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3.0 Audit Results

3.1 Governance

Agreements and Provincial Acts clearly define responsibilities

The original transfer agreement in 1966 and subsequent MOUs in 1987 and 1988 define the contractual arrangement between VAC, Ontario’s Ministry of Health and Long Term Care and Sunnybrook Health Sciences Centre. These documents are all still in effect and combined, define the expectations of how SBVC provides Veterans with priority access to clinical services, care and treatment as well as enhanced services to meet their needs. The following outlines the legal responsibilities as defined in these agreements.

Ontario’s Ministry of Health and Long Term Care is responsible for managing its health care system. This responsibility is identified in clause 3(b) of the 1988 Agreement which states that "Ontario shall use its best efforts to ensure that Sunnybrook carries out its obligations as referred to herein." The Ministry of Health and Long Term Care sets the framework for the operations and monitoring of care in hospital and long term care homes through a number of Acts within the province of Ontario. The Public Hospitals Act and the Long Term Care Homes Act give direction to the operations and monitoring of care in hospitals and long term care facilities, respectively. In addition, the Excellent Care for All Act sets standards that focus on the quality of care received as well as the patient experience for both hospital and long term care facilities.

The Sunnybrook Health Sciences Centre is responsible to provide care in compliance with the regulations and standards. This responsibility is identified in clause 17(2) of the 1988 Agreement which states that "… the examination, treatment and care of all patients …" is the responsibility of Sunnybrook.

Table 2 - Key Provincial Legislation
Legislation Application to Sunnybrook Veterans Care Centre
Public Hospitals Act Yes
Long Term Care Homes Act No
Excellent Care for All Act Yes

Given that Sunnybrook Health Sciences Centre’s primary mandate is acute care, it falls under the Public Hospitals Act. Although the SBVC is not technically required to follow the Long Term Care Homes Act, operations are aligned with many of the principles and standards of care outlined in this Act. This is further described in Section 3.2.

VAC, as a financial contributor, is responsible for ensuring that funding is utilized in line with agreements. VAC’s method of monitoring the spending is through a detailed annual review of expenditures called Operating Cost Reviews. Operating Cost Reviews as well as VAC’s role in supporting Veterans in long term care facilities are further described in Section 3.5.

3.2 Monitoring

Under the Excellent Care for All Act, Sunnybrook Health Sciences Centre is responsible for monitoring the quality of care of patients admitted to their facility. The Ontario Ministry of Health and Long Term Care provides directives for this monitoring through a number of mechanisms that include:

  • undergoing annual quality inspections (long term care facilities only);
  • developing and implementing Quality Improvement Plans;
  • monitoring and reporting of quality indicators; and
  • conducting resident/family satisfaction surveys;

Long Term Care Home Quality Inspection Program is not mandatory for the Sunnybrook Veterans Centre

Under the Long Term Care Homes Act, the Long Term Care Home Quality Inspection Program involves a review that focuses on risk issues, quality of life and resident care outcomes. These reviews are undertaken by certified inspectors external to the facility. These annual reviews have replaced what was known as the Compliance Management Program. These annual inspections are neither mandatory for SBVC nor part of their monitoring mechanism.

Quality Improvement Plans are developed annually

Sunnybrook Health Sciences Centre finalized its second quality improvement plan (2012-13) which is posted on their web site for the public. Also included on the web site, is the progress made on the 2011-12 plan. The Plan identifies three priority indicators which are monitored and reported by the SBVC. They are:

  • hand hygiene compliance;
  • nosocomial clostridium difficile infection rates; and
  • improved patient satisfaction with the NRC & Picker survey question "Would you recommend this hospital to friends and family?"

Quality Indicators are monitored and reported

SBVC has been monitoring key quality and safety indicators for the past eighteen months. SBVC has chosen to voluntarily monitor these indicators in order to benchmark their performance with other Complex Continuing Care centres and Long Term Care facilities. The quality indicators and safety indicators that are monitored and reviewed on a quarterly basis include:

  • Weight loss;
  • Worsened pain;
  • Worsened stage 2 to 4 pressure ulcer;
  • Newly acquired stage 2 to 4 pressure ulcer;
  • Physical restraints;
  • Falls;
  • Worsened bladder continence;
  • Worsened bowel continence; and
  • Worsened behavioural symptoms.

Through a risk adjustment procedure, Complex Continuing Care facilities have the ability to benchmark results. SBVC has been trending and benchmarking their results since June 2011. Results to date indicate excellent performance in several domains. For those areas where results fall below the provincial benchmarks, quality initiatives are put in place and monitored for improvements.

Resident and family satisfaction surveys are conducted

Both residents and families are surveyed every two years for their satisfaction with the care delivered at SBVC. The last survey was conducted in 2011 with 248 residents and 229 families responding to the survey. The participation rate was 62.7%. Results indicated that the overall satisfaction with care was extremely high, with rates of 91% for residents and 96% for families. SBVC exceeded both the Ontario and Canadian averages and was the Ontario high performer in all seven domains of resident satisfaction (autonomy, staff, dignity, medical care & treatment, food activities and living environment) and in six domains of family satisfaction (global quality, care and services, communication, assistance with eating, activities and living environment).

While the summarized findings did not indicate any areas for concern, by those who completed the survey, several family members did indicate to the audit team that they no longer participate in the survey process. Reasons given were the perceived lack of follow up when issues were repeatedly raised through the survey process and the feeling that the two year period between surveys was too long.

Opportunity for Improvement

Improve the communication of survey results and other monitoring activities by making the links between the results and quality initiatives undertaken, to improve engagement of residents, families and other stakeholders.

Management Response from Sunnybrook Veterans Centre

Agree. For the past 20 years we have shared our NRC Picker Resident & Family Satisfaction results (both strengths and areas for improvement) with our staff, residents and families through posters and newsletters. We have consistently identified areas for improvement which were also ranked as higher priority by residents and families to focus our improvement initiatives both at the unit and facility level. We review our clinical quality indicators provided by the Canadian Institute for Health Information on a quarterly basis to inform our continuous quality improvement efforts. We also review the 121 Standards contained in Accreditation Canada’s Long-term Care Services document at the front line staff level to identify care processes where there is opportunity to improve.

We plan to enhance communication of our responses to these surveys/monitoring activities to ensure that all residents and families have access to this information and can provide input on an ongoing basis. Examples include, unit specific notice boards detailing initiatives we are implementing and inviting feedback from residents and families, and unit community meetings where residents and families can engage in discussions about quality improvement initiatives.

3.3 Quality of Care Delivery at the Sunnybrook Veterans Centre

Care is provided in line with Standards

The delivery of quality care is based on standardized assessments, used to identify individual resident needs and interdisciplinary care plans. SBVC utilizes the Resident Assessment Instrument – Minimum Data Set 2.0 which has been mandated since 2005 for use in Ontario LTC facilities. This tool standardizes the assessment and care planning process for residents receiving long term care services with the ultimate outcome of improving care to residents.

Point Click Care is the software used to support the e-health record and has been in place since June 2011. This powerful tool provides a dashboard summary of care received by residents and allows Patient Care Managers or unit managers to monitor, in a timely fashion, the assessments, goal attainment and treatment results of all residents. File review results confirmed that SBVC uses the standardized assessments upon admission to develop resident specific goals and interdisciplinary treatment plans in 100% of files reviewed.

Another key component of providing quality of care is the review and updating of care plans. The file review identified that up-to-date care plans were absent in 27% of resident’s charts. When resident’s goals and care plans are not up to date, there may be unidentified needs that are unmet.

One of the principles endorsed by the health care team at SBVC is the use of evidence informed/based care. The review of the e-health records confirmed the use of several evidence based assessment tools to evaluate skin integrity, balance, fall risk, level of cognitive impairment and swallowing difficulties, to name a few. Following assessment, there is also documentation of the use of evidence informed protocols to address resident needs such as continence and bowel management.

SBVC is not required to conform to the Long Term Care Homes Act; however, several of the related policies and programs are in place. These include a:

  • written policy on minimizing restraints;
  • written approach for responsive behaviors;
  • falls prevention program;
  • skin and wound program;
  • continence and bowel management protocol; and
  • pain management program.

Training for the application of the assessment tools related to these policies and programs is well supported by Advanced Practice Nurses who act as subject matter experts and resources to the staff.

In discussions with residents and families, there appears to be opportunities to improve the information given to them on:

  • the decision-making process to establish care plans;
  • the contents of the care plans; and
  • best practices as well as details about the actual protocols.

Opportunity for Improvement

Enhance the quality assurance process to ensure that up-to-date goals and care plans are individualized to each resident.

Management Response from Sunnybrook Veterans Centre

Partially Agree. This is more of a documentation issue than a reflection of actual practice. We have individualized care plans for each of our residents which include up to date goals and objectives for care. Sunnybrook implemented a computerized clinical documentation system in June 2011, which requires all care plans to be individualized to each resident based on clinical assessments made by the inter-professional health care team (physician, nurses, physiotherapy, nutrition, recreation therapy, etc.). In the electronic system, a care plan is flagged as “out of date” when any one from the team has not indicated a final sign-off.

Assessments are completed quarterly by all inter-professional staff and subsequently the care plan and goals are reviewed/revised. We will enhance our monitoring system to ensure this process is followed consistently and ensure there is electronic sign off from each member of the team.

Opportunity for Improvement

Share care planning and care protocols with residents and families to promote a more collaborative approach.

Management Response from Sunnybrook Veterans Centre

Partially Agree. We actively engage our residents and their families in care planning on admission and throughout their stay in the Veterans Centre. This collaboration begins on admission during interviews with the inter-professional care team and at the admission family conference. Collaboration continues with family conferences offered annually, with any change of health status or change in care plan, or as requested by residents and families. Families who are not able to attend interviews or conferences in person are offered communication with the care team by telephone or teleconferencing.

Moving forward, we will work to identify those families who may require a greater level of interaction than others and offer more frequent communication for all families regarding their resident’s health condition and treatment options. We recognize the need to ensure frequent and regular dialogue with families of residents with more complex care needs. We will also ensure that our residents and families are aware of how to request more frequent communication with the care team or the new Office of the Resident and Family Experience at any time during their stay. As well, we will be establishing a Family Education Centre where residents and family can access health information.

Relationship with residents and families could be improved

Critically important to the quality of long-term care delivery is the individual’s quality of life. Providing individuals with more choice and control over the services that they receive in the settings of their choice will enhance quality of life.

To deliver a comprehensive approach to care, the technical competencies must work hand in hand with the behavioral competencies (knowledge, skills, attitudes, and actions). These personal qualities or characteristics influence how successful someone will be in their work.

Sunnybrook Nursing Standards, which are derived from the College of Nurses of Ontario Standards focus on:

  • really listening with the intent to understand the person’s reality;
  • respecting choices and providing information and teaching as requested or indicated by the individual or groups;
  • responding to concerns, needs and issues expressed by persons; and
  • reporting concerns/needs to team members and recording actions they take to address persons’ concerns and needs.

The file review indicated that the clinical care and technical competencies of the medical team including nursing and allied health professional staff are comprehensive and of a high quality. Discussions with residents and families confirmed this for the most part. However, residents and families identified the factors that negatively impacted the experience with care were:

  • high workload;
  • changes to the primary nurse; and
  • lack of continuity on weekend shifts.

SBVC has established that residents and families should be involved with care decisions. This involvement can occur in a variety of ways. Routine, on-going discussions should take place between the resident/family and their Primary Nurse. The file review indicated that notes on family discussions were present in 49% of the files reviewed. On a more formal basis, the interdisciplinary family conference should be used within three months of admission and at a minimum, yearly thereafter. The file review found family conferences at the three month period were completed at 100%. The yearly review was completed and/or present in 56% of files.

To support behavioral competencies, one of the tools used by SBVC is a program named “Partners in Veterans Care”. This training program is intended to bring families and staff together to improve communication, to understand each other’s perspectives and to work as partners in the care of the resident. This program is still in the process of being rolled out across the organization.

The majority of families, who participated in interviews or focus groups, indicated that their satisfaction with care was highly dependent on the local unit practices. In units that regularly scheduled family meetings/conferences to discuss issues, families reported a higher satisfaction with their understanding of care protocols and their ability to raise issues and concerns. In addition, the visibility and implication of the Patient Care Manager was also cited as a key factor to the success of the unit.

Residents and families also indicated that the overburdening of staff with basic nursing tasks made approaching the staff to discuss personalized needs, issues and requests difficult at best. Their concerns often started as “minor irritants” and if not properly resolved early, could contribute to an adversarial environment.

Opportunity for Improvement

Review the effectiveness of the Partners in Veterans Care training program as a means of improving communication between staff and families.

Management Response from Sunnybrook Veterans Centre

Partially Agree. Sunnybrook’s Partners in Veterans Care program was evaluated and has been heralded as a leading national best practice as an example for other facilities across the country. The purpose of the Partners in Veterans Care Program is to strengthen collaboration between families and the inter-professional staff, ultimately further improving the quality of life for the Veteran residents of Sunnybrook. Staff and families from all 16 Veteran units at Sunnybrook participated in and evaluated the program. In Sunnybrook’s 2010 survey, Accreditation Canada identified the program as a leading practice, which requires that the practice be innovative, creative, evaluated, sustainable and have demonstrated intended results.

Since its launch the program has evolved and the next phase, which emphasizes therapeutic communication, has been developed and implementation has begun. Individual sessions will be evaluated and as well, the total program will be evaluated for ongoing knowledge translation.

Opportunity for Improvement

Promote a more collaborative approach through family conferences and inclusion in decision making.

Management Response from Sunnybrook Veterans Centre

Partially Agree. Our care teams offer family conferences on admission, annually, with a significant change in health status, and at any time the family, resident or health care team feels it is necessary. Residents are encouraged to participate in these conferences. In accordance with Ontario legislation, residents who are capable of making health care decisions can determine which family members are present and included in discussions regarding their care. For residents who are incapable of making health care decisions, their legal substitute decision maker is included in decision making and can discuss with other family members as necessary to ensure that care planning and decisions respect the resident’s autonomy and are likely to benefit.

We will also ensure consistent documentation by staff of opportunities for family conferences and shared decision making.

3.4 Sunnybrook Veterans Centre Complaints Management

Management of concerns, issues and complaints requires improvement

Sunnybrook Health Sciences Centre has a policy which describes the process for raising concerns, timely response and monthly reporting. This policy is supported by a policy statement which stipulates a zero tolerance toward recrimination against residents and their families who bring forward concerns.

Consistent with this policy, residents and families have a variety of opportunities to raise issues and concerns. These are clearly identified on the SBVC website and in the welcome/orientation package.

Table 3 – Opportunities to raise issues and concerns within SBVC
Informal Opportunities Weekly Residents Council
Monthly Family Advisory Council
Formal Complaint Process Level 1 – Primary Care Nurse
Level 2 – Patient Care Manager
Level 3 – Manager, Patient Relations & Safety

The Manager, Patient Relations & Safety, is responsible for addressing any issues and/or concerns raised by residents and families including safety and clinical risk issues. This manager investigates formal complaints and co-chairs several committees and councils where issues and concerns are raised. The individual also acts as a resource to staff for complaint management. At any point in the complaint process, a resident or family member can go directly to the Manager, Patient Relations & Safety. This position is critical to effectively manage and resolve complaints.

Despite the multiple communication mechanisms for raising concerns and the strong policy statements, several residents and families expressed their lack of knowledge of how to make a complaint, or mistrust of the formal complaints management system when a complaint is made. In a few cases, there was an expressed hesitancy to bring issues forward for fear of discrimination against their loved one. Families also spoke of the need for SBVC staff to follow through on action items quickly and effectively as a means of regaining trust in the system.

SBVC utilizes a complaint management software tool to facilitate the timely collection of information related to issues and concerns that impact resident quality of life and experience with care. Thirty two complaints were filed between April 1 and December 31, 2012. As identified in the chart below, a file review identified that 28% of the files were closed without an evaluation of the satisfaction with the outcome. The final note in many of these files was that final contact with the complainant could not be made.

Formal Complaints: Satisfaction with Outcome
April-December 2012

A pie-chart showing the satisfaction of outcome between the months of April and December 2012.

* N - the number of formal complaints from April 1, 2012 to December 31, 2012

Source: SBVC complaints management database

Table Version: Formal Complaints: Satisfaction with Outcome
April-December 2012
Response Type Number of Responses Percentage
Satisfied 15 47%
No Evaluation 9 28%
Disatisified 8 25%

* N - the number of formal complaints from April 1, 2012 to December 31, 2012

Source: SBVC complaints management database

Monthly reports on the status of on-going complaints are presented for discussion with the Director of Operations and there is evidence that this is done. The reporting mechanism is to also include a presentation and discussion at Sunnybrook’s Veterans’ Advisory Committee of the Board. A review of the minutes for the calendar year 2012 did not indicate that any reports were tabled. The November 2012 meeting was cancelled and an Ad Hoc meeting was dedicated to a review of the recent media coverage around complaints of poor quality of care but no minutes were taken.

Opportunity for improvement

Work on follow-up mechanisms, including mediation when necessary, for those complaints when resolution is less than satisfactory in terms of outcomes.

Management Response from Sunnybrook Veterans Centre

Partially Agree. Historically, the Veterans Centre has had two systems for complaints management – at the program level there is an electronic system, Patient Feedback Monitor, and at the unit level the Managers track complaints in electronic and/or paper files. Recently we have extended the Centre’s electronic system to all Managers, thus there is one database that has all information.

The Audit Team reviewed the 32 complaints that were raised to the program level over 18 months. These central files did not reflect the resolution completed at the unit level, this has now been corrected with the extension of the Patient Feedback Monitor system.

Regarding dissatisfaction with complaint resolution outcomes (which nine families expressed), generally these relate to resident transfers to another level of care, non-availability of single rooms and staffing levels. Management will continue to monitor, look for opportunities to minimize transfers and ensure follow-up.

Opportunity for improvement

Report regularly on complaints management to Sunnybrook’s Veterans’ Advisory Committee of the Board.

Management Response from Sunnybrook Veterans Centre

Agree. Quality of care indicators, utilization, and safety reports are discussed regularly at the Board committee which meets bi-monthly. Information related to our complaints management system will be included in these reports.

3.5 Veterans Affairs Canada’s Role

The support to Veterans and their families in long term care facilities needs to be clarified.

While VAC’s role is not to monitor the quality of care provided to Veterans at the SBVC, as stated in Section 3.1, it is important that VAC supports Veterans and their families before and during their stay in provincial long term care facilities by:

  • providing a smooth transition during the admission process;
  • maintaining on-going support for Veterans and their families; and
  • working through a liaison type of relationship with long term care facilities at an operational level.

The way by which and by whom VAC accomplishes these activities differs by region and by facility. The following represents how VAC operates at SBVC.


A Client Service Agent (CSA) is responsible for assisting Veterans and families with and through the admission process. At SBVC, the CSA works closely with the Manager of Patient Relations & Safety to facilitate this process. It appears to be working well and no issues or concerns were identified.

On-going Support

The CSA maintains contact with the Veteran and family as part of the continued administration of benefits to which the Veteran is entitled.

VAC’s District Nursing Officer also supports the Veteran and family. In response to concerns raised by residents and families, the activities of the District Nursing Officer were modified to provide full time liaison services within the SBVC. The main responsibility is to provide on-site support and assistance for Veterans and families as requested. The activities of this position were discussed and developed in collaboration with SBVC’s Director of Operations. Additional activities include:

  • visiting with Veterans, especially those whose family cannot visit regularly;
  • participating in resident and family councils; and
  • working with the SBVC Manager of Patient Relations & Safety in the investigation of major complaints.

During the site visit, families expressed appreciation for the opportunity to bring forward their issues and concerns to VAC representatives and expressed their desire to have this type of opportunity repeated. While monitoring the quality of care and complaints management are provincial responsibilities, families also expressed their expectations that the Department play a stronger role in oversight at SBVC.


There are several other VAC staff members who have and maintain a liaison type of relationship with the SBVC. These include the:

  • Regional Director General;
  • Area Director for Toronto; and
  • Ontario Director of Quality of Care.

They are also members of the Veterans Advisory Committee which reports to the Board of Directors of Sunnybrook Health Sciences Centre. This Committee provides the link between VAC and Sunnybrook Health Sciences Centre. As part of the Terms of Reference, presentation and discussion of performance reports, satisfaction survey results and complaints management are tabled at this Committee. The liaison activities between VAC and SBVC appear to be working well as no issues were identified.

Recommendation 1

It is recommended that the Assistant Deputy Minister Service Delivery clearly establish and communicate VAC’s role as it relates to transition, on-going support, and liaison activities in support of Veterans, and their families, who are admitted to provincial facilities for long term care.

Management Response from Veterans Affairs Canada

VAC management agrees with this recommendation. The key activities to support Veterans, and their families, in long term care will be clearly established with staff and communicated to Veterans and their families.

The Operating Cost Review for 2011/12 has not been completed

The operating cost reviews are an annual financial review of expenditures to verify that funding provided by VAC was utilized in line with agreements.

The recommendations of the 2010-2011 review indicated that the establishment of a reporting schedule between Sunnybrook Health Sciences Centre and VAC would help prevent delays in the completion of the yearly reviews and that Sunnybrook Health Sciences Centre should develop better methods of tracking workload statistics utilized for the allocation of costs. However, these actions have not been taken.

Recommendation 2

It is recommended that the Director General Finance Division complete the 2011-2012 operating cost review as soon as possible.

Management Response from Veterans Affairs Canada

VAC management agrees with the recommendation. The 2011-2012 operating cost review of Sunnybrook Veterans Centre is underway.

3.6 Audit Opinion

The assessment of governance and the review of quality of care generally met the audit criteria without any significant issues identified.

For SBVC, the audit team noted, that five of the seven opportunities for improvement, identify the need to improve communication with residents and families. Effective and respectful communication is a critical part of providing high quality care, so it is important that these areas be actioned in a timely manner.

For VAC, the audit team noted the need to clearly establish and communicate VAC’s role in supporting Veterans, and their families, in long term care and the need to complete the 2011/12 operating cost review.

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