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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.

Current Events

In January 2011, the Ministry of Health appointed a supervisor at  tel-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.

Appointing a hospital supervisor means that the hospital board no longer has the confidence of the Minister of Health. What do you think can be done to improve the governance of hospitals in Ontario?

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This article has been closed to comments. 4 comments

  1. Mark

    I think there is a serious question underlying this debate – and that is what should hospitals look like in the health care system we need. It seems that we have far too much capital invested in a hospital centric system. I see no possible way that hospital board members can do the work that they are tasked to do – we have a number of places with immense budgets and incredible service complexity, factored against the political imperatives and manipulations of local communities. Although the idea for a hospital board should be to allow local connectivity, I am not sure that they do in fact achieve that. Although there has been a move to more capable boards, it seems we are still not far away from boards that are figurative only, friends of the institutional leadership, and little real capacity to address or understand the complexity of the health care system at a local level or how to participate in the larger system.

    All in all, I am convinced that if we were to begin with a blank page, we would have far fewer hospitals with far less capacity and far less centralization of resources. We fooled ourselves believing that siting resources in hospitals would provide economies of scale and instead have achieved the inefficiency of size.

    So – let’s get rid of most boards, spin off the unnecessary services from hospitals to service specific institutions and get what we really want.

    • David

      The existing structure of quasi-independent Boards for each of the Province’s hospitals perseverates a disintegrated hospital sector and impedes development and implementation of effective and efficient regional care delivery systems; Board members, however dedicated and capable (as most are), are placed in an untenable position of conflict between their community, their institutional allegiance, and their accountability to the health authority and Ministry.

  2. Executive Lead Blogger

    For the most part, hospitals are outdated entities ill-prepared to address the chronic disease tsunami that is currently only beginning to wet our shores. We need new, flexible and innovative structures and processes to address what is coming. Hospitals are part of the future, but not necessarily looking how they look right now. Same with primary care, same with home care and same with long-term care.

    We have followed the path of coordinating care around providers long enough. The pendulum now has to swing back the other way – towards clients/patients and care givers. If we abandon the latter category, we risk losing BILLIONS of dollars worth of volunteer (read family member and unpaid) hours of service which our provincial coffers cannot even begin to replace given the current economic climate.

    No one is talking about this in the current election rhetoric. This is the ostrich issue: everyone has their head in the sand on this. Some are busy skewering the LHINs without saying what will replace them, others are plannign to build long-term care homes where they are not going to be needed and others are throwing breadcrumbs to a shrinking number of primary care practitioners who are capable of doing house calls (bet modern medical schools don’t team new grads how to survive outside hospitals…it would be a riot to see a new grad function on a house call!).

    We are bereft of two things: leadership and the guts to try new things. This is Ontario folks…supposedly one of the smartest jurisdictions in the world. We can do better.

  3. pat scholfield

    The main problem with the Niagara Health System (NHS) is the system is too big and a new super hospital is being built in the far northwest corner of the region it will be serving. In order to pay for this monolith, the NHS is closing and cutting services and beds all across the rest of the system, thereby not only making the system challenging to access for many, but creating an unsafe system. All the while this was happening the NHS was lying about their goals, stating it was all about quality and patient safety. Hence the public has no trust in the NHS.

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