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2.0 About the Audit

2.1 Audit Objectives

The objectives of this audit are as follows:

  1. To review the quality of care provided to Veterans at the SBVC.
  2. To assess the controls in place to monitor care and to address concerns raised by Veterans and family members.

2.2 Scope

The scope of the audit encompassed the full complement of 500 beds dedicated to Veteran’s care. The time period covered was from June to December 2012; however, fieldwork was extended into January to ensure that sufficient evidence was collected to fully substantiate the audit results.

The following did not form part of the audit scope:

  • Financial expenditures or the use of funds - as these have been previously audited by VAC in 2006. Further, the Department conducts annual operating cost reviews; and
  • Current staffing ratios - as these ratios are established by the Ontario Ministry of Health and Long Term Care.

2.3 Methodology

This audit was conducted in conformance with the Internal Audit standards as outlined by the Institute for Internal Auditors, and is aligned with the Internal Audit Policy for the Government of Canada, as supported by the results of the Quality Assurance and Improvement Program.

Given that the audit was initiated based on concerns raised by residents and families, additional efforts were made to ensure that all residents and family members interested in meeting with the audit team had the opportunity to do so. This resulted in 140 resident and family members contributing to the audit through an interview or focus group.

Additionally, three separate file reviews were conducted to strengthen the evidence collected. For all files reviewed, consent was obtained from the resident or family, in advance of the review. These reviews were conducted by health professionals and any information recorded will be kept confidential and protected in accordance with the Privacy Act and the Personal Health Information Act.

Finally, to strengthen the governance for this audit, an external advisory committee was formed to monitor progress and provide strategic direction. The committee included representation from the Office of the Veterans Ombudsman, the Royal Canadian Legion Ontario Provincial Command, and VAC’s Departmental Audit Committee.

Multiple lines of evidence were utilized

Review of Agreements

The original transfer agreement, dated 1966, between VAC, Sunnybrook and the University of Toronto identified the responsibilities of the parties and provided the framework for the transfer.

The Memorandum of Understanding, dated 1987, between VAC and Sunnybrook described in detail the roles and responsibilities as well as the services provided.

The Memorandum of Understanding, dated 1988, between VAC, Sunnybrook and the Ministry of Health in Ontario described in detail the roles and responsibilities as well as the services provided.

Other Documents Reviewed

The provincial standards for long term care, as well as relevant policies and procedures for the SBVC and VAC were also reviewed. Key documents reviewed include:

  • The Long Term Care Homes Act 2010;
  • The Ontario Nurses’ Association of Ontario – Staffing and Care Standards for Long Term Care Homes; and
  • Accreditation Canada Long Term Care Standards.

Reports generated by the SBVC, VAC or external parties were also reviewed. Key documents reviewed include:

  • Sunnybrook Health Sciences Centre Quality Improvement Plans;
  • VAC’s Operating Cost Review 2010/11;
  • Accreditation Canada 2010 report;
  • NRC Picker 2011 resident and family satisfaction surveys; and
  • Canadian Institute for Health Information quality improvement indicator trends results against provincial benchmarks.

Data Analysis

For the purpose of this audit, the audit team had access to SBVC’s information management system. This system allowed for a detailed analysis of the monitoring of quality indicators, incident reporting, and complaint management. This information provided for a detailed analysis of key activities.

Point Click Care is the software tool which manages the e-health records of the residents. Access was given, with the consent of the residents and families, for the audit team to extensively review 108 records.

Direct Observation

Direct observation of all 16 units of the SBVC was conducted from December 10 – 15, 2012. With resident/family consent, the audit team observed various aspects of care including but not limited to: clinical practices (eg. medication distribution, meals, bed time procedures), shift changes, interdisciplinary team meetings and physical or occupational therapies. For all units, this observation occurred during day and evening shifts, as well as on the weekend.


Interviews were conducted with 115 residents and family members. The purpose of these interviews was to record the residents’ and family members’ experience in the SBVC and to identify any areas of concern.

Interviews were conducted with 75 employees and managers from the SBVC. The purpose of these interviews was to record roles and responsibilities, as well as to discuss standards and procedures in the delivery of care.

Interviews were conducted with 11 VAC employees and managers from district, regional and head office. The purpose of these interviews was to record VAC’s interaction with the SBVC as well as to discuss roles and responsibilities.

Focus Groups

Five focus group sessions were conducted with 25 residents and family members. Participants in these focus groups were different from those who were interviewed. These structured sessions covered the same topics as the interviews and served to record residents’ and family members’ experience and to identify any areas of concern.

File Review

Twenty files were reviewed in detail using tracer methodology. Tracer methodology involves a thorough review of the resident’s medical chart and care planning tools to seek information which will be used to structure interviews with the resident or family as well as with the staff at the SBVC.

Eighty-eight files were reviewed for evidence of following the provincial standards. Some examples include: resident assessments, establishment of goals, involvement of residents/family in care planning, monitoring, and incident reporting.

Thirty two complaint files were reviewed for evidence related to system structure, complaint resolution and satisfaction with process and outcomes.

Details on the sample and selection criteria are provided in Appendix C.

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