the province. As of 2011, 95% of physicians in Ontario practised in urban areas and 5% in rural areas. At the same time, 14% of the population lived in rural areas. 
2. At the end of 2011, 66.7% of nurses were working full-time in Ontario, just slightly under the Ministry’s goal of having 70% of nurses working on a full-time basis.  This percentage dropped to 63.9% in 2014.

Charts: Auditor General 2015