2008 Legislative Session: Fourth Session, 38th Parliament

SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

MINUTES AND HANSARD

MINUTES SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

Tuesday, December 2, 2008

10 a.m.

Douglas Fir Committee Room

Parliament Buildings, Victoria, B.C.

Present: Rob Fleming, MLA (Chair); Rick Thorpe, MLA (Deputy Chair); Harry Bains, MLA; Randy Hawes, MLA; Olga Ilich, MLA; Bruce Ralston, MLA; John Rustad, MLA; Claude Richmond, MLA; Ralph Sultan, MLA; Claire Trevena, MLA; John Yap, MLA

Unavoidably Absent: Bob Simpson, MLA

Others Present: Cheryl Wenezenki-Yolland, Comptroller General; John Doyle, Auditor General; Josie Schofield, Committee Research Analyst

1. The Committee considered the Auditor General’s report entitled Management of Aboriginal Child Protection Services: Ministry of Children and Family Development (Report No. 3, 2008/09)

2. Resolved, that the Committee accept the report of the Auditor General entitled Management of Aboriginal Child Protection Services: Ministry of Children and Family Development; and the response by the Ministry of Children and Family Development. (Randy Hawes, MLA)

3. The Committee considered the Auditor General’s report entitled Interior Health Authority: Working to Improve Access to Surgical Services (Report No. 6, 2008/09)

4. Resolved, that the Committee accept the report of the Auditor General entitled Interior Health Authority: Working to Improve Access to Surgical Services; and management’s response therein. (John Yap, MLA)

5. As the Chair was unavoidably absent at this time, the Committee adjourned at 12:49 p.m. to the call of the Deputy Chair.

The following electronic version is for informational purposes only.

The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

select standing committee on
Public Accounts

Tuesday, December 2, 2008

Issue No. 25

ISSN 1499-4259

[ Page 479 ]

TUESDAY, DECEMBER 2, 2008

The committee met at 10:03 a.m.

[R. Fleming in the chair.]

R. Fleming (Chair): Good morning, Members. Good morning, Auditor General. Welcome to Public Accounts Committee. We have an agenda before us with two hearings this morning on two reports — Management of Aboriginal Child Protection Services, and the second item is Interior Health Authority: Working to Improve Access to Surgical Services.

If there is no other business to put on the agenda or amendments to be made, I would ask that the agenda be moved for adoption at this time.

Meeting agenda approved.

R. Fleming (Chair): Mr. John Doyle, we'll begin with you, as always, to lead us off on the first item here from your office: Management of Aboriginal Child Protection Services audit. Welcome, and good morning to you.

Auditor General Report:
Management of Aboriginal Child
Protection Services: Ministry of
Children and Family Development

J. Doyle: Thank you, Chair, and good morning. Good morning, Deputy Chair and Members.

The report on managing aboriginal child protection services was published in May 2008. At the time we carried out our audit, aboriginal children accounted for only 8 percent of the one million children in B.C., but they made up 51 percent of children in the province's care.

Protection is one part of the child welfare services managed by the Ministry of Children and Family Development. We focused our audit on the high-risk, high-impact component of child welfare — that is, protection for children who may be at risk of harm.

The Auditor General of Canada simultaneously issued a report on the management of child welfare services for Canadian first nations children and families. Our two audits were performed concurrently in order to present a broader picture.

Like most jurisdictions, British Columbia is facing growing pressures to address inequities in the lives of aboriginal children. In 2007 the government stated a goal to ensure that "children and youth in B.C. have their developmental needs met and are supported by healthy families and inclusive communities."

[1005]

As part of accomplishing this, the government has turned its attention to the aboriginal children, who make up more than half of those it serves.

I expected to find aboriginal child protection services that were appropriately designed, resourced, managed and reported on to meet the goals set for it. I found the ministry had attempted to work collaboratively with aboriginal organizations and the federal government to deliver effective, culturally appropriate and equitably accessible child protection services mainly through aboriginal agencies to aboriginal children and their families.

However, several challenges, some anticipated and some not, have slowed the transfer to aboriginal agencies of responsibility for delivering services. As a result, many of the child protection needs of aboriginal children and their families continue to remain unmet.

My report contained ten recommendations to improve the delivery of aboriginal child protection services. Subsequently, the ministry provided an action plan detailing how it will deal with my recommendations. That action plan is now published on my website, and an updated version is kept on the ministry website, I believe.

With me today are Morris Sydor, assistant Auditor General, who's going to manage the technology; and Kathy Crawley, director, who is going to make the presentation. Kathy was a senior member of the team that actually carried out the audit work. I will now turn over to Kathy to make a brief presentation regarding this particular report.

K. Crawley: Good morning. I had the pleasure of working with the Ministry of Children and Family Development on this audit culminating in a report published in May of 2008. As performance auditors, we look to see how well organizations are managing their programs to meet the goals that they themselves have identified as important.

For this audit, the focus was on how well the ministry was managing efforts to provide aboriginal child protection services that were culturally appropriate, equitably accessible and effective. The ministry provides child protection services to all children in the province. However, the scope of our audit focused on child protection services to aboriginal children and their families.

To understand the similarities and the differences of how these services were delivered across the province, we travelled to all five regions and included the central office in Victoria.

While on the road, in addition to visiting a sampling of the ministry offices, we also met with the executive directors of aboriginal agencies in those areas. Some were providing full child protection, while others were working towards accomplishing that level of service. We did not audit these agencies. Rather, we were assessing how well the ministry was supporting them to take over the delivery of aboriginal child protection services.
[ Page 480 ]

We concluded that many protection needs of aboriginal children were unmet and that the ministry needed a strategic approach to change it. Although the ministry had made attempts to collaborate, many challenges slowed the transfer of child protection services to those aboriginal agencies.

Regarding the need for a strategic approach, the way they were delivering services was only partly meeting the goals mentioned at the beginning of this presentation. The aboriginal children's needs for protection service were not known, so the resources to meet those needs were also not known. The way the ministry was managing the change was not in step with the goals, and there was inadequate reporting on how they were doing.

Our key findings are reported under the four themes — up on the slides. The ministry service delivery approach was the first one; resource needs; then how they were managing the changes; and then finally, reporting how they were doing.

Regarding the delivery of aboriginal child protection services, the ministry recognized it needed new methods and tools. It hadn't defined what "culturally appropriate" looked like or how to determine it. After almost 20 years since inception only eight of the 24 aboriginal agencies were delivering full child protection services, which meant that 70 percent of aboriginal children and their families were still being served by the ministry.

[1010]

We also found that two sets of standards were being used — one for the aboriginal agencies and a separate set for the ministry — and that the internal audits provided no assurance that the children's needs were being met. Our three recommendations for service delivery approach can be found on pages 8 and 9 of our report.

Our second focus or theme was on the ministry's assessment of aboriginal child protection service needs and the resources required to deliver them. What we found was that the ministry didn't have enough information to either assess the population of aboriginal children's needs or determine what staff resources were required. This also meant the ministry had been unable to determine the financial cost of delivering culturally appropriate services. As a result, it had been unable to develop a persuasive business case to negotiate for both provincial and federal funding.

Additionally, we learned that there's a substantial shortage of aboriginal workers to meet the known demand. Our four recommendations regarding needs assessment and resources can be found on page 9 of our report.

The third theme was how well the ministry was managing the significant change required to transfer child protection services to the aboriginal agencies. We found that there had only been limited success. The ministry recognized the need for a better change management strategy. Of particular concern, though, was that culturally appropriate practice was not well defined, and practices were not required or supported when ministry staff continued to provide child protection to the majority of aboriginal children.

We also found that despite the intent to work collaboratively to support aboriginal agencies, some ministry change practices were seen by some of the agencies as not being in the spirit of building the partnership to make the shift.

Lastly, the collaborative of oversight of provincial groups focused on identifying problems rather than finding solutions. Our two recommendations for managing change can be found on page 10 of our report.

For the last theme, on reporting how well services were delivered, we found only limited information was provided. What was lacking was information on costs and what successes and challenges the ministry had experienced. More importantly, there was no information on what impact the services had: were the children any better off? Our last recommendation, regarding reporting, can be found on page 10 of our report.

That concludes our brief presentation.

R. Fleming (Chair): Thank you.

Auditor General, is there anything to add to that presentation?

J. Doyle: Not at this time, Chair.

R. Fleming (Chair): Not at this time. Okay. Well, we'll have members ask questions for you and your audit team. Maybe what we'll do at this time is ask the representatives of the ministry to come forward and begin their presentation.

Good morning, Mr. Sieben.

[1015]

M. Sieben: Thank you, Chair. My apologies for the delay.

R. Fleming (Chair): No troubles. I'll let you introduce your team from the ministry and begin the presentation now.

M. Sieben: Seated to my far right is Sarf Ahmed, our assistant deputy minister for management services. Seated to my immediate right is Debra Foxcroft, assistant deputy minister for aboriginal policy in regional support division. I'll ask Deb to introduce two of her senior staff in the gallery who might assist us with the odd question, depending on how things go towards the end of this discussion.

D. Foxcroft: Good morning. I'd like to introduce my director of operations, Rob Parenteau, and also Dena Carroll, director of policy and legislation.
[ Page 481 ]

M. Sieben: We're really pleased to be able to come and speak with you today about something that's extremely important to us and where we spend a fair amount of our time and focus as a child welfare ministry — inclusive of child welfare, in any event — and that's looking at how best to improve child welfare services for aboriginal and first nations peoples.

MCFD acknowledges the challenges and complexities associated with the delivery of child welfare in an aboriginal and first nations context, certainly as it's described and identified in the Auditor General's report. Child welfare on reserve is an area of concurrent jurisdiction, meaning that both the federal and provincial governments have a responsibility in this area.

To provide just a little further context and sort of the nature of the complexity of our business, British Columbia is home to the second-largest aboriginal population in the country after Ontario. According to the 2006 census, there are a little under 200,000 aboriginal people in B.C., accounting for 5 percent of the population of the province.

This aboriginal population grew by 15 percent between 2001 and 2006 and more than three times the rate of the non-aboriginal population, and by 39 percent between 1996 and 2006, which is more than four times as fast as the non-aboriginal population.

First nations people accounted for the majority of this bigger population group — about 66 percent — followed by Métis and Inuit. Of the three aboriginal groups, the Métis population saw the fastest growth between 1996 and 2006 at 132 percent, compared to 18 percent for first nations populations. In 2006, 60 percent of the aboriginal population in B.C. lived in urban areas, while 26 percent lived on reserve, which is significant for the sake of how you're looking to develop services.

To focus a little bit more specifically on the child welfare context and as mentioned by the Auditor General, in October 2008 of the 9,026 children in the care of the director under the Child, Family and Community Service Act, 4,729 are aboriginal, which is pretty much exactly 52.4 percent of the population. When the audit was done and as referenced by the Auditor General, this figure was around 51 percent. So while there is a slight increase there, it's been relatively constant over the course of the last couple of years, despite some of the comments that have been in the media recently.

For the sake of our presentation today, what we'd like to do is identify how we have responded to the recommendations as framed up in the workplan reference by the Auditor General. We'll look to cluster the recommendations under the themes spoken to in the Auditor General's report and identify the actions that are underway.

Evidence of our strong commitment to looking for improvement in this area is an extremely strong link between focus on aboriginal child welfare and MCFD's Strong, Safe and Supported action plan.

[1020]

The action plan is a broad look at delivery of services to vulnerable children and youths, inclusive of early intervention prevention services, and then when an intervention is necessary, a commitment to a strength-based, functional developmental approach and then a strong commitment to improved quality assurance activities.

One of the five pillars that anchors the Strong, Safe and Supported plan is the pillar devoted to aboriginal activities. Within this pillar, there are two components. One pertains to governance, which is really how best to involve and respond to the interests of first nations and aboriginal peoples to be the ones making decisions relating to children and families in their communities.

The second is the actual delivery of aboriginal child and family services. The audit focused on the latter, specifically through aboriginal agencies, and that's where we'll spend a fair amount of our focus today.

D. Foxcroft: Good morning. We are going to be sharing the presentation, so I'll be speaking to the next few slides.

In terms of the way forward, I think it's critical in our work to build those relationships and the trust and the capacity for first nations aboriginal communities. That would include the delegated agencies, the first nations, the nation to nation, the chiefs and council, and our aboriginal organizations. It's consistent, also, with the new relationship and the vision and the transformation accord. There's a commitment provincewide to build a new relationship built on respect, reconciliation and recognition of aboriginal rights in the title to the foundation for building ongoing relationships between the province and the first nations.

In terms of supporting people to plan and develop models of service delivery, we do have processes in place and have had them for 20 years. In my experience as the director of the first delegated agency in the province…. There has been, I believe, a huge development in terms of building the capacity from 20 years ago. We now have 24 delegated agencies, and 21 of them are urban organizations. They're all supported by tripartite kinds of agreements with the federal government in terms of funding. The province also has agreements in terms of the delegation and how they do their work.

I just wanted to say that in terms of the action that we're talking about, from the Strong, Safe and Supported we now have an action plan on how we're going to work towards an aboriginal approach to child and family services. It would be based on their culture, their traditions, their nations, their cultural groupings. We would support the delivery of those and improve effective, culturally appropriate services within the
[ Page 482 ]
available resources. It's the delegated agencies and other aboriginal organizations that define what "culturally appropriate" is. It has to come from their own communities and themselves.

Quality assurance and accountability need to be developed in an aboriginal context. We are looking urgently at how we're going to evaluate the gaps in services, particularly relating to children in care. We are looking at how we will implement that strategy to meet those immediate needs and our time lines. In terms of working towards that is to develop a practice forum to identify those gaps in services.

We need to speak to supporting the enhancement and success and development of a full range of services that are culturally appropriate from aboriginal child and families, including prevention programs for aboriginal children and youth. We plan to do that through the winter.

[1025]

The actions to date in terms of measuring approach to transfer services to delegated agencies. As I said, our delegated agencies serve 1,800, or 39 percent, of the 4,675 aboriginal children in care of the province.

Since 1987 the province has been transferring responsibility for child protection and family support back to aboriginal communities. There are 21 first nations delegated agencies and three urban. The urban areas cover the Vancouver area, the Surrey Métis child and family service, and Surrounded by Cedar here in Victoria. So 141 of the 199 first nation bands are represented by agencies that either have or are actively planning toward delegation. Of the 141, 118 are represented by a delegated agency in operations.

A number of existing first nations agency deliver or plan to deliver services, both on and off reserve. Four agencies provide voluntary services and recruit and approve foster homes, ten have additional delegation necessary to provide guardianship services for children in continuing care, and nine have been delegated to provide, in addition, the above full protection, including authority to investigate reports and remove children. One agency is a startup that has a delegation agreement that is not delivering services at this time.

We have implemented, in partnership with the Lalum'utul' Smun'eem adoption agreement. This is the first in British Columbia and the second in Canada, where they would be…. It's an adoption service to develop services that are going to meet their culturally appropriate ways and traditional ways of bringing children into their permanent homes. An adoption ceremony has been developed — or they had an adoption ceremony — and six of those children were adopted just this year. They plan to adopt 20 more children under their adoption program.

VACFASS signed a new DCA in December 2007, and the agency went operational to provide the full range of child protection services for all aboriginal people in the Vancouver area, in March of 2008. They are currently employing 100 delegated social workers, and there are currently 469 children in the care of the agency, including 307 continuing-care wards, 92 temporary custody wards and four special needs agreements. This agency is the largest urban aboriginal agency in Canada.

We also have looked at different approaches in terms of service delivery. The Nenan Dane Zaa Deh Zona Family Services Society, which is in the northeast, is a community development initiative exploring the establishment of a combined agency with urban aboriginal agencies and the treaty 8 chiefs, who represent 14 communities that are using a triple-A approach, which involves three phases: assessment, research and community development. They expected to complete the assessment and analysis phase by January.

In terms of that theme and service approach, I believe that we have been successful in transferring delivery of services.

In terms of recommendation 2, the revision of the AOPSI operational standards completed in November 2008, and recommendation 3, the aboriginal participation in the development of the ministry's new computerized integrated case management system, which will provide comprehensive data to assist with better planning, monitoring, collection. Services are provided by delegated agencies and are guided by aboriginal operational practice standards and indicators that were developed in 1999, in partnership with the delegated agencies.

[1030]

A review of the operational standards was complete in November of 2008, and the practice standards review is expected to begin in December in partnership with our aboriginal steering committee.

Now the delegated agencies are involved in the ICM project, which is expected to be rolled out in March of 2009. Aboriginal participation includes a delegated agency. Representatives are invited to participate in the ICM project, so that is underway.

In terms of the Strong, Safe and Supported action, our ministry speaks…. The delegated agencies are jointly developing the AOPSI, aboriginal operational standards, in partnership, which includes complaint resolution processes, and that should be complete in the spring of 2008.

In terms of themes, the service delivery approach, recommendation 1. We have now five new agencies in the planning process: two first nations in the Wet'suwet'en; Okanagan Nation; and one urban in the Campbell River area, the Laich-Kwil-Tach; and two Métis organizations, one in Kamloops and also the one in Kelowna.

The ministry service standards. We're looking at a draft workplan. A consultation plan has been developed and is to be linked to the Strong, Safe and Supported
[ Page 483 ]
action plan framework. In the Strong, Safe and Supported action plan it states: "Reviews of our practice standards" — which, as I said, will begin in 2009 — "and the issue of adopting the AOPSI standards is expected to be on the agenda at our next partnership meeting with the delegated agencies."

In terms of themes, No. 1, service delivery approach, and the recommendations to No. 1 and No. 3, indigenous approach to quality assurance will be developed with the aboriginal partners to reflect current research and culturally appropriate best practice. It will be informed by the broad ministry quality assurance framework.

As we said, there is an initiative across ministry in developing a strategy for monitoring and developing and reporting outcomes. By mid-November the cross-ministry research policy and practice branch office of the chief information officer have completed a background paper to develop the outcomes and indicators for children.

We are now posting the audits in terms of accountability as of September of 2008, with agreements from delegated agency directors. We have six practice audits of the delegated agencies, which have been posted on the first nations forum website, and the ministry quality assurance framework is identified in pillar 4 of the Strong, Safe and Supported plan.

If aboriginal agency children are going to be successful, it's important that they all must be working on an aboriginal cultural approach to quality assurance — if that's going to be successful.

S. Ahmed: I'll quickly go through the next three slides, which talk about needs and required resources. In Budget 2008 the province allowed $4.55 million to build capacity and deliver additional services for aboriginal agencies. We used that funding to help the first full delegation of an urban agency in Vancouver. About 12 social workers were recruited, and the funding also helped promote aboriginal adoptions.

We are receiving more funding from INAC. In '06-07 it was $17 million, which has gone up to $24 million because we have been serving more aboriginal children based on that. In ourselves, in the ministry, we have increased the funding to delegated agencies, as most services get transferred, from about $35 million in '06-07 to what we are projecting as $66 million in '08-09. This is for a wide range of services.

[1035]

About 1,800 aboriginal children, which are in the care of delegated agencies, as well as early childhood development; family supports; supported child development; child and youth mental health; and various other services which these agencies provide.

We've also been working with the federal government on an enhanced prevention model through last spring and summer. What we've been hearing from the delegated agencies was that there needs to be some kind of funding framework or costing framework so that there is equitable funding amongst delegated agencies. So we, in working jointly with them, have developed a costing framework for that.

One of the other points which the Auditor General's report had made was about human resources and the shortage of aboriginal workers. The ministry has been taking a number of steps in this regard. Some of them are listed on the slide. For example, in January of '06 we had 119 aboriginal workers working for the ministry. Today we have 240.

We've also developed various other initiatives. The aboriginal child protection recruitment project. The first cohort is expected to graduate in 2009. There has been an exchange program, which was piloted this summer. Also, we are increasing aboriginal child and youth mental health practitioners as part of our mental health plan. Seven clinical positions were contracted to aboriginal organizations in the last year or so and five aboriginal wellness coordinators as well.

Moving on to what we are planning to do and what is underway. We're looking at the costing framework to see how best some of the recommendations out of it could be implemented. We're also getting better baseline information about what we spend on aboriginal children and families. We've got the information where there are targeted services. What we are working on where the services are both provided by agencies to a mixed client caseload…. Some are aboriginal, and some are non-aboriginal, so that is that piece of information we're working on to develop as well.

We of course are awaiting any federal government decisions on any provincial prevention model funding in the coming year. Earlier Deb and Mark talked about pillar 4 in our Strong, Safe and Supported — work which will happen as part of that, and is happening, and will inform our future funding requests, whether they are to the province or to the federal government.

R. Fleming (Chair): Members, I will have to relinquish the chair to the Deputy Chair in order to attend a memorial service, so I'll do that now. Normally, I don't like to go back to the 1990s, but it's a pleasure to hand the chair over to the former Chair of the committee, Mr. Thorpe, this morning. I know you're all in good hands.

[R. Thorpe in the chair.]

M. Sieben: I'll speak to the next couple of slides.

Another strong theme from the Auditor General reports pertains to change management and the need for MCFD to intensify our efforts here. As noted by Deb, we currently have 24 delegated agencies in the province, and this has occurred over a span of about 20 years.

A creation of a delegated agency is less about moving responsibility for child welfare services in a holus-bolus
[ Page 484 ]
manner to first nations and aboriginal peoples, and it's more about responding to community-based interest to develop culturally appropriate services in specific communities.

[1040]

They are created through tripartite agreements between ourselves, first nations communities and the federal government. The on-reserve delegated agencies are predominantly funded federally. The urban and Métis agencies receive a fair amount of their funding through the province. They are community-based, culturally relevant and stand the best chance of providing services that are meaningful to first nations and aboriginal peoples in a core child welfare mandate.

We currently have around 1,700 of the children in care receiving guardianship services through child welfare agencies. The aboriginal agencies are able to design, develop and monitor, then, how child protection services are developed and provided to their community members.

As Sarf noted, we're also working with our federal colleagues and first nations to develop a new B.C. first nations enhanced prevention services. This is in response to requests, both from the province and first nations leaders, for the federal government to address what's referred to as directive 20-1, which has historically, over the course of the last ten or 15 years, been the primary funding model by which aboriginal agencies and first nations communities on reserve have received support for their children.

Built into that structure was a funding formula that was really focused on providing services to children in care, not providing opportunity to fund preventative services that might lead to protecting and serving vulnerable children and families without having to bring them into care.

So this development is extremely significant, both for MCFD and how we fashion up child welfare services in communities as well as first nations themselves, given that a fair amount of our focus over the course of the last few years and in the years to come is how best to develop and further enhance our prevention and early intervention services.

As has been discussed a time or two, we've seen somewhat of a decrease in the number of children in care overall over the course of the last ten years or so, particularly the last five or six years. This is largely due to us being able to avail ourselves of what the Representative for Children and Youth refers to — and Mr. Hughes did as well — as "new child welfare approaches."

They're mostly on the prevention side. Simply stated, this new prevention opportunity on reserve means that many of the practices and policies that we've been looking to advance will now have application and traction on reserve.

With that said, we are also looking to find ways to be more inclusive of different service methodologies. We currently have a number of first nations communities coming before us asking us to take a look at different ways to do business outside of a delegated agency model. We're looking to respond to that.

B.C. is also the first jurisdiction in Canada to commit toward the implementation of Jordan's principle, which is a child-first principle pertaining to the delivery of health and social services to children. It's a big area of discussion between ourselves, our first nations partners and colleagues, as well as the federal government, who are necessarily linked to the successful implementation of Jordan's principle.

The last slide from me speaks to the recommendation from the Auditor General relating to how best to ensure that the Legislature — and then through the Legislature also to the public — can keep apprised of developments in child welfare. MCFD is suggesting that…. We've developed the beginning of a relationship now with the Select Standing Committee on Children and Youth, including updating that committee on our progress in regard to our Strong, Safe and Supported action plan and, specifically, pillar 4, which frames up our activities relating to aboriginal child welfare.

We're looking to commit to continue to update the Select Standing Committee on Children and Youth on Strong, Safe and Supported generally and on our work relating to aboriginal child welfare specifically.

Deb now will say just a few words as a conclusion.

D. Foxcroft: Thank you. Just in terms of the conclusion, I wanted to say that, as you can see, work is well underway.

[1045]

We acknowledge more needs to be done, but as part of our success, the federal government needs to be supported, and that is critical in the success of the aboriginal approach.

I think that we are going to be moving on to focusing more on the Strong, Safe and Supported operational and action plan through our pillar 4, which is the aboriginal approach. That work is well underway with first nations leadership and the first nations process in terms of the Indigenous Child at the Centre, at both the provincial and the regional levels, where chiefs and nations are involved.

We will continue to support very successful programs, in terms of Roots Are Forever program and Coming Home Camps, which support the relationships with first nations communities and with MCFD children in care. These are based on making connections with communities through community homecomings — making a connection to their culture, to their traditions, to their language and to their extended families.

We will continue to focus on strengthening the relationship with first nations and aboriginal directors and other service providers to explore a full range of services
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for aboriginal children and families, inclusive of child protection.

I just want to say that it also is critical that the aboriginal people and our aboriginal partners are involved in the decision-making on the policy and in the development of services and that they are leading these changes — based on their culture, their communities, the expertise of their families — and that it's in the preparation of the community, when they're ready to be involved and at the pace of the community. It's about the readiness, and it's also about…. We know that the priority for aboriginal children and families is at the top of their agenda. So I just want to thank you for that.

R. Thorpe (Deputy Chair): Thank you very much, Mark and Deb and the rest of the members of your team.

Do we have any questions, either of the Auditor or of the ministry?

C. Trevena: I'd like to thank both the ministry and the Auditor for their presentations. I've got a number of questions that I wondered if you could help out on.

First…. I think maybe this is to the ministry. In the Auditor's report it says very clearly that on the financial side: "The ministry has yet to develop a process to identify the financial resources required to provide the needed services." It goes on to say that "all regions continue to describe their financial situation as underfunded" and that the "level of funding received was not based on a community-by-community analysis to know how much funding is needed and where the money is needed most."

I'm not sure if this is a question for the Auditor or the ministry, but the ministry states that there has been more money allocated. From my understanding of what was said, a lot of this is going to Vancouver. I wondered: is this adequate, and is this working in response to the Auditor's report of looking on a community-by-community basis?

S. Ahmed: I will have a crack at that one. What is happening is that every year, as we determine the need, we are transferring resources to the aboriginal services within the ministry, as we've mentioned in our slides. We have received some new funding.

We have some actions still to take in this respect, where one of the recommendations, as you point out, was about the community-by-community. So that is a piece that is in our action plan and work that needs to occur to determine that piece. But whatever information comes through that is, you know, taken into account, then, through the annual funding processes.

C. Trevena: Just a little bit more on that, if I might. I don't want to harp on this, but as it was said, it has been 20 years, and I think one of the members of the ministry said that this has been quite successful. It has taken 20 years, and it's happening slowly, and things are…. But this is a slow and successful progression. This is something that we often face, both in our communities and as it's discussed in the Legislature: the problems with aboriginal child welfare.

I wondered if you could be a bit more specific on whether that is adequate funding that you're receiving and how you are looking at the community-by-community basis on this.

[1050]

M. Sieben: The MCFD — in pillar 4, the Strong, Safe and Supported action plan — has a commitment to look increasingly on a community basis relating to need. With that said, need within first nations communities is likely beyond the scope of MCFD in and of itself.

Delegated agencies in and of themselves are focused specifically on core child welfare service delivery, and MCFD's strategy relating to the development and further expansion of delegated agencies isn't necessarily intended to address need overall in those communities. It is how best to respond to those individual communities' requests for involvement and development of child welfare services, still within the framework of provincial child welfare legislation.

So on the different end of things, as noted in one of the slides, there is also a governance initiative which speaks to how best to discuss that with first nations communities, either through a broader treaty process or through a sectoral process relating to child and family services more broadly — what they are looking for and what they are needing on a community-to-community basis in order to manage more of their business. So it's important to differentiate between what the role of delegated agencies are within that and still what MCFD is committed to on a community-to-community review of need in those communities.

D. Foxcroft: I just want to speak to the nation-to-nation, the community-by-community. I think that in the new models and new model approaches, it would include nations, and when we say "nations," it can be from five to 14 first nations involved when we are looking at those new approaches, which would include community assessment, community needs, the gaps in services. So those are things that we'll be looking at now into the future.

C. Trevena: If I might follow up. One thing that Mark mentioned was the broad needs, and there is clearly…. You can't look at issues of child welfare in isolation. You have to look at housing, poverty and other issues. Does the present structure allow you to look at this cross-sectoral approach, and is that hampered by…? Is that part of
[ Page 486 ]
the regionalization process that the ministry is doing, or is that a separate issue?

M. Sieben: It's really not possible to say that things are completely separate from one another. So, yeah, the governance and regionalization initiative that MCFD has looked to develop with first nations and aboriginal leaders is also intended in some way to be inclusive of what might be identified more broadly as need beyond the scope of MCFD.

But with that said, particularly on reserve, a significant player in these discussions is the federal government, given that the responsibility lies not just for child welfare but for most of the social and housing areas with the federal government with that.

Finally, as also noted in the presentation, much as the overall aboriginal population that now resides in urban communities…. That, of course, is provincial. But at the same time, part of our discussions with first nations leaders looks to how best to support our first nations populations within their own communities so that perhaps there is less mobility to urban communities, where there is less attachment to culture and language and family.

C. Trevena: I just have a couple of more questions, Chair, if that's okay. The delegated authority to the aboriginal authorities. What proportion of the funding goes from the ministry to the delegated authorities? Is that part of this new package that you were explaining?

M. Sieben: Generally. I'll ask my colleagues to help me out here a little bit, but on-reserve aboriginal agencies are predominantly funded by the federal government.

C. Trevena: Right.

[1055]

M. Sieben: For a number of those delegated agencies, they also have gotten into relationships with our regions to provide some services off reserve. That speaks to the growing capacity within those delegated agencies to serve not only within but beyond their own communities.

The exceptions to that general model are the urban agencies such as the Vancouver Child and Family Services, which provides child welfare services now and is a fully delegated agency to aboriginal peoples in Vancouver — and two others, Métis Family Services and Surrounded by Cedar. Those agencies predominantly have their funding through the provincial government, given they're not land reserve–based.

C. Trevena: My final — maybe my final — question, if I might, Mr. Chair. Again in the Auditor General's report, the question about culturally appropriate services is definitely raised many times. It says very clearly that the problem is that the ministry has not even defined what it means by culturally appropriate practice. Again, we've been talking about 20 years of trying to define this. I know that in my communities, it's still trying to be defined within each first nations group.

I wondered: how is the ministry actually working on creating a definition that is going to be valid for when you are doing what has to be done, which is monitoring the success of the ministry programs, which is part of this audit?

M. Sieben: That's a really good question, and it's a very strong recommendation from the Auditor General that we're looking at how best to respond to within the context of what you can do — when you're talking about 198 different nations — at the end of the day, but a broader aboriginal child welfare strategy.

For example, there are specific child welfare standards — the AOPSI standards, which are adopted for all of the aboriginal agencies — that go towards that end. What service delivery actually looks like and what's culturally appropriate from one community to the other, though, does subtly change from one community and one nation to the next. Deb is likely the better person to speak to work going on in her area that is intended to try to address that.

D. Foxcroft: Yeah, and I think that in terms of culturally appropriate, as I said earlier, it really needs to be defined by the aboriginal and first nations people because, as we said, 198 first nations in the province and different cultures and language and traditions and identities…. The AOPSI standards and our training have specific curriculum in the training that is to meet the needs of the aboriginal approach, or how they're going to do their practice, which is different from the ministry.

In developing our new standards, we are looking at an aboriginal approach that is based on their tradition and their language and coming from the community. So I don't think there can just be one specific standard or definition for all aboriginal and first nations peoples in the province.

C. Trevena: If I might follow up very briefly on that, what sort of time frame are you looking at? Are you looking at different regions with different time frames or across the ministry to try and develop culturally appropriate programming for the different first nations? Obviously, you have very skilled MCFD staff across the province who are working very closely with the first nations already. So what sort of time frame are we now working on, on this?

D. Foxcroft: Well, in our operational plan we have time frames and deliverables up to 2012, but it would
[ Page 487 ]
probably be…. It's going to take as long as it takes in terms of where communities are at. But in terms of our practice standards, I think that's going to happen within the next few years in the development of that process and with input from the other approaches that we're looking at from nation to nation.

[1100]

H. Bains: Thank you very much for the presentation, first of all. I'd like to ask a question along the lines that Claire has just asked. I was looking at recommendation 3: "Indigenous approach to quality assurance will be developed in collaboration with aboriginal partners to reflect current research and culturally appropriate best practices."

Yet we are still struggling with the definition. We still don't understand what this actually means. The reasons given under 98, "Different communities," and how you apply one definition…. So what do you actually mean by this, saying "culturally appropriate best practices"?

D. Foxcroft: The culturally appropriate best practices would be how first nations and aboriginal people would interpret, I guess, our standards, our policy and our legislation into the work that they have to do with their children, youth, families and communities, based on their traditional practices, based on their culture, based on their community.

As I said, every community or nation may be different. That is where it has to come from in terms of culturally best practices. It's about aboriginal people, first nations people, doing the work, because they're the ones that, we know, best know their families and their communities and how they can do their work differently.

M. Sieben: Within child welfare practice for delegated agencies the framework is still the Child, Family and Community Service Act. That particular piece of legislation is fairly amenable to interpretation. It's rights-based, and it's fairly consistent with the UN convention on the rights of the child.

Beneath the legislation, MCFD has policy and standards in place for delegated agencies to help facilitate looking at culturally appropriate services and service delivery, to develop specific policies and standards in partnership with delegated agencies as a collective table. Then, as Deb noted, within those individual communities there still necessarily has to be a discussion about what that legislation means and what those standards mean in that community.

This is very much the challenge sort of presented by the Auditor General. The recommendations were not really to address that definition, unless we start up at the top with the legislation, look to standards and policies and still engage on a community-by-community basis relating to what that's going to mean there — this in conjunction with other discussions going on with first nations leaderships, apart from what any piece of legislation says but what they might see as their inherent rights to make decisions relating to their children and families.

H. Bains: Just one more. When we talk about how many aboriginal workers are working to help the children…. When you talk about the total numbers, do they include the delegated agencies on or off the reserves?

S. Ahmed: The number we gave in the presentation was for ministry staff who are aboriginal, not for the staff who are working for the delegated agencies.

B. Ralston: I understood Mr. Sieben to say that he disputed, to some extent, some of the recent media reports about the increase in the number of aboriginal children in care. I take it that the number is rising, and I'm wondering, given all the collective efforts of the ministry, why that is so.

M. Sieben: Sure, I don't mind having a shot at that. And I'd look to clarify what I might have been interpreted as saying too.

[1105]

The proportion of aboriginal children in care has increased, particularly over the course of the last ten years. Most of that rise in the proportion of aboriginal children in care is due to a drop in the number of non-aboriginal children in care.

So while there has been some increase over the course of the last ten years in numbers of aboriginal children in care, it's been at a slower pace most recently — for the last few years — and in fact, at different times there has been a drop.

But really, what we've seen are some results that provincially for what the representative and Mr. Hughes referred to as "new child welfare practices" that have to do with prevention and early intervention, which we haven't been able to introduce in any broad strokes within a first nations context due to the federal 20-1 funding formula, which only looked to fund children's services once a child came into care.

The new development that the province has been committed to, along with first nations and aboriginal leaders, in developing a federal approach to providing prevention services is a significant component of how we might address and arrest the increasing proportionality of aboriginal children in care.

While the increase hasn't been, from our point of view, as significant as what was portrayed in the media over the last year, it is still by no means any indicator of success. It's still the place where MCFD intends to concentrate its focus over the course of the next few years.
[ Page 488 ]

B. Ralston: Notwithstanding what you say about proportionality, has the absolute number of aboriginal children in care risen or fallen over the last five years?

M. Sieben: I've got an example for you, so I'll just find it.

B. Ralston: Well, I wasn't looking for an example. I was looking for an answer.

R. Thorpe (Deputy Chair): Maybe the member could let the representative of Children and Families answer the question.

M. Sieben: In October of 2008 there were 9,026 children in care, of which 4,729 were aboriginal — of which the proportion was 52.4. In October 2006 the proportion of aboriginal children in care was 50.9, and I've got the absolute numbers for that too. In 2006 there were 9,271 children in care, and 4,716 of which were aboriginal children.

B. Ralston: So it has remained constant in that period of time. Are you able to give numbers further back, then?

M. Sieben: I don't have them available today, but yes, we can.

B. Ralston: I take it, then, from your answer that your broad explanation for the persistence of this number of aboriginal children in care is due to an inability to implement, in cooperation with the federal government, some of the initiatives that the ministry has implemented here in British Columbia. Is that my understanding — your explanation for that?

M. Sieben: It's certainly a component of it. As was noted by the Auditor General as well as myself and my colleagues when we started our presentation, these are complex issues — areas of concurrent jurisdiction between the federal government and ourselves. The communities that identifiably have need, some of which have been harmed in the past by child welfare practices of a different era…. The problems are structural.

With that said, within a pure child welfare context, a greater opportunity to develop preventative and early intervention services in first nations communities allows us to address some of these problems, particularly the poor proportionality of children in care — yes. So are we likely to need additional support from federal government and other provincial ministries in order to be even more successful? Probably the answer to that is yes too.

[1110]

B. Ralston: What initiatives have been taken to secure the cooperation of the federal government? It's hard to imagine that the federal government would be resisting that, but perhaps you can clarify that.

D. Foxcroft: As we said, we are working on a framework for developing the prevention model in partnership with the federal government and our delegated agencies over the last year and a half, and have got to the point of the framework going to the federal government and Treasury Board. That was a joint partnership with the federal government, the aboriginal agencies and our ministry.

We do have a partnership table that the federal government, the provincial government and the delegated agencies are at, on a regular basis, to discuss common issues, to discuss the on- and off-reserve issues and to work together at those tables with them so that there is work with Indian and Northern Affairs here at the regional level. So there is cooperation at this level in terms of our province and the federal government on how we're working together on initiatives and trying to resolve them collectively.

J. Rustad: Thank you for the presentation. I just want to pick up a little bit on some of the earlier questions. In particular, in the north I know that there have been quite a few strides with regard to building those relationships between the ministry and first nations, but I also know there's a significant number of children in care in the north.

I'm wondering if you can explain a little better, or let me know some of the steps that you are taking with the first nations in the north, and also, what role INAC plays with regard to that in the federal involvement, and whether that's being a hindrance or whether we can find a way to be able to make that more helpful in the future.

D. Foxcroft: In terms of the north, there are a few initiatives that are happening. I think I spoke to the Nenan proposal with the treaty 8 chiefs. The first nations there are working on an initiative and a community assessment and are looking at how they're going to deliver services in the urban off-reserve and on-reserve…. That is coming from a community development approach with the first nations there and the regions. There are also delegated agencies — there must be about six delegated agencies; I can confirm that with my colleague — that are working on child welfare initiatives.

The relationship in terms of the federal government and these new initiatives. At this point the federal government hasn't been at the table. We are looking at them as new initiatives and hope to get them at the table once the process and the service delivery are developed. In terms of the relationship, federally it is, again, with the delegated agencies in the north, but those new initia-
[ Page 489 ]
tives are specifically with our ministry and the province at this time.

R. Thorpe (Deputy Chair): Mr. Hawes, did you have a question?

R. Hawes: With respect to the approximately 4,700 aboriginal kids that are in care, would you have numbers…? You've got eight aid agencies. That includes the kids in care under the agencies, I would presume. Do you have any idea, or do you have numbers that would say how many of those 4,700 kids are under the care of the aid agencies versus the remaining 16 agencies — or is it 24? — that aren't…?

[1115]

M. Sieben: It's probably between 24 and eight.

R. Thorpe (Deputy Chair): Do you want Rob to come to the table?

M. Sieben: Thank you, Chair.

R. Hawes: An adjunct to that question, then, would be…. Of the 198 bands there are 118 that are represented by the 24 agencies. How many kids would be in care from the 80 bands that aren't in the process or would appear not to be in the process — under an agency at all?

R. Parenteau: I'm sorry. I don't have all those figures right in front of me. I do know that of the approximately 4,700 or so aboriginal children currently in the care of the director, MCFD, about 1,800 of those children would be in the care of delegated agencies. Now, I don't have the breakdown in front of me in terms of when you look at those fully delegated agencies versus partially delegated — what the spread is.

Those figures are readily available, and we can make those figures readily available. At this point in time, I believe about 39 percent of the aboriginal children currently in care are in the care of delegated agencies.

R. Thorpe (Deputy Chair): Rob, if you, Mark and your team could supply that information through the Clerk's office, we will pass that back through to committee members.

R. Hawes: But I wasn't quite…. I guess where I was going partly was: of the 80 bands that aren't part of any of the agencies…. I think that's the number that was provided to us, was it not? There are 118 bands that are under the 24 agencies?

R. Parenteau: Yeah, I believe at the last count — actually, an updated count — we're close to about 130 first nations that are represented by operational delegated agencies.

R. Hawes: I'm just curious if, of the ones that aren't under any agency, there are a disproportionate number of kids in care from the bands that aren't part of any agency yet. I'd be very curious to know if that was the case and, if it was, why.

R. Parenteau: Right. So if I understand, there would be maybe a smaller percentage of children in care from communities represented by a delegated agency. Is that…?

R. Hawes: Yeah, if you were to do on a pro rata or, you know…. Is it disproportionately the number of kids in care coming from the now approximately 68 bands, then, that are…?

R. Parenteau: The ministry-served communities.

R. Hawes: Yes. Is that disproportionate?

R. Parenteau: I'm not sure. I mean, we could easily do an analysis of that.

R. Thorpe (Deputy Chair): What I might suggest, if members are okay with this, is that instead of asking the staff to speculate on what the answer may or may not be, maybe they could supply that information through the Clerk's office.

R. Hawes: And the other question that I did have was: with respect to kids that are in care and are being fostered, do you have any idea of the breakdown? Of the 4,700 kids, how many kids would be in aboriginal homes versus non-aboriginal homes? And is there a real capacity problem there?

R. Parenteau: Well, clearly, I know there's an issue with the recruitment or retention of aboriginal foster homes, which has always been a significant challenge. Again, we could do that analysis to determine the percentage of aboriginal children in care, in terms of being in non-aboriginal foster homes versus aboriginal foster homes. But it has always been extremely difficult to recruit first nation aboriginal homes, to ensure there are aboriginal children placed in aboriginal foster homes.

R. Hawes: That takes me to where I was kind of trying to go here, and that's: are you making reasonably good progress in developing capacity in aboriginal homes to receive aboriginal children?

R. Parenteau: I believe so. I believe that with the 24 delegated agencies, all but four have…. Well, all of
[ Page 490 ]
them, actually, that are operational have what's called the C3 delegation, which allows them to recruit foster homes. With the capacity of those agencies to recruit homes, they are looking to recruit aboriginal caregivers from within their own community and whatnot. So with adequate resources, that is clearly their focus.

I believe we're seeing more and more aboriginal homes recruited. We also have the Federation of Aboriginal Foster Parents Society, which also assists in the recruitment and retention and training of aboriginal foster homes and supporting aboriginal caregivers and, actually, non-aboriginal caregivers with aboriginal children who are placed in them. So we are slowly moving towards, hopefully, building better capacity in that area.

[1120]

R. Thorpe (Deputy Chair): Ms. Trevena, you had one more question?

C. Trevena: I have one more question. Thank you very much for your indulgence, Mr. Chair.

In the numbers that are being quoted about the number of children in care, are these children who actually have been removed from their families, or are they in contact with the ministry? I ask that because in the discussion on recommendations 1 to 3, it's the standards that are being used and at what stage a case is seen as resolved or seen as working on in a different standard.

Are the numbers that we're talking about actually children who've been removed from their families or children who are in contact and working with the ministry?

R. Parenteau: Children who are in care can be in care in a variety of ways. They may have been removed, in which case their legal status could vary. They could be a temporary ward of the court, or they could potentially be a continuing-care ward.

The delegation of agencies and whatnot allows for voluntary services, which means they can bring children into care by agreement with the parent as well, which does not require the removal process. Through that, they could be in a voluntary care agreement or a special needs agreement.

I believe I was just looking at VACFASS as an example. They have several hundred children who are continuing-care wards. They also have, I think, at this point four special needs agreements, which means they have the care and custody of that child, but the guardian still remains the actual parent of that child.

So there are varying legal statuses that are associated with being in care.

C. Trevena: The follow-up I have on this is because of the questions about the standards being used and the measurement of the standards that were raised very clearly by the Auditor General in the report, and the question about whether this is actually the right way of going forward.

The recommendation actually says whether this is to adjust the service delivery approach to support ministry service that meets needs of families or whether we should be doing something completely different…. Is this something that is being looked at, or is it just…? Is it a very thorough review or just looking at changing the standards a little bit?

Maybe this is a question for Deb, because this is the section she was presenting.

D. Foxcroft: Sorry, could you repeat that again?

C. Trevena: On the standards, if we're looking at the different ways that a child might be in care and the different meanings of that, and how that relates to the standards under the audit…. Then it says in your response to the recommendations that you're continuing to discuss whether or how best to adopt these standards — the AOPSI standards. I wanted to know how that relates to the different number of children in care.

D. Foxcroft: I'll ask my colleague to speak to it.

R. Parenteau: Well, the AOPSI, aboriginal operational and practice standards and indicators, are the separate and distinct standards that have been developed for delegated agencies. Periodically they go through a process of review.

This year, starting, actually…. I think our first meeting will be December 11 with the newly formed steering committee. We are taking a very significantly different approach to the revision of the practice standards. The practice standards, again, pertain to voluntary services, guardianship services and child protection services. So the full array of delegated services are addressed within those practice standards.

That process to address that involves a joint steering committee of our delegated agency partners, as well as Indian and Northern Affairs Canada and representatives from our branch, aboriginal policy services support. We also have, this time, representatives from the mainstream ministry quality assurance team, who are all going to participate.

We have resourced that table to provide for resourcing support to do extensive research this time around. We are proposing that we tackle the issue this time — not just to do superficial changes to language within those standards or to simplify language but to really start to look at fundamentally shifting those practice standards from an extension of ministry standards to standards that are a reflection of more of an indigenous world view and traditional family systems.

[1125]
[ Page 491 ]

Also, to start to incorporate into the development and construction of those standards, standards which are more outcome-based…. We can hopefully, then, through the basis of audit and review with our agencies when measuring those standards, make some determinations that there are better outcomes for children.

Now, that's an extraordinarily difficult task to achieve that, and I believe we have to be patient with that. So we are looking at, at least through the end of the next fiscal year, retaining the resources to tackle that job. But it is very much a joint effort, and the input of those delegated agencies is critical, as they are the ones who are able to bring those perspectives.

The resourcing, though, and the research involved will also include looking at the position papers and the documents, the articles, and also to engage the indigenous child welfare institutes and whatnot to examine that literature and that research in terms of what constitutes best practice within an aboriginal context.

Still, though, the challenge — I think it's really important, and we have to reiterate — is that this all still has to occur within our existing legislative framework. The standards still have to reflect the principles and the tenets of the Child, Family and Community Services Act, so it is very much a challenge. How do we do that but still incorporate into those standards, truly, that indigenous approach?

I'm quite confident. I'm actually quite excited about this process. There's a great deal of motivation and excitement within the aboriginal community about this. What I think it does…. It's one of those doors that can open up that I think might change, hopefully on the agency's part, their renewed interest in maybe moving towards taking on the child protection role. I think we have to change things within the landscape that make that more attractive to agencies.

As you know, there are currently only nine that do the full child protection function, and much of that, I think, is because there is a historical link to child protection being equated to the removal of aboriginal children from communities. Therefore, we have to change the landscape to allow them to practise child protection in a manner that allows them to look at alternatives to, potentially, removal, and this is one of those steps.

R. Thorpe (Deputy Chair): Seeing no further questions….. First of all, let me thank the Auditor General and his team for their report, and also, I thank the Ministry of Children and Family Development for their work.

Do I see Mr. Hawes? Would you like to make a motion?

R. Hawes: I would move that we accept the report of the Auditor and the response of the ministry.

Motion approved.

R. Thorpe (Deputy Chair): We will take about a five-minute recess here while we change the guard for the next order of business.

The committee recessed from 11:28 a.m. to 11:36 a.m.

[R. Thorpe in the chair.]

R. Thorpe (Deputy Chair): So over to the Auditor General, please.

Auditor General Report:
Interior Health Authority:
Working to Improve
Access to Surgical Services

J. Doyle: Today we will be reviewing our report on access to surgical services, which was published in August 2008.

Nearly half a million surgeries are performed in British Columbia operating rooms each year. These include emergency surgery resulting from trauma or illness as well as elective surgery. Emergency surgery is provided on a first-available basis, whilst elective surgery is scheduled in advance. Wait-lists may be created for elective surgery but not for emergency surgery.

More people are requiring surgery as the population ages, and the medical conditions needing surgery continue to increase due to improving technology and to an expanding ability to treat. Many British Columbians are waiting for elective surgery. According to the Ministry of Health, in January 2008 there were about 73,000 patients waiting for surgery.

This report looked at how one health authority, Interior Health, was managing the delivery of surgical services. We chose Interior Health because it provides a broad mix of surgical services to both a rural and an urban population. It has a total population of over 700,000, which is about 17 percent of B.C.'s population. It has two major referral hospitals and four service area hospitals offering acute care and full surgical services. There are also some smaller acute care sites providing some level of surgical service.

In 2006 Interior Health handled over 80,000 surgical cases. To handle this volume requires a lot of surgical resources and careful management. Effective management of surgical resources is a necessary condition to reduce wait-lists. I expected to find a comprehensive framework for surgical services, effective surgical services management, information to support the service, and performance reports. At Interior Health I found some very good work being accomplished, but more has yet to be done.
[ Page 492 ]

Finally, I'd like to say to other health authorities that this report is also important for them. The recommendations here are relevant. I've mentioned before, at presentations to the Public Accounts Committee, the ripple impact of recommendations in one audit having an impact in other areas. I will be going to other health authorities when we follow up on this particular report to determine what action they have taken.

With me today is Morris Sydor, on my left. Morris is the assistant Auditor General responsible for this work. On my right is Reed Early, who is the manager who was responsible for a lot of the work in regard to the entire length of this particular project. I will now ask Reed to make a brief presentation on our findings.

M. Sydor: Actually, I'll be making the presentation. I decided to move from my usual technology role.

Good morning, Deputy Chair and Members. I'm going to provide a brief overview of the audit, highlighting our key findings and recommendations.

[1140]

Our audit purpose was to assess whether Interior Health Authority has systems in place to optimize the use of resources to provide safe, efficient and effective surgical services. Specifically, we assessed whether Interior Health has a comprehensive framework in place, demonstrates effectiveness in surgical services management, has information systems to support surgical services and reports on its performance, both internally and externally.

Our overall conclusion was that Interior Health did not have the necessary systems in place to optimize the use of resources for efficient and effective surgical services. It lacked clear direction, integrated human resource planning and defined roles, responsibilities and accountabilities.

However, it had taken steps to improve effectiveness — for example, through pre-surgical screening and standardized operating room bookings. It had information systems and a suite of indicators to manage surgical services. Finally, Interior Health was reporting on performance to the ministry, but not to the public.

The first area we looked at was to see whether there was a comprehensive and fully integrated framework, including capacity planning, clear roles and accountabilities, and mechanisms to assist with resource planning and management. We did not find all of these components in place. We found no authority-wide planning for human resources, but in its absence, an operating room managers group was monitoring staffing across the authority.

Physician planning was done at the site level and rolled up to an authority-wide plan, but action on the plan was slow. The surgical council formed several years ago to improve the regional surgical program had succeeded on several key initiatives, but it lacked actual line authority, needed updated terms of reference, and its role and responsibilities were not clear in some key areas, such as budgeting and capital planning.

We did find mechanisms in place within health service areas to assist with resource planning and management. These included plans for capital asset management, capital outlook planning and prioritization of equipment needs. Here we recommended that Interior Health Authority put in place a focused approach to human resource planning for surgical services — including succession planning — and also provide direction by clarifying the surgical council's role in developing a regional surgical program.

Second, we expected Interior Health to demonstrate effectiveness in surgical services management. We found that they were not yet demonstrating this but were taking steps. For example, Interior Health had some key initiatives in place, such as pre-surgical screening clinics with standardized assessment tools, standardized operating room booking forms and a set of surgical services reporting indicators.

In addition, the Health Authority, through the surgical council, was developing other initiatives, such as regional-wide surgical policies, standard care protocols and monitoring of services. However, areas needing attention included the process for allocating surgical time in the operating room, orientation of staff, assessment of training needs, reviews of performance and tracking and reporting of patient incidents.

We recommended that the Interior Health Authority assess the adequacy of various methods used to allocate operating room surgical time; that it continue standardizing equipment and surgical policies and practices; that it develop a standardized orientation for surgical staff, formally assess staff training needs and use the results to support continuing education needs.

As well, we recommended that Interior Health continue the development and implementation of an authority-wide continuing medical education program, that it ensure that all surgical services staff receive regular performance reviews, that it implement standardized patient incident reporting and that it clarify the surgical council's role in advancing patient safety and its place in the quality management structure.

We also looked at whether there were information systems in place to support surgical services management. We found that Interior Health had implemented an information system, which allowed for tracking operating room case times and use of facilities, personnel supplies and equipment, and that there were procedures to monitor data quality. There were also a variety of reports produced and available on request to support the management of surgical services.

However, an ongoing challenge was integrating the Picis OR Manager system with related hospital information, such as clinical assessments from pre-surgical
[ Page 493 ]
screening and using the information to assist bed management. Here we recommended that Interior Health Authority assess and implement strategies using Picis OR Manager information to better inform bed management.

[1145]

The last area we looked at was whether performance of surgical services was being reported internally and externally. We found that Interior Health reported on the performance of surgical services internally and to meet the reporting requirements of the Ministry of Health. However, the Health Authority did not provide reports to the public on their performance, including that of surgical services. We recommended that our Interior Health report to the public on their performance, including surgical services.

That concludes our presentation.

R. Thorpe (Deputy Chair): Thank you very much. Now we will hear from, I believe, the Ministry of Health and Interior Health — is that correct? — or just the….

Interjection.

R. Thorpe (Deputy Chair): That's correct. Are there two different presentations?

A Voice: Yes, there are.

R. Thorpe (Deputy Chair): And who is going first?

Interjection.

R. Thorpe (Deputy Chair): Interior Health? Thank you. If you could introduce yourselves, that'd be appreciated.

C. Mazurkewich: I'm the chief operating officer for strategic and corporate services with Interior Health, and I've been the executive lead for surgical services for about five years. My name is Chris Mazurkewich.

Dr. Andy Hamilton is the co-chair of the surgical council for Interior Health, and he will be doing part of the presentation.

W. Hill: I'm Wendy Hill. I'm the assistant deputy minister for the health authorities division for the Ministry of Health Services.

C. Mazurkewich: Essentially, we were quite, actually, a little bit nervous and had a little bit of anxiety when the Office of the Auditor General said they were coming to do a surgery access review. I have to say that we were pleasantly surprised with the professionalism, the clinical understanding and the systems overview that it brought. Actually, our folks felt there was a very good working relationship with the Office of the Auditor General.

From our side, I just wanted to point out that…. They mentioned a quote. I just wanted to quote something else from the report, which is: "The report is a nudge in the direction of greater efficiency and effectiveness, to a health authority that is already moving in that direction." We took that as a positive. We recognize that there are recommendations that we need to achieve, and we're looking forward to working our way through those. I'll talk about those in a minute.

The second thing I wanted to mention is that, with the Ministry of Health, we actually think there are some provincial initiatives that are helping, as well, as we look to improve surgical services access from both a quality and access perspective. Those are things around the provincial surgery registry that have been put into place, the patient learning system that I'll talk about in a minute, the patient safety and quality council. Those kinds of provincial initiatives also support us and allow us to move forward in a manner quicker than we could just by ourselves.

In essence, we agree with all the recommendations. There wasn't a single recommendation that we had a problem with. We think they're all legitimate, and we're making progress and moving forward on each and every one of those recommendations.

Just briefly, as you can see here, we've actually had sessions with our staff over the last few months, and we're putting together action plans. When we talk about the target completion of 2013, we actually hope to have the action plans developed and ready by February.

We're talking 2013 as the year to actually implement and do the education, and there's a variety of things that we feel will be forthcoming. We've actually hired the physician leader recruitment, and we're working through the physician resource planning as well.

On this one here, we've actually completed this from our perspective. We took the advice of the OAG.

R. Thorpe (Deputy Chair): When you're talking about this one, can you make reference to what you're talking to so that they record it properly in Hansard? Thank you.

C. Mazurkewich: Sure.

Recommendation 2: clarify "surgery council's role in developing a regional surgical program." We've done this. We took it to our senior executive team. We had some discussions. We clarified the role. The large mandate is essentially planning, setting policy, setting new standards and monitoring, as well as having input on budget and safety and quality agenda items.

Recommendation 3: "Assess the adequacy of…methods used at individual sites to allocate surgical time." We're working through a literature review as well as going
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through what each hospital within Interior Health does, and our target is to have a recommendation through surgery council to our executive team and to our health authority medical advisory committee by September 2009.

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Recommendation 4: "Standardize equipment and surgical policies and practices." We're moving forward on a number of fronts around those initiatives. We hope to have everything done by September 2009. We've already got a regional equipment list compiled and some of the other individual items.

Recommendation 5: "Develop a standardized basic orientation" for staff." We've got an Interior Health–wide regional orientation, which is a sort of common entry point into Interior Health. Now we're working with the various hospitals and on the surgical services, developing a region-wide orientation, specifically for the operating room nurses and surgical services nurses.

Recommendation 6: complete "a formal assessment of training needs." We're working through a variety of items, including such things as…. We're evaluating the operating room nursing education programs. We've had three or four different programs of how to train nurses to be operating room nurses. We're now doing a post-evaluation of which ones were most successful, what was the best value for the money, so we can pare it down from three or four to one or two.

There's a high turnover of OR managers. It's a very difficult job. We're actually now going through a process with about approximately 12 nurses who wish to become OR managers. We're going through a coaching and education process around them. So there are a number of different initiatives that we're doing to assess the training needs.

Recommendation 7: "Implement an authority-wide continuing medical education program." That's under the direction of Dr. Rob Halpenny. We're doing the continuing medical education program for the entire Interior Health. Surgical services would be one component of that plan. It's been underway for about a year, and we expect to have it completed this July.

Recommendation 8: "Ensure that all…staff receive regular performance reviews." For the last few years the non-contract staff have been doing performance reviews. We've trialed and tested in a few departments doing unionized staff, and now we're rolling that out across IH. This coming fiscal year will be the first year we'll have done the unionized staff.

"Implement a standardized patient incident tracking and reporting system." This one is through the leadership of the Ministry of Health Services as well as the Provincial Health Services Authority. Within Interior Health we're rolling this out, and my understanding is that at this point we've got more hospitals implemented and are reporting more incidents, which will allow us, then, to investigate, make recommendations and enhance the quality services being provided. We're on track for that and leading the way.

Recommendation 10: clarify the role of the surgical council in advancing patient quality and safety and integration into Interior Health quality management structure. This one has been warmly adopted by the surgical council. They are now the lead hand on a number of safety initiatives associated with quality, such as infection control, administering antibiotics on a timely basis.

We've put the accreditation lead under the surgery council. They're leading the province for workplace safety on safety scalpels and leading the initiative around that. So there are a number of initiatives that they now oversee.

Recommendation 11: "Assess and implement strategies using Picis OR Manager information to better inform bed management." We're starting to produce some of the preliminary information off of that. We hope to have it done by December.

We actually have a second phase that will have some more information by February '09. This is to help us with the average length of stays, where we are cancelling surgery because of bed pressures and working our way through the processes. We've had a first meeting with one of the hospitals, with the surgeons and administration, and they were very excited with the types of information coming off and the usefulness of it.

Recommendation 12: "Report to the public on performance, including that of surgical services." We're working in partnership with the Ministry of Health Services on a website design that would allow for public information around surgical wait-lists and other appropriate information.

I just wanted to conclude by turning it over to Dr. Andy Hamilton.

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A. Hamilton: Just for the record, I'd like to state that I'm actually an anaesthesiologist and I practise part-time clinically, so I'm not just speaking as an administrator working for Interior Health.

I'd like to reiterate what Chris said — that we welcome the opportunity to engage with the Auditor General's department in this review of surgical services and that we totally agree with their findings. In fact, our council had identified many of the issues, and this involvement with the Auditor General allowed us to expedite planning and implementation of solutions to the problems. I think that was a real benefit for us, which we appreciate.

As Chris has said, we are well on our way to implementing solutions to these problems, and we will continue to do so and report on it on a regular basis.

Mr. Doyle, in his introduction, intimated the importance of waiting for elective surgery and how much of a problem this is across British Columbia. We are not
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unique in that regard. This is a common problem across the country and, indeed, internationally.

Over the last five years the Ministry of Health Services and the health authorities have been laying the foundations for building the solutions to this problem. In particular, our own surgical council in Interior Health over the last year or two has embarked on a number of projects, and we feel now that we are on the brink of being able to make a real difference for our patients.

Mr. Chairman, if you agree, I'd be happy just to expand a little bit on some of these projects.

The most important fundamental premise that we have to think about is data. What you can't measure, you can't improve. What the Ministry of Health Services has been putting in place is the surgical patient registry. This is the most accurate information we've had on patients waiting for surgery, and it is so important.

To build further on that, our surgical council has done two audits of patients waiting for surgery. The first time, we audited all those patients who had been waiting over a year. The second time, we audited those patients who are waiting longer than the FMM targets — the federal targets for wait times, mostly the hip and the arthroplasties and the cataracts. In addition, the second time, we audited all the other patients waiting over a year.

In the first audit we removed 64 percent of patients, which is huge. And that, basically, is just cleaning up the data. Even the second time, we removed 46 percent of patients. It just shows the importance of making sure this data is clean and accurate.

We're now starting to give reports to surgeons on their waiting times. We're giving them detailed information on their own patients waiting for surgery — how long their median wait times are. In addition, we're identifying the ten patients who have been waiting the longest.

The feedback that we've had from surgeons is very useful, and it's both positive and negative. Often, when they look into those patients, either they don't need surgery, or it can be addressed quickly. In addition, it has exposed other interesting problems.

One particular surgeon, for example, reported that he didn't think the information was accurate. As an anaesthesiologist, I thought that of course it was the surgeon's problem and that they just weren't getting their booking information in, in time. But in fact, when we looked into this in more detail, the problem was not in the surgeon's offices but in the booking office. There was therefore a gap analysis, and we could address the problem.

Now, when we have waiting lists for surgery, there is a spectrum of urgency. Again, through the Ministry of Health Services and the Provincial Health Services Authority and groups of surgeons, we have developed prioritization tools for patients waiting for surgery. What this means is that patients are scored according to urgency.

At the present time we haven't started using that, but Interior Health and the surgical council have started piloting the use of these tools so that we can make sure those urgent patients have their surgery within an appropriate time but that we don’t forget about the less urgent patients at the tail of the queue. We're working on a system to roll that out across our health authority.

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We also have, as Chris intimated, our Picis OR Manager system that is linked now to other databases within Interior Health. Very shortly we're going to produce a suite of indicators that will allow us to monitor patient flow through the hospital — and not just bed management but delays and cancellations on the day of surgery, for whatever reason, whether it's emergencies, lack of beds, problems with equipment or issues like that — so that we will be able to identify bottlenecks and address them.

Another very interesting mini-audit that we've done recently is that…. We heard from orthopedic surgeons that they were having trouble finding patients to come in for their hip and knee surgeries, and this is in situations where we're supposed to have long waiting lists for surgery.

So we did a little mini-audit with the surgeons' offices and the medical office assistants, and it became apparent that not every patient on the list was available to have their surgery, for various reasons. Sometimes it was medical reasons, sometimes it was because they were going south for the winter, or sometimes it was because they were still playing golf happily and didn't want to have it until fall. It's a question of who's waiting for whom.

But when you put all of the patients on the list, the clock is still running. So there is an apparent long waiting time for surgery. When we actually analyzed this further and put these patients in a kind of suspended category, we were much closer and, in some cases, did meet our federally mandated targets. Across the country we've never heard of this situation, but I'm sure that we're not unique in this regard.

Finally, we're continuing to work very closely with the Ministry of Health Services and, in fact, are helping to organize a conference in January, in Vancouver, of all of the health authorities to help learn about the strategy for managing access to surgery and to help plan the future implementation and to really operationalize what we learn so that we can make a difference for our patients in British Columbia.

C. Mazurkewich: In summary, what we saw as the Office of the Auditor General is good governance. You have to have good information, and you have to have standards. Then that assists you in the drive to improving quality and getting better and fairer access for the citizens of this province.

R. Thorpe (Deputy Chair): Thank you.

Wendy, are you now going to make a presentation?
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W. Hill: Yes.

R. Thorpe (Deputy Chair): Dr. Hamilton, just while they're changing, thank you very much for your upbeat, lively presentation. It's nice to see people with such passion.

W. Hill: Thank you very much, Deputy Chair and committee members, for the opportunity to speak to the Auditor General's report on surgical services, specifically with Interior Health.

We would like to have the opportunity now to give you an idea as to how what's happening in Interior Health fits within the broader context of the provincial strategies that are underway, which Dr. Hamilton spoke to, in part.

Within the Ministry of Health Services we do have provincial oversight of all acute and surgical services. We essentially have three vehicles to do this. We have the surgical councils that exist in each of the health authorities. Their mandate, of course, is to improve surgical services through coordination and standardization.

The surgical councils provide input to the provincial acute care council. This is a council that was established about six months ago. It has cross–health authority representation and is intended to provide advice to the Ministry of Health Services on provincial policy and planning projects, including surgical services.

The provincial acute care council then reports up through the health operations committee. This is a committee that I have struck and that I chair, which consists of senior operations executives from each of the health authorities across the continuum — from prevention, promotion, home and community care, mental health and addictions, and acute care services.

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The focus of that committee is on policy development, system innovation and standardization for all service areas. That committee has been in place for approximately a year now.

Provincially, there is a significant leadership occurring on the health human resources planning. This is led through the assistant deputy minister at the Ministry of Health Services, Valerie St. John. She is working in partnership with all of the health human resources representatives from the health authorities.

They are planning specifically in the area of service and delivery innovations, skills acquisition, growth and renewal strategies, recruitment and retention strategies, labour and regulatory system innovation and an annual health human resources objectives-and-measures approach. This is work that is being done on a provincial basis that then comes back down through to the health authorities through the strategic health human resource planning positions that are in each of the health authorities.

Regional initiatives that are specific to surgical services. I thought I would just include some examples so that there would be some idea as to the work that is going on in British Columbia.

The Fraser Health Authority is improving the consistency of surgical services delivery by decreasing the variability in job descriptions. They're standardizing the perioperative job descriptions across Fraser Health. For those of us who don't understand "perioperative," it means what happens in the operating room. It took me a while to learn that myself.

They are also creating standard job descriptions for all operating room staff in the Fraser Health Authority. This will improve efficiency, effectiveness, standardization and the capacity to be able to plan effectively not only for the utilization of the OR resources but also manage the surgeons' time and the wait-lists.

Northern Health Authority is currently initiating a very extensive HR planning process specifically to identify their current staffing levels and project what their human resource needs are into the future and to revise their program management structure at Prince George Regional Hospital in order to improve the planning focus on key service areas, and that includes surgery.

Vancouver Coastal has implemented a regional operating room nurse recruitment and training strategy, including a designated number of operating room nurse training slots per site, and Vancouver Island Health Authority has got a very detailed and fulsome physician resource planning model that has been completed. The surgical services are working within the people plan for staff resource requirements.

I mention these as examples because from each of these health authorities that are focusing on a particular area of need and interest on their health human resource side, the other health authorities learn and are able to adopt a number of the pieces of work that are happening within the other health authorities.

Dr. Hamilton — and, I think, Chris as well — mentioned the patient safety learning system. This is a provincewide electronic incident reporting information system. This is the only province that has implemented the patient safety learning system in such a fulsome manner, and the intent is to be able to track, monitor, learn and intervene earlier in order to ensure that the safety of patients within our system is the best within the country. In order to support that, we have the British Columbia patient safety and quality council, who provide advice and recommendations on patient safety and quality of care.

The council is led and chaired by Dr. Doug Cochrane, whom many of you may know. We're particularly pleased to have Doug in this role, as Doug has also been named as the chair for the national Canadian Patient Safety Institute.
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We have Safer Healthcare Now, which has been in place in the province for the past several years. This is a national patient safety campaign that came out of the Baker-Norton study of 2004, and it's aimed at reducing preventable complications and deaths. We have had substantive uptake amongst all of the health authorities. One of the key initiatives within the Safer Healthcare Now campaign in British Columbia is the surgical site infection collaborative, and our B.C. teams have shown significant improvement in a number of practices that are known to prevent the incidence of surgical infections.

We are also fortunate in British Columbia to have the Provincial Infection Control Network, which is known as PICNet, and PICNet is currently pilot-testing a surveillance program for surgical site infections in Vancouver Coastal and in Interior Health Authority.

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We also have provincial strategies around wait times. I think that we have talked about the surgical patient registry and the value that that brings. So it is part of our overall wait-time strategy.

We have also done an acute care demand capacity analysis looking at developing a provincial model for forecasting the need for in-patient beds out into the future, including surgical beds as well as medical beds. We've had a surgical resource allocation project underway through the provincial acute care council.

We also participate and engage in patient experience surveys. These are provincially coordinated surveys. They are conducted annually to measure performance from the patient's perspective. And of course, the Sullivan reviews have been conducted in recent years, and we continue to address and monitor recommendations out of that.

The surgical patient registry. I won't go into any detail because it's been spoken to well.

Performance reporting. We've had some references, and we understand and appreciate the recommendation from the OAG on the need to have not only a performance measurement framework but also a capacity to be able to report. We are paying very close attention to that, and we are looking at it from a provincial perspective. When we go out to report, we would like to be able to report data that is comparable between health authorities and facilities. So we are working that piece through.

At this point in time we are focusing our efforts on the surgical wait-times website, where we will publicly report surgical wait-time data by facility specialist — and, provincially, for select procedures — and we will build on that over time.

The other piece that we are doing, as well, has to do with patient education. It's very important. I think it's been referenced before. We are looking to enhance resources for patients around education about not only their condition but what they may expect from the system when they are being scheduled for surgery.

Fraser Health Authority is doing some very interesting things. They are involved in the Canadian pediatric wait-time project. This is a project that has been underway for a number of years. They are initiating the data supply to the federal infrastructure, and the whole intent is to supply benchmark data that can be compared nationally in order to promote or support evidence-based change within our health authorities.

They have taken the lead on this through Surrey Memorial. It will be one of 16 community hospitals across Canada that will be part of the approach. There are already 16 tertiary pediatric hospitals involved.

Under OR booking and OR scheduling improvements, they've been taking a look, particularly at Royal Columbian Hospital, at the arrivals, the postponements and cancellations. They are focusing on scheduling practices to improve their performance in those areas.

Northern Health Authority is developing an expansion of the Prince George Regional Hospital operating room in order to enable an increase in the volume of surgical services. They're undertaking a review of surgical services at Prince George to look for opportunities for enhancement of efficiency and throughput, and that is being done through a transformation fund initiative with the Ministry of Health Services.

Vancouver Coastal is focusing in the area of resource allocation methodology, looking at OR time allocation within the hospitals by surgical services and physicians at each site within Vancouver Coastal. We are very much looking forward to that particular piece of work informing the work of the other health authorities as well.

They are also implementing a concept called surgical smoothing. We can actually project the peaks and valleys in in-patient bed usage over a two-week period and then proactively adjust the cases on the OR slate in order to match the bed capacity that's available and try to get the best utilization out of those beds.

Vancouver Island has undertaken a move towards, again, standardization and a more methodical use of their OR allocation. It's based on the implementation of a different OR management system called ORSOS. Interior Health is using Picis. They're just names for OR management systems. VIHA is actually using an Island-wide wait-list management approach, which is quite different. It is a critical component of being able to get the best use out of our operating rooms.

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Continuing medical education has been a focus for Vancouver Island as well. They are taking particular steps on implementing a general surgery Island medical program clinic in January at the Royal Jubilee Hospital, and they are very high users of telemedicine for medical consultations and for education opportunities.

I must say that Vancouver Island is not the only one that uses telemedicine. Interior Health and Northern
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Health are high users of telemedicine and are often supported by our facilities in Vancouver Coastal and Fraser Health.

Provincial Health Services Authority. We often don't think of them. They do have Women's and Children's, and they have made a focus on the 2B oncology in-patient unit. They have increased their in-patient bed capacity from 17 to 24 and decreased the number of off-service oncology patients. They've enhanced infection control practices, and they continue to meet their emergency wait-room standards.

They have undertaken all of this through a transformation fund initiative and, basically, a business process redesign.

That is the end of my examples. I'd be happy to entertain any questions.

R. Thorpe (Deputy Chair): Anyone have any questions?

H. Bains: A couple of questions. Perhaps the ministry or the Interior Health could answer this. I believe it was one of the recommendations — and answer to the recommendation. I believe it was No. 6. It talked about the assessment of training needs.

Perhaps you could educate us about…. I will just zero in on one area — the nursing area. How many total nurses are there in the region? How many are retiring in the next five years, and what is the training capacity in those five years?

C. Mazurkewich: I don't have those numbers. I can get you those numbers of how many nurses we have. I can say this. The operating room nurses are amongst the oldest nurses that we have within Interior Health, and Vancouver Island Health Authority and Interior Health have the oldest overall workforce. That, along with labs and radiology actually, are three of our key areas that we're focusing on because of the age of the people.

We've been training, over the last few years, anywhere from 40 to 70 registered nurses, licensed practical nurses, OR techs for the operating rooms. If the committee wants, I can bring you the information and send in the exact figures to you.

R. Thorpe (Deputy Chair): That information you can send through to the Clerk's office, and they'll make sure committee members get that information.

H. Bains: I think the reason I ask…. We were speaking to folks in Fraser Health, and so I'm just trying to do some comparison where Interior Health is. We were told that there are 5,000 nurses in the Fraser Health area, and 2,300 of them will be retiring in the next five years. The capacity of training in the region is about 50 a year. Plus there are another few, maybe a dozen or so…. They were looking at perhaps a maximum of 500 nurses that will be trained through the system in those five years.

There's a huge capacity gap, not only to fill those vacancies left by the retiring nurses, but also, there will be additional need of 500 additional nurses in five years' time.

I'm just curious to know if you could give us that data so that we know whether this issue is similar to Vancouver and Fraser Health and Interior or if it is just unique to the Fraser Health.

C. Mazurkewich: No, I don't believe that's unique to the Lower Mainland. I'll be able to give you those numbers. We've actually done some of the calculations.

H. Bains: One more question, Mr. Chair, if I may. There was also, in the Auditor General's report, that the surgical performance reports were shared internally but not with the public. Then there's a response to that saying that the consultation had begun with the Ministry of Health Services to redesign the website information.

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My question is: the information that was shared internally — will the entire information be put on the website, or will it be only parts of it?

W. Hill: The parts that will be shared on the website…. Often what happens with internal reports is that they have a lot of personally identifying information about surgeons, and surgeons' practice, etc. That type of information is not useful to the public. What is useful to the public is to know what the wait times are, where they are going to be able to get their care the most quickly. Not all of the information that is shared internally will be posted on the website — only that information which is in the public interest.

H. Bains: Maybe if I could follow up on that. Maybe the comment from the Auditor General will be warranted here, because this is your recommendation about public reporting in that particular area — whether the information that will be shared with the public is exactly what you were recommending or were you asking for more?

J. Doyle: I would ask the public what they were interested in, in making decisions regarding access to Health, particularly surgical services. I've seen a variety of practices over time, and I always come back to the same first principle, which is: ask the people who are going to make decisions based on this information.

I understand the privacy. I understand the sensitivities around some of this information, but basically, if we are going to provide citizens with information, it should be suitable for them to make decisions — whatever that means. I think that sort of behooves the Ministry of Health and
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the health authorities to actually find out what citizens actually want.

A. Hamilton: The other group that is very important in this are the family doctors who are referring the patients, and they actually need to be able to compare what the waiting time is at different hospitals and for different specialists. As Wendy said, one of the early things that we can do is put the median wait times out in public reporting so that patients and family doctors can do that. Then we can build on that as we fine-tune what the public and the family doctors need to know.

R. Thorpe (Deputy Chair): Thank you, Dr. Hamilton. Any other questions?

C. Trevena: I've got a couple of quick questions. One, I think, is mostly aimed for the Auditor General, who said in his report that this is actually quite good and congratulates the Interior Health Authority and it's something that others can learn from. We've had the description from Ms. Hill about the structure of various committees, from the surgical councils through to the health operations committee.

Do you think that this is an adequate way for other health authorities to get this sort of information, or is there another way that health authorities can be learning from the example of Interior Health?

J. Doyle: Thank you for the question. I think it is very important that there is information sharing across Health. What I have found over a number of years working within different health authorities in different countries is that solutions that work in one place don't always work somewhere else. So there is an issue around making sure that it works in a particular location and then to take the best parts of that and transplant it into a different location. Traditionally, that takes a good deal of time, effort and thought to make sure that that occurs.

I think the best measure is not a theoretical discussion around whether this is the best approach, but whether it actually achieves results. I think the commitment from both the ministry and from the health authorities to delivering on performance reporting is a welcome initiative which will actually allow citizens and legislators to determine whether results are appropriate.

C. Trevena: Thank you.

My other question is for Ms. Hill. It's something that I just simply don't understand in your presentation, and it might just be because I'm not used to medical terms. Like my colleague picked up on Fraser Health, I pick up on Vancouver Island Health Authority, which is the area I represent.

You say, under the health human resources initiatives, "They have a fulsome physician resource planning model and surgical services working within the people plan for staff resource requirements," and I'm afraid I don't understand what either of those phrases mean.

W. Hill: Oh. Maybe I can help. A physician resource plan is one that is undertaken to take a look — very similarly to what we do with nurses — at how old the physicians are, how long they are practicing, do we have any gaps in the types of specialties that we need, are we short of family physicians in Parksville — that type of thing.

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Then it is all rolled up into a plan for the specific health authority. Interior Health does very similar work. All of the health authorities do a human resource plan. Vancouver Island has done some very innovative and detailed work around developing that physician resource plan and doing the modelling that can now be shared with the other health authorities.

The people plan is a human resources plan. I think that's the simplest way to put that.

J. Rustad: Thank you for the presentation and the report. I'm curious about the nurse situation too. Quite a few years ago we had a challenge around nursing. I'm thinking particularly of the north, but it's applicable to all of the health authorities — Interior as well. We saw the fact of the number of nurses that were going to be retiring quite some time ago. I mean, you can see that in the statistics of the aging population.

I'm just wondering: in terms of the lead time in training, how long does it take to be able to get programs up and running or ramp up programs, get people trained and get them into place? I know that over the last number of years we've done some significant increases in the number of nurses trained over what was done, say, seven years ago or ten years ago or whatever the case may be.

So I'm just wondering how much lead time there is in that system and when that increase in training will be able to come into the workforce.

W. Hill: That's actually a question that would be best answered by my colleague, Valerie St. John, who is leading that work. What we can do is undertake to provide the information on the projections for seats and when the graduates will be coming out, if that's reasonable.

R. Thorpe (Deputy Chair): Yes, if you would, again, provide that through to the Clerk's office, we'll make sure that members of the committee receive that information.

W. Hill: Absolutely.

R. Sultan: I, too, would like to compliment the Interior Health representatives on an excellent presentation. For
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me, the take-away line will be, "Who's waiting upon whom?" as we debate these wait-line and queue issues.

My question is, I think, in line with the theme of the presentation today. I recently attended a meeting of Vancouver Coastal where they describe the, I think, consistently growing load of patients that they are called upon to serve from elsewhere in the province. I presume they're from Interior Health — which is perfectly understandable, given their special competencies and the growing complexity of many procedures that can't be offered everywhere in the province.

The issue becomes, in my mind…. I would address this question to the Auditor General. How confident are we that the resources — the money, shall we say? — follows the patients adequately? All of these authorities are under funding pressures, and it's increasingly important, it would seem, that as we have these interauthority transfers of patients and procedures, somehow the funding track in a very efficient manner as well. Do you have confidence that that's being handled as best as can be?

J. Doyle: Thank you for the question. In my background I've been a CFO of a health authority. Also, I've shared accommodation with the equivalent of the provincial wait-list bureau and listened carefully over long periods of time to the problems of cross-boundary transfers of people.

First of all, I also heard the arguments for centres of excellence where a particular type of treatment should only be dealt with in one particular place within a large community like a province, simply because it's more efficient and effective to do that.

It is always going to be a reality that people will move and shift, particularly with more information being made available, to those places where they are likely to receive the best treatment. Sometimes that comes at great cost to the individual. Sometimes it's part of the structure of Health.

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I actually don't know how that's going to be dealt with into the future, and I think the question is better placed in the hands of the ministry for them to work out how transfers of this nature should be dealt with, because it's one system. It's not a series of silos. It's a coordinated health care system for all citizens and inhabitants of British Columbia.

So I, with respect, would pass the question over to them to address.

H. Bains: Just staying in line with…. As I got the answer — and we are going to get the information about the need in the next five years versus the training and the gap — and your comment that it may not be any different than what we see here on the Lower Mainland…. We were also told that there are from 1,000 to 5,000 foreign-trained nurses in the Lower Mainland right now.

My question is: knowing the need gap that we're facing, what initiative has the ministry taken to accept those foreign-trained nurses or put them through examination or acceptance somehow — or train them or bring them to the level that is necessary to practise here in British Columbia? Are there any concrete steps being taken so that we could have those folks who are already trained…? It will not be as much financial burden on our education system. At the same time, the need of the patients will be fulfilled, or close to it. So are there any concrete steps that the ministry has taken?

R. Thorpe (Deputy Chair): First of all, Mr. Bains, that is absolutely not within the realm of the report that we're here to discuss today. But if the member from the Ministry of Health wanted to give a brief answer to that, it's obviously a very detailed question, which I'm sure that staff haven't come here prepared to answer. It's outside the realm of the Interior Health Authority and the Auditor General's reviews.

W. Hill: It's also outside the realm of my expertise. This, again, is a piece of work that is being undertaken through the provincial health human resources planning strategy, under Valerie St. John.

R. Thorpe (Deputy Chair): Thank you, Miss Hill.

Yes, Mr. Bains. One more question.

H. Bains: I don't want to beleaguer this point, but there is a point that was made here — assessment of our training needs. Perhaps that's where it may fall, and that's why I'm asking this question — when you're assessing the training needs, whether this thing falls in that category or not. If you say it's not, then perhaps it's not.

W. Hill: The credentialing of foreign-trained nurses, physicians or other health professionals is not within the assessment of training needs as we look at it within a surgical services program, either provincially or locally. The assessment of the training needs are specifically to the staff, the physicians and the other health care providers that are providing those particular services in that location, so it is a little bit different, I think.

R. Hawes: Yesterday in a different committee we heard from the Chief Electoral Officer that his software program is no longer supported by Oracle or Microsoft, and he's got a big expense now to try to replace it.

We've heard about Picis and ORSOS, two different programs. I don't know how sophisticated these are, and I don't know how many there are around the province. It would appear that we don't have a standardized management system. Are we vulnerable here at all to seeing
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withdrawal of support for any of this software, and if so, how much is it? Is it highly expensive to replace? Would we be looking to go to a standardized management model across all health regions?

W. Hill: Another very good question, and one that would be best answered by another colleague of mine, Elaine McKnight, who does have the lead for all of the information management information technology work within the health system.

So I can't answer the question about the vulnerability on systems becoming obsolete. I honestly don't know the answer to that question. I am personally familiar with both Picis and the ORSOS systems. Both of them are extraordinarily good.

[1235]

They essentially do pretty much the same job, but a lot of the choice over those two systems has to do with some of the other IT infrastructure that's available in the health authorities. There is no question that we will be looking to go to a standardized approach on our information systems over time — understanding we have some legacy systems in place.

R. Thorpe (Deputy Chair): I have a couple of questions.

First of all, thanks to the Auditor and to the Ministry of Health and to Interior Health for their very, very good presentations. As one member of this committee, I'm quite pleased that everybody seems to be working together, which is obviously in the best interest of British Columbians.

I don't know, Dr. Hamilton, if you or Chris could answer this. By the fall of 2009, by my count, 75 percent of the recommendations of the Auditor General's report will be implemented. Is that correct?

A. Hamilton: Off the top of my head, I think you're probably pretty accurate there.

R. Thorpe (Deputy Chair): Okay. One of the items that is in there — I think it's recommendation No. 1 — was with respect to the human resource planning. I think you had down 2013, if my memory serves me correctly. Is that the full implementation, or is that the development of an action plan? Maybe you could just explain, from where we are today — 2008 — to 2013, what is happening and how that benefits improving access to surgical services.

C. Mazurkewich: Our human resources planner has been meeting with various departments, because it's not just the operating rooms. You actually need the surgical beds. You need the postoperative recovery room. You actually need central sterilization. You need all of the staff in the supporting departments to actually support it. She's been meeting with each one of them and doing projections around retirements, our normal turnover and where we acquire people from.

What we're doing with that is…. This winter, in January-February, we're slated to come back with a five-year action plan. What you see as 2013 are the recommendations that we'll be getting internally in terms of how we will address the retirement issue. But also, hopefully, we'll be doing some expansions over those periods of time as we have some of our new facilities coming on board — for instance, in Vernon, where we're going to have the capacity to go from four to five operating rooms, and within Kelowna General Hospital, where we have some additional operating rooms coming on.

It's fitting in with those as well, looking at the expansion possibilities as well as retirements and normal turnovers. And the training programs, as I mentioned before…. Are we training people in-house, which we've done? Are we using BCIT to train people? We actually have a deal with Jamaica for licensed practical nurses, working with Okanagan College to bring them in at Canadian standards.

It's looking at some of those outreach programs, some of the internal programs, and making sure we've got our way mapped through so we can meet the numbers that we require.

R. Thorpe (Deputy Chair): One other question, and I think I'd direct this to Dr. Hamilton. I liked the fact that you talked about how the surgeons were all working together. One of my questions is: what criteria are you planning to use for the allocation of operating room time at the various hospitals, and (1) how will that impact on individual patient surgeries, and (2) how will that impact on surgeons?

A. Hamilton: Thank you for that question, Mr. Thorpe. That's a very good question. There is a temptation by surgeons sometimes to build their waiting lists so that they can argue, "Well, I've got a huge waiting list, so therefore I need more OR time," where what we really need to do is work with surgeons to make sure that their waiting lists are optimally managed. It would be better, in fact, to reward good behaviour than poor behaviour. It isn't just the length of the list that is important in this regard.

The other thing in our region is that we are a huge geographic region, and we have a number of large facilities and a number of smaller facilities. Surgeons are all private practitioners who make a lot of their money by working in the operating room. We need them to stay in our communities. Therefore, they have to get enough OR time to make a living. If we take OR time away from them and they decide that they're going to leave, then that does not serve the community.

These are a number of factors that we're thinking of.
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R. Thorpe (Deputy Chair): Chris, you wanted to add something?

[1240]

C. Mazurkewich: Yeah, I just wanted to give an example using thoracic surgery, which we consolidated into one program a few years ago. The old way of the system was that the closer you were to the surgeon, the better access you had, so measure yourself in kilometres from a surgeon.

Now we have evidence, with the new program we put in for thoracic surgeons, that regardless of where you live in Interior Health, you have similar access. So your wait time to see them, your time to surgery — it's all been measured, and it's equitable. As a geographically dispersed health authority, that's critical for us for rural health care.

We've seen that in some of the other areas, so one of the allocations we've been looking at is equity across. If you're in Nakusp, you have equal access to a thoracic surgeon as somebody who lives in Kelowna. That's a key principle for this health authority.

R. Thorpe (Deputy Chair): Under your recommendation No. 4, which says that you're going to have the target for completion of the standards by September of 2009, you mentioned "shared services organization, provincial." How will new shared services — if it is in fact a new shared services organization — improve surgical services at Interior Health?

A. Hamilton: The shared services organization is a provincial project whereby all the health authorities are going to cooperate in purchasing equipment for surgical services, not just for surgery. Within Interior Health we already have our own med-buy system. Basically, what it does is allows us to purchase equipment at better rates, to standardize equipment and to coordinate the equipment and resources that are coming in that we need in the operating room for maximum efficiency and for cost.

R. Thorpe (Deputy Chair): Chris, did you want to add something?

C. Mazurkewich: Yeah, I just want to give a simple example. We purchased some urology tables. They run, if memory serves me right, at around half a million dollars. By standardizing those urology tables, then we're able to see that the surgeons have the same equipment. Then we go to the issue of: what do your outcomes look like? How is your accessing? What happens there?

We can also minimize, as Dr. Hamilton said, the biomedical expenses, so we're putting more money into direct patient care as opposed to having to put it into the supporting infrastructure. If you take that on a provincial basis and you look at some of those kinds of things….

My classic example is using MR. If you do that, then you can have common protocols throughout. Then when you're measuring and comparing the quality of services that people are receiving throughout B.C., they're not distinguishable by the types of equipment you have or the types of supplies. You're looking at the clinical care that's being provided.

It is going to have a major impact. It'll probably take us…. My estimate is three to seven years to fully realize the full benefits of it. But just with the examples I've seen in Interior Health, I can't imagine we can't see similar benefits across the province.

R. Thorpe (Deputy Chair): You were talking about having a coming together in January of the various health authorities and the Ministry of Health. Are those the types of things that you will be talking about at that session?

A. Hamilton: I'd be delighted to tell you more about the program and invite any of you to come to the conference, because I think you'll find it very interesting. It's going to be a combination of things, and the ministry will set the scene with an overall strategy, of where we are now and what we've done.

Then we're inviting all the health authorities to present on their own projects throughout the province so that we can all have the opportunity to learn about what's working for them and what hasn't worked.

Then we're inviting a number of provinces to come and share their experiences. We're inviting Alberta, Saskatchewan, New Brunswick and Ontario representatives to come and share their own experiences and their own projects, their own learning.

We're having a couple of other presentations. One is on access to the surgeons' offices, because one of the waiting times we have is waiting to get to see the surgeon and how surgeons can optimize the management of their offices to help get patients in sooner.

The other one that we're having at the end of that day is on quality. There's a program in the States that is managed by the American College of Surgeons, called the national surgical quality improvement program, which is a fantastic program for collecting data on and for monitoring quality and outcomes in a very systematic way.

[1245]

To give you a little more background on this, it was started in the veterans hospitals in the States, which were perceived to be not providing such good service, so it was mandated through Congress that they do this. Gradually, it has built, such that all the teaching hospitals are having to come onto this program now.

Once centres of excellence like Massachusetts General and Boston, who thought they were doing a great job,
[ Page 503 ]
started collecting the data, they realized they actually had some issues that needed dealing with. It just comes down to having good data so that you can improve.

To go back to the conference, the next morning we're having speakers from the U.K. come in to talk about their experience because, as of this month, they are on target for having an 18-week wait from referral by the family doctor to the procedure. They have done an incredible amount of work and put a lot of money into it, but they also managed things very successfully. We're going to hear what their issues are, what their learning is and how they did it, and I think that will be very useful.

Just finally, we're going to have a panel. Wendy is going to be on the panel, with a number of other people, to discuss with the audience what the important next steps are for improving access in British Columbia. So I think it will be a good conference.

C. Mazurkewich: I just wanted to clarify Dr. Hamilton's comment. The veteran affairs changeover on quality…. That's publicly funded in the United States, and with the changes that they've brought into that system, they're actually outperforming almost all private health care systems in the United States — and at a cheaper cost.

R. Thorpe (Deputy Chair): Well, that's good. I see no further questions.

Let me just give you some food for thought for your conference in January. As we move forward in this very important thing…. I'm sure the Auditor General will be shocked at this.

Looking at page 2 of his report, the second-last paragraph: "The fact that Interior Health knew of the need for these recommendations and intends to implement all of them is a testament to the health authority's knowledge of its business and to the relevance of the report."

Pause. Next sentence — very important for your conference. "If every health authority takes note and pays attention, we will not need to do this audit again, and all B.C. residents will benefit."

Thank you, Auditor, for that visionary statement. Thanks to Interior Health and the Ministry of Health for their excellent presentation today.

J. Yap: I move that we accept the Auditor General's report and management's response therein.

Motion approved.

R. Thorpe (Deputy Chair): Just for members, the Chair and I are working to try to get a meeting date. It will be December 10. We're not sure if it'll be a split day or later in the afternoon, but we are working on it. It will be on December 10, and it's envisaged that we will be reviewing the three reports that we had initially talked about.

Motion to adjourn?

The committee adjourned at 12:49 p.m.

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