Mahsi cho, Mr. Speaker. Mr. Speaker, I have the privilege of speaking for the first time in our new building here. Mr. Speaker, the Standing Committee on Public Accounts has the honour of presenting a report on the committee follow-up of the Department of Health's response to recommendations contained in Committee Report 18-12(3), tabled on March 24, 1993.

Mr. Speaker, at the request of the 11th Assembly, the Auditor General of Canada performed a comprehensive audit of the Department of Health in late 1991 and early 1992. Their report was formally tabled in the Legislative Assembly on November 17, 1992 and was referred to the Standing Committee on Public Accounts for review. The standing committee completed its public review and tabled report 18-12(3), Public Review of Tabled Document 5-12(3), Report of Auditor General of Canada on a comprehensive audit of the Department of Health, on March 24, 1993.

Mr. Speaker, when the standing committee's report was tabled in the Legislative Assembly, the chairman made a commitment to actively follow up the recommendations on a timely basis.

Mr. Speaker, with regard to the monitoring process, the process of follow up committee recommendations began in August of 1993, in preparation for the September meeting of the standing committee. At that time, the chairman contacted each of the witnesses who participated in a public review of the Auditor General's report, asking for their observations on the Department of Health's response to the recommendations. In addition, the chairman asked the Department of Health to provide the committee with a status report regarding each of the 28 recommendations.

In asking for these responses, the chairman noted that the committee was fully aware that the department had not had sufficient time to respond fully to all the recommendations. However, the committee expected that activities scheduled for completion in the fall would be complete or near completion and that those scheduled later would be under way.

The committee received ten responses from previous witness, or stakeholders, in the process. The names of these respondents and the organizations they represent are listed in Appendix A.

Mr. Speaker, the written response from the Department of Health was received on September 10, 1993. The committee asked to receive this information by August 25. Further, when departmental officials appeared before the committee, Members were informed that this was not the official or formal response to the recommendations themselves but rather an update of activities taken. Department of Health officials said that the official response would be submitted to the committee by the end of September. At the time of tabling this report, Mr. Speaker, this response has not been given to the committee.

Overall, the committee found the Department of Health's response to its request for information to be completely unsatisfactory. The timing and nature of the response prevented the standing committee from fulfilling its monitoring responsibilities efficiently and effectively. Consequently, this report, originally intended to be a comprehensive assessment of the department's response to committee recommendations to date, merely summarizes, and where possible comments on, information provided by previous witnesses and by the department.

Mr. Speaker, the information presented in this section comes from three sources. These sources are as follows: Written responses from witnesses who made presentations to the committee in January 1993; a written response from the Department of Health; and, department officials, in their appearance before the standing committee in September 1993.

The 28 recommendations from the committee are produced in Appendix B of this document. These recommendations were reported to the Legislative Assembly under eight headings. These headings, used again to organize the summary information presented in this report, are listed as follows: a) comments on the management response to the audit and public review; b) organization review; c) planning for the future; d) managing people; e) managing information; f) capital assets; g) financial issues; and, h) management reporting and accountability.

Comments on Management Response to the Audit and Public Review

Mr. Speaker, the Department of Health indicated, in its written response to the Committee, that it is "developing information on organizational structure and on human resource management and will make every effort to meet future information requirements of the Legislative Assembly".

Mr. Speaker, the committee noted that the department's efforts in this regard are not yet evident. Moreover, the committee expressed extreme disappointment in the department's response to its most recent request for information. Mr. Speaker, stakeholders did not comment on this particular recommendation.

Organizational Structure

In its written response, Mr. Speaker, the Department of Health indicated that these recommendations will be addressed as part of the Memorandum of Understanding project, currently being undertaken by Western Health Planning Associates. The consultants for this project are reviewing the roles, responsibilities, relationships, reporting requirements and communication channels between the Department of Health and the regional health boards. Written documents that will guide the department's relationships with the health boards are being developed.

The Department of Health indicated that many of the specific projects or activities required to respond to the recommendations two and three must await completion of the Memorandum of Understanding project. Departmental officials expect that the final report will be submitted by November.

However, the Department of Health reported, when appearing before the standing committee in September, that some activity has occurred in response to recommendations two and three. Specifically, officials noted that on site technical and professional consulting services have been delivered to various boards.

Some of the stakeholders who responded to the committee's request for information reported that the Department of Health has not, to their knowledge, complied with these recommendations.

Planning for the Future: Functional Review

Mr. Speaker, the Department of Health officials reported that they would soon be selecting a consulting group, from a short list of three, to conduct a full-scale functional review of the department. The department specified, in the terms of reference for the project, that the functional review is to be complete by the end of this calendar year, December, 1993.

Respondents, generally, Mr. Speaker, suggested that they were aware that a contract would soon be awarded to consultants for the completion of a functional review.

NWT Way and Planning the Delivery and Administration of Health Care Services

Mr. Speaker, in response to recommendation number five, the Department of Health, in conjunction with a number of stakeholder groups, has developed a set of health system principles. These principles, as listed, were agreed to, in draft, on June 3, by stakeholder groups involved: one, health is a concern and responsibility of society; two, individual and community responsibility and actions toward health will be promoted and encouraged; three, the people will be actively involved in health planning, management and decision-making; and four, the linguistic, cultural and spiritual values of residents will be reflected in the health system; five, protection will be provided and encouraged against infectious disease, injurious substances and harmful practices; six, required and effective services will be available and accessible to all persons and provided in a manner acceptable to them; seven, services will be provided by the most appropriate provider and as close to home as possible; eight, services available within the NWT will be maximized; nine, services will be provided in the most efficient and economical way and within existing resources; ten, aboriginal people will increasingly be involved as service providers, managers and decision-makers; 11, lastly, opportunities for education, training, employment and economic benefit for residents will be provided or encouraged in the operation of the system.

Mr. Speaker, departmental officials reported that the consultation process and the development of principles are work that is leading into the development of a strategic plan for the department. The strategic planning process is being guided by a steering group, chaired by the Minister and includes chairpersons of health boards and the deputy minister.

The steering group is supported by technical and professional groups from within and outside the department. Departmental officials reported that it may be desirable, at some point, to hire a consultant to tie the process together. The department expects to have a draft document ready by the end of the calendar year, December 1993.

One respondent indicated that they were not aware of the Department of Health preparing and/or updating a document that formally defines the rationale, purpose and substance of the NWT Way for health delivery. On the other hand, other respondents indicated that they have been involved with the department in developing a plan for NWT health systems.

Mr. Speaker, it would appear that, for some respondents, the department's efforts in planning for the delivery and administration of health care services have not met expectations, either with respect to the consultation process and/or the results. As one respondent indicated, "It would appear that the department continues to 'plan to plan' for the delivery of health services in the Northwest Territories."

Further, Mr. Speaker, some respondents are not aware of any ongoing process developed by the department through which organizations can provide input into the formulation of an approach to deliver health care services in the Northwest Territories.

Mr. Speaker, the Union of Northern Workers felt that the NWT Way of health care basically calls for nurses to perform more functions of doctors. They are concerned that this will cause more workload and stress for their members in remote areas.

Summary of Health Planning Activities

The deputy minister provided the committee at the September meeting with a synopsis of planning activities. He reported that the major activity is the strategic planning exercise. The strategic plan is expected to drive the system, the decisions and the allocation of funding. However, he noted that there was a preliminary step to the strategic plan, that being in agreement to some fundamental principle to assist in making decisions as the plan unfolds and in the operation and management of the system that emerges.

Accompanying the strategic planning exercise is the Memorandum of Understanding project that will guide the relationship between the major players and concurrently review the structure of the department. Overlying all of this activity is an informatics strategy for the overall Government of the Northwest Territories. The informatics strategy will describe the information and flow of information throughout the government.

Mr. Speaker, the committee noted a lack of overall coordination in the planning and monitoring activities currently being undertaken in the Department of Health. The committee feels that coordination is badly needed to bring all of the various planning and monitoring activities together into a cohesive framework and to ensure that overlaps and redundancies are avoided.

Workload Instruments and Procedures Applicable to Nurses

Departmental officials informed the committee that the workload measurement study and recommendations have been completed and have been reviewed and discussed with various boards. The tool is there and some of the boards are using it on an ongoing basis. To really make the tool work, computers are necessary to streamline the process and make the best use of time. The department is aiming to get more computers into the regions and into the health centres.

Mr. Speaker, some respondents noted that they were aware that the nursing services division of the Department of Health had completed development of initial baseline measures for workload assessment tools. Further, they noted that they expect this work to be followed up with the development of quality assurance standards.

Managing People

Affirmative Action and Training Programs

The department indicated in its written response that a strategy to attract and support aboriginal people who want to enter the health profession is being expanded to include a clearly-defined mission statement. A proposal for developing a health care training program is being expanded to include a clearly defined mission statement, a proposal for developing a health career training program, and the use of Arctic College, federal government, and aboriginal groups training programs. During the department's appearance before the committee, officials indicated that they would undertake to have a draft strategy available by the beginning of session, November 17, 1993.

The Department of Health officials informed the committee that work had begun on this strategy and other projects related to committee recommendations in the human resource area, in collaboration with the Department of Education, Culture and Employment. Health officials said that they were unable to provide any more details to the committee at this time. The committee called the Department of Education, Culture and Employment to appear before it, in order to supplement the information provided by the Department of Health.

The deputy minister of Education, Culture and Employment informed the committee that his department was assisting the Department of Health to develop responses to committee recommendations in a number of different areas. These include:

- The development of labour market profiles related to the health professions. Copies of this document were distributed to the committee.

- The development of a laddered approach towards the provision of services and professional opportunities within the health professions. This includes finding opportunities in para-professional areas such as community health representative program, the certified nursing assistance program, the ophthalmologist technician program, and the interpreter/translator program.

- Trying to identify the number of students who have engaged in post-secondary training and used departmental programs related to the health professions.

- Trying to match training programs to job opportunities.

Mr. Speaker, with respect to attracting and supporting aboriginal people who want to enter the field of health administration, the Department of Health informed the committee that it has been very successful. The department obtained two positions for trainees in health policy. They advertised for applicants and were overwhelmed by the response. The successful candidates were to be notified the week following the committee meetings.

In its written submission, the Department of Health informed the committee that it will develop a strategy for attracting and supporting aboriginal people who want to enter the field of health administration. This, and the strategy dealing with health professions, will become a part of a comprehensive affirmative action plan and be available for the fall session of the Legislative Assembly.

One respondent, St. John Ambulance, shared their own experience in attempting to train aboriginal people to qualify for health-related jobs in the community. This organization informed the committee that they had encountered a number of difficulties in these attempts.

Other respondents stressed the importance of involving aboriginal and other health care organizations in the planning of such endeavours. These respondents felt that the chance of success would be increased if these organizations had input and if the input received from the various organizations was coordinated.

One respondent indicated that the Department of Health needs to develop a comprehensive strategy and action plan with respect to affirmative action, health care and cross-cultural training.

Further, some respondents suggested that the Public Accounts committee monitor the strategy and quality of the plans developed by the department in this area and not focus solely on the number of aboriginal people hired and trained, and the number of people who receive cross-cultural training.

Cross-Cultural Orientation And Training

The deputy minister of Education, Culture and Employment informed the committee that its cross-cultural awareness training programs were generic, that is intended for all government employees. No special work is being undertaken with the Department of Health in this particular area.

The Department of Health, Mr. Speaker, informed the committee that the issue with respect to cross-cultural orientation was one of choosing an appropriate vehicle for implementing such a program. The department will have a recommendation on this matter by the opening of the next session of the Legislative Assembly.

Exit Interviews

The Department of Health officials reported that a system of conducting exit interviews has been implemented across the Government of the Northwest Territories.

Respondents, Mr. Speaker, indicated an awareness that a system for conducting exit interviews has been implemented for all departing departmental staff. Further, it was noted that the department has endeavoured to encourage health boards to implement a system of exit interviews for all departing staff.

Training - GNWT Performance Review And Planning System For Staff Appraisal

Mr. Speaker, with regard to training, GNWT performance review and planning system for staff appraisals was also included in recommendation 14.

In its written reply, Mr. Speaker, the Department of Health said that all supervisors would be surveyed by September, 1993 to assess specific learning needs with respect to the performance review and planning system. Workshops will commence by November 30, 1993 and will be completed by April 30, 1994.

Mr. Speaker, some respondents indicated that they were not aware of the implementation of any process to comply with this particular recommendation.

Managing Information

Health Research

North Of 60 Research Program

With regard to section E, managing information which covers recommendations 15 to 24. Mr. Speaker, in its written submission to the committee, the Department of Health indicated that Health Canada has the lead role for the north of 60 research program and is conducting an evaluation of the project. The Department of Health, the Yukon government and the NWT Science Institute were partners in this initiative. Health Canada anticipates completing the evaluation by November 30, 1993.

Summary Of Health Research Studies

Mr. Speaker, the Department of Health also indicated, in its written reply, that a summary of health research studies and scientific papers conducted by the Department of Health for the years 1988 through 1993 will be completed by December 31, 1993. Further, standards for research developed elsewhere are being reviewed to determine their applicability to the NWT environment.

When appearing before the committee, Mr. Speaker, departmental officials reported that the research summary was being expanded to include all such work done in the territories, rather than confining it to work done by the department. Second, they reported that there are some well-crafted guidelines for research that have been developed by other organizations. The department believe that they may be able to adapt those to their specific requirements in the territories, as opposed to developing a new set of guidelines.

Mr. Speaker, one respondent indicated that they were not aware of the activities undertaken by Health to comply with the recommendations regarding research. Another respondent advised that they have recently received a report regarding research issues.

Another respondent suggested that, "The summation of the Health research studies should include applied research information developed by other government departments as well as academic institutes or research laboratories,"

HIS System

Mr. Speaker, with regard to the HIS system. In the written response provided to the committee, the Department of Health said that a new system will be developed in flexible modules to ensure its ability to meet new and changing Department of Health requirements and policies. The first phase deals primarily with the HIS in support of decentralization. It was completed by October 31, 1993.

Further, the integration of the health information system (HIS) and community health management information system (CHMIS) reporting will be considered in subsequent phases of development beginning in the new fiscal year.

In appearing before our committee, Mr. Speaker, the deputy minister of Health said that intense efforts to decentralize the health insurance services division has taken precedence over these and other initiatives.

One respondent indicates that they were not aware of departmental plans to comply with our recommendation. Another respondent reported that their executive director is a member of the patient information systems group initiated by the various health boards with departmental input.

Registration Tracking

With regard to registration tracking which is part of recommendation 18, Mr. Speaker, departmental officials informed the committee that they are proceeding with a re-registration of all NWT residents for health insurance services. It is expected that this will be completed by the end of December and will serve the new decentralized operation. Further, efforts are continuing to quickly and accurately determine when individuals leave the territories so their names can be removed from the system.

Mr. Speaker, the deputy minister indicated that there is some possibility of linkage to systems outside the NWT, which would indicate when a person has taken up residence elsewhere, but it may be a complicated exercise and, in fact, the cost may be a real barrier.

Mr. Speaker, respondents reported being aware that the department is endeavouring to implement various audit procedures in order to comply with this recommendation.

Agreements Re Reciprocal Medical Billings

The department's written response to our committee indicates that a coordinating committee on reciprocal billings, under Health and Welfare Canada, has been reviewing a variety of reciprocal billing issues. The NWT Department of Health has participated in that review. The results will be made available to federal/provincial/territorial health departments to provide a framework for determining whether changes to any of these standing agreements are required.

Further, it is noted that copies of all territorial/provincial reciprocal billing agreements for physician services (medicare billings) are presently on file in the health insurance division.

Mr. Speaker, respondents reported that they had been advised that an agreement on the eligibility and portability of hospital and medical care insurance has been put in place for all provinces and territories, except for Quebec, and that these agreements have been included in the Department of Health's files.

Recovery Of Reciprocal Billings

With respect to the recovery of reciprocal billings, the department noted that it is currently fully occupied with decentralizing the health insurance division. All resources are directed to this task. Once this is completed, in March, 1994, the procedures for reciprocal billings will be reviewed and the necessary action undertaken.

When appearing before our committee, Mr. Speaker, the deputy minister noted further that it is important to evaluate how much effort should be put into attempting to recover relatively small amounts of money, particularly in relation to what it costs to collect. This is to be investigated and reported by the end of March, next year.

Respondents reported that they have been advised that the department has implemented the administrative clarification guide respecting the arrangement for the reciprocal processing of out of province hospital claims, and that this guide is being followed and outstanding payments are being recovered.

Policy and Procedure Repository

The department reported, in its written response, that it is exploring ways to facilitate sharing of information between headquarters and boards. One option under consideration is electronically held data bases accessible through electronic mail. The Dr. Otto Schaeffer Resource Centre will continue to be the principal focus for hard copy.

When appearing before the committee, the deputy minister indicated that this exercise was tied to the development of the government's overall informatics strategy. Some respondents indicated that they were not aware of the department's plans for compliance to this recommendation.

Cross-Training and Rotation of Senior Health Managers

The Department informed the committee, in written form, that the current process through which senior managers become familiar with activities and mandates of other divisions or with board administration begins with an adequate orientation and includes regular updates at senior management meetings. In addition, the department is actively encouraging the temporary rotation of senior officials at the board and headquarters levels.

When appearing before the committee, the deputy minister requested that the committee view this recommendation and departmental responses to it in the context of the functional review.

One respondent said that, to date the Department of Health has not engaged the boards in any discussions regarding the development of a process through which senior managers can become familiar with the activities and mandates of boards. This would include temporary rotation of officials. Another respondent indicated that they were aware of the secondment of a Department of Health official to acting executive director -- presumably of a health board.

Policy and Legislative Division

The department indicated, in its written response, that the current mandate of the policy and legislation division will be assessed as part of the functional review, which is to be completed by the end of this calendar year.

Respondents indicated that the development of a new mandate for the policy and legislation division should be dealt with as part of the Department of Health's functional review, as well as part of the development of the memorandum of understanding process between health boards and the Department of Health.

Standardization Of Board Accounting Systems

The department, in its written response, reported that they are collaborating with health boards to select a standardized accounting system. If Financial Management Board approval is received, implementation will likely occur by April 30, 1994, with an evaluation of the system conducted at each phase. The deputy minister noted during the committee meetings that this exercise will take place within the context of the informatics strategy.

One respondent feels that, although the department is working at purchasing a single accounting software package, it has yet to deal with the central issues that will ensure that accounting for health expenditures will be standardized across the NWT health/hospital boards.

One respondent reported that their director of finance and administration is a committee member studying present systems and working toward standardization.

Capital Assets: Post Occupancy Inspections

Mr. Speaker, the department responded to this recommendation by saying that all new and renovation construction projects will be evaluated after completion. A post-occupancy evaluation (POE) of a facility -- for renovation or new construction -- identifies successful and problematic facility situations or conditions. A preliminary process is in place and will be validated with the completion of the POEs planned for 1994-95.

Some respondents, Mr. Speaker, indicated that they were not aware of the department's plans to implement this recommendation.

Capital Assets Tracking System

The Department of Health, in its written submission, indicated that the initial installation of the capital assets tracking system (CATS) will be complete for one hospital and one health board by December 31, 1993. The balance will be completed by March 31, 1994.

Respondents indicated that they were aware that the Department of Health is developing a capital assets tracking system. Only some of the health boards reported that they were involved in this development.

Financial Issues

Our committee did not make any comments or recommendations, Mr. Speaker, in regard to financial issues.

Management Reporting And Accountability: Management Training In Management For Results System (MFRS)

The Department of Health informed the committee that the first management for results workshop for managers and consultants was held in May 1993, in Yellowknife. A second workshop for health board managers was conducted in Iqaluit in June, 1993 and a third MFRS workshop for board and headquarters managers was held in Yellowknife on August 23

and 24, 1993. A fourth course will be held in March, 1994, site to be determined.

All workshops have been well-attended and a total of 65 participants have been trained, to date. By the end of the fiscal year, 1994-95, the objective is to improve managers' understanding of the development and use of results information. All participants in workshops will be followed up by headquarters staff.

Report On Definitive Objectives

The Department of Health informed the committee that a comprehensive report and plan for meeting any unfulfilled objectives will be complete by November 3, 1993.

Some respondents indicated that they were not aware of any plans for the Department of Health to comply with this recommendation.

Comments And Conclusions

Department Of Health Response To The Standing Committee On Public Accounts

The written response from the Department of Health was not received by the requested date. Further, Mr. Speaker, when departmental officials appeared before the committee, Members were informed that this was not the official or formal response to the recommendations themselves, but rather a brief update on activities taken. Department of health officials said that the official response would be submitted to the committee by the end of September. This official response has not been received at the time of writing this report. To date, Mr. Speaker, we still have not received that official response.

Overall, the committee found the Department of Health's response to its request for information to be completely unsatisfactory. The timing and nature of the response prevented your standing committee from fulfilling its monitoring responsibilities efficiently and effectively. Consequently, this report, originally intended to be a comprehensive assessment of the department's responses to the committee recommendations to date, merely summarizes and, where possible, comments on information provided by previous witnesses and by the department.

It is interesting to note that the committee received more information about specific interdepartmental initiatives, which respond to committee recommendations, from the Department of Education, Culture and Employment than they did from Health officials.

Management And Planning

Mr. Speaker, the Department of Health reported that initiation of many of the specific projects or activities, that must be undertaken to respond to committee recommendations, must await completion of the memorandum of understanding project, the functional review, the government's informatics strategy or any number of other internal or external events.

There appears to be a lack of overall coordination in the planning, timely implementation and monitoring of the various initiatives currently being undertaken in the Department of Health. Mr. Speaker, the committee feels that improved management and coordination are badly needed to bring together all the various initiatives which have been identified as requirements for the efficient and effective delivery of health care services in the Northwest Territories. The department requires a cohesive framework to organize its work and to ensure that gaps, overlaps and redundancies in service deliveries are avoided.

Stakeholder Responses

Mr. Speaker, the committee found the stakeholders' observations of departmental performance to be inconsistent. It appears that the Department of Health has managed to develop solid, effective working relationships with some stakeholders in the health field. However, others indicated dissatisfaction with the department's performance and with the consultation and communication process.

Respondents stressed the importance of involving aboriginal and other health care organizations in planning the delivery of health care services. It was felt strongly that the chance of implementing successful solutions to current difficulties would be enhanced considerably if the organizations had input and if the input received from the various organizations was coordinated.

Next Step

Mr. Speaker, your Standing Committee on Public Accounts will continue to monitor the Department of Health until Members are satisfied that the department is accountable in carrying out its responsibilities and is responding appropriately to the health care needs of the citizens of the Northwest Territories.

Motion To Receive And Adopt Committee Report 4-12(4), Carried

Mr. Speaker, that concludes the committee report. I would therefore move, seconded by the honourable Member for Iqaluit, that Committee Report 4-12(4) be received and adopted.