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Prior to 2007, ANHH was accredited with the Regina Qu'Appelle Health Region, but changes in the process required the Fort Qu'Appelle hospital to get its own accreditation. In 2008, ANHH met the standards and received it. Accreditation Canada surveyors returned in 2011 and, at that time, ANHH was required to do some followup work before it received exemplary standing.

This time around, ANHH has been accredited with exemplary standing, but with no followup actions required. This marks eight years of exemplary status, something fewer than five per cent of Canadian hospitals receive. Breitkreuz said it's thrilling news for the hospital.

"The public can be well assured that when they come to the hospital, they will receive the best possible care. And when they come to this organization, it has been recognized as an organization that exceeds national standards," she said. ANHH is a 14-bed rural acutecare hospital that also provides 24-hour emergency services and 24-hour lab and X-ray services. There is an on-site women's health centre with a low-risk birthing unit.

We were measured against six standard areas ... those include medication services, medicine management, primary-care services, infection-prevention control, governance and leadership," said Breitkreuz. "In all those six areas, we were measured against a number of standards and were one point short of perfect in every one of those areas." Despite being almost perfect, she said ANHH is continuing to consult with First Nations leadership and the public to ensure it meets the community's needs.

It plans to expand services for renal care because this was identified as an area where a gap existed. kbenjoe@postmedia.com

While private facilities like the Cambie Surgery Centre and the Centric Health Surgical Centre (formerly False Creek Surgical Centre) consider themselves hospitals, the college makes a distinction and Oetter said private facilities are inspected and accredited for one-night stays only. "We think of them as private facilities, not hospitals. When you think of hospitals, you think of 24-hour staff, security guards, meals and so on," she said.

Cambie has five operating rooms plus a dental procedure suite and seven private post-op recovery rooms. He said whether the facility is a hospital or not is really a matter of semantics. "Think about all the tiny community hospitals around B.C. and you can see that we are far more advanced and closest to the best hospital in B.C. Our staff are all the best you can get." Day said Cambie has been inspected and approved not only by the college but by the national body that audits and accredits hospitals - Accreditation Canada. Such accreditation isn't mandatory, but college approval is required.

About 50,000 people pay for their procedures themselves each year in private facilities. Renee Hourigan, spokeswoman for Centric, declined to comment. Dr. Brian Day, owner of the Cambie Surgery Centre, said it would be easy to accommodate patients for longer periods and to meet any new requirements. "We're not going to hire a chef, but we already provide snacks and meals to patients. We give them menus and they choose what they want and the food is delivered."

There are nearly 80,000 adults and children waiting for surgery in B.C. hospitals and median waiting times have not changed in several years despite reforms. According to the policy paper, 90 per cent of elective surgery patients got their surgery within 40 weeks in 2013/14, while the rest waited longer. In 2013/14, 5,503 publicly funded operations were performed in private facilities, down from the 7,839 cases performed in private clinics the year before. Another 541,886 scheduled (elective) operations were done in B.C. public hospitals. There are about a dozen private surgery centres in B.C. offering a range of operations, general anesthetics and overnight stays.

About 700 B.C. surgeons have privileges to work at private surgery centres. Under B.C. law, any facility where surgeons work must be inspected and accredited by the college to ensure high standards of care and patient safety. Sarah Plank, a spokeswoman for the Health Ministry, said the government is analyzing what kind of cases might be suitable for funded private surgery centres. The process is in the early stages so a timeline of up to two years is "not unreasonable," she said.

However, according to Jain, it was SteriPro who initiated the proceedings to bring the contract to a close. "It was SteriPro that took Trillium to task," says Jain. "We filed a change inquiry notice, and according to our agreement, the next step would have been arbitration, and we would have won a very, very large compensation from Trillium if we had gone to arbitration." Rather than going through arbitration, SteriPro opted to begin negotiations to terminate the contract. "We got compensated a significant amount of money by Trillium to enter into this termination agreement. So, it's not that they terminated the contract. We terminated it."

Jain explains that rather than being dissatisfied with SteriPro's service, the hospital instead had carried on along a trajectory of increasing demand for those services, but neglected to honour the contract elements that mandated further talks about increasing compensation along the same lines. "There were some issue in the contract that enabled us to increase our compensation with increased volume," says Jain. "When a hospital's surgical case volume goes up by 70 per cent, you would expect that our compensation would increase by 70 per cent, but it went up by zero per cent over the last four years, and that's because Trillium did not engage in the discussions that were dictated in the agreement to enable us to increase our compensation for the extra work and the extra labour force that we needed to employ the work that needed to be done."

For Jain, the notion that it was the hospital who terminated the SteriPro contract is factually incorrect, but the added idea that that decision would have been made because of lapses in quality runs counter to the high mark that he sets for his company, and which is attested by the level of accreditation they've received.

"We are the first private facility accredited by Accreditation Canada, which looks at all your work. We've been accredited strictly for reprocessing, Which is a very stringent and highly controlled and monitored service that meets all the standards set by the CSA." With regards to the company's contract with Pembroke Regional Hospital, two main concerns were raised by CUPE representatives during their March media event: that prolonged turnaround time on instruments needing cleaning could lead to shortages at critical times, and that the 400-plus kilometre one-way trip to Pembroke from the SteriPro facility could result in compromises to the sterilization of the equipment. On the topic of instrument inventory, Jain points out that the issue was raised during the preliminary portion of contract talks with the hospital, and to mitigate that concern, SteriPro agreed to cover the cost of an augmentation to the hospital's existing inventory with brand new equipment so that they would always be sufficiently well-stocked to deal with routine and unforeseen situations.

When it comes to the notion that distance presents an insurmountable hurdle to assuring the sterilization of treated instruments, Jain points to his company's provision of service to a trauma centre in Newfoundland, and their various other contracts, as his main response. "If we can service a major trauma centre on the East Coast, we can service anyone from coast to coast. We consider ourselves the experts in sterile transport, because we have developed the methodologies and the techniques, and we've tested them out, to ensure that instruments can be transported safely by road or by air. We currently transport instruments to major hospitals throughout the GTA, and we transport them safely."

In addition, Jain says that SteriPro has a number of detailed tracking and data systems to ensure that every step in the process is wellsupervised and documented. "We have temperature and humidity-controlled and monitored trucks, which have GPS monitoring on them as well. If there was a particular case that had an infection, we can pull out all the records on that particular tray of instruments and provide the data to show when it was sterilized, by whom, and under what conditions that sterilized set was kept. So the chain of sterility from the time that it comes out of the sterilizer to the time when it goes on the shelf in the storage room in Pembroke is completely documented, and we are practically the only ones in Canada who can do that, and we maintain all that data in our database forever. If there was a case that was done 10 years ago where, say, an orthopaedic implant which became infected 10 years ago, we can provide the hospital all the records they need to prove that sterility was not the issue." Over the past few months, SteriPro officials have been working to get the necessary underpinnings of their service to PRH in place, and they are expecting to be fully operational for surgical equipment reprocessing by the end of April. rpaulsen@postmedia.com Twitter.com/PRyanPaulsen

"This is a new way of doing business so we need to sort which activities are being done and then who has the overall oversight over them."

"My reaction was, 'I can't believe this happened to me'," Kaiman said from her dress shop in Woodstock, Ont. "They told me my chemo was watered down and that basically he thinks it may not affect me, but there are no guarantees."

Marchese has said the problem arose not from how the bags were prepared but in how they were administered at the hospitals.

We need answers and I am going to make sure the College of Pharmacists gets the tools they need."

For instance, the Ontario Nurses’ Association is supporting its members in challenging the CNO’s policies that discriminate against disabled nurses, including the branding of nurses as “incapacitated” on the CNO website, even though these nurses are able to work.

In fact, ONA has recently won an important commitment from the Ontario Human Rights Commission to discuss with the CNO the necessity of removing barriers that prevent nurses with mental health or addiction disabilities from accessing employment.

Since the crisis, all the hospitals involved have stopped outsourcing gemcitabine and cyclophosphamide mixtures and brought it in-house, mixing their own medications.

Their trust would be further hit. Within two weeks, the Star reported that health-care companies are allowed to mix drugs for hospitals without federal or provincial oversight, prompting top health officials — Ontario health minister Deb Matthews and federal health minister Leona Aglukkaq — to scramble to close that regulatory grey area.

This week Jake Thiessen, the founding director of the University of Waterloo school of pharmacy, submitted a final report of his investigation into the issue. There has been no formal indication when it will be made public. Hospital administrators say they have been told it will be two to three weeks before they or the public see this report.

The Ontario College of Pharmacists has passed legislation that allows it to inspect any premises where a pharmacist works — not just licensed pharmacies.

All of the changes taken together would have seen Marchese Hospital Solutions still able to supply drugs as it did but subject to inspection by the college.

The federal government has new rules defining who can be a drug producer, adding that any facility supervised by a licensed pharmacist can do the job. The province has said that hospitals can only purchase drugs from accredited suppliers.

There is very little clinical evidence to indicate what might happen to a cancer patient who receives an underdose of chemotherapy.

At the same time, many of the more recent advances in chemotherapy have been in drugs that alleviate side effects like nausea.

In an oncology pharmacy, strange is not good. And on March 20, one week before Marley’s last cyclophosphamide treatment, Craig Woudsma, a 28-year-old pharmacy assistant, and a colleague at the Peterborough Regional Health Centre, had a bad feeling.

In this case, it was a shipment of new gemcitabine chemotherapy bags that required refrigeration, according to the label. Previous batches, from a different supplier, had not.

Woudsma noticed more differences. The bags from Marchese only had a total volume and concentration on the label — 4 grams of gemcitabine in 100 mL of saline — instead of the specific concentration, the amount of drug per single mL of saline, as the old bags indicated.

The new bag’s label did not contain enough information for him to accurately mix the patient’s dose. He needed to know the specific concentration.

When preparing the solution, staff at Marchese Hospital Solutions, in Mississauga, Ont., dissolved the medication into a pre-filled 100 mL bag of saline. These bags typically contain between 3 to 20 per cent more solution than 100 mL,

“I told the pharmacist in the area. And then it kind of went above me at that point ... They came to me saying, this is kind of a big deal; teleconferencing with the minister of health, that kind of stuff,” said recently, sitting on the front steps of his red-brick, semi-detached home in the village of Millbrook, Ont. “It’s kind of a foreign concept, to think that what we do, in our corner of the hospital, is going to get that kind of exposure.”

This means that the bag Woudsma was holding contained 4 grams of gemcitabine in more than 100 mL of solution. The concentration of the medication wasn’t what the label would have made him think. It was weaker than advertised.

People have asked Woudsma why he was able to catch a problem that went undetected at other hospitals for more than a year. Simple, he says. He had something to compare it to.

The company’s pharmacy workers did not remove the known overfill when mixing the medication because they thought each bag was going to a single patient

referred to in the industry as overfill, included to account for possible evaporation.

The hospital had switched that very day to a new supplier — Marchese Hospital Solutions. A bag of the old supply from Baxter CIVA was still on site.

Medbuy, a group purchasing company for hospitals, starting in 2008, had a contract with Baxter Central Intravenous Admixtures to provide drug-mixing services. The two drugs in question, cyclophosphamide and gemcitabine, were outsourced because they come in powder form and are tricky to mix. It takes about four hours to reconstitute them in liquid, and in that time they must be shaken every 20 minutes.

As that contract was about to expire, Medbuy issued a request for proposals for drug-mixing services: Baxter CIVA, which wanted its contract renewed, Quebec-based Gentes & Bolduc and Marchese all stepped forward.

The details of the new arrangement remain known only to Medbuy. It was founded in 1989 to get better deals for hospitals buying products like scalpels, bed pans and even some medications in bulk. The company’s 28 member hospital organizations in Ontario, New Brunswick and Prince Edward Island spent a combined $626-million on contract purchases in 2012.

Marita Zaffiro, president of Marchese, testified at Queen’s Park that the Medbuy contract did not indicate the hospitals wanted the labels on these drugs to cite a specific concentration. The reason she included it that way in the RFP was simply to show what could be done.

Sobel ran the calculations in his office. For a single patient to require a 4,000 mg dose of cyclophosphamide, on a common breast cancer treatment regime, that patient would need to be about 7 feet tall and weigh 2,200 lbs.

“The chance of 1,200 patients getting 4,000 mg exactly — it’s just impossible.”

Four Marchese pharmacists who played a role in the new contract work revealed to the Queen's Park committee in June that they had either limited or no background in oncology.

Marchese Hospital Solutions began as Marchese Pharmacy, a Hamilton-area community drugstore that expanded beginning in 1998 when Zaffiro became president. In 1999 the company obtained a contract to supply the Hamilton Niagara Haldimand Brant Community Care Access Centres, business they did until the contract expired in 2011, shortly before it was awarded the Medbuy contract.

It lost the CCAC contract in 2011, shortly before the Medbuy deal, and shed employees. Fifty-seven were either laid off or left the company during this troubled time, according to internal newsletters. But then things started looking up.

Zaffiro attempted to get accreditation for the site, according to her Queen’s Park testimony, approaching both the Ontario College of Pharmacists and Health Canada, neither of which took steps to regulate the fledgling business because each thought the other had jurisdiction.

Medbuy, Marchese and Jake Thiessen have maintained that cost was not a factor in the error. Marchese’s bid on the request for proposal came in at about a quarter of the cost of previous supplier Baxter Corporation. Bags from Marchese cost from $5.60 to $6.60; Baxter charged $21 to $34.

CEO David Musyj thinks about what went wrong. The problems, he says, go far beyond Marchese and Medbuy. “All of us are culpable,” he says. “We could have done some things internally that could have prevented this. We could have weighed the bags when they came in.”

The proposed changes were prompted by the recent discovery of under-dosing of chemotherapy drugs supplied by an independent company to four hospitals in Ontario and one hospital in New Brunswick.

It makes no sense that clinics are inspected every five years when hospitals must apply for accreditation every three years. And it is irresponsible for the college and government to protect those that fail at the expense of public safety.

Consumers of health care have the right to transparency. A sanctioned physician is named on the college website. It should be no different for clinics in violation of government standards. The law must be rewritten to allow the college to name names.

That question dominated the recent Public Health 2016 conference in Toronto. Speakers described persistent inequity and inaction across the health system, from research to medical training to hospital care. “The common response is to deny that the problem lies in the structures,” said Charlotte Loppie, director of the Centre for Indigenous Research and Community-led Engagement at the University of Victoria in British Columbia.

She argued that it’s a mistake to see “colonization” as something that happened in the past. “It’s about the control that some people have over other people, which obviously continues today in the health policies and programs that are developed and expanded on indigenous communities, rather than with those communities.”

Research Loppie spoke at a panel hosted by the Canadian Institutes of Health Research (CIHR), which faced criticism in February for awarding less than 1% of funding to Aboriginal health projects in its first major competition since restructuring. “We know we have to work to get this right and get this better and I think we’re learning as we go,” said Nancy Edwards, scientific director of the Institute of Population and Public Health at CIHR.

According to Edwards, Aboriginal health is now a “standing item” at science council meetings, which bring together CIHR top brass every four to six weeks. There has also been “a lot of consultation” with indigenous researchers and communities. There isn’t a single barrier standing in the way. “It’s not that simple,” she said.

Speakers at the Canadian Public Health Association’s annual conference urged structural change to improve indigenous health.

Loppie said she considers Edwards an ally, but noted that CIHR has “a long way to go” to correct the disadvantage to Aboriginal health research under the new funding structure. “Change is a difficult point,” particularly at the most senior levels of administration, she said.

Medical education Australia’s experience integrating indi genous health education into medical training shows how change at that level can help transform a system. Australia’s version of a Truth and Reconciliation Commission recommended compulsory courses for all health professionals in 1989. But this didn’t become reality for doctors until 2006, when the Australian Medical Council set standards that the indigenous health training schools must provide.

With accreditation on the line, change was rapid and meaningful, said Janie Smith, a professor of innovations in medical education at Bond University in Australia. “If you don’t meet the standards, you can’t run your program, so it’s very powerful.” Bond’s medical program overhauled its case-based curriculum to include indigenous examples to teach core concepts. Students also complete a two-day cultural immersion workshop in first year and a remote clinical placement in fifth year.

“It’s a really important principle that this is the normal program and it’s funded out of the normal budget,” Smith said. Integration in core curriculum teaches students that cultural sensitivity is fundamental to being a good doctor, like understanding anatomy. It also protects indigenous health education from “toe cutters” when budgets are tight. Although Canadian medical schools are expanding their indigenous health content, some educators noted that it’s still peripheral to core training.

Lloy Wylie teaches medical students as an assistant professor of public health at Western University in London, Ontario. She recalled one indigenous health session that only a third of students attended. “When it’s voluntary, only the people who don’t need the training show up.”

Hospital care Wylie said she encountered the same indifference among some medical colleagues at Victoria Hospital in London, Ont., where she is appointed to the psychiatry department. “There are still some very unsettling things that I see going on in our hospital system.” She shared stories of “huge jurisdictional gaps” between the hospital and reserve, of patients with cancer denied adequate pain medication because of assumptions about addiction, and of health workers “woefully unaware” of indigenous culture and services.

People in the hospital weren’t even aware of the Aboriginal patient liaison that was in the hospital,” Wylie said. There are some recent bright spots; for example, British Columbia and Ontario are boosting cultural sensitivity training for health workers. But Wylie noted that the same workers “go back to institutions that are very culturally unsafe, so we need to look at changing those institutions as a whole.”

Brock Pitawanakwat, an assistant professor of indigenous studies at the University of Sudbury in Ontario, cited the importance of creating space for traditional healing alongside clinical care. In some cases, it’s a physical space: Health Sciences North in Sudbury has an on-site medicine lodge that provides traditional ceremonies and medicines.

These services are as much about healing mistrust as any physical remedy, Pitawanakwat said. “Going into a hospital after attending a residential school, there’s still that negative emotion,” he explained. “If you look at these buildings in archival photos, they’re almost identical.”

Wylie suggested that the fee-for-service model could also be changed to support physicians building better relationships with patients. “Anything we do to make our hospitals more welcoming places for Aboriginal people will be good for everybody,” she said. “Right now, they’re really alienating for everybody.”

Created in January 2011, the authority started accepting complaints related to abuse or risk of harm a few months later. It has since investigated 150 homes. Valentine said the 50 in question have unresolved problems related to multiple complaints.

“When you are frail and have care needs, it’s very challenging to make an effective complaint,” Wahl said. “But just because a home hasn’t had complaints doesn’t mean it’s a good place.”

Homes range from expensive buildings that resemble luxury hotels, charging more than $6,000 a month, to low-cost houses that charge $1,200 a month.

At least 40,000 Ontario seniors live in retirement homes

Valentine said the focus is on homes with the worst complaints. But seniors’ advocate Judith Wahl argues that many troubled homes fly under the radar because residents do not speak up.

Regulations that will allow the authority to hold homes accountable for a full range of complaints won’t begin until 2014.

The licence application forms ask for detailed information, including the owners’ personal and financial history, presence of automatic water sprinklers in suites, staff training programs, and patient-care demands such as dementia, pressure ulcers or problems with bathing, eating or diapering.

Ontario Retirement Communities Association (ORCA)

80 per cent of Ontario’s retirement homes are members of ORCA and must pass an accreditation test before joining

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

It is at places like these that PSWs say they're expected to perform duties that go beyond their training and their scope of practice. The PSWs we spoke to are concerned that performing those duties may put their professional well-being and the safety or residents at risk. 

There are no national standards for PSW training programs. 

Health Canada estimates that there are 100,000 PSWs working in Ontario alone.

In Ontario, community colleges, private career colleges, Boards of Education, and Not-for-Profit training organizations operate PSW schools.  The courses - which range between 600 and nearly 800 hours in length - include theory plus supervised practical work experience.

PSWs can assist clients to take their own medications.  That means they may help seniors open pill bottles and blister packs.  According to PSW training, what they shouldn't do is measure medications and administer them to seniors. 

Increasingly, they're being asked to that and more.

"We actually do wound care as well."

"When I started, it was another PSW that was on duty that was training me to do everything."

Natrice Rese is a retired PSW who speaks for the Ontario Personal Support Worker Association (OPSWA).

We're being pushed beyond what our training is, and we're being told if we don't like it, we can leave."

"It was written in the book.  If levels are between this and that, you dose that."

"Everybody that works there is burning out and it's getting pretty scary," says Jen.

"When a mistake happens, then it's the PSW's head that rolls,"

it's not illegal for PSWs to perform duties like injecting insulin or administering narcotics at retirement homes.  But the rules governing what PSWs like Jen and Brenda can do at retirement homes are unclear and open to disagreement.

In 2010, the Ontario Government passed the Retirement Homes Act.  It requires that the people licensed in the province to run retirement homes ensure all the staff employed there have the proper skills and qualifications to perform their duties and that they possess the prescribed qualifications.  However, the Act does not give specifics on what duties PSWs can and cannot perform.

the laws that regulate health professionals do permit PSWs to perform some of these nursing-type duties provided they are part of the resident's routine activities of living

For example, it's probably okay for a PSW to inject the same dose of insulin each day to a resident with well-controlled diabetes because that's part of the resident's daily routine.  But, it would not be permissible to inject insulin where the dose needs to be adjusted frequently.

permission for the PSW to perform a nursing duty under 'exception' provisions must be granted for each resident

Paul Williams, a health policy expert at the University of Toronto says little is known about what kind of medical care is delivered at retirement homes.

Williams was part of an expert panel set up by the Ontario Government to consider how to regulate retirement homes.  He says he sees little appetite for tight regulation of retirement homes.

"If we start to regulate, if we put in quality improvement stuff, if we start to accredit along recognized lines, you're going to push the cost up,"

As for regulating PSWs like the provinces do nurses and physicians, Williams says that's just as unlikely.

When you professionalize a group, you take responsibility for what they do.

"Maybe there's a disincentive to governments to regulate PSWs because quite frankly, it will probably cost you more money.  You can't pay twelve dollars an hour (a typical wage for PSWs) to someone who is professionally regulated."

Last year, BC became the first province to set up a registry of PSWs, known there as care aides and community health workers.  The registry sets province-wide training standards and ensures a fair process for investigating complaints against front line workers.  Earlier this year, Ontario announced plans to set up its own PSW registry.

The issue of who does what while caring for your loved ones will undoubtedly grow in the years ahead.  Given our aging population, would-be residents of retirement homes are increasingly likely to be frail seniors with dementia who require complex medical care.  They will need skilled, competent and well-educated professionals to meet their medical needs.