Legislative Assembly of Ontario

REVIEW OF SPECIAL AUDIT ON TORONTO GENERAL DIVISION OF THE TORONTO HOSPITAL

MINISTRY OF HEALTH

CONTENTS

Thursday 29 October 1992

Review of special audit on Toronto General Division of the Toronto Hospital

Ministry of Health

Michael Decter, deputy minister

Pat McGee, acting assistant deputy minister

STANDING COMMITTEE ON PUBLIC ACCOUNTS

*Chair / Président: Mancini, Remo (Essex South/-Sud L)

*Vice-Chair / Vice-Président: Cordiano, Joseph (Lawrence L)

*Callahan, Robert V. (Brampton South/-Sud L)

Cousens, W. Donald (Markham PC)

*Duignan, Noel (Halton North/-Nord ND)

*Frankford, Robert (Scarborough East/-Est ND)

Haeck, Christel (St Catharines-Brock ND)

*Hayes, Pat (Essex-Kent ND)

Johnson, Paul R. (Prince Edward-Lennox-South Hastings/Prince Edward-Lennox-Hastings-Sud ND)

*O'Connor, Larry (Durham-York ND)

Sorbara, Gregory S. (York Centre L)

*Tilson, David (Dufferin-Peel PC)

Substitutions / Membres remplaçants:

*Owens, Stephen (Scarborough Centre ND) for Ms Haeck

*Wessenger, Paul (Simcoe Centre ND)

*In attendance / présents

Clerk pro tem / Greffier par intérim: Arnott, Douglas

Staff / Personnel: McLellan, Ray, research officer, Legislative Research Service

The committee met at 1014 in room 151.

REVIEW OF SPECIAL AUDIT ON TORONTO GENERAL DIVISION OF THE TORONTO HOSPITAL

The Chair (Mr Remo Mancini): The standing committee on public accounts is called to order. At last week's meeting, the committee decided to continue with the review of the audit on the Toronto General Hospital and the committee decided to call certain witnesses today.

I understand that we have Michael Decter, the Deputy Minister of Health, Ms Pat McGee, the acting assistant Deputy Minister, and Mr Coty Thompson here today. Could they please join the committee and take a seat at the front?

There was some talk last week by members of the committee that we might want to swear in our witnesses, considering some of the testimony that had been given to us. I don't think that's going to be necessary, but that might be something the committee might wish to discuss further as we go along in these proceedings.

Mr Stephen Owens (Scarborough Centre): Is there a concern that somebody is not telling the truth? Is that what the issue was?

The Chair: That was the discussion last week from members from all sides of the committee. Just read Hansard and you'll be able to get the feel of what the members had to say. We don't need special permission to swear in witnesses; we have that authority already.

Mr Owens: I think it's a little bizarre to start doing things like that.

The Chair: In the past other committees have done it. As a matter of fact, you might recall one of your former colleagues, Michael Breaugh from Oshawa, who served as the Chairman of the Legislative Assembly committee; he felt it should be standard procedure for all committees, not just his committee. That's just a little bit of history.

The research officer for the committee has prepared for us, and we thank him for it, a list of 25 questions that had been asked by different committee members. I understand that we have answers to questions 17 and 22. I'm not sure how the committee wishes to deal with this. Do you wish to receive the answers to those two questions now? Do you wish to wait until we get to those questions and deal with the questions in a chronological order?

I have received advice also this morning from the auditor's office that possibly the ministry -- they'll have to confirm it themselves -- would have answers to questions 4, 9, 18, 19, 23 and 24, and that probably the hospital officials would and should have answers to all the other questions.

I want to do this with the concurrence of the majority view of the committee. Do you want to handle this in a chronological fashion? Do you want to get to the answers right away? What's your advice, if any? No advice? Okay. Then what I would suggest is that we keep the questions in front of us so that we know what in fact has been asked, that we make note of the answers that the auditor's office believes the ministry officials may have, and you may want to add other questions to your list as we go on.

MINISTRY OF HEALTH

The Chair: Mr Decter, we want to thank you and your staff for appearing this morning. As you know, the committee has been very concerned with reports and deputations that we have been receiving in regards to the financial operations of the Toronto General division of the Toronto Hospital. That led the committee to ask the Provincial Auditor to do an audit based on allegations and deputations that we had received from CUPE Local 2001. I'd like to ask you if you have looked at the auditor's findings, if you've had a chance to do that?

Mr Michael Decter: First of all, thank you for the invitation to be here. It's a pleasure to be here and we welcome the opportunity.

Second, just in case there's an expectation that we're aware of the specific questions you made reference to a moment ago, we have not received those questions; therefore, our ability to answer them --

The Chair: We'll get you a copy immediately.

Mr Decter: Okay. We'll do our best. Obviously, we'll be able to supplement our answers from our files.

I have had a chance to review the report of the audit, the October 6 document, and would frankly compliment the Provincial Auditor and his office for doing a rather thorough job of investigating the allegations. We were pleased to see the comprehensiveness and the amount of detail on each of the allegations and felt that most of them were significantly laid to rest by the report.

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The Chair: I take it then that you are also familiar with the allegations that were presented to the committee which led to the audit?

Mr Decter: Yes. Those allegations had been presented to the ministry at an earlier date than they had been presented to the committee and had been raised by the ministry with the hospital --

The Chair: Sorry to interrupt, but I also would assume that you're familiar with the discussions that took place in the committee between the time the allegations were made, followed by the audit, followed by the report by the auditor's office to the committee, and the discussions that we've had that led to your invitation?

Mr Decter: We've tried to follow your deliberations fairly closely. We may not have caught every nuance of every member's intervention, but we've tried.

The Chair: I just wanted to make sure that was on the record, that you have all of the information that we have. You've now been presented with the list of questions that have been asked by members. Now that we've established the fact that we all have the same information, I'd like to turn the floor over to the committee members who've asked that you and your staff appear. They may have a question, they may have a series of questions, or they may have just general comments to make. I'm taking a list.

Mr David Tilson (Dufferin-Peel): I have a comment I'd like Mr Decter or his staff to respond to. As has been indicated and as you know, the Provincial Auditor's office conducted an audit of the Toronto Hospital. There was some difficulty expressed in receiving information. Tied in with that, there was a presentation made to this committee by the Canadian Union of Public Employees, Local 1744 and 2001, making very serious allegations with respect to the operation of the Toronto Hospital.

You've indicated that you had received that report. I don't know what inquiries you made as a result of it. I'd like you to tell us what the ministry did when those representations were made to you. We, after hearing the representation from the union and acting in good faith, proceeded to instruct the Provincial Auditor to go back again and deal with those very serious allegations.

Almost all the allegations, generally speaking, have proven to be completely false. Well, the Chairman is shaking his head and he's right: they're not completely false, and I suspect we all want to ask you some question on some of those topics this morning. But a lot of the facts were difficult. I'm saying that without having now heard the union's response. I can assure you that I, for one member, as we've gone to all this trouble and expense, would expect the union to return and listen to the auditor's report and give us its comments.

Having said that, the great concern I have is that there appears to have been some substantial mischief done. We all know that hospitals are having a great deal of difficulty operating. They receive moneys from the government; they receive moneys from donations; they receive moneys from other different sources. That mischief, I hope, will not affect fund-raising of the Toronto Hospital.

I guess that's my concern: what you believe the ministry can do -- assuming that there has been a mischief done, and I believe there has -- to alleviate concerns that members of the public who are making donations to the Toronto Hospital may have as a result of alleged mischief that's been made by the union.

Mr Decter: Let me try and put it in context. I think the fairest thing to be said is that both Dr Hudson and I assumed our current positions about the same time the summer before last, and were both confronted rather early in our tenure with a series of allegations about activities at the Toronto Hospital, in fact, many of the same allegations that were investigated by the auditor and reported out to the hospital and to this committee.

The fundamental underlying problem was a very bad labour relations situation existing between the bargaining agents and the hospital management. I think on that fundamental issue we've seen enormous improvement. The minister and I met in June with both the leadership of the hospital management team and with the leadership of the bargaining agents and were told that although there had been some real difficult situations, including a long-standing Ontario Nurses' Association blacklist of the hospital, the management team and the heads of the bargaining agents were meeting regularly and were on the road to some constructive resolution of their problems.

We were told by both sides that they thought they could make the Toronto Hospital a model for labour relations in the health sector, of a positive sort. To the extent that much of this conflict really was a manifestation of a lack of a good relationship between labour and management at the hospital, I think the hospital is well on the road to recovery. I think anyone considering supporting the hospital financially should take that as a very positive sign that progress has been made.

I would give credit to both parties. I think it took both Dr Hudson's willingness to change some attitudes on the management side, and some leadership on the ONA's and some of the other bargaining agents' part to be willing to participate in the process. I would also in passing say that Vic Pathe, who serves the province enormously, well gave some very sound advice to both parties.

On the specific allegations, they fall, I guess, in two categories, some of which are issues of long-standing of which the ministry has been historically aware. The Begley and Associates issue is not a new one. It's been a relationship of long-standing. Pat McGee could speak to it, but it's been looked at by the hospital and by the ministry on numerous occasions without any resultant conclusion that there was anything wrong with the relationship.

I guess I'd say also that in terms of some of the other specifics, these are really things, including the acquisition of computer hardware and software, that fall squarely within the purview of the hospital management and its board. The ministry does not fund and does not dictate how those decisions are to be taken. They involve significantly money that comes from other than government sources. I believe the appropriate place for, if you like, the buck to stop on those decisions is with the board of the hospital and the audit committee of the hospital.

Mr Tilson: I suppose, Mr Decter, there obviously is a fine line as to what independence the hospital should have. We can't have the ministry coming in and telling the hospital how to dot its i's and cross its t's and everything, except when substantial amounts of moneys are given to hospitals.

I guess that's really what we're going to be leading up to, the overall policy of the ministry, because if these problems occur at Toronto Hospital, there's no reason to say that they might not be occurring around the province. If these problems are occurring and we say, "The buck stops at the hospital," that may or may not be the case. If problems are discovered, what does the ministry do? Do we just say, "That's your problem," notwithstanding the fact that a substantial amount of transfers are being made to the hospitals?

Mr Decter: Of course the ministry does have a very substantial oversight role as to the balance between the ministry role and the role of hospital boards. I think Mr Wessenger could probably speak from significant experience to the range of views that exist in Ontario. That range of views will come to bear on the new Public Hospitals Act. The current act is relatively clear about where various obligations lie, as are our guidelines. I did bring along copies of our 1992-93 and 1993-94 hospital operating plan process and guidelines for the committee.

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It's fair to say that we are becoming more involved than maybe we have been historically in requiring hospitals, particularly in the interhospital planning process, to work through the district health councils and to be more open. The ministry has wanted to see a more open and accountable hospital process. The Ontario Hospital Association, meeting this week, passed a resolution in support of opening up the meetings of boards of the hospitals. The Toronto Hospital, for the first time in its history, took that step recently. So we are seeing an opening up of the accountability process in information terms.

The line is very clear. The Ministry of Health funds hospitals and we are very involved in the planning process, but we are neither the owners nor the managers of the hospitals of the province. They have volunteer, independent boards that have legal responsibilities.

In an extreme case, the minister has the authority to appoint an investigating team. That action was taken a little over a year ago or two years ago in the case of St Michael's Hospital. We get a lot of regular financial reporting from the hospitals. If a deficit situation or some other issue arises that is of significant concern, the minister has the ability to appoint an investigation team.

Mr Tilson: At least from my philosophy, and I believe the philosophy of our party, sometimes governments can interfere too much. At the same time, issues have developed, and one that appears to have developed at the Toronto Hospital is the acquisition of very expensive equipment of which the servicing can only take place from California, I believe. Some time was spent on that subject.

You're telling me Mr Wessenger can educate me. I'm sure he can, but I would like you to talk in general terms. If that type of problem is occurring at Toronto Hospital, then presumably it could be occurring around the province.

Mr Decter: In terms of types of problems, if we're speaking specifically about the acquisition of computer hardware and software, I think it's fair to say it's been an issue right across the country. I've been involved in a couple of other Canadian jurisdictions. Hospitals have not been immune to the problem that many organizations have suffered.

Frankly, there've been two issues. One is that computer technology has changed rather rapidly. Often, by the time you implement a system, someone has come along with something that seems better. There are major teaching hospitals in other jurisdictions in this country that have been through three complete hardware-software-mainframe investments in 15 years.

This is not an uncommon problem. It's not a problem unique to the hospital sector. Many other organizations have made a choice and invested and then have come to find, particularly with the movement to much more use of minicomputers and local area networks, that the big mainframe solution that was favoured for a couple of decades has been overtaken, in many instances, by much smaller computers linked together. A lot of organizations have found themselves in the position that by the time they got the system up and running, it looked like it was not as good a deal as it was when they made the decision.

Mr Tilson: That's my very point. We all know that. Even a small businessman knows how fast equipment, particularly computer equipment, can become redundant. It can simply become out of date. Knowing that and knowing that the government is giving a substantial amount of transfers to hospitals -- I'm not just looking at the Toronto Hospital -- I'm looking at what your ministry's philosophy is as to what requirements hospitals should have before they make substantial acquisitions.

Mr Decter: Here we did seek and receive repeated assurances that our operating funds were not being used in this area. Our view would be that the hospital boards, broadly representative and containing in every instance significant private sector expertise, have to acquire equipment they think will meet the needs of the hospital, based on the recommendations of the management of those hospitals. There are 223 hospitals out there and they will have different needs and make different decisions.

There are some situations, and I would single out Sunnybrook, where they've been able to do quite remarkable things in terms of costing to the patient level with their investments. We certainly encourage the hospitals to talk to each other through the OHA and through other forums, but I don't think this is an area where a provincial policy or a provincial decision would serve the interests of the hospital system very well.

If you think about it, there's just such a range of needs. There's often a lot of difference in the individual investments that may already be in place. Some hospitals have automated parts of their operation; admitting, or patient records. There may be a case for the province taking a look at this and seeing what the experience has been, but my view on this is that this is like the acquisition of other types of equipment, something hospitals need to be accountable for, and 223 of them aren't going to get every decision right, but that's just one of the realities of us all being human beings.

Mr Tilson: Mr Chairman, perhaps other members of the committee --

The Chair: Mr Cordiano had a supplementary. I'll allow one supplementary, then we're going to Mr Frankford.

Mr Joseph Cordiano (Lawrence): Can I then go on to my questions?

The Chair: Mr Tilson used about 18 minutes, and I was going to allow Mr Owens and Dr Frankford to share about 18 minutes.

Mr Cordiano: Are we not doing this in rotation?

Mr Tilson: We go clockwise.

The Chair: We go this way. We started with Mr Tilson.

Mr Cordiano: My supplementary probably -- I'll give it my best shot to be brief. I think this question is more broadly based in terms of its perspective, because what emanates from the audit that was done on the Toronto Hospital leads us to a variety of conclusions, which I think would probably have me think that there could be more problems associated with systems, with a general approach, or the lack thereof.

My question surrounding this area would be the fact that the Ministry of Health should perhaps be looking at policies that could be used across the entire system, that should streamline the process for each of the hospitals, because why reinvent the wheel each and every time when you're making purchasing decisions? I think those things ought to be done, and what I'm hearing from you is that the Ministry of Health either hasn't looked at this or hasn't implemented any plans with respect to that. In fact, you're not even thinking about changing the system with respect to those decisions.

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The whole structure and the whole way that hospitals have been operating, in my opinion -- and that's an individual opinion -- need to be changed, and that process needs to be commenced by this government, which is very seriously looking at eliminating costs across the board. I think part of the problem that we see here emanates from the systems that failed to work, and directions that -- I'm not saying it should be a top-down direction, but it should be a process that's commenced, initiated, perhaps, by the ministry to look at the entire system, and then these sorts of problems can be avoided. I'd like to get your opinion on that view.

Mr Decter: We have established, the ministry and the Ontario Hospital Association, a joint planning and policy committee with some subcommittees, so I don't want my comments directed to computer hardware and software, to be taken as a general point. We are working very hard with the OHA to develop policies on funding, policies on service realignment, and policies on labour adjustment that cut across the whole sector, and it may well be a good idea to have that joint policy process also look at the issue of acquisition of information systems. I think it's important that it's joint, not the ministry doing it on its own --

Mr Cordiano: Oh, I agree.

Mr Decter: -- because there is significant cooperative potential with the OHA, and that process seems to be working fairly well.

There are two existing joint purchasing agencies. The Hospital Council of Metropolitan Toronto runs one, and the Ontario Hospital Association runs the other. The hospitals in Ontario spend about $2 billion a year on acquiring goods as opposed to services, everything from computers to drugs. The two agencies each account for about 15% of that -- my last memory of the numbers -- so about 30% of what the hospitals acquire is acquired through these two purchasing agencies.

We have provided some funding for a study to look at whether those two organizations should be merged and what the problem is: why they aren't playing a bigger role in acquisition. The issue seems to be that the small hospitals use the agencies and the bigger hospitals have enough marketplace clout to deal one-on-one with suppliers.

We're looking at whether we can do a better job on that in two directions; one, frankly, to get lower prices out of more clout, but two, to get more economic development benefits for the province. Eighty per cent of that $2 billion flows directly out of Ontario to mostly American suppliers, and there is a strong sense that we haven't looked at how much leverage we might have, not to subsidize people to locate in Ontario but to look, through those agencies, at how we might reinforce economic development in the province.

The Chair: Thank you for the supplementary, and thank you for the answer. We have Mr Owens, Mr Frankford, Mr Duignan: You're all going to share 18 minutes. I'll leave it up to you gentlemen as to how you're going to do that for the first round. If necessary, we're going to have a second round of questions.

Mr Owens: I would appreciate that, Chair.

I'd like to make some general comments as well as address some of the issues that Mr Decter has raised.

In terms of this audit, I have absolutely no doubt about its thoroughness, and I appreciate the work of the team that has gone in. I appreciate the work of Mr Archer and his initial report. I think, though, that in my view it's not the questions that are answered that cause me difficulty; it's the questions that are raised and left unanswered that cause me difficulty.

The issue with respect to Begley is one that I find extremely problematic, and Mr Decter, you've indicated that the ministry has reviewed this relationship and has felt that there is no basis for conflict. In terms of some of the issues that haven't been raised, I haven't heard anything about a value-for-dollar audit being conducted on this relationship: the kinds of projects that this contractor undertakes, the kinds of difficulties that have been incurred by the hospital in trying to enforce its obligations under the Occupational Health and Safety Act. I can assure you that many, many difficulties with respect to issues like asbestos removal, even in light of the fact that the hospital had been convicted in provincial court for violating the Occupational Health and Safety Act, for violating the asbestos regulations, continue to be a problem as a result of the relationship that this company enjoys with the hospital.

You touched on an aspect with respect to labour relations, and I can heartily agree with you that the labour relations conducted in this hospital have been absolutely abominable, to the point of reprehensible.

Yet another question I have in terms of whether it's the initial audit or whether it's even the supplementary audit: Why was there no look taken at the cost of labour relations, the type of work that was going on within that department, not in trying to reach agreements but in terms of the delay process, in terms of opting out of a provincially agreed-to process with respect to central bargaining that saves institutions like the Toronto Hospital Corp money, getting into two-year-long contract negotiations, getting into protracted pay equity negotiations? These are the kinds of questions that are raised by this audit and the supplementary audit.

The other concern that I have is in terms of the issue of the union's testimony. This committee is charged with a particularly important job, which is to look at the spending of the government. In my view, it doesn't matter which government is in. This committee has an obligation to hear from people who have concerns about the way in which taxpayers' money is spent. It's my view that the union didn't appear here to cause mischief. The union appeared here to relay concerns of long-standing concern around the operation of this hospital.

I can assure you that it is this committee and this government that have taken a hold of these concerns and have actually taken a look at some of the difficulties. This stuff didn't start happening the week before the union testified here. I can assure you of that, and now we're hearing rumblings about some kind of retribution being meted out to the person who placed the testimony on record. I can tell you that as a taxpayer taking off my coat as an MPP, if this kind of stuff happens, then we will never, ever have the open and free-flowing dialogue that is so important in trying to ensure that taxpayers are given the best value for their dollar.

For some reason, members opposite seem to think that the Toronto Hospital Corp has been completely and totally vindicated. But I'll tell you something: You look at the initial audit report, page 44, section 2.8 -- it talks about nine purchases totalling $3.2 million: "Senior management would not provide us with documentation on the selection process. One purchase was for computer equipment costing approximately $1.2 million. Senior management stated that these items were not funded by the Ministry of Health's operating grants and consequently were beyond the scope of our inspection audit." Code 4 -- politely put, "Buzz off; this is none of your business." Well, I'm sorry. That is our business. It's the business of legislators to be able to assess the value for dollar that taxpayers are receiving for their money.

So, in conclusion, Mr Chair, I'm concerned that people are going to walk away from this committee thinking: "Oh, bad union. A terrible person who came and launched these allegations against the hospital. They've been vindicated." Well, I'm afraid that there are still many, many questions that need to be answered. Again, it's unfortunate that we were dealing with a problem that has taken place in a historical context, and perhaps what this committee should be taking a look at is moving forward and determining how these problems cannot be allowed to happen again. The Ministry of Health is on the right track with respect to its public hospitals review, and I think that in terms of the role of this committee we should be looking to making recommendations as to how that accountability can be put into the process.

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The Acting Chair (Mr Pat Hayes): Mr Decter, do you want to respond to that?

Mr Decter: Just to say that where ministry funds are involved we insist on a public tendering process, and we also insist on a very detailed breakdown of costs which would show up any excessive payment. If a larger percentage of a project was going in consulting fees, we would be aware of it. On the ministry-funded projects, on the hospital-owned source projects, where ministry funds are not involved, then, while we urge public tendering, that becomes really the decision of the board of the hospital rather than something the ministry has significant influence over.

I would just say on the labour relations front that it's important to recognize that the ministry is not the employer and that the obligation for having viable labour relations rests with the two parties at the level of the hospital. We do fund the process that provides for central bargaining through the OHA, and most of the hospitals in the province participate in that process. The Toronto Hospital, I believe, has not, but is now considering becoming part of central bargaining, which I think might go some distance towards resolving some of the issues.

Mr Robert Frankford (Scarborough East): I wanted to get back to the computerization question. I'm really rather surprised by the contention that this is something which hospitals should primarily do individually and that we recognize that there are the 200-odd hospitals.

I'm not a great expert on computers, but I'm not totally illiterate either. It would seem to me that there is a great deal that the ministry could do around setting standard criteria, which I don't think involves purchase necessarily but would set some standardized guidelines. Obviously, the health system is not just those 200-odd hospitals; the health system is a whole range of institutions and practitioners out there.

In the time we're talking about, the ministry made a major change in introducing individual health numbers, and I think that this is an indication of what will have to happen in the health system and the potential, when one can have unique identifiers, that this has to be part of an overall system. So without necessarily saying that the ministry should set precise specifications of the hardware, I would submit that there is a great deal that the ministry could be doing in setting criteria, and I don't see why they have to use the hospital association as an intermediary. I think this is something where one can use one's own expert and set some standards.

I would note that the system we're talking about here is apparently a proprietary American system, a rather closed system. I have not been able to gather really how much it would relate with other systems, and I've already asked for some technical information which I hope could be provided so that we can get some indication of the transferability of what they're doing here. I think it's very dangerous if hospitals get tied closely with individual proprietary systems. This, perhaps, gets me into another quick question on the amount of information and the number of studies that are provided on what is being done now that the Toronto Hospital is a teaching hospital.

I don't know whether this formally provides any obligations about publishing studies, but I think it's regrettable that we don't get good professional studies on what is going on. I hope the health care system is something which is based on science, based on professionalism, and where there's an obligation to publish and present exactly what is going on. I've asked for that; I haven't seen anything provided. I don't know if the ministry has any formal clout here, but if it doesn't, then it's very regrettable.

I also raised the question about the district health councils' involvement. If one is getting into public policy around standardization of computer systems, standardization of information and outcomes, then it would seem that this is something which is very much desired, on a reasonable basis, at the very least. The Toronto Hospital certainly made a big move. I'm not sure what the exact status is right now of its comprehensive health organization, which I think clearly would require a major computerization of the enrolled population. I'm not clear how the Ulticare system ties in with that, but if it doesn't, then I think it's a missed opportunity. This is an area where the ministry has, to my mind, considerable leeway in setting some standards.

Mr Decter: The ministry has been actively involved. In fact, all of the ministers of health from across the country have recently moved forward on a national health information institute. There are two existing organizations that set standards for information in the hospital sector, MIS and HMRI.

The concern among ministers was that in addition to those two very hospital-focused organizations, which were member-owned but funded essentially by government through hospital budgets and sometimes directly, that Statistics Canada had developed a health information centre and that Health and Welfare had. Ministers nationally have taken a decision to put those four entities together -- it's going to take a little time -- and to try and get comparable health information as well as hospital information, so that hospitals and other health care providers and consumers can compare. Both MIS and HMRI have been valuable in that regard. Hospitals can get comparable data. They can look at how they stack up against their peers across the country, across the province. It's been a very important management tool.

I think we have to distinguish, though, between the automating of functions inside a hospital, which is what mostly we've been about, and the integration of those automated systems outside the hospital, the external links, which we have not done very much about. One of the driving reasons for moving to the unique identifier in terms of the health number was to be able to get data that could be used across the whole health sector, not just in terms of an encounter in an individual hospital. We are making progress there, although I wouldn't be surprised if this committee wanted us back, after the auditor reports, to talk about the health card. We would welcome an opportunity to come and tell you what we're doing to address problems in that field.

The Chair: Mr Duignan, real quick.

Mr Noel Duignan (Halton North): Well, I have a number of questions, but I'll try and put them very quickly.

One, does the Ministry of Health have a set of conflict of interest guidelines for hospitals? Two, going on your earlier comments, first of all you said you're basically satisfied with the arrangement of Begley and Associates with the hospital, but then you said that where public money is involved, you'd like to see a tendering process. The auditor is concerned that Begley and Associates, which has been with the hospital for some 10 years, has never been tendered. Are you concerned about that? I'll just leave it at that, because I don't have enough time to ask more questions.

Mr Decter: I'll ask Pat McGee to speak to that. I think there's a distinction here between the hospital's decision to, in essence, have this ongoing relationship, which is really a function that in other hospitals is performed by direct employees, done on a contractual basis. There's a distinction between that and individual capital projects in which we insist on a public tender. Maybe Pat could speak to that briefly.

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Miss Pat McGee: On each of the letters we send out on a capital project with the approval, we ask for proof of public tendering, and we look for the advertisement in the paper before they're funded. So we insist on public tendering of all capital projects for which ministry funding is provided.

The situation with Begley is that all the large hospitals I know of have planning departments. They have huge physical plants that need a lot of engineering expertise to maintain and they all have some form of planning expertise in-house. It's my understanding that Toronto Hospital uses Begley; they've gone on contract with him rather than hiring someone directly on to the staff. It's been a long-term relationship.

I do not have any documented evidence that we questioned this, but I know we did question it over the years. Every time there was a new director in the capital planning branch, it was questioned.

Mr Duignan: The auditor has expressed a concern. It says, "I think we as auditors are generally concerned, whenever we come across a process where competitive situations do not exist, that there's fair and equal access to all potential suppliers."

We still, as a committee, do not know the amount of money we're dealing with. That's one of the questions we're still waiting to be answered by the auditors. It's a concern I have. This same gentleman is using public space provided by the taxpayers of this province to get other contracts, even though they may be small, outside the hospital.

Mr Decter: All I can say is that in terms of the specific financial issues and the ongoing maintenance activities, those are questions that I think would be best directed to Dr Hudson in terms of the hospital management. Those are decisions that they make in the same way that any other hospital might make a decision to use its own maintenance department to do something or to go outside and tender it.

What I'm saying is that when it comes to the major projects, which are capital-funded by us, they are compelled to go outside, they are compelled to issue a public tender, and they have done that. We certainly support the auditor's view that a public tender process is the best way of ensuring price and quality, but the Begley and Associates issue I think is really an issue of the hospital choosing to operate a certain part of its planning function on a contractual basis rather than a staff basis, if you like, a direct employee basis. That's something we've been aware of, that we've looked at from time to time. As I say, we have not had cause to come to question it.

As to conflict-of-interest guidelines, the ministry has a code of conduct for its employees. I could not answer specifically whether the Toronto Hospital has a specific conflict-of-interest regime applying to its own employees.

The Acting Chair: Thank you, Mr Decter and Miss McGee. Mr Cordiano.

Mr Duignan: Mr Chair, that wasn't the question I asked. The question I asked is, does the Ministry of Health have a set of conflict-of-interest guidelines for hospitals?

The Acting Chair: I guess you want a yes or no.

Mr Decter: I don't believe we do, but I'd be willing to look into what we have done on that over the years.

The Acting Chair: Mr Decter, can you get that answer back to this committee? We'd appreciate it.

Mr Decter: Yes, we'll provide a more formal answer.

Mr Cordiano: Let me start off by asking your view with respect to changes that are planned or that we hope to have in place some time in the future with respect to the Audit Act, which governs the Provincial Auditor with respect to what he can and cannot undertake.

It is our view, and I think I can say this on behalf of the committee, that we're looking to make changes to that to allow for the auditor to make value-for-money audits in the quasi-public sector. What would be your view on changes to the act in respect of that? Would you welcome such changes in order for us to conduct that kind of assessment on the quasi-public sector?

Mr Decter: I'm tempted to take the view that, as that's a question for legislators to eventually decide, it's dangerous ground for a non-elected official to have a strong view on. At some point, the assembly of this province will have to pronounce on that issue.

Mr Cordiano: Let me ask you in another way, so it might not be as much a political decision as it would be one from an administrative point of view. To improve efficiency, would it be favourable for this system to have in place value-for-money audits itself -- leaving aside for the moment the role of the Provincial Auditor -- to set itself up to do value-for-money audits, changing its very nature in terms of the systems that are in place now, so that when those audits arise, in would be in place for that to occur as time goes by? Would you agree with that initiative?

Mr Decter: Very strongly, and I appreciate you rewording the question so that I could give it a more direct answer. I would strongly favour the use of value-for-money auditing in the sector. We have a very good recent example: The Queen Elizabeth Hospital undertook a process, I think influenced somewhat by their chairman, Gordon Coperthwaite, who's a long-time pillar of the audit profession in this country and advocate of comprehensive audits. I was pleased to endorse their report and encourage, through them, other hospitals to do the same thing.

The difficult issue, of course, is who should do it. To what extent is it a function of the hospital internal audit? To what extent is it a function of the hospital's external auditors? To what extent is it a function of the Provincial Auditor? Should all three do it? That's the question that's a little dodgy for me.

But should it be done? Absolutely, yes. I think there's nothing but value to be gained from a greater focus on value for money. The whole shift we're trying to make in the health business is from looking at inputs to looking at outcomes. That's very consistent with the value-for-money approach, which starts to ask not "How much are you spending?" but "What are you getting for what you're spending?" I think it's entirely consistent with everything we're trying to do as a ministry.

Mr Cordiano: I'm glad to hear that, because that requires a philosophical shift, if you will, in terms of managerial approaches. It's something that obviously this committee is very interested in. Hopefully, we'll be heard across various ministries in the government as well as in the quasi-public sector.

The auditor has been attempting to do this in a variety of ministries, and obviously that's been ongoing for some time, but getting to the quasi-public sector is a real challenge for us: We're going to require legislative changes in order to have the auditor conduct the type of audits which he now has the authority to conduct with respect to the public sector.

I think it would be at the direction of this committee, at least in my opinion, that we move towards having the auditor play a role in the outside inspection audit at some point in the future. If you are undertaking changes with respect to the internal workings, as you've suggested, and the managerial approaches and value-for-money kind of management, then from my point of view it is important that as a legislative body we have a public accounting, if you will, of the kinds of expenditures that are being made now and not given that value-for-money accounting.

I think it's important. The point I'm trying to make in a long-winded kind of way is that the auditor will begin to prepare the office for that type of scenario, and I think the sector has to do the same thing: You set your management systems in place in order to allow for an external audit to take place down the road, so that it's built right in. I don't know if I'm making myself clear here.

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Mr Decter: I think it comes full circle to the availability of the information. If you only keep data on inputs, then it's very hard to get at value for money, so part of the shift that has to take place is a lot more emphasis on outcomes and what outcome we should be expecting.

In the case of the health sector, we have put some considerable funding into an institute at Sunnybrook. It's a joint venture of the government and the Ontario Medical Association, very much to start to get at, what do we know about outcomes and how do you begin to factor the outcome data in? Then you've got something, in my view, to audit, and you can come and look at, how is this hospital doing relative to its resource use and its outcomes compared to some other hospital? That's very much the push that we're making.

It seems to me that serves everyone's interests. It serves the interests of the internal audit on an ongoing basis and it also serves the interests of an overview or external audit by having the information there. Without a good information base, it's very hard for anyone to do more than ask some tough questions.

Mr Cordiano: Hearing that, I would like to revisit this question at some point in the future and to ascertain what kind of progress is being made in that regard. Perhaps you could shed some light on if there in fact is a time line that you have or some kind of general scheduling of this, when it's about to take place. What do you foresee?

Mr Decter: I think it varies a little by program area and sector. The institute at Sunnybrook is very much focused on the $4 billion of expenditures on physician services. The efforts in terms of case-costing in the hospital sector are very much focused on that sector and the $7 billion-plus that we spend in that sector.

There are other more focused efforts under way in the drug program to get at utilization, and utilization becomes a bit of a proxy for outcome in terms of looking at effectiveness and appropriateness, not simply, what did it cost us and how often did it happen?

It's not going to be a decade before we have progress, but I think it is going to be most of the 1990s before we've got the whole system turned around from looking very much at how much money's being spent or how many beds there are to looking to, what are the health outcomes and how does the resource use match with getting those outcomes?

Mr Cordiano: I realize that, but I think there are some things that can be done, as we look at the question before us with respect to Toronto Hospital, that would not take those lengthy time lines, because you're not measuring outcomes that are health-based but rather economic decisions. That's probably the initial thing that I think ought to be undertaken.

We can revisit this question at some point; I think it would be useful to do that. I know around here one does not really know when we will get to that, but I think it would be something of interest to me, to look at what kind of plans are being initiated in that regard.

Mr Decter: I think it is very important, though, to link to the health data. I know there are difficulties with that, but it isn't just a matter of what a day is costing you in a hospital but, how is the length of stay, compared to peer hospitals? If people are keeping patients in too long, then their average cost goes down but they're not necessarily providing better or more cost-effective care. They may simply be providing more care than is necessary. You need to have some good data and look at issues like lengths of stay, of case-costing.

Not to slight in any way the Toronto Hospital, but if you want to have someone in to show you where the leading edge is in this field, I believe Sunnybrook is very much on it. We're encouraging a lot of other hospitals to look at how it's dealing with these issues, because it seems to have got a good way down the line in terms of being able to provide information to both providers and consumers.

Mr Cordiano: Perhaps they could provide us with the kinds of examples that would help our committee to deliberate in that regard. That's a good suggestion. I think we might look at that, if it's agreed here.

The Acting Chair: Mr Tilson, you have two minutes left.

Mr Tilson: I'm sorry? How many minutes?

The Acting Chair: Isn't that what the previous Chair said? I thought I heard him say you had two minutes and then we'd start rotating, then we would start back again.

Mr Tilson: Two minutes? It'll take me two minutes to ask the question.

The Acting Chair: Try it.

Mr Tilson: I don't know whether you've seen the questions Mr McLellan prepared for our assistance today. I'd like specifically to refer to page 4, question 18. That of course has to do with the high isolation unit, which was raised as one of the concerns of the union, specifically on pages 15 and 16 of the auditor's comments.

If you turn to page 16, there's the heading "Use of the Unit." Obviously, there's a problem with this unit, and the question has been, has the Toronto General decided on the future of this unit, and what is the ministry's role in the review?

I don't know whether we know the answer to that question from the hospital's perspective, but since the ministry funded this thing from the outset, and since I read under the heading "Use of the Unit," "From the completion of construction to the time of our audit, the unit has never been used for the purposes intended," and then it goes on, I'd like you to comment on this subject.

Mr Decter: I'll make some general comments and then, given her greater familiarity, I would ask Pat McGee to either correct or simply supplement what I've had to say.

I think the high isolation unit is an example of an investment that was made to anticipate a problem. There were two cases of Lhasa fever, or suspected Lhasa fever, in the late 1970s, and there was considerable concern. I will say one of the motivating forces, generally, for some of the expenditures we make is public concern about things that are unknown and unusual. We went through this with the meningococcal disease earlier this year and did some inoculation that I think if you looked at it in hindsight, you'd say, "Well, we probably did more inoculation in some areas than hindsight would say was a good idea." But at the time there were very profound concerns about the spread of that disease.

We have not had, fortunately, any recurrence of cases of Lhasa fever, to the best of our knowledge, since that initial concern, and I think it's fair to say that the isolation unit has been passed by as a concept by medical thinking; that it was a concept that at the time people embraced and the ministry pursued and funded and that there is some question about whether there is a role for that unit. I believe we've asked our public health people to have a look at what's going on and to perhaps deal with the hospital on it, but I'd ask Pat to add any comments about the history of this.

Miss McGee: As I recall, the situation was that there were travellers from outside Canada, Canadians, who could not be treated, and they were having to go to other countries for treatment if they had acquired this disease. So it was built by Ontario as a national resource and it was being built with the cooperation of the federal people, using their guidelines, but it was a very new disease and a leading edge. So there was difficulty in getting the unit approved because the standards, as they increased knowledge, were changing as rapidly as the changes were being made.

The hospital built it at the request of the Ministry of Health. They have subsequently asked us if they could please dismantle it and use the equipment for other purposes. We've tried to maintain staff competence in the use of the equipment in the room, because they always had to be ready in case there was an illness. As Mr Decter has said, we've asked our public health people and our laboratory experts to look at it, to see if we still need it and if we could dismantle it.

Mr Tilson: Again, I'd like you to refer to question 18. As I understand it, you've adequately expressed what has happened, and I appreciate that, but could you provide details as to where you're going to go now? You say you're going to look at it, but what does that mean? Is there going to be a formal review of some sort for this dismantling?

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Miss McGee: Yes. We have asked our laboratory people and our public health people to determine whether there's still a need for the unit and whether it would be appropriate for us to dismantle it and use the equipment for other purposes.

Mr Tilson: So the answer is yes, you're participating with the hospital in a review to determine what you're going to do with it. Is that what you're saying?

Miss McGee: Well, it's a ministry project and ministry people will decide whether they need it to continue.

Mr Tilson: When do you expect that to be completed?

Miss McGee: I would think three months at the outside.

Mr Tilson: It just seems that a decade has gone by and it hasn't been used. It's a long time to not use something.

Miss McGee: Well, it was a preventive piece of equipment.

Mr Tilson: I understand your comments, yes.

Miss McGee: In the history, one patient did arrive and we had to close down the Etobicoke hospital, because the patient landed there and we had to take everybody out of the hospital while they cared for him.

Mr Tilson: Mr Chairman, do I have another question?

The Vice-Chair (Mr Joseph Cordiano): You have one minute left.

Mr Tilson: I'd like to turn to question 23 which Mr McLellan has prepared for us. Mr Owens, of course, has spoken of the fact that the union-employer relationship has not been the best, and that has become quite apparent. However, subject to what the union representatives are going to say -- I gather they're coming to this committee next week -- I believe the process has been abused. It certainly doesn't justify a group coming and making the allegations they have simply because of bad union-employer relations. I guess I'm getting back to the first area I started with Mr Decter. On almost every page you turn to in the auditor's report, there's no foundation for these allegations, or very little foundation for these allegations.

I guess I'm addressing question 23, whether it's this hospital or another hospital where there has been a breakdown in union-employer relations. I'll just ask the question as it's phrased: Are there established, or if not, are you going to establish, Ministry of Health guidelines on the procedures and process to be followed in addressing allegations such as those that have been put forward by CUPE; not only to you, Deputy Minister, but to this committee?

Mr Decter: I think one has to be careful to delineate differing kinds of allegations, because there are ranges of allegations and they call for differing actions. If there's an allegation that involves anything that might have the potential of the Criminal Code, it would be reviewed by our legal people, the Attorney General's legal people, and in all likelihood would be referred to the Ontario Provincial Police for investigation.

If it's something that involves an alleged financial misappropriation, then in our view it's an audit issue and either we would seek the assistance of the Provincial Auditor or, more appropriately, we would seek, through the hospital, for it to do that. We have that ongoing in one of our other agencies where there were allegations. The board of that institution decided to ask the Provincial Auditor to come in and have a look at the allegations. I think that's an appropriate step.

Mr Tilson: Mr Decter, I'll just take, almost at random, pages 8 and 9, for example, of the auditor's report. On page 8, the concern with respect to a $5-million computer mainframe, there are comments about that that were alleged by the union. The auditor says, "We were unable to find any evidence to support this concern." There is the comment on page 9, "Patient files have been lost." Auditor's response: "We were unable to obtain any evidence that patient files had been lost."

Surely this is something that's serious enough, when you have health employees making allegations such as this, which has obviously caused this committee a great deal of time and has caused the hospital a great deal of time, and the statements are not accurate. Therefore, I think question 23 is quite relevant.

Mr Decter: I'm trying to walk you through an answer. It depends on the gravity of the allegations and what we do about them. If it's a simple matter of an allegation on which we have fact the other way, then we so advise our minister and no action is taken. Usually, the person making the allegation is informed that in our view there's no evidence to sustain that.

In many cases, these are really things that are not known to us, but are known to the hospital. They involve the detail of an internal operation of a hospital. It is, in our view, an issue that needs to be dealt with by the board of directors of that hospital.

Mr Tilson: When these allegations were made to you, Mr Decter, you indicated that the union had spoken -- I don't know whether that was necessarily to you personally, but to someone on your staff -- and similar allegations that were put forward to this committee, what did you do as deputy?

Mr Decter: I asked, first of all, for staff and the ministry to give me a briefing on these allegations. I think, as evidenced, some of them were issues of long-standing, which had been looked at on other occasions; some of them were new issues. The second step I took was to meet with Dr Hudson and obtain the hospital's view of these issues. He indicated to me at that time that he took it as a very serious matter, and that he had asked, I believe, the Provincial Auditor to come back in -- this was subsequent to one visit -- and have a look at these allegations. Since that process was under way, I was satisfied the allegations were going to be addressed, but I'll come back to it.

There are many concerns raised in any workplace. One of the things we have not done very well and that we're trying to do better is to find a way for front-line workers not simply to raise concerns and have them, in many cases, not answered. I'll take this criticism in my own ministry. We have had a committee on which the bargaining agent is represented, and when I met with them, shortly after I took this job, their most significant complaint was they'd raise concerns and then they'd never get an answer as to whether there was any substance or not.

I think what we're trying to do is involve front-line workers in a constructive way so that they're not just making complaints, but they're able to participate in making suggestions about how things might be improved. We've had tremendous support from the OPSEU members, within our ministry, in putting forward ideas on how to reduce expenditures, how to work more efficiently.

Mr Tilson: So what you're telling me, Mr Decter, is that currently, the Ministry of Health does not have a process to deal with allegations such as this but you are in the process of developing a process.

Mr Decter: No, what I'm telling you is there is not a single process to deal with a wide range of allegations. There are differing processes set out in government -- in some cases in statutes and in other cases in regulations -- as to how various types of allegations are dealt with and we follow those, but there is not a single process to deal with a complex range of differing concerns.

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Mr Tilson: I guess the concern I have is that a series of allegations, whether it comes from a union or employees or whoever, comes forward. Somehow these allegations ended up before this committee and it seems rather strange that the Ministry of Health does not have -- it's a very expensive proceeding to send them. I think it was four days we sent these people out to review these very serious allegations many of which, it seems to me, could have been addressed by the ministry.

It would appear to me that currently, there does not appear to be a process to deal with any allegations of any sort. I appreciate that there could be criminal allegations at one extreme and a loss of paper clips at the other. I understand that, but I think it's a legitimate concern that hopefully will be addressed to have some sort of procedure in the Ministry of Health to deal with concerns of workers, of just people in the health system, of waste, of -- I don't know -- improper conduct, of outdated material, all these topics that have been raised. That procedure doesn't appear to exist.

Mr Decter: I must say I disagree completely with your characterization of my response in the current situation. I believe that allegations that are made are, and in this case, were investigated. I cannot assure you that in every case the people making the allegations are going to be satisfied by the ministry response. In fact, there were calls from some of the people involved to put the hospital under trusteeship, which is something which is in the power of my minister to do. That step was not taken, but we were very concerned and we were pleased that the hospital had asked the Provincial Auditor to come back in and have another look.

I just would say that I believe we do an extremely thorough job of looking into allegations. There are a vast number of them, if you understand the size of this system, that come our way, but where there is more evidence that something isn't working out there of a general sort -- we try and get them to the right body if they're concerned. That should properly be at one of the regulated health professions. We have a steady stream of patient concerns about individual cases. Those are appropriately dealt with whether by the College of Physicians and Surgeons or one of the other bodies.

I guess I'm trying to say that we don't have a single process. I don't want to be in any way agreeing that there is no process. There are many processes. They were followed in this instance. There is a great deal of ministry work in looking at these allegations. At the end of the day, the auditor has more scope than we do to go in and actually look at the detail, as they did in this instance. There are other cases where we've asked either our own internal auditors or the Provincial Auditor to look at institutions that we fund.

Mr Tilson: Mr Decter, in dealing with these allegations that were made by the union, does your ministry have any documentation that this committee could review to determine how the ministry dealt with these specific allegations?

Mr Decter: I believe we could certainly provide some information. The committee received these allegations in a more complete form than the ministry did. Some of them were things that were conveyed to us verbally.

The Chair: To add to Mr Tilson's request then, could we get a copy of the allegations and the form in which you received them and you response on what you did?

Mr Decter: To the extent that it exists in hard copy; much of this was conveyed to us verbally and many of the responses were verbal. There were meetings that took place. There's no transcript or minutes of those meetings, so I cannot go on more than memory of that.

Mr Tilson: This committee is not treating these allegations lightly, and if they are not founded, we will be very concerned. I think the Chairman's question and my question were that we need to have information to be fair to everyone, to be fair to the union, to be fair to the hospital and to be fair to the ministry.

Can you make available to this committee -- we're proceeding next week, I think -- all documentation and notes that you have that can assist us as to the concerns of the union, the action taken by the ministry and any other response in dealings with the union on these allegations?

Mr Owens: On a point of clarification, Mr Chair: What is the intent of the member to do with the information should it be provided? What do you expect this committee can do?

The Chair: Please go ahead, Mr Tilson, and answer the question.

Mr Tilson: This committee, in the open process that I believe we have in this committee, responded to very serious allegations, very shocking allegations. I can remember when the union came here to make these allegations. We've now had the Provincial Auditor's office spend four days on these allegations and it has come through, page by page almost, saying that these allegations are not substantiated.

It gives me great concern that we've spent taxpayers' money on this open process, in the trust of this union coming forward in these allegations, notwithstanding the difficult situation that may have existed in the past between the employer and the union; notwithstanding that, we have properly dealt with these allegations.

I am concerned now about the process the ministry has in dealing with allegations, the similar allegations that were made to the ministry. I am concerned with the process that was followed by the ministry in dealing with these allegations. I am concerned as to whether or not these same allegations were made to the ministry or whether they were different allegations. I'm concerned that because we have gone through this process, I don't believe this committee has all the facts before it to properly determine whether or not these problems exist or whether there are other problems.

Mr Owens: My concern again, Mr Chair, is that I don't have an understanding of what the member wants to do with these pieces of paper should they exist.

The Chair: Maybe I could tell you what I would like to do with them. I'd like to be able to review the complete file that is within the Ministry of Health. I'd like to compare the allegations made to the ministry as to the allegations made before this committee. I'd like to see the response compared to what the auditor found. I'd like to have an idea of what the mechanism is with inside the ministry and how it handles these serious matters. I'd like to be able to know whether or not this committee, with the help of the auditor's office, could give advice to not only the Ministry of Health in this particular situation, but maybe in future situations. I think we've got a lot of information here, but there's also a lot of loose ends.

Mr Owens: I don't disagree with the member's request. My concern is that throughout his comments, there's a vague insinuation that there should be some sort of retribution meted out to the union, and I want to tell you publicly again --

The Chair: I have nothing --

Mr Owens: -- that I fully disagree. The group came here as taxpayers.

The Chair: I hope you're not insinuating that my comments were --

Mr Owens: If we went after every group that came before a --

The Chair: Order, please.

Mr Owens: -- a legislative committee --

The Chair: Order, please. I hope the member's not insinuating my comments were in the same light.

Mr Tilson: On a point of personal privilege, Mr Chairman: I am concerned about those suggestions. If you listen to my answers and read them in Hansard, you will note that I qualified my comments. I am not forming any conclusions until I've heard the union come back and explain its point of view with respect to the position that's been taken by the Provincial Auditor's office. I want to have all the facts before. I haven't made any allegations; I've made suggestions that at this particular point in time --

Mr Owens: Who suggested you made allegations?

Mr Tilson: Well, that's what you have said. You've said that there's a hidden innuendo --

Mr Owens: No one suggested you made allegations.

Mr Tilson: Mr Chairman, through you, there has been a suggestion of innuendo in my questions. I have suggested the word "mischief," yes, I have, because at this particular point in time, that's what appears to have --

Mr Owens: You have to prove intent.

Mr Tilson: Let me finish.

Mr Owens: Can you prove intent?

Mr Tilson: That what appears to have taken place.

The Chair: Order. I think all members have had a chance to express their views on this. I understand the points of view of both members and respect their points of view. I think at this stage we have to decide what information we want. When we receive the information, I will leave it up to the best judgement of each individual member as to how he wants to use that information.

I want this information because I want to be able to compare the allegations that were made before this committee with the information given to the ministry. I want to be able to compare the ministry actions and responses as to what was found by the Provincial Auditor. I want to be able to give some thoughtful consideration to whether or not we can be of assistance to the Ministry of Health, and therefore to the taxpayers of Ontario, in how future situations similar to this may be handled.

I want to know whether or not the ministry took the matter seriously. I want to know a lot of things, and these pieces of information that I'm requesting are going to help fill in and colour in the entire picture that is not yet clear. So I'm hoping that with the assistance of the committee we can request this information.

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Mr Owens: And I fully agree, in terms of ensuring that when one is colouring the picture we have the full spectrum of colours, that one wants to ensure that we also have the hospital's process in terms of dealing with the complaints within the time frame by which these concerns were raised.

In terms of what Dr Hudson is doing now, as Mr Decter quite accurately points out, he is attempting to make strides with respect to the operations of the hospital, with respect to the labour relations issue. However, we've got a snapshot of a period, whether it's the view of the initial auditor's report or the view of the second audit report, that is problematic from many, many respects. Unlike some of the comments that I've heard, I don't accept the second report as prima facie evidence of clearing of the hospital. As I mentioned in my initial comments, there are many, many questions that still need to be answered with respect to the operation of this hospital.

Mr Tilson: Are you challenging the integrity of the auditor's office? Good heavens.

Mr Owens: Oh, please, don't play games. Grow up.

The Chair: Order. I think we've all had a chance to put our points of view across. Is there is a consensus on the committee that we request this information that I've outlined?

Dr Decter, could you please provide this committee with the information that we've requested in regard to the allegations that you received, the manner in which you received them: writing, verbally, the ministry responses and all documents, papers and things that would make up the entire file?

Mr Decter: With the very important caveat that a great deal of this is not a written record and a great deal of this happened a good time ago and was done verbally and involved a number of people.

So if there's an expectation that the ministry itself had conducted a parallel examination of these issues, it did not, because it was aware that the Provincial Auditor had been asked by the Toronto Hospital to come back in and look at these issues. So I don't want to leave anyone here with the impression that the ministry duplicated the work of the auditor. We did not. We assured ourselves on the issues that we were made aware of, of what our advice to the minister was, and I've outlined that to you today.

So we will certainly look at what we have, but I'll be very direct with you: We don't have a lot of resources available to try to reconstruct events of some period in the past. I can tell you in a general sense that we were aware of the allegations and we took what we viewed as appropriate action to see them addressed.

The Chair: Dr Decter, there are two points I'd like to make. One, just as a matter of simple clarification. The Toronto General Hospital did not request the auditor to go back in; that decision was made here in this committee.

Second, I understand the conditions that you're placing on the producing of this information. I think the request of the committee is that you give to this committee all papers, documents and things which relate to the file that we're discussing, and I think we're all clear on the matter that we're discussing. When we have a chance to review the information that you're able to provide us, it will then be up to the committee to decide whether or not that is enough information or whether or not we're going to need the good services and cooperation of your office to continue in our efforts to try to get the whole picture in some kind of chronological order that can be understood.

We're talking about many millions of dollars, a great effort by this committee. We've not undertaken this work lightly and we just are not going to be able to sit here and hear from yourself or anyone else that: "It was a long time ago. It wasn't all in writing. We can't remember all of these things." Unfortunately, if that's the major part of the information that we're going to be receiving, we're going to have to just keep digging a little bit harder. We're seeking your cooperation and we're seeking to work with you. We're providing you and your office every piece of documentation that we have as quickly as we have it and we're asking you to do the same.

Mr Decter: You have our full cooperation. I may have misstated -- and I will ask Pat McGee -- I may have misunderstood which auditor the Toronto Hospital had asked. Is it that Dr Hudson asked the hospital's own auditors to have a look at these matters?

Miss McGee: I think when Dr Hudson first took over as president he was concerned about labour relations and instituted an investigation into that, because he was very concerned. He had a number of audits done and investigations of activities within the hospital.

Mr Decter: These were done by --

Miss McGee: I think it was Ernst and Young.

Mr Decter: Let me just correct that. My impression from my conversations with Dr Hudson have been that --

The Chair: Actually, I don't want the conversation, because other members have things they want to ask you, and time's very limited. I'm not here to condemn anyone; I'm not here to make any premature judgements or premature decisions. I just want to express the view of the committee that we've requested these documents and we would hope that in a timely fashion we could receive them.

Mr Tilson, I don't think we have any more time for questions from yourself. If the government party wishes to take another three minutes for further questioning, we have that time. Then I'm going to allow Mr Cordiano three minutes, and then we have one final matter to deal with before we adjourn today.

Mr Owens: Just a quick question to Mr Decter: In terms of the process that you've undergone here today and in terms of the reading of Mr Archer's initial report, the auditing team's second report, I guess I'd like you to know that in terms of pointing fingers I'm not interested in this at this point. What I'd like to understand from the ministry perspective is that there's now an understanding that accountability processes need to be built into these institutions. I'd like to have an understanding that when the dust finally clears on this particular issue, we're going to be able to go forward as a government and to insist that these kinds of accountability processes are built into the process.

Mr Tilson referenced question 23 on the list in terms of guidelines and procedures. I think that question is intended more for a process within an institution to answer these allegations or questions or problems, so we don't have to get to this point where people are hauled before a committee and discussions about having to be sworn in. I'm concerned and I'd like to know from your perspective how you view the process that will take place after the dust is clear on this issue.

Mr Decter: My insight into relationships among various people at the Toronto Hospital is less than perfect. Every sign I've seen suggests that there are a more constructive attitude and some processes in place and labour and management working together, which is encouraging.

To take your first question, the broader one and probably the more profound one in terms of our operations: The strengthening of the accountability system, both inside the hospitals and between the hospitals and the community, is the central task of the Public Hospitals Act review. The reason that three years ago a steering committee was appointed was largely the accountability issue. That has been to some degree obscured by a rather lively debate over governance and some of the other issues that come into any reworking of the act. But at the core of the ministry's concern from day one on the Public Hospitals Act was strengthening the accountability, and one need look no further than the report of the investigation team into St Michael's Hospital to understand some of the problems that have existed historically and some of the situation.

I have to tell you, from my perspective as deputy minister, the situation at St Michael's Hospital was a very serious one. The situation at Toronto Hospital seems to have been one in which there were very serious allegations, but the hospital is in good financial shape, the hospital is performing well, and one has to draw certain conclusions. I'm far more worried about a replication of the St Michael's situation, and we have taken a number of steps to strengthen the reporting of financial results to the ministry and sent some very strong signals to the hospitals about our expectations of their auditors in this process. All of the hospitals of this province have qualified audit firms that audit their accounts and report to their boards, I think in most cases through audit committees. That's how corporate governance works in this country. We place a good deal of faith in that, and we think we get generally excellent results from that.

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In the St Michael's case, there was evidence that we weren't being as clear, for example, about what moneys might be owed by the ministry to a particular hospital or what our policies were on deficits. We've been painfully clear to the hospitals in the last several years about those policies. I don't think there are any illusions out there on the part of any hospital trustee as to the ability of a hospital in this province to run a deficit and expect the ministry to fund it. We simply will not.

So it's a tougher environment, and I think there is more emphasis on accountability, but not just of a financial sort. There needs to be, in the hospitals, more accountability of the hospital to the community -- and I think the opening of board meetings is part of that, but not all of it -- and more accountability of the management team to all of the people who work in the hospital and more transparency to how the hospital process functions. We see some encouraging developments that way, and the ministry will continue to try to encourage that, both by regulation and by guideline.

The Chair: Do you have a question? A brief question?

Mr Larry O'Connor (Durham-York): As you can tell, we've got some concerns that there has been a labour-management problem at the hospital. It has been raised by some of the committee members who feel that maybe this is part of why the audit took place.

I guess part of the problem also is there's a whole change taking place in health care right now. We're seeing a change, and the large institutions that have been around in the past aren't being utilized as effectively as they could be, with vacant beds and what not right now.

Right now, then, we're seeing a whole shift there. I know the ministry has been encouraging the hospitals to talk to their employees, make them a part of the change in the direction of health care, and it appears that maybe some of the problems we've got here could be some of that as well. I was just wondering if you could outline a little bit how that direction is going and how it's being received by the hospital community and if you had any direct contact with any hospitals in particular that have difficulty in dealing with that.

Mr Decter: In general, the guidelines that I distributed earlier, which are guidelines that are being used by each and every hospital in the province in terms of the planning for the future, do set out some very direct expectations about the involvement of people in the hospital on one side and the involvement of the district health councils on the other.

I'm very encouraged by what I see. Far from there being lots of bad examples, there are actually plenty of good examples of hospitals and their workforces rolling up their sleeves and getting down to the business of managing health care in a tough time. I guess I put at the top of the list that there are now 150 hospitals in the province that have labour adjustment committees that have been established in the past six months. There were none six months ago.

This was an initiative jointly of the ministry, the Ontario Hospital Association and the health care unions, I think a very constructive initiative, to put in place the machinery to deal with the staff adjustments that are going to take place. Hospital services are shifting to an outpatient basis. Health services are shifting away from hospitals towards the community, and we need to reskill and retrain a good number of workers to make that shift.

The nature of work in the health care business is changing, partly driven by the technology -- we can do a lot more things without a hospital stay than we used to -- and partly driven by changing societal expectations. Many women are not interested in a long hospital stay for birthing. In fact, we're looking at three out-of-hospital birthing centres because there is real consumer pressure to move in that direction. So we're seeing a lot of changes.

I spoke at the Ontario Hospital Association annual meeting twice this week and both times basically tried to reinforce the message that we're very pleased with what we see going on, that there's been remarkable cooperation and a lot of willingness to change old attitudes. I would say we have not yet seen that necessarily reflected in the collective bargaining process, but we remain hopeful that we will. This is a sector that, because of legislation, tends to go to arbitration frequently.

I'll stop there. I see the chairman's becoming impatient.

The Chair: Mr Cordiano has time for one question.

Mr Cordiano: Very briefly going back to the concerns, let me ask you, do you not feel that we somehow ought to be somewhat concerned with the lack of a formalized procedure in noting and documenting allegations that were made, no process to handle that? If that is in fact the case, it gives me concern, as well as others on the committee who have expressed their concern. I hope if that was the case, that in fact it will not be the case in the future, because what you've indicated is that there probably isn't very much that has been notarized as a result of the allegations that were made and any steps that were taken.

Mr Decter: Again, I will respectfully disagree. I think that when the Deputy Minister of Health of a province meets with people making an allegation and then subsequently meets with the chief executive officer of the hospital in question, that's taking the allegations extremely seriously. I can tell you that there was no lack of seriousness to our response to the allegations.

Again, I will say to you that in our view the people who are accountable for the vast majority of the issues raised here are the people who serve as directors and managers of the hospital, and, in the first instance, that's where we expect investigation to take place and remedial action to take place, if it's necessary. So there's no lack of seriousness here.

Mr Cordiano: I wasn't suggesting that.

Mr Decter: I can tell you we receive, as a ministry, five million calls a year, and there are many things that are alleged. Our job is to try and assess the seriousness and to try to take the appropriate level of action.

You cannot have, in my view, one process that is going to deal with everything from someone showing up in my office saying, "I was at hospital X yesterday and I got treatment I wasn't happy with," to a very important group within the health care system coming forward and making some very serious allegations to this committee. I think the seriousness of the response has to match the seriousness of the allegations and, in a sense, the scale of them, and I believe the ministry responded appropriately.

I believe that all I've tried to say is that writing everything down is not necessarily something we do in every instance. We don't document every meeting or every phone call or every action we take, and I don't think, frankly, anybody else does either. So whether I wrote notes of my discussion with Alan Hudson or not, I can't tell you -- I'll go back and look and we will provide everything we possibly can -- but I'm just trying to indicate that we try and manage many of these situations in a very direct, hands-on way, rather than in a very formal, written way. That's the only point I was trying to make earlier.

The Chair: Thank you. Time has pretty well expired for this morning. We want to thank you and your staff for coming. We'll await the information. Thank you for your cooperation.

Before we adjourn, the clerk has one small announcement and a bit of information for the committee members.

Clerk pro tem (Mr Douglas Arnott): The regular clerk of the committee has indicated that the union representative invited to appear next week will be able to attend. That person has indicated he would like to be accompanied by his legal counsel. It's really up to the committee to decide what role it would perceive for the legal counsel attending. I don't know what role the witness himself would have in mind when being accompanied by counsel. This may be an issue you'd want to address.

The Chair: Mr Callahan, your advice on this matter?

Mr Robert V. Callahan (Brampton South): I think it's appropriate that if a person wants counsel, certainly I have no difficulty with that. If you're talking about the role of counsel, the role of counsel, I suppose, would be to advise the witness as to whether he should answer a question or not, what the implications are, and I think that's appropriate. I think that's a fair way to deal with it.

The Chair: I was going to say something, but I won't.

Mr Callahan: Go ahead, go ahead.

The Chair: Mr Tilson.

Mr Owens: Are you looking for a job?

The Chair: No, I wasn't going to say that.

Mr Tilson: I have no comment.

The Chair: Any other lawyers on the committee who wish to make a comment?

Mr Owens: Who would be or would like to be. Anyway, I just want to associate myself with Mr Callahan's remarks. I would say we would agree that there is no difficulty.

The Chair: I, for one, do not see and would not hope that the legal counsel would take an active participation in answering the questions.

Mr Owens: I think that, Chair, would depend on the tone and tenor of questions that were asked of the witness.

The Chair: It may. Any other announcements from the clerk's office?

Clerk pro tem: In addition, the clerk has asked me to remind members who have not sent in their registration forms or information on attendance at the Canadian Comprehensive Audit Foundation conference that they should do so as soon as possible.

The Chair: What's the date of that conference?

Clerk pro tem: The dates are November 22 to 24.

The Chair: Where's it being held at?

Clerk pro tem: The information has been sent out to you. I'm not sure of the location.

The Chair: I think it's Metro, but I'm not sure.

Mr O'Connor: What day of the week is that?

The Chair: I'm not sure. Could I just ask the committee members to review their packages and let the clerk know if there is any interest in attending this conference.

I thank all members for their cooperation. We'll see you next Thursday morning. The committee stands adjourned.

The committee adjourned at 1203.