The OAG conducted an
audit of Access to Health Services for Remote First Nations Communities which
was included in the Spring 2015 Report of the Auditor General of Canada.
Health
Canada’s (HC) First Nations and Inuit Health Branch (FNIHB) was the prime focus
for this chapter.
The objective of the
audit was to determine whether HC, for the selected two provinces (Manitoba and
Ontario), has reasonable assurance that eligible First Nations have access to
clinical and client care services, and medical transportation benefits.
The chapter is critical
of HC in a number of areas such as nursing training, nursing scope of practice,
medical transportation documentation and infrastructure management.
FNIHB
is the focus of all 11 recommendations. Many of these recommendations can only
be addressed in collaboration with partners. Proposed actions will be refined
in collaboration with First Nations partners.
Auditor
General’s Recommendation
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Response
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Actions
and Timelines
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Progress Update
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Recommendation
# 27:
HC should ensure
that nurses working in remote First Nation (FN) communities successfully
complete the Department’s mandatory training courses.
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HC
recognizes that training is very important. Going forward, HC will strengthen
its efforts to meet mandatory training requirements for its nurses and
establish processes to monitor compliance and completion rates.
One of the
challenges in meeting these requirements has been the significant vacancy and
turnover rates in nursing. The first order of priority has been to assign
adequate level of nurses in all Nursing Stations. HC’s Nurse Recruitment and
Retention Strategy is striving to augment and stabilize its nursing workforce
in efforts to address these shortages.
HC
will work to balance its training needs and service to communities, ensuring
that training does not result in a loss of services in a community.
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Deliverables:
- Recruitment
Strategy including streamlined application process, marketing campaign
and the creation of a Nurse Resource pool.
Expected Completion
Date: March 2016.
- List
of mandatory training courses in each Region delivering clinical care.
Expected Completion
Date: May 2015.
·
Report on
Regional mandatory training efforts.
Expected
Completion Date: June and October 2015.
- National
Education Policy for HC nurses to articulate roles and responsibilities,
monitoring and reporting on compliance and completion rates.
Expected Completion
Date: May 2015.
·
Regional
Education Action Plans to address training compliance and completion rates.
Expected
Completion Date: September 2015.
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HC is implementing
the Nurse Recruitment & Retention Strategy approved in the Fall 2013. Three
key initiatives are being implemented within this strategy that support HC’s
response to the recommendation. A marketing campaign was launched in February
2015 with a streamlined application tool, over 500 nursing applications have
been received to date. The establishment of a Centre of Excellence for the development
of a centralised nurse resource pool is underway. Status: On track to meet target.
Formal meetings
were held with each Regional Executive to review the National Education
Mandatory Training policy and confirm consistent application of the five core
courses as follows: Advanced Cardiac Life Support (ACLS); Trauma Support; Paediatric
Advanced Life Support (PALS); Controlled Substances; and, Immunization.
Status: Completed, May
2015.
A standardized process
to collect reports on regional mandatory training is being developed in
collaboration with HC Regions.
Status: On track to
meet target.
National
Education Policy on Mandatory Training for HC Employed Nurses Delivering
Clinical Care has
been developed and approved by S/ADM, FNIHB.
Status: Completed,
May 2015.
A standard approach
to designing and reporting has been finalized and Regional Education Plan
development is underway.
Status: On track
to meet target.
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Recommendation
# 37:
HC should ensure
that its nurses are provided with appropriate supporting mechanisms that
allow them to provide essential health services that are outside their
legislated scope of practice.
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HC agrees that
nurses need appropriate supporting mechanisms to perform their important
duties and a number of mechanisms are already in place.
HC will continue
to strengthen and formalize its management and risk control framework for
clinical care. Elements of this framework include:
- Clinical
guidelines, standards and accreditation;
- First
Nations and Inuit (FNIHB) Drug Formulary and Drug Classification System;
- Mandatory
Nursing Training Courses;
- Formalized
access to physicians and nurse practitioners when the situation requires
interventions outside the nurses’ legislated scope of practice;
- Appropriate
medical delegation mechanisms;
- Nurse
registration; and,
·
Work with
the provinces and the nurse regulatory bodies to explore potential strategies
to support nurses working in remote and isolated First Nations communities.
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Deliverables:
- Engagement
Strategies on supporting nurses scope of practice for each region where
clinical care is available.
Expected
Completion Date: September 2015
·
Joint
regional working sessions to develop a working paper that will identify and
operationalize solutions for each region to support HC nurses to work within
their scope of practice.
Expected
Completion Date: September 2015.
·
Clinical
Practice Guidelines updated and web-enabled.
Expected
Completion Date: June 2016.
- Accreditation
Plan presented to senior management.
Expected
Completion Date: September 2017.
·
Documentation
detailing physician access arrangements.
Expected Completion
Date: May 2015.
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Regional
discussions on the development of engagement strategies for supporting nurses
scope of practice are underway.
Status: On track to
meet target.
Regional
discussions on the development of a working paper to identify solutions for
nurses to work within their scope of practice are underway.
Status: On track to
meet target.
The work on the
revisions to the Clinical Practice Guidelines is underway. A Governance
Structure is in place to provide oversight of the review schedule for the revisions.
Status: On track to
meet target.
HC is in the
process of developing an Accreditation Strategy that will help to identify
and overcome barriers to the uptake of accreditation by nursing stations,
community health centres and treatment centres. This work will be guided by
a Task Group comprised of Regional Accreditation Managers and representatives
from the National Native Alcohol and Drug Abuse Program and Clinical and Client
Care, with secretariat support by the Quality Improvement Accreditation Program.
The planning and implementation work will require close collaboration and
engagement with First Nations communities where clinical care is delivered. Building
on the work that has already been done, a presentation to Senior Management
is targeted for September 2015.
Status: On track to
meet target.
Meetings were held
with regions to review physician and NP coverage. The inventory has been
completed and will be used to support future discussions related to needs of
clinical care.
Status: Completed,
May 2015.
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Recommendation
# 53:
HC should work
with FN communities to ensure that nursing stations are inspected on a
regular basis and that deficiencies related to health and safety requirement
or building codes are addressed in a timely manner.
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HC will continue
to work with FNs to ensure that buildings are inspected on a regular basis
and that deficiencies are addressed in a timely manner. In particular, HC
will standardize procedures to ensure Facility Condition Reports (FCR) are
systemically shared with building owners. HC will also make more explicit the
requirements and timelines for routine inspections and corresponding repairs,
by including relevant requirements in the Capital Contribution Protocol.
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Deliverables:
- Process
changed to reflect systematic sharing of FCRs with FN communities.
Expected
Completion Date: May 2015.
- Regional
national tracking system implemented for inspections and completion of
major repairs and deficiencies identified in FCR's.
Expected
Completion Date: June 2015.
- Updated
Framework for FNIHB’s Capital Planning and Management Framework.
Expected
Completion Date: September 2015.
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Following a
January 22, 2015, Capital Program Review Reporting Committee meeting, Regions
now ensure FCR findings are formally communicated to First Nations via
written letter as well as the sharing of FCRs.
Status: Completed
and Implemented: January 2015.
An excel file is
being set-up with the Regions for the Regional national tracking system to
track and monitor inspections done and follow-up when deficiencies are
delayed. Systems will be regionally based and reported with a National roll
up.
Status: On track
to be completed and implemented: June 2015.
The framework is
being updated and will include specific guidelines regarding the conduct and
sharing of FCRs with building owners. The FCR will be the basis for joint
planning with the First Nations building owners for maintenance and
renovation projects.
Status: On track
to be completed and implemented: September 2015.
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Recommendation
#56:
HC should work
with FN communities to ensure that new nursing stations are built according
to applicable building codes.
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Ensuring
buildings are to code is a priority for HC. HC has a longstanding process to
require an attestation by an architect or engineer to provide
assurance that the construction is completed and is compliant with the
applicable building codes. To increase clarity, going forward, HC will make
adjustments to the process to ensure that the scope of this attestation is
clear for all parties involved in a construction project.
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Deliverables:
- Updated
Capital Protocol document to clarify the requirements of attestations.
Expected
Completion Date: April 2015.
- Communication
to all Facility Management Staff regarding attestation requirements.
Expected
Completion Date: May 2015.
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The capital
protocol document has been updated to clarify the requirement of
attestations. The changes clarify that HC will only release the final
payment associated with any infrastructure or capital project once the
recipient can provide proper documentation that a project or the work is
complete and it meets applicable codes, laws or standards as referenced in
the Agreement. The protocol specifies the type attestations from industry
professionals that will be accepted.
HC has undertaken
changes to its process and tools to support better coordination and
engagement with its First Nations partners. On the basis of these, engagement
at the regional level will be improved.
Status: Completed
and Implemented: April 2015.
A communiqué to
facility management staff has been sent with specific expectations on how
attestations are to be addressed in the Protocol document and how facility
management staff are to use attestations from industry professionals in the
project delivery process.
Status: Complete,
communications sent out in May 2015.
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Recommendation
#64:
HC should work
with FN communities to ensure that nursing stations are capable of providing HC’s
essential health services.
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Allocating
nursing resources to support delivery of health services in a safe,
supportive and culturally appropriate manner is a priority for HC. In
collaboration with First Nations, HC will review the clinical care complement
in an effort to progressively move towards the creation of inter-professional
teams where possible to support the delivery of essential services in a
culturally appropriate, safe and effective manner.
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Deliverables:
- Mapping
of current models of care.
Expected Completion
Date: October 2015.
- List
of potential nursing stations to move toward inter-professional models
of care.
Expected
Completion Date: December 2015.
- Feasibility
study of selected sites vis-à-vis implementation of inter professional
models of care
Expected
Completion Date: December 2016.
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HC has initiated
the analysis and data collection and will engage with First Nations
communities to advance this initiative.
The Nursing
Station reporting template (NSRT) will provide data for this deliverable.
Discussions on mapping and reporting are underway.
Status: On track
to meet target.
The NSRT will
collect information on current models of care and plans for moving towards an
Inter-professional care model. The NSRT will be sent to regions in June, data
analysis will be done in Summer 2015, with a report anticipated in Fall 2015.
Status: On track
to meet target.
Feasibility study
for implementation of Inter-professional models of care will be undertaken
once NSRT data has been analysed and the report completed.
Status: On track
to meet target.
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Recommendation
# 65:
HC should work
with FN to communicate what services are provided at each nursing station.
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HC, in
collaboration with FNs, will provide a list of all Clinical Care services
offered at each nursing station for communication to community members.
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Deliverables:
- Each
nursing station will provide an overview of the health services offered.
Expected Completion
Date: September 2015.
- Develop
communication products to increase community members understanding of
services available.
Expected
Completion Date: December 2015.
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Initial discussions
undertaken for the development of an overview of the health services offered
in each nursing station. This will be done in in collaboration between the
Regions and First Nations communities.
Status: on track
to meet target.
Further
discussions are needed with Regional Nursing Operations on the communication
products. This will be done once the overview report is final in Fall 2015.
Status: On track
to meet target.
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Recommendation
# 81:
HC should work
with FN communities and Aboriginal Affairs and Northern Development Canada
(AANDC) to facilitate the registration of FN individuals.
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HC will ensure
that information materials about the Indian Registry process are available in
all nursing stations and will continue to work with partners to improve the
availability of information in health facilities.
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Deliverables:
- Registration
forms and brochures available in HC operated centres.
Expected
Completion Date: September 2015.
·
Letter to
First Nations partners to encourage them to display registration information
in community hall centres.
Expected
Completion Date: September 2015.
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HC is working in
collaboration with AANDC and will print and circulate registration forms to HC
operated nursing stations and other facilities.
Status: On track to
meet target.
Regions are also collaborating
with AANDC on communications products for First Nations partners to encourage
them to display registration information in community centres.
Status: On track to
meet target.
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Recommendation
#91:
HC should
maintain sufficient documentation to comply with TBS 2009 directive on
recordkeeping and demonstrate that MT benefits are administered in accordance
with 2005 MT policy framework.
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HC’s goal is to
ensure that eligible clients receive timely coverage for medical
transportation in accordance with the provision of Medical Transportation
(MT) Framework. At the same time, the department is making efforts to adapt
its processes to avoid undue burden for clients and health care
professionals. As part of this effort, HC will modify its current guidelines
to better align with current operating practices related to assertion of
medical needs and confirmation of attendance.
As recommended, HC
will disseminate to its staff clear instructions on the processing and
retaining of transitional records necessary for the adjudications of
benefits.
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Deliverables:
- New
Medical Transportation Operational Guidelines introduced and integrated
into regional operational manuals on the administration of MT benefits.
Expected
Completion Date: April 2015.
- Regional
Guidelines on Document Retention Policies sent to NIHB Regional
offices.
Expected
Completion Date: April 2015.
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HC has addressed
these two action items by developing administrative guidelines for
documenting medical referrals, justification of non-medical escorts,
confirmation of attendance, availability of local services and retention of
transitory administrative documents. The guidelines were disseminated via
email at the end of April.
Status: completed
April 2015.
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Recommendation
# 107:
When allocating
nursing staff levels and other support, HC should work with FN communities,
and take into account their health.
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HC will work with
FN communities to better integrate clinical care with culturally-appropriate
community health planning as a means to ensure that HC’s services are further
aligned with other health services under the control of the First Nation
community.
HC is funding a
number of community-based programs that aim to respond to community needs in
the areas of mental health, maternal and child health, public health and home
and community care in addition to Clinical Care. These community-based
programs are funded to support community health needs and are most of the
time managed by the communities themselves.
The allocation of
nursing resources is complex, and depending on the community, different
approaches are required. The allocation process takes into account
population size, the geographic location, accessibility of other health care
services and other specific operational considerations as identified with the
communities. As recommended, HC will enhance its practices through the
community health planning process.
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Deliverables:
- Redesigned
Health Plan Guide.
Expected
Completion Date: June 2016
- Toolkit
to share models and lessons learned to support collaboration.
Expected
Completion Date: September 2016.
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Discussions are
underway on the redesign of the Health Plan Guide.
Status: On track
to meet target.
Work has begun on
the redesign of the health planning process which will include elements to
aid recipients to identify how clinical and client care will be managed in
their community.
HC will engage
with First Nations in a manner consistent with its Engagement Protocol to
ensure that the redesign fits community needs.
Status: On track
to be completed and implemented June 2016.
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Recommendation
# 116:
HC should work
with FN communities, provinces, and health service providers to ensure that
FNs living in remote communities have comparable access to Clinical and
Client Care (CCC) services as other provincial residents living in similar
geographic locations.
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HC’s priority is
to support First Nation communities receiving health services and benefits
that are responsive to their needs and improve their health status.
HC will work with
FN communities to build health service delivery models for remote and isolated
communities, which will better respond to the community’s needs and
contribute to ensure FN have comparable access to Health Services.
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Deliverables:
- Clinical
Care Access report presented to Senior Management that will analyze
access and associated issues.
Expected
Completion Date: July 2016
- Report
to identify best practices in enhancing access to culturally appropriate
clinical care
Expected
Completion Date: April 2017
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Discussions are underway
within HC on the development of a Clinical Care Access report.
Status: On track
to meet target.
HC is presently
designing an approach to serve as the basis for engagement with First Nations
communities and others to meet this requirement.
Status: On track
to meet target.
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Recommendation
# 130:
Working with FN
organizations and communities, and the provinces, HC should play a key role
in establishing effective coordinating mechanisms with a mandate of
responding to priority health issues and related inter-jurisdictional
challenges.
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Management
Response:
HC is committed
to working with partners to better coordinate its actions and effective
interventions where possible. HC will continue to work with FN organizations
and communities, and the provinces to explore opportunities for enhanced
integration and coordination of health services based on joint priorities.
This being said, these partnerships, due to their multi-lateral nature, can
take time to develop. This should in no way be an indication that they are
not productive or effective. In fact, experience to date has demonstrated
that some of the strongest and most productive relationships require a
significant start-up phase to lay the foundation for future collaboration.
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Deliverables:
- Document
that highlights key initiatives and progress underway on service
integration and coordination with partners.
Expected
Completion Date: March 2016
·
Identification
of challenges and opportunities in clinical care delivery in Ontario and
Manitoba.
Expected
Completion Date: November 2015
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HC will continue
to be actively engaged in trilateral tables.
HC has engaged
the Trilateral First Nations Senior Health Officials Committee (TFNHSOC) in
Ontario as it relates to nurse recruitment and training.
Status: On track
to meet target.
HC continues to
work with FN and provincial partners to identity challenges and opportunities
through participation in various internal and inter-jurisdictional tables.
Status: On track
to meet target.
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