Why does the government appoint hospital supervisors?
In August 2011, a supervisor was appointed at the Niagara Health System to “restore public confidence” in the hospital.
The Ontario Public Hospitals Act allows the government to appoint a supervisor to take over the administration of a hospital if it is considered in the public interest to do so.
While appointing a supervisor happens infrequently, it is an important mechanism to attempt to improve public confidence in hospitals.
Ontario’s Hospitals & The Government
All but a handful of hospitals in Ontario are not for profit organizations, and receive the vast majority of their funds from the provincial government. Yet, on a day-to-day basis, hospitals operate independently from the Ministry of Health and Long-Term Care. Hospitals are large, complex and expensive organizations, and in 2010/2011 they consumed about 30% of Ontario’s $46 billion health care budget.
Hospitals serve Ontario’s diverse communities and regions. One way that hospitals are accountable to their communities is through community members who are elected or appointed to the hospitals’ board of governors. Board members have the task of overseeing the hospital’s administration and quality of care by hiring and regularly evaluating the Chief Executive Officer (CEO) and approving the hospital’s strategic plan and budget, among other tasks. The Excellent Care for All Act, passed in 2010, has introduced additional requirements for hospital accountability regarding quality and patient safety, including the introduction of mandatory quality improvement plans and board quality committees.
There are many complexities and challenges to running a hospital in Ontario today. Balancing the budget, labour negotiations, inter-professional relations, quality of care and patient safety are just some of the issues that challenge hospital boards and administrators.
Sometimes these issues can spiral out of control and, rightly or wrongly, shake the public’s or the government’s confidence in the hospital. In such cases, there are provisions within the Public Hospitals Act for the government to assume control of the hospital. Gilbert Sharpe, a lawyer at Fasken Martineau and former director of the Ministry of Health Legal Branch says that these provisions enable “governments to act in the public’s interest” and give government the power to “step in and be accountable for public money and peoples’ care.”
Public Hospitals Act
The Public Hospitals Act allows an investigator or supervisor to be appointed when there are concerns about the quality of the management and administration of a hospital, poor management of financial resources, and/or poor quality of care.
Chris Carruthers, a health care consultant and former Chief of Staff of the Ottawa Hospital says that in the past supervisors were generally brought in when hospitals “found it difficult to live within their budgets” and that “locally elected board members are sometimes unable to make tough decisions about … cost constraint, realigning services for quality of care” as they have major implications in many of Ontario’s smaller cities and towns, where the hospital is frequently the largest employer.
Since the Public Hospitals Act was passed in 1981, 19 supervisors have been appointed across Ontario’s 150 hospitals. A senior hospital administrator says that appointing a supervisor is “a fairly rare occurrence, and speaks to the system’s ability to manage itself.” However, when there are major concerns about the management of a hospital, the government has two potential approaches. The first is less interventionist, and involves appointing an inspector or investigator to visit the organization. The investigator is tasked with studying a problem and issuing a report. These reports can suggest improvements that the hospital board and administrators can implement, or can suggest that a supervisor needs to be appointed to carry out the specific recommendations.
The other option is to appoint a supervisor who “has the exclusive right to exercise all of the powers of the board” or hospital corporation. Supervisors report directly to the Minister of Health and Long-Term Care. In urgent cases, a supervisor is appointed directly by the Minister, without an initial investigation.
The powers of a supervisor are extensive. Previous supervisors in Ontario’s hospitals have dismantled hospital boards, senior administrative teams and physician leadership. Supervisors can also make substantial cuts to services to balance budgets. Supervisors remain until they have fulfilled their mandate, and are required to submit a final report outlining their work to the Minister of Health.
Other countries have dealt with issues of hospital accountability for performance differently. In the United Kingdom, for example, a system of ‘star ratings’ for hospitals was put in place ten years ago. This system publicly posted scores for hospitals based on a number of performance targets. If a hospital received a low score, it was publicly shamed, and top executives were at risk of losing their jobs. This controversial approach to hospital performance and accountability was cancelled four years after it was introduced.
In January 2011, the Ministry of Health appointed a supervisor at Hôtel-Dieu Grace Hospital in Windsor to “implement the governance and management issues” that were outlined in a report about the quality of surgical and pathological services. This report described poor relationships and communication among the hospital’s physician leadership, administration and board. Most recently, in August 2011, the Ministry of Health appointed a supervisor at the Niagara Health System to “restore public confidence in the local hospital system” after a number of well-publicized challenges at the hospital, including an outbreak of C. difficile. This was the second time a supervisor has been appointed for these hospitals in the past 10 years.
Natalie Mehra, director of the Ontario Health Coalition, says that some supervisors in Ontario have “eradicated democratically elected boards and wiped out community membership” by changing hospitals bylaws so that board members are appointed, rather than elected, which she says leads to “little community accountability.” However others point out that supervisors are accountable directly to the Minister of Health and when a supervisor is appointed, the Ontario Ombudsman has the power to investigate complaints about that hospital. Mehra also says however that “there are instances when using supervisors is appropriate and in the public interest.”
With the appointment of supervisors becoming more common in Ontario, it is important to understand when, where and why supervisors are being appointed, and what practices should be in place so that most hospitals’ do not require this extraordinary measure to be taken.