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Qualitative standards-setting for Canadian health care services Allen, Elizabeth 1984

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QUALITATIVE STANDARDS-SETTING FOR CANADIAN HEALTH CARE SERVICES by ELIZABETH ALLEN B.A., The University of Br i t ish Columbia, 1979 SUBMITTED IN PARTIAL FULFILMENT OF REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning) in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard A THESIS THE THE UNIVERSITY OF BRITISH COLUMBIA November 1984 © Elizabeth Al len, 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Hea l th Care & Epidemiology The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date Abstract The purpose of this study was to examine the process of standards-setting in the Canadian health care system to determine how quality health services are assured and maintained for the elderly population who require care. The interrelatedness of al l aspects affecting the provision of quality services was examined: the professional, organizational and administrative aspects governing care delivery. The historical development of health care standards-setting revealed the unsatisfactory nature of regulatory act iv ity in Canada. A shift from a focus on structural standards to a preference for peer-review mechanisms established the professional mechanisms as the preferred means of control; essential ly , quality health care services were equated with meeting the normative standards of practice. These professional aspects of care delivery, however, increasingly have led to the medicalization of needs and the fragmentation of services. Standards-setting, from government leg is lat ive standards to quality assurance programs, supported and promoted normative practices that tended to escalate costs and provided the wrong incentives for acute and long term care services. The evolution of the long term care services in Brit ish Columbia was identif ied to i l lus t rate the deficiencies in the current approaches to health care standards-setting. Gaps existed in the provision of services for the elderly who required long term care. The nature of long term care services was i i examined and discussed. Long term care services were not so much based on outcomes, as in the acute care system, but on the processes of care - - the aspects of care provision that would enhance the quality of l i f e for the elderly who require health care services. Current standards-setting practices did not address or provide for these services. The administrative aspects governing care provision were explored as a means to assure quality service delivery. Canadian health care developments were compared to those in the United Kingdom and the United States. Regardless of the approach - - in the United Kingdom with i t s national Health Service, or in the United States with the proliferation of regulatory act iv i ty - - «costs continued to increase and confl icts arose between the professional and administrative aspects governing services. It becomes apparent, however, that as cost constraints increase micro-level decisions wi l l become more dependent on macro-level decision making. Current standards-setting practices do not address or provide for services that require expanded models of care provision. Appropriate standards-setting for care processes, therefore, must include not only the professional aspects but take into account the administrative and organizational aspects when developing services. Based on the findings of the study, recommendations are made for standards-setting for long term care services. i i i TABLE OF CONTENTS Page Abstract i i L i s t o f Charts v i i i Acknowledgement i x Dedication x SECTION I: INTRODUCTION 1 CHAPTER I: INTRODUCTION 2 DEFINITIONS 3 FORMAT OF THE STUDY 5 SECTION I I : STANDARDS-SETTING FOR CANADIAN HEALTH CARE SERVICES 6 CHAPTER I I : HISTORICAL DEVELOPMENT OF HEALTH CARE STANDARDS-SETTING 7 LEGISLATED STANDARDS 8 PROFESSIONAL STANDARDS 11 EDUCATIONAL STANDARDS 13 PROFESSIONAL CONDUCT 16 CONTINUING EDUCATION PROGRAMS 18 DEVELOPMENT OF STANDARDS AT THE INSTITUTIONAL LEVEL 19 QUALITY ASSURANCE DEVELOPMENTS 20 CHAPTER I I I : GOVERNMENT FUNDING OF THE CANADIAN HEALTH  CARE SYSTEM 22 DEVELOPMENT OF FEDERAL SOCIAL SECURITY PROGRAMS 22 CHAPTER IV: SPECIFIC STANDARDS-SETTING MECHANISMS 30 STANDARDS-SETTING MECHANISMS 30 MANDATORY MECHANISMS 30 i v Page Legal Mechanisms 31 Statutory Legislation 31 Federal Legislation 32 Provincial Legislation 32 Professional Li censure/Registration/Certification 34 The Medical Acts 34 Institutional Legislation 35 Hospital Act 35 VOLUNTARY MECHANISMS: FORMAL 36 Registration 36 Industry Regulation 36 Accreditation 37 Referral Agency to Fac i l i t ies as a Control Agent 38 Labour Unions 39 Continuing Education 39 VOLUNTARY MECHANISMS: INFORMAL 40 Public Education 40 Consultation and Education for Institutions 41 Volunteers 41 Surveillance by Family, Friends, or Others 41 Community Advisory Groups 41 Consumer Representation on Committees/Boards 41 Advisory Group to Program or Licensing Bodies 42 INTERNAL MECHANISMS 42 Quality Assurance Programs 43 Quality Assurance in the Canadian Health Services Systems 43 v Page DISCUSSION 44 EMPIRICAL STANDARDS 46 Discussion 47 SECTION I I I : STANDARDS-SETTING FOR LONG TERM CARE SERVICE 51 CHAPTER V: EVOLUTION OF LONG TERM CARE AS A SEPARATE SERVICE IN BRITISH COLUMBIA 52 BACKGROUND 52 LONG TERM CARE IN BRITISH COLUMBIA 56 DISCUSSION 59 CHAPTER VI: STANDARDS-SETTING FOR LONG TERM CARE INSTITUTIONAL SERVICES" 61 COMPREHENSIVE LONG TERM CARE SERVICES 62 CONCEPTUAL MODELS 63 ORGANIZATIONAL ASPECTS WITHIN LONG TERM CARE INSTITUTIONS 66 Pr o f e s s i o n a l Organization 66 Organizational S t r u c t u r e s 68 IMPLICATIONS FOR STANDARDS-SETTING 71 CHAPTER VII: ADMINISTRATIVE ASPECTS IN HEALTH CARE STANDARDS-SETTING 73 COMPARATIVE DEVELOPMENTS 73 MODELS TO COMPARE DEVELOPMENTS 76 Lowi (1964) 76 Spiers (1975) 77 I l l i c h (1975) 78 Johnson (1972) 78 THE PATTERN OF HEALTH INSURANCE DEVELOPMENT (CANADA) 80 v i Page CONTROL OF THE MEDICAL PROFESSION BY GOVERNMENTS 81 RESISTANCE TO CHANGE 82 WHAT IS APPROPRIATE STANDARD SETTING FOR CANADA? 84 THEORIES ON REGULATION 84 A NEW CONCEPT OF QUALITY ASSURANCE 86 SECTION IV: CONCLUSIONS AND RECOMMENDATIONS 88 CHAPTER VIII: CONCLUSIONS AND RECOMMENDATIONS 89 BIBLIOGRAPHY 95 APPENDICES 122 APPENDIX A: The Provincial Reports: Quality of Care 123 APPENDIX B: Br i t ish North America Act 124 APPENDIX C: Health Security for Br i t ish Columbians, the Foulkes Report 1973 126 APPENDIX D: Philosophy and Definition of Long Term Care 127 APPENDIX E: Legislation 130 APPENDIX F: Canadian Long Term Care Programs 131 APPENDIX G: Some Fundamental differences between acute care and long term care models 139 APPENDIX H: Social and Community Support Systems Intervention Model in Management of Chronic Illness 140 APPENDIX I: Analysis of Matrix in Health Care 141 v i i LIST OF CHARTS Page Chart I: Alternative Methods of Standards-Setting 45 Chart II: Characteristics of Institutional Care in the Social Model vs. the Medical Model 67 Chart III: Organizational Model of Acute Care 69 Chart IV: Organizational Model for Long Term Care 70 Chart V: Basic Organizational Contrasts 70 Chart VI: Definition and General Characteristics of the Social Model vs. the Medical Model 72 Chart VII: Models for Health Care Developments 79 v i i i Acknowledgement Sp.ecial thanks to my thesis committee: Anne Crichton, Beverly Burnside and Mary H i l l for their support and contributions to the development and completion of the thesis. ix DEDICATION To my c h i l d r e n , Andrew Tovey and C h r i s t i n e Tovey and my parents, P h y l l i s and George Greenwood. x 1 SECTION I Introduct ion 2 CHAPTER I INTRODUCTION The purpose of this study is to examine the process of standards-setting in the Canadian health care system to determine how quality health services are assured and maintained for the elderly population who require care. Qualitative standards-setting is examined in detail to answer the question "are the current standards-setting mechanisms appropriate for assuring the quality of long term care service developments for the elderly in B.C.?" To accomplish th is , the study wi 1 1 : identify the development in qualitative standards-setting in Canada to determine the nature of the process for assuring quality health care services; ! identify the developments in long term care services to determine the nature of the process for comprehensive service delivery; determine appropriateness of current standards-setting practices for assuring quality services for the elderly; 1. See Appendix A for the approaches to evaluating quality of care in the Provincial reports l i s t e d . 3 examine how government involvement in redistributive policies changes the context in which standards-setting occurs; so that the study wi l l recommend how standards-setting can occur for the provision of quality (comprehensive services) and for long term care services, in part icular . DEFINITIONS In developing i ts argument, the study employs certain terms that require def ini t ion. For the purpose of this study, Slee's (1982) definition of qua!ity as: . . . the degree of conformity with generally accepted principles and practices, and the degree of attainment of achievable outcomes, consonant with appropriate allocation of resources . . . (p. 1) is challenged. The term standard, defined as . . . an authoritative or recognized example of correctness, perfection or some definite degree or any quality or something set up as a rule for measuring, or a model to be followed (Webster, 1971:2223) Normative standards are those relating to or dealing with norms, their nature or mode of discovery and existence (discipline) (Webster, 1971:1540) 4 whereas Empirical findings are those based on factual information and capable of being confirmed, ver i f ied or disproved by observation or experiment (Webster, 1971:743). Regulation is broadly defined as "principles, rules or laws imposed by external authority for controlling or government behaviour" (A.H.A., 1977:1). The term regulation takes on varying shades of meaning and i t s interpretation has become highly controversial. While direct control is "having the power or authority to direct, to regulate or to keep within l i m i t s " , indirect control "occurs when an agency exercising authority attempts to establish l imits on their behaviour" (1962:208). The Economic Council of Canada (1978) defined regulation in an interim report as: . . . a pol it ical -administrative process specif ical ly designed to replace or modify the operation of economic markets, or, in some cases, to f i l l gaps where no markets exist . Both the decision to regulate and the decision to change regulatory processes signif icantly are made in the pol i t ica l arena. For these reasons, the Council has found i t necessary to examine both administrative and, to a lesser extent, po l i t ica l processes (p. XI) . Regulatory mechanisms, therefore, are intended to modify or constrain the behaviour of health care providers or health care insurers, including the training of such providers and the entry of such providers (or insurers) into the health care system. 5 FORMAT OF THE STUDY The scope of the research is substantive in nature, leading to the identif ication and examination of the historical developments of normative and empirical standards set for health care and their effect on long term care inst i tut ions. The method of data collection is through examination of relevant documents, agreements and regulations, review of the l i terature related to standards, and the collection of expert opinions. The study is organized to accomplish the l i s t of objectives set out above. The nature of standards-setting in the Canadian health care system is determined. Chapter II identif ies the historical development of Canadian health care standards-setting. Chapter III identif ies Canadian government involvement in the funding of health services. Chapter IV, then, examines the specific standards-setting mechanisms that are available for standards-setting. The next section examines the nature of standards-setting for comprehensive health care programs. Chapter V identif ies the evolution of long term care in Br i t ish Columbia as a separate service within the context of the general health care developments. Then, Chapter VI examines standards-setting for long term care services. Chapter VII examines the comparative development in standards-setting to determine how to proceed with standards-setting for comprehensive services (long term care). The conclusions and recommendations in Chapter VIII ref lect the developing argument of the previous chapters. 6 \ SECTION II Standards-Setting for Canadian Health Care Services Section II determines the nature of the standards-setting processes in the Canadian Health care system for assuring quality health services delivery. The historical development of qualitative standards-setting is followed by government involvement in the funding of health services. The specific standards-setting mechanisms are then examined, to provide further insights into the standards-setting process. 7 CHAPTER II HISTORICAL DEVELOPMENT OF HEALTH CARE STANDARDS SETTING This chapter explores the historical development of legislated, educational, professional and institutional standards. As these evolve, mechanisms are created that ensure the standards are maintained. The pre-Confederation period in Canada was characterized by l imited government involvement in social service provision. Religious organizations, families'and voluntary lay groups managed matters of health within local communities. Hospitals and personal social services were organized by religious orders as charities or by c i t izens ' groups, sometimes working with municipal authorit ies. These institutions were devoted to the care of people whose needs were largely social rather than medical. The f i r s t hospitals in Canada were in settlements along the St. Lawrence Valley. These institutions were mainly refuge centres for orphans, the aged poor, the infirm without resources and the sick poor. Buildings were bui l t for the insane as early as 1714 (Hastings & Mosley, 1966:1). Provision was made for the care of lepers in 1844 (Cameron, 1972:1). It was not until after the American Revolution that Canada began to receive any great volume of immigrants, but when boatloads bringing cargoes of sick people began to arrive in the St . Lawrence Valley the problem of infection control started to create demands for government action. 8 LEGISLATED STANDARDS Government action was basically reactive. After 1832, colonial departments of health, concerned primarily with public hygiene, established local boards of health. These were intended to control epidemics and were often disbanded when the immediate threat of disease subsided. Standards were set for reporting infectious diseases and for cer t i f icat ion of those in danger to themselves and others in the community. For example, an act in 1707 controlled the sale of meat; in 1821 quarantine stations were established (Heagerty, 1934:54); an ordinance in 1748 dealt with foundlings (Gregoire, 1972:65) and an Act in 1820 made provision for sick and disabled seamen (Gelber, 1973:3). Programs and legislat ion were l imited, specific and quite local ized. It was not until the second half of the 19th century that legislated standards were generalized and clearly spelled out. This became necessary when the four existing provinces decided to federate, and had to decide what were federal and what were provincial responsibi l i t ies . The Br i t ish North America Act (BNA) 1867, joined the Br i t ish Colonies in North America into a Federal Union. The provinces were to retain certain powers and authority: Sections 91 and 92 of the BNA Act* outline the distribution of powers to parliament and the provincial legis latures. The Act allocated the powers of "quarantine control, the establishment and maintenance of marine hospitals, and health service's iSee Appendix B for BNA Act. 9 required by immigrants, the military and convicts" to the federal government. These services were to be administered by related departments with no specific reference to health care issues. Regulation of health care institutions was essentially retained by the provinces. The exclusive powers of provincial legislatures were described in Section 92:7 of the 1867 Act, and included the establishment and maintenance and management of Hospitals, Asylums, Charities and Eleemosynary Institutions in and for the province, other than marine hospitals (Bryden, 1974:20-22; Canada, 1970:16-20). Any jur isdict ion that was not specif ical ly assigned to federal responsibility necessarily fe l l within the provincial domain. The mechanisms used to control institutions was a Societies' Act which required the bodies named above to report on their accounts to a Registrar once yearly. As noted above, hospitals were originally refuges or asylums for orphans, the aged poor, the infirm without resources and the sick poor. Physicians rarely v is i ted these inst i tut ions. Although anaesthetics were introduced between 1840 and 1950, they were used in offices and homes. With the advent of microbiology, the growing knowledge of asepsis after 1860 allowed patients to be treated with a greater degree of safety in inst i tut ions. There was reluctance, however, to enter hospitals due to the fear of infection and i t was not until the 1920's that this reluctance decreased in Canada (Agnew, 1974). 10 In Br i ta in , with the growth of a sc ient i f ic approach to medicine in the early 19th century, voluntary hospitals began to be used as training centres for doctors. When the germ theory was developed and infections began to be controlled, a battle for authority over the hospitals was joined. The original purpose of these institutions had been to relieve poverty through charitable contributions of money or services, but after the introduction of aseptic medicine they were becoming centres for the treatment of the s ick . Canada did not have many charity hospitals in the mid 19th century. There was less struggle for control here since most institutions were opened after the new medical function of general hospitals had been established. By the late 19th century they were seen to be workshops for doctors treating sick people who were admitted on grounds of i l l n e s s , not poverty. This change in objectives was important; until the goals were clear, standard setting could not begin. In due course, provincial governments removed hospitals from the Societies Act. They were recognized to be different - to have large professional staffs who were not employees but who needed to be regulated by some method or other. Thus the Hospital Acts have two main functions: regulation of accountability for funds, and regulation of accountability for quality of care given by the medical s ta f f . Responsibility for the day-to-day management of hospitals rests with a Board of Trustees, which delegates to the Medical Staff the duty of providing quality care. The mechanism of "hospital privileges" determines access to the institution and provides the potential for strong control over the quality of service (Kessel, 1958:25). The Board 11 grants hospital privileges on recommendation of the senior medical staff , who make the actual decisions. In 1971 the Ontario Minister of Health, Lawrence, established a Commission of Inquiry into a denial of hospital pr iv i leges. The Grange Report (Ontario, 1970-71) suggested rationalizing the process - a recommendation opposed by the Medical College. It was ruled that the Ontario Cabinet actually had the power to overrule Medical Col lege Council decisions. A provincial Hospital Appeal Board was established in 1971 to hear appeals from doctors denied hospital privileges by Boards. This provided an example for other provinces. PROFESSIONAL STANDARDS As outlined above, most institutions were religious charitable organizations in the early days of the colonies. Physicians acted as consultants to these charitable inst i tut ions, and in settled areas they managed health matters and policies within their local communities. Canada inherited both Br i t ish and French traditions in the practice of medicine as, at f i r s t , a l l physicians were immigrants. From the early 19th century an entrepreneurial system existed. Medical power was based on a free-enterprise system regulated in a minor way by Br i t ish common law precedents. Canada inherited the traditions of Stratton v. Swanlord (1374) which established a concept of malpractice based on normal standards (Hilary, 1374), and a ruling by Bonham (1609) that established the right of the judiciary to overrule the legislature (Sharpe & Sawyer, 1978:13). As well there was a tradition developed in 12 the exclusive Royal College of Physicians that i t should be a se l f -regulating body with sharp punitive powers, accountable to no public authority. These Br i t ish precedents had influence on the attitudes of Canadian governments to the medical profession. There was l i t t l e definite control of the profession until 1788, when an act governing conditions of practice by Medical Boards was passed in Lower Canada. Similar boards were established in Upper Canada in 1795 and Nova Scotia in 1828, but there was l i t t l e control over large numbers of unlicensed practitioners until the late 18th and early 19th centuries. Some early practitioners in Canada had diplomas from recognized European Universities; some had no credentials at a l l . The borders were open and medical entrepreneurs from the U.S. moved from one side to another at w i l l . This led to some very ' f ly -by-night ' practices, especially in the frontier areas. Practitioners who fe l t this situation was not in the best interest of the profession, petitioned governments to empower them to set stan-dards and license practitioners (Canadiana, 1963:8). The College of Physicians and Surgeons of Upper Canada was formed in 1843 for this pur-pose. However, the f i r s t real Medical Act was passed in 1865 in Ontario with the formation of the Royal College of Physicians and Surgeons. Medical Acts provided a rational basis to registration and the movement towards a system of self-government for the medical profession. In keeping with the BNA Act, responsibil ity for personal health care was exercised by the provinces, who delegated the authority to physicians, regulated through Medical Acts that brought the medical profession into direct negotiation with governments. 13 Collegia! associations evolved. The standards for medical practice, however, remained dubious for a long time in North America. Unlike co l leg ia l i ty in Br i ta in , this system in Canada did not, at f i r s t , have the effect of ensuring adequate educational standards among registered practit ioners. EDUCATIONAL STANDARDS Patterns of medical practice grew from two closely related factors, medical teaching and the regulation of practice. At f i r s t , and for many years, medical schools were self-governing and independent of the universit ies. The relationship was a f f i l i a t i o n for the granting of degrees. Medical schools evolved where the need was apparent. Montreal Medical Institution was opened in 1873, later to become the medical faculty of McGill University. In Ontario, various medical schools became part of the University of Toronto in 1887. In Newfoundland there were no medical schools; medical practitioners were graduates of English and Scottish Universities and were scattered in small settlements. Western Canadian medical schools were established later and developed in similar ways, in response to the needs of the community. The Medical Council of Canada, established under the Canada Medical  Act (1865), was empowered to examine candidates for medical registration on behalf of provincial medical licensing bodies. Although the Medical Council was able to set a uniform standard for graduates from universities across the country, numbers of immigrant physicians who 14 arrived would go straight to the province of their choice and take the provincial College's exams. Gradually, the provincial Colleges developed restr ict ive entry c r i t e r i a , being unwilling to admit candidates who had not received training in recognized University programs. And i t was not until 1929 that a Canadian Royal College of Physicians and Surgeons for specialists was established with restricted entry requirements. In Br i ta in , empirical standards had come to be seen as important and hospitals used for sc ient i f ic research became more prestigious. In North America the whole question of medical practice standards and their relation to empirical research was raised by the Flexner Report (1910), which began the f i r s t serious effort at qualitative manpower planning. This study of medical education in the United States and Canada focused attention upon the need for adequately trained physicians. I t was particularly c r i t i c a l of many of the medical schools on the continent at the time. Of the schools in Canada, only McGill University and the University of Toronto were rated as excellent. Upgrading came through closure of many marginal schools and revision of admission c r i t e r i a , standards of curr icula, qualif ication of faculty, and a firmer basis of financing in those that survived. This was consistent with a realignment of the method of North American medical education from apprenticeship to formal scholarly training by scientists and physicians devoted to research. The Flexner Report set the basic development plan for sc ient i f ic medicine. I t accelerated the pace of educational and service changes, and received substantial backing from wealthy corporations and the government. 15 After 1910, North American educational standards for practice began to be addressed. Research was promoted and studies such as those by Codman (1914) pointed out the real need to improve the quality of surgical care and surgical education in hospitals, for new surgical treatment methods required f a c i l i t i e s that were available only at hospitals. Technological discoveries in medical science, in turn, necessitated specialization in the services provided in the diagnostic and treatment centres which hospitals had become. Medical teaching changed chiefly in the direction of adding more instruction as more knowledge was accumulated. The d i f f i cu l ty of developing satisfactory curricula became apparent. As specializations grew, the inabi l i t y of an individual practitioner to have comprehensive knowledge of medical advances became a concern. Rekindled concern for quality of care as the increasing costs of health care were increasing led to the Federal grants for hospital construction (1949) and health resources f a c i l i t i e s (1965). Concern for educational standards extended this second aspect of federal funding for hospitals that were educational f a c i l i t i e s until 1980. In 1976, Crichton wrote of the medical schools: The position of the Medical schools in Canada is very ambiguous. They do not seem to be regarded as arbiters of quality medical care nor as the apex of the referral system in Canada. Yet they have these functions in other countries. In Canada they are seen only as a very expensive part of the post secondary education system (1976:63). As the Medical Schools developed, students were subjected to a prolonged period of socialization and training in which they were 16 expected to internalize standards, acquire a repertoire of s k i l l s and master a general set of theoretical principles that would enable them to make decisions and act autonomously in a responsible and expert fashion. Internal controls were developed that guided the profession and controlled the practice of medicine in Canada (Clark, 1964). Different groups have been successful in lobbying for recognition and improving educational standards. The nursing profession in Br i t ish Columbia, from 1923, for example, worked towards raising educational standards that were achieved with the revision of the Act in 1946. National academic standards are now set for the health disciplines in Canada. Medical schools are accredited by the Liaison Committee on Medical Education of the Canadian Association of Medical Colleges and the Association of American Medical Colleges. A l l ied provincial health personnel professional associations have accredited other programs through the assistance of the Canadian Medical Associaton (Roemer and Roemer, 1981). PROFESSIONAL CONDUCT The Code of Ethics of the Canadian Medical Association enunciates seven principles of conduct: I Consider f i r s t the well-being of the patient. II Honour your profession and i t s t radit ions. I l l Recognize your l imitations and the special s k i l l s of others in the prevention and treatment of disease. 17 IV Protect the patient's secrets. V Teach and be taught. VI Remember that integrity and professional ab i l i t y should be your only advertisement. VII Be responsible in setting a value on your services. ( leaf let : Canadian Medical Association, 1979) Regulation and the educational developments of the various health disciplines follow similar patterns. Licensure is the process by which government agencies grant permission to engage in a given profession and excludes those who do not hold a license to practice. A license cert i f ies that the holder has attained a minimal degree of competence, whereas registration recognizes an individual's professional identity through association with an occupational group. Since that group has authority, through a practice act, to l imi t entry to the profession, registration - - even when i t is not mandatory, as with nursing does take on the character of licensure. Regulation of health personnel has been made more effective by enactment of new registration laws in a number of provinces. The most innovative is the Professional Code of Quebec (1973), and the Health  Disciplines Act (Ontario, 1974) give joint lay professional boards responsibil ity for coordination and monitoring of regulatory act iv i t ies of the health professionals, including physicians, dentists, registered nurses, optometrists and pharmacists. 18 Legal standards governing professional conduct are also set by common law. Although recent precedent has established that Hospital Boards are indeed responsible for care delivered (in Ypremian v.  Scarborough Hospital) i t has been held that a hospital is not accountable for any negligence of employees, such as nurses or doctors, carrying out their professional duties, as contrasted with their administrative ones. The rationale for the l imitation was that the hospital did not and could not order, direct or control the exercise of professional knowledge or judgment (Picard, 1979). In 1942, however, the principle of Respondant superior was upheld and hospitals have, increasingly, been found l iab le for the actions of their employees; however, self-employed professionals remain accountable to their professional bodies and are judged by normative standards. CONTINUING EDUCATION PROGRAMS The l i terature on educational accreditation refers to basic or professional education (JAMA, 1972). Aspects of education that make one think about the nature of c l in ica l practice, ways in which we can improve quality now, and standards of professional competence on entry to general practice have not been addressed adequately, said McLachlan in 1971 from a Br i t ish perspective. Continuing education of Canadian physicans became an issue in 1963 when Kenneth Clute and associates conducted a study of practitioners in Ontario and Nova Scotia. They reported that 40% of Ontario's general practitioners and 60% of Nova Scotia's general practitioners did not 19 meet their c r i te r ia of effectiveness and eff iciency. This study led to the formation of the College of Family Practice and the encouragement of continuing education for general practit ioners. The Universities and Community Colleges profit ing from federal-provincial post secondary education grants and the new f a c i l i t i e s bui l t from the Health Resources Fund (1966) began to establish continuing education divisions, as did the health professional associations. Indeed, i t is now quite a competitive area. DEVELOPMENT OF STANDARDS AT THE INSTITUTIONAL LEVEL With the development of Hospital Acts, Codman's recommendations were taken up by the American College of Surgeons. This body recruited the administrator of the Vancouver General Hospital, Malcolm McEachearn, who became the chief advocate of accreditation of hospitals across North America. Accrediting procedures were developed by pooling the interests of medical and hospital organizations leading to a jo int American-Canadian standardization program (1923). It was not until 1958 that a dist inct Canadian program was begun after formation of the Canadian Council on  Hospital Accreditation (CCHAM1952) - - a voluntary commission under the Companies Act. The CCHA then provided i t s members with a connecting link to federal and provincial departments of health and hospital services, many professional and sc ient i f ic colleges, associations and societies, and developments internationally. 20 Accreditation provided overall direction towards a specific standard of care in hospitals by requiring adherence to provincial health acts, medical bylaws, peer review, medical audit committees, quality assurance programs, continuing educational programs and the l i k e . Accreditation is a mechanism that has improved the standards of health care and encouraged uniformity across Canada. QUALITY ASSURANCE DEVELOPMENTS Accreditation mechanisms promoted the development of quality of care mechanisms for the personal medical care system. Nembcke (1956) rekindled Flexner's concern for improving patient services through medical audit procedures. The focus was on micro-issues with less concern for the overall direction of the system (De Miguel, 1975; Warner et a l . , 1980). The formal quality assurance programs in the form of medical audits and peer-review became requirements for accreditation in the 1950's. This development was prompted by the fear of regulation from outside the profession and the need for cost-containment. Research became the means to establishing quality standards (Mather, 1971; Widdell, 1972). The impl ic i t assumption in quality assurance mechanisms at that time was that i t is more productive to review practices of individual physicians in hospitals than to review the organization and administrative structures of hospital relationships involved in the delivery of medical services (macro-issues). Concurrent review and (medical) peer-review 21 techniques became established as the best methods for evaluating medical quality of care (Campbell, 1974). Quality assurance programs were developed by nurses in the 1950's in response to the concern for quality of medical care issues. Soon efforts were coordinated and national and provincial standards projects developed. As leaders in this area, these professionals soon recognized the need for a voice on accreditation committees and indeed were successful by the late 1950's. Concern over minimal standards of care and practice has led to a series of studies which addressed the need for education standards for practice (RNABC, 1980) to ensure quality health care delivery. Until recently the American Joint Council on Hospital Accreditation introduced the principles and standards for quality assurance as an addition to the former accreditation requirement: There must be integration, coordination and synthesis of existing information so problems can be clearly ident i f ied, solutions specif ical ly developed and carried out, and essential follow-up performed so that a l l concerned can be assured that acceptable quality is maintained (Williams & Donnelly, 1982:189). 22 CHAPTER III GOVERNMENT FUNDING OF THE CANADIAN HEALTH CARE SYSTEM The historical development of health care standards and the emergence of institutions to house the "indigent" and poor were examined in Chapter I I . Thus the foundation of the Canadian system was l a i d . As precedent accumulated, these standards ensured the maintenance of the structures that promoted their development. The Federal Constitution l e f t health care decisions to the provinces and provincial legislat ion supported the professional health care developments. It was not unti l the foundations of the health system were firmly established that the Federal government set policy to shape the direction of health care developments. DEVELOPMENT OF FEDERAL SOCIAL SECURITY PROGRAMS A Royal Commission was formed in the 1930's when provincial governments found they could not raise enough money to support basic ; health and welfare services. Almost one half of the hospital beds in Br i t ish Columbia were occupied by the "indigent" who became the financial responsibil ity of the province (Cassidy, 1945). Thus, Federal social security programs were needed to ease the plight of the local and provincial governments' responsibi l i t ies for the poor. Legislation was enacted at the national level in 1935 to provide a nation-wide program of social insurance to include medical care costs. As outlined under \ 23 the BNA Act (1867), this was seen as an invasion of provincial prerogatives by the Supreme Court. A number of voluntary insurance plans then emerged, sponsored by medical societies and by hospital associations. Meanwhile a Royal Commission considered how the Canadian Constitution was working and whether major changes in the distribution of Federal/Provincial power ought to be made (Rowel1-Sirois Report:1940). Attitudes towards national health funding were f inal ly changed by the Rowel 1-Sirois recommendations and by the war. National services were needed for veterans and reconstruction reports from the United States (Burns, 1942) and the United Kingdom (Beveridge, 1942) influenced Canadian developments. The Canadian Federal government commissioned reports on Social Security (Marsh, 1943) and on Health Insurance (Heagerty, 1943) and produced an overall policy statement for the Dominion-Provincial conferences in 1945/46. The Federal Department of National Health and Welfare was established in 1945; i t was to have: . . . control over a l l matters relating to the promotion or preservation of the health, social security and social welfare of the people of Canada but not to cover any health authority operating under provincial laws (National Health and Welfare Act, 1944; Bryden, 1974:83) The Federal and Provincial governments also agreed to introduce national health insurance, but the order in which programs were introduced reflects po l i t ica l rather than health care planning log ic . This commitment by the Federal government to national health insurance in 1943 and the subsequent legislation beginning in 1948 took 24 the form of financial incentives for hospital construction and professional training for employees in health services in the provinces. This made good po l i t i ca l sense — to develop a plan for hospital construction f i r s t - - as the medical profession was supportive of the development of better "workshops" for themselves. The introduction of the National Health Grants Program (1948) was the beginning of a process of continuing and piecemeal adjustment between the two levels of government. Hospital construction was given prior i ty and costs increased, and in the mid 1950's the provinces became aware of the need for federal support to meet hospital costs as well as construction costs. The Hospital Insurance and Diagnostic Services Act (1957) provided matching grants for the provincial acute care hospitals. Meanwhile physicians, at f i r s t supportive of Heagerty, had become strongly opposed to the Federal involvement. They wanted to stave off government intervention but were having d i f f icu l ty col lecting fees at the time of service, so had decided to set up their own Trans-Canada Medical Plans. Physicians appealed to trade unions who sought to have such plans included in their col lect ive agreements. With the support of the medical profession and unions, insurance plans spread across Canada in the late 1940's and early 1950's. The next step proposed for national health insurance leg is lat ion, namely payment of physicians' fees by government, was l ike ly to run into opposition from the medical profession. This was realized in the Saskatchewan "str ike" of 1962. Canadian governments became aware of the pol i t ica l attitudes of physicians and the extent of the efforts they 25 would take towards self - regulat ion. Another Royal Commission (1961-64) investigated the health needs of Canadians at that time. As late as 1961 only 59% of Canadians had any form of medical insurance. Those who needed i t most - the poor and elderly - did not have i t . The Commission considered whether medical care should become one of the Federal/Provincial cost-shared programs and, following the Commission's recommendations and extensive Federal/Provincial bargaining about administrative mechanisms for financing the scheme, the Medical  Care Act was passed in 1966. This universal health insurance plan was to improve some of the inequalities in health services to Canadians. In 1969, even before the Medical Care Act (1966) was accepted by a l l provinces, a task force was set up to enquire into expenditures. The Report of the Task Force on the Costs of Health Services (1969) recommended a change from an open ended matching grant to a block grant system. Criticisms of current policy included over-use of hospitals, uneven development of hospitals, prominence of the medical model, lack of health care research, and a lack of linkage between different parts of the system. Other equalities arose out of the emphasis on acute care. Inequalities continued, medical f a c i l i t i e s and services increased, yet programs in public health, mental health and for care of the elderly were not addressed directly by the Federal government. In addition to health insurance, Canada's social security system involved other complex issues around the care of these groups. 26 Health Services in post war years were paralleled by the development of a complex Federal social security program financed from taxation and (contributory) social insurance payments, with benefits payable mainly to individuals (Canada Pension Plan, 1965). Social assistance programs became cost-shared under the Canada Assistance Plan (1966) so that provincial welfare programs did not need any longer to reflect Elizabethan poor-law attitudes (Crichton, 1976:59-67). The Federal Health Care programs were shown to have contributed to the escalation of health care costs, yet those with long term problems were denied services especially designed for their needs. The "blocked bed"l phenomenon became a focus of concern and provided a strong impetus for development of community care alternatives for the chronically disabled. The Federal Task Force of 1969 addressed the issue of increasing costs of health services. The Federal Government stopped cost-shared programs for construction of Acute Care Institutions in 1969, but those hospitals connected with educational institutions continued to receive funding for teaching and research f a c i l i t i e s for an additional decade under the Health Resources Fund provisions (1966). These f a c i l i t i e s 1. A "blocked bed" i s most commonly seen as the use of an acute care bed by the elderly who are waiting for transfer to nursing homes. 27 used new technologies and required further specialization by the professions. This enormous technological expansion raised ethical problems about equitable distr ibution, the interdependency of health specialists and their relationship to the consumer. After years of negotiation, Federal/Provincial f iscal arrangements were f inal ly moved from a cost-sharing basis to block funding of programs with the Established Programs Financing Act (EPF) 1977. This gave the provinces strong impetus for monitoring accountability of health programs instead of just collecting matching funds from Ottawa. Additionally, the Task Force had sparked a number of studies of possible restructuring of health service organizations. The Castonguay  Report (Quebec:1970-71) prompted planning reports from other provinces. The Nutrition Survey (1971) stressed ways of improving fitness for Canadians; the Hastings Report (1972) proposed an alternate model of health care delivery in the Community Health Centre concept. A New  Perspective on the Health of Canadians, (Lalonde, 1974) proposed emphasizing preventive medicine concepts and consumer responsibi l i ty . It was concluded that the current system was limited in i t s capability to meet new goals. An appeal was made for a broader focus on health care and research, rather than attention to medical issues. But, despite the undeniable logic of developing a health care system emphasizing prevention and health promotion, i t was hospitals that were wanted, by people l i v ing in local communities, by the doctors, by the businessmen and by the pol i t ic ians (Crichton, 1980:12). 28 None of these studies had a major impact on changing the health care system. The provinces were waiting for Established Programs Funding and the renegotiation of the Canada Assistance plan of 1966. When the Established Program Financing Act (EPF)(1977) came, i t included Federal support for extended health care services and provided financial incentives for the provinces to establish long term care programs. Many people were concerned about the new arrangements however, particularly the medical profession. A mini-Royal Commission was set up to examine the effects of the EPF Act. In the Report of the Health  Services Review (1980), Mr. Justice Emmett Hall encouraged the federal government to continue with i t s policies of equitable distr ibution. A Senate Committee on Federal/Provincial Fiscal Arrangements (1982) reported that this policy should be pursued. Consequently, in 1984 we have witnessing a new Canada Health Act proceeding through Parliament. The Canada Health Act (1984) restates the Federal role in support of universal health insurance. The fact that this Act deals only with some narrow issues of financing has led to some cr i t ic ism. Mr. Herb Breau, Chairman of the Senate Investigating Committee, has stated that the Act was not intended to enlarge the sphere of federal government involvement but solely to reinforce the principles established in the 1940's, namely: universality comprehensiveness reasonable access portabil i ty non-profit administration 29 Criticism continues. The Canadian Medical Association has set up a Task Force on Resources going into health care to review whether the amount of Gross National Product allocated is adequate. 30 CHAPTER IV SPECIFIC STANDARDS-SETTING MECHANISMS The historical developments in the previous chapters outlined the evolution of a number of mechanisms that set qualitative standards in the Canadian Health Care system. Formal legislated, professional and educational mechanisms directed institutional standards setting. The following chapter examines the specific mechanisms that set these standards for health care developments. The information helps determine the nature of the process for assessing quality services in Canada, and provides data for the recommendations in the concluding chapters. STANDARDS-SETTING MECHANISMS Political, economic and social factors provide the context in which health care developments occur. These factors act on the external mechanisms that direct health policy developments in Canada. The form of control for these mechanisms is of a mandatory or voluntary nature. MANDATORY MECHANISMS The External Mandatory Mechanisms are listed below. 31 Legal Mechanisms: Case law/Common law Under common law, health care institutions need only achieve compliance, that is, meet standards set by governments, the professions and the institutions. Therefore, . . . hospitals could be found liable for failure to meet standards established by legislation, by bylaws of the hospital and by the Joint Council on accreditation of hospitals (Schroeder, 1972:55-57). Legal standards force compliance through their compulsory status. The American health care system has used rulings in malpractice suits and negligence law to set accepted standards for regulation of quality of care provided in U.S. hospitals. These legal interventions as regulatory measures are steadily increasing in the U.S., resulting in defensive medical practices and great health administrative costs (PSRO, 1978). They have not improved efficiency and effectiveness of health care institutions (Mechanic, 1976). Health Law stresses the need for accountability of the medical profession and hospitals, yet promotes the conservative ideology of individualism and free-enterprise. Federal health insurance schemes, such as the Canada National Health Insurance program, are viewed as contrary to the objective of free-enterprise. Statutory Legislation Government participation in the delivery of health care can take several forms: i) services and benefits may be provided directly through government departments - for example, quarantine services by 32 Federal government, and school immunization through local health boards. ii) funding payments may be made to another government for provision of health care services or facilities by that government. iii ) government may appoint members to a statutory body where management is by government employees and the staff are not public servants. iv) funding may be provided to non-governmental agencies. Federal Legislation Funding by government is contingent on meeting some form of requirement, either as general principles, or in the form of very specific regulations. The latter model is used with U.S. Federal funding of Medicare - Medicaid for services for the elderly. In Canada, the BNA Act delegates most of the decisions regarding health care developments to the Provinces. Maintaining the principles of the National Health Insurance scheme, the funding body, the Federal government has a considerable amount of indirect power. Provincial Legislation Direct Provincial control has until recently been minimal, with the development of standards delegated to the professions. Provincial governments were seen as funding bodies interested in quality questions only in relation to claiming National Health Insurance payments from Ottawa. There are various methods of participation that Provincial governments can employ: 33 i ) Fiscal controls: Fiscal controls may or may not be tied to some other form of regulatory requirement, but reimbursement could determine the level of quality government wi l l support. The elements of control can include: budget approval, rate sett ing, control of referrals or placement, incentive reimbursement, outcome reimbursement, or use of some competitive market force. These controls can be legislated or set by program pol icy . These mandatory control mechanisms may lead to resistance to the controls as "bureaucratic rules" by the public and the providers of services. i i ) Licensure: This form of regulation requires an Act and Regulations, which define the minimum regulatory standards to be met and the process and sanctions of enforcement of these standards. There i s much concern in the U .S . over lack of ab i l i t y to enforce the many licensing Acts in their health care system. i i i ) Program Standards: Standards of care or training which establish program expectations may be part of licensure or established by a separate Program, Act or pol icy. I t is more common in Canada to amend existing Acts than to introduce new legislat ion for program developments. iv) Contracts: Contracts imply a competitive market with a time limited agreement and public commitment and/or disclosure. They may 34 be established by legis lat ion or as a program policy with the ab i l i t y to negotiate specific standards or requirements. Governments usually use highly standardized contracts, and the time spent in negotiation is usually minimal. Contracts put the onus on boards of institutions to assure quality services through competent administration. These contracts are subject to sanctions through the c i v i l law process. Professional Li censure/Registration/Certification Government sets the requirements for the education or training of care givers, and maintenance of professional standards is delegated to professional associations. This method assures that provision of qualif ied staff wi l l result in quality services. Governments usually assume some responsibil ity to see that appropriate education and training programs are available. The Medical Acts The historical developments reflect the desire on the part of the public, as expressed by leg is lat ion , to give licensing authorities power to regulate more and more aspects of the medical practit ioner's practice. However, the reason government has been wi l l ing to give the medical profession such statutory power was outlined in a judgement by the Br i t ish Columbia Court of Appeal in these words: The provisions of the statute show that the powers are given not primarily for the benefit of the medical profession but for the primary purpose or protecting public health and safety (Sawyer and Sharpe, p. 165). 35 The public has benefitted from the setting of normative standards as they are not in a position to evaluate the expertise of the professional group. In B.C., as in the other provinces, a separation of control exists between the B.C. Medical Association, a voluntary group which concerns itself with the economic interests of its members, and the College of Physicians and Surgeons, a licensing authority which concerns itself with quality control and the protection of the public interest. The College, established by legislation, is entrusted with the regulation and discipline of the medical profession. It maintains a register containing the names of all those who are licensed to practice, and regulates those so registered to maintain standards of conduct and competence acceptable to the professional body. Licensing and educational standards are set by medical professional groups. Internal professional standards control the socialization process and the educational progress of students. This leads to extreme compliance with existing standards, set by the dominant medical profession (Scott, 1982). Institutional Legislation Hospital Act The Hospital Act was passed in British Columbia in 1948 for the licensing of institutions which had been regulated under the Societies Act for many years. This change required the organization of a "definite medical staff" to determine which doctors would be admitted to a hospital as staff and to define the members' (Roemer & Friedman, 36 1971:36). In 1961, revision of the Hospital Act stipulated that the "governing boards of hospitals were responsible for the standard of quality of care provided". VOLUNTARY MECHANISMS: FORMAL The mechanisms listed below are considered voluntary mechanisms. These methods of regulation are delegated by government to involve the professional groups. Registration With registration, the onus is on the provider to supply proof of compliance with government standards. Registration is similar to licen-sure requirement and enforcement, but does not require pre-inspection, and a copy of the regulatory requirements is provided to consumers. In simple registration, there is no supervision or enforcement of promul-gated requirements, standards may be part of an education package given to institutions, and reliance is placed on non-regulatory supervision and public education. This is often used where there is less technical care and consumers have knowledge of the services required. Industry Regulation Industry Associations could have responsibility for assurance of quality delegated through provincial legislation or programs to institu-tions. This would include membership requirements and surveillance of the membership. Institutions could then be denied membership if they did not maintain a certain level of service. Associations exist provincially for hospitals and long term care facilities that could fulfill this role. 37 Accreditation Accreditation is a voluntary, peer review process of evaluation based on broad principles and supporting standards that go beyond the minimum standards required by government for licensure. The Canadian Council of Hospital Accreditation (CCHA) is a voluntary organization for setting standards for Canadian hospitals and is composed of five national associations represented as follows: The Canadian Hospital Association (5 chairs) The Canadian Nursing Association (2 chairs) The Canadian Long Term Care Association (1 chair - 1981) The Canadian Medical Association (4 chairs) The Royal College of Physicians and Surgeons of Canada (2 chairs) Accreditation is the process of assessment of all the circumstances in a health care facility. Buildings, equipment, environment, safety factors, qualification of personnel, and their organization into a well functioning and integrated whole are all considered. While accreditation is a measuring device establishing and quantifying (as far as possible) the standards of institutional operation, it is also a mutually educational, consultative process to foster knowledge and wise judgement for all concerned. One of the most important aspects of accreditation is that it provides for an intense study, an intense review of your operation, far more in depth than any legisla-tive standards and/or process which can be provided by 38 government. It points out obvious weaknesses, inherent strengths, analyzes the facility on a department by department basis, on a program operational basis, giving management, the Board and the public served, a springboard for improvement (Long Term Care Associa-tion pamphlet, 1984). The CCHA accreditation mechanism interfaces with national hospital associations in both Canada and the United States and has been the most accepted mechanism in British Columbia (B.C.) for setting standards for health care. It is a major voluntary mechanism for achieving compliance with the existing medical-professional framework for the health care system and for assuming that it is maintained. Preparing for Accreditation ensures that the internal mechanisms for setting traditional standards are in place. Each accreditation, in turn, has the effect of strengthening the nature of that control. The acceptance of a hospital for accreditation by the CCHA is assumed to be a sufficient guarantee of quality (Bradley, 1972). Because of this assumption and general attitudes in government self-help rather than regulation, there have been no provisions in the B.C. Health Acts for quality assurance. Referral Agency to Facilities as a Control Agent In this method it is expected that the referral agency has a "professional and moral" responsibility to insure the adequacy of the institutions used or recommended. The referral agent is seen by the provider as a source of business, and can often penetrate the institution where others may not, particularly where the agency is responsible for assessment of patient care levels to facilitate reimbursement. Referral agencies can maintain data on the 39 characteristics of the facilities; these may be referenced by consumers or families when they require placement. Labour Unions Labour Unions are considered as voluntary mechanisms that set standards in health care. They add further constraints to the system. Economic issues are less important in standards-setting, however, than the accompanying agreements regarding conditions of service. The restrictions set by agreements have enormous implications for the performance of work and, in addition to simple union agreements, inter-union jurisdictional boundaries lead to other restrictions affecting performance. Unions seek to assure clear role definition and general mechanization of the system and that works against comprehensive models of health care delivery. Professional registration restrictions, for example, may not allow tasks to be shifted or personnel redeployed to enhance the effectiveness and efficiency of care delivery (Teans et Comers, 1969; Hershey, 1969). As Scott said, Occupational registration is a constraint imposed on the Health care system and another concrete manifestation of the enduring power of the occupations and professions in determining the arrangements under which health care will be dispensed (1983:3). Continuing Education Basic professional education is regulated by Universities and i Colleges, which are themselves accredited or inspected. Continuing education is less highly organized. Because professional and educational activity in continuing education has often been less than satisfactory, 40 hospitals have had to f i l l gaps when technology has outrun educational provision (Somers, 1974). For example, critical care nursing courses have often been offered to meet individuals' needs for further training. Less formally peer review, career performance assessment, or self-evaluation programs may be considered as continuing educational mechanisms employed by institutions. Continuing education in Canada is a voluntary mechanism; where continuing education programs have been compulsory these have been evaluated as being ineffective in improving standards (Somers, 1974). VOLUNTARY MECHANISMS: INFORMAL The voluntary mechanisms listed below are usually seen as an adjunct to mandatory standards and not as sole methods of control . Other than the continuing education mechanism which advances or updates the professionals' training, the following mechanisms can be used in areas where health services are less technical and more understandable to the general public. Public Education This method aims at educating the public in order to raise general awareness of what should be expected of facility care; encouraging communities to take responsibility for surveillance; enabling communities to support other efforts to achieve quality care and make use of regulations as a consumer protection. 41 Consultation and Education for Institutions This may be offered by government in two forms: as consultation by the regulator regarding the requirements of regulation; or as advice not specific to regulatory requirements. For the latter, some governments have referred facilities to external agencies; or government may pay for consultative service where a simpler regulatory system makes available funds to be redirected in this way. Volunteers Knowledgeable volunteers provide some surveillance over care, and community health and social services may play a significant role in initiating, coordinating,, and operating volunteer groups. Surveillance by Family, Friends, or Others This is an important source of surveillance, as consumers are often unable or afraid to raise concerns due to the dependent relationship with the provider. Surveillance is exercised in two ways: personal observation of the condition of the institution and patient; and listening to the concerns of the patient. Community Advisory Groups With this method, interdisciplinary groups composed of professionals and laymen form to provide surveillance and a voice for the consumer. Consumer Representation on Committees/Boards Resident committees are one way to encourage consumer participation in the surveillance of facilities, and are encouraged in Canadian Mortgage & Housing Corporation funded housing. Residents can also be represented on monitoring or inspection teams. 42 Advisory Group to Program or Licensing Bodies Advisory groups of providers, consumers, or community members are often established by government to provide input to the regulatory process. This may be on a regular or ad hoc basis. Sometimes an advisory group is formalized as a council or individuals may be invited to become members of a regulatory body. INTERNAL MECHANISMS The external mechanisms act on the internal mechanisms that regulate institutions. The latter tend to correspond to their external counterparts. For example, under statute law, the B.C. Hospital Act (1961) delegated ultimate responsibility for operating institutions and providing quality patient care to the hospital governing boards which, in turn, delegated operations to the administrator and surveillance of quality care to the medical staff. Legal protective mechanisms of institutions are not discussed in any detail except that this process mainly consists of ensuring proper record keeping and seeking legal help as necessary for advice or representation in court. Hospital Risk management programs that arose in the United States over concern for increase of litigation were investigated by Canadian hospitals, but neither the Hospital Associations nor the insurance companies promoted this activity (Mysak, 1982). Internal legislation takes the form of bylaws that direct the operation of the organization and provide the structural and procedural apparatus by which objectives under incorporation are achieved. In passing bylaws, the hospital acts as a 43 legislative body and makes what, in effect, becomes law (Rozovsky, 1979). These internal mechanisms are directed by the Hospital Act (1961), which ensures that a medical-professional system is in place. Quality Assurance Programs As concerns increased for quality of care in the Canadian health care system, additions to the structural macro-approaches to standards-setting were undertaken by the Canada Council for Hospital Accreditation (for example). Concerns led to the need for setting up a micro-mechanism to focus on clinical aspects of care by the professions. Quality Assurance programs were developed with a strong focus on peer-review. The medical focus was on outcome measures while the Nursing profession sought process standards of care. The following discussion on quality assurance helps .illustrate the focus of qualitative standards-setting in Canada. Quality Assurance in the Canadian Health Services Systems Legislative standards that established the position of the professions encouraged development of empirical (research based) standards that become equated with quality assurance. Provincial governments had no reason to oppose the delivery of "quality" services when they had no financial input into the system; Canada accepted the American ideology of voluntary control of service providers within very broad frameworks, and the mechanisms regulating the professions and institutions were voluntary peer-review mechanisms. The growth of institutional bureaucracies and the development of stresses within the voluntary accreditation model resulted in the 44 emergence of quality assurance programs to address micro-aspects of health care. This structural change took place before the development of financial concern about costs of technological development was addressed by governments. The micro-macro distinction needs further definition. Conflicts between administrative and professional models in institutions are legitimate when you consider that macro care focuses on the characteristics of populations or patients and is governed by principles applicable to that aggregate -- for example, the overall shape of the distribution of services or outcomes, the specification of minimum or model levels of service (Brickman et al., 1980). By contrast, micro care is focused on the needs and interests of individual patients and is governed by a principle that assesses the needs of an individual as a basis for determining appropriate action. The emphasis is on individual need, its assessment and satisfaction (Freidson, 1970). DISCUSSION The regulatory mechanisms that set standards seek to modify institutional performance. Certain mechanisms are more effective than others in achieving compliance to a specific model of service delivery. Mandatory standards meet with resistance while voluntary mechanisms are more accepted as regulatory measures in the Canadian health care system. Those mechanisms of a formal-voluntary nature which combine elements of the two methods have been particularly effective in achieving compliance to the standards set (see Chart, page 45). They all, however, ensure CHART I ALTERNATIVE METHODS OF STANDARDS SETTING Mandatory Mechanisms L e g a l S t r u c t u r e s ( c a s e - l a w ) (common law) F e d e r a l L e g i s l a t i o n ( f u n d i n g ) P r o v i n c i a l L e g i s l a t i o n ( 1 i c e n s i n g ) (program) ( c o n t r a c t s ) P r o f e s s i o n a l L e g i s l a t i o n I n s t i t u t i o n a l L e g i s l a t i o n V o l u n t a r y Mechanisms  (Formal) P r o f e s s i o n a l r e g i s t r a t i o n E d u c a t i o n f o r P r o v i d e r s I n d u s t r y r e g u l a t i o n A c c r e d i t a t i o n (Peer Review) Labour Unions V o l u n t a r y Mechanisms  (InformaTT C o n t i n u i n g E d u c a t i o n P u b l i c E d u c a t i o n C o n s u l t a n t t o I n s t i t u -t i o n s V o l u n t e e r s S u r v e i l l a n c e by F a m i l y , F r i ends Community A d v i s o r y Groups Consumer R e p r e s e n t a t i o n on Committees/Boards A d v i s o r y Group t o Program o r L i c e n s i n g B o d i e s 46 the maintenance of the medical-professional institutions that created them. P o l i t i c a l , economic and social environmental forces (including developments in health care in other countries) act on the external mechanisms that direct the internal developments that in turn feed back to the external forces that direct health care developments. EMPIRICAL STANDARDS The following sections discuss micro-research and the measurements of quality of care that aid in determining the nature of the standards-setting process. Research by Nightingale in 1858, Groves in 1908, and Codman in 1913 led to the setting of standards for institutional care, as proposed by Flexner in 1910. For the next 30 years, however, very l i t t l e work was done on quality of care. "Expert opinion" set normative standards; since this opinion was "expert", measurement of the results of care was thought to be unnecessary. In the early days, expert opinion also took into consideration the matter of costs. If the patient could pay, well and good; i f not, the practitioner and the inst itut ion had to decide whether to provide free service. Quality of care was closely related to ab i l i t y to pay. As third party payment systems became entrenched, the matter of payment no longer troubled practit ioners. This problem was handed over to governments and insurers. 47 Accreditation processes, like the legal standards established earlier, set up a framework which was later adjudged insufficient to deal with micro-matters. The accreditation mechanism implicitly and explicitly states that quality of care is assured through attainment of normative macro-standards set out by the Council. However, accredita-tion officials agreed that "the observation and the experience had been that standards were not used widely enough nor well enough in the pursuit of a definite level of excellence" (Bradley, 1972).1 Physicians began to give their full attention to the development of empirical micro-standards in the 1950's. The rationale underlying the development of these standards came from a perceived need for two separate and distinct elements to determine quality of care: first the creation of universal absolute standards; second a monitoring process though which standards are enforced. Quality of care research further legitimated accreditation standards that were already equated with excellence. The incremental adjustments in the accreditation system led to short-range planning with no apparent recognition of the consequences of these actions. Quality assurance was simply layered onto the regulatory system. The pressure to develop quality assurance programs came from the United States. Great Britain stayed with "expert opinion", but has had to acknowledge the advances made by United States academics in this area (McLachlan, 1976). Discussion The focus of research has been on micro-medical issues, with some debate over how to establish a system to examine the process and outcome of care. Donabedian (1967) described a systems approach which, though 48 unable to encompass quality of care, is an influential conceptualization of evaluation in the health care system and helps illustrate why accreditation mechanisms do not achieve the desired objective of quality control. The nature and influences to which quality assurance is subjected are analyzed in three areas: Structure, Process, and Outcome. Structure: The level of quality measurable by norms or stan-dards, or through comparisons of facilities and equipment, organizational structure, professional qualifications, etc. Process: Professionally accepted standards of practice and procedures and their governance. Outcome: Indices of effect of therapies. The Donabedian adaptation of the systems model is limited in measuring quality of care issues. There has been increasing sophistication in the debate about what is necessary and sufficient to assure quality service. In 1967, Donabedian saw Outcome as a criterion of quality in medical care, and validity of Outcome as a dimension is rarely questioned (p. 168). He asked whether Outcome measures could be used with discrimination, partly because these measures are concrete and seemingly amenable to precise measurement. In much of the literature, Process and Outcome are in contention for recognition as the method which best assesses quality of care 49 (Donabedian, 1966:168-69; Brook et al., 1973; McAuliffe, 1979; Glass, 1980). Outcome reflects both the power of medical science to achieve certain results under any given set of conditions and the degree to which "scientific medicine" has been applied in the instances under study. Research is really just beginning to examine the linkages of these dimensions, with the assumption that there is some relationship (Phaneuf, 1973). An interesting expansion of the Donabedian model was suggested by the British researcher, Sir Richard Doll (1974:5), who added another dimension to Structure, Process, and Outcome, that of "Social Acceptability". Social Acceptability was based on the idea that Outcome has implications other than recovery. He described two facets of social acceptability. One was the level of quality and standards accepted by the community -- i t was possible to indicate such levels by comparisons with other areas within a nation or other countries. The second facet was not as easily indexed — the interpersonal, supportive, and psychological aspects of the physician/patient relationship. This factor gives rise to satisfaction on the part of the doctor and the patient, accompanying and sometimes replacing the cure. From the patient's point of view, i t is certainly the most visible, easily perceived, and greatly appreciated of the quality components. So far, this has not been measured by traditional mechanisms, although social and clinical research in this area are beginning to converge (Killilea, 1982). The information on aggregate models for assessing quality have the most promise (Kane & Kane, 1982). 50 Donabedian recently defined the assessment of quality: Assessment of quality is a judgment concerning the process of care, based on the extent to which the care contributes to valued outcomes (1982:3). Ultimately, Structure and Process have to be judged, with reference to each policy decision, by observing the Outcome. This raises the question, "What are desired Outcomes?" and brings the discussion back to the problem of achieving the highest possible quality of care within the constraints of administration. 51 SECTION III Standards-Setting for Long Term Care Service This section examines the evolution of long term care as a separate service. The nature of long term care services is determined and current standards-setting practices discussed. A discussion of administrative aspects of care provides insight into how to proceed with qualitative standards-setting in the Canadian health care system. 52 CHAPTER V EVOLUTION OF LONG TERM CARE AS A SEPARATE SERVICE IN BRITISH COLUMBIA Long Term Institutional care in British Columbia is one aspect of the Ministry of Health's Long Term Care (LTC) Program, now known as the Continuing Care Division: Institutional Services. The following sections describe the evolution of Long Term Institutional Care in British Columbia as a separate service. BACKGROUND In the 19th century, Canadian governments provided only basic public and mental health services to the community. Families were expected to look after themselves and their friends. When necessary they could seek help from doctors, whom they were expected to pay, or from hospitals financed from charitable or municipal funds and patients' fees. For the few elderly people who had no families there was charity or social assistance (based on Elizabethan Poor Law) or sometimes institutional care provided by charitable organizations. In the last resort they were placed, by provincial government authorities, in mental or public hospitals. Titmuss (1972) has called this residual welfare. 53 As Canada became more urbanized and as the numbers of elderly increased, traditional social networks began to fai l . Families and neighbours could no longer look after all their elderly, particularly the chronically i l l . Public responsibility for the elderly came in the form of grants for hospitals. Often the indigent were provided with care but there was no separate provision for the elderly as a group. Acute care hospitals were intolerant of long stay patients who "blocked beds" that were needed by very sick people; costs were estimated at 40% to 50% of the total hospital operating costs in B.C. (Cassidy, 1945). Many elderly were sent to mental hospitals. There, no separate provision was made for this group of people until treatment became a focus and the laws for compulsory treatment changed in 1961 (D'Arcy, 1975). Legislation such as the Provincial Infirmity Act (1948) did respond to the need for chronic care housing which dealt with the "maintenance and care of the incurable". Gradually some groups began to address the issue of services for the elderly. This led to the emergence of proprietary chronic care hospitals. Proprietary owners supplied two types of service — one for those who could pay privately and a separate service for "welfare recipients". Pressures began to develop for government intervention to provide more equitable services. The federal government had become concerned about health and social security provision in the 1940's, as outlined in the previous chapter. When the National Health Grants of 1948 made funds for construction of hospitals contingent on submission of provincial plans, British Columbia undertook two studies. The Hamilton Report, "A Hospital Plan and 54 Professional Education Program for the Province of British Columbia" (1949), focussed on hospital bed requirements. It also estimated health manpower needs and the education establishments required to meet them. The Elliot Report, "Survey of Health Services and Facilities in British Columbia" (1952), described the federal, provincial and local public health and mental health services, hospital facilities and other health services. The National Health Insurance programs dealt with public health, mental health, and acute care but there were large gaps in provision. Chronic care was not addressed in these programs. This oversight became more apparent as the numbers of elderly grew, social supports weakened and the acute care industry became less tolerant of those requiring chronic care. Most of the elderly in British Columbia were concentrated in Victoria and Greater Vancouver (B.C. Research, 1974). The United Way of Vancouver, a body responsible for coordinating charitable efforts and planning concerns, set up a research department in 1959 to streamline its activities. One of the concerns was for the care of the elderly. In 1969 a new provincial advocacy group was formed. It assumed some of the activities of the Committees on Aging and Health which were formerly carried by the Social Planning & Research divisions of the United Way. This Social Planning and Review Council of B.C. (SPARC) was concerned specifically with health issues for the elderly. Their report on Community Care for Seniors (1972) provided an identification and analysis of the existing services and needs for service in all levels of institutional and community care for the elderly in British Columbia. 55 It identified a strong need for community support services which would enable the elderly to remain in their homes or communities. An analysis of the network of existing services observed that, . . . as the elderly move through the system, service to them suffers because of the division in jurisdictions, financing formulas, legislative regulations, and sanctions (SPARC, 1972). This report concluded that the system of care should be "integrated, humane, community oriented, and research based." The provincial government had been building acute care hospitals quite rapidly during the period 1949 to 1966, though more in the interior than in the cities. In 1965, a Regional Districts Act was passed and in 1966 the Regional Hospital Districts were enacted and were responsible for planning for future hospitals. Only three districts were active in planning: Kitimat-Stikine in the north (which had few elderly people), the Capital Regional District of Victoria, and the Greater Vancouver Regional Hospital District (GVRHD). The last body had to sort out a confused situation in the Lower Mainland. Institutional planning was undertaken by the GVRHD and a number of reports were written.1 The provincial report, Health Security for 1. GVRHD reports planned for, allocation of institutional beds: A Pattern of Care Report (1969) set plans and construction priorities for Vancouver hospitals and a Geriatric Report (1975) provided the rationale for developing facilities for those who needed Long Term Care. An Extended Care Report (1973), and Intermediate Care Report (1974), a Home Care Report (1975), a Personal Care Report (1974), and a Bed Matrix Study (T976) were developed. 56 British Columbians (1974), known as the "Foulkes' Report"^ addressed the need for the provision by government of a continuum of services for the elderly. LONG TERM CARE IN BRITISH COLUMBIA By 1969, the inadequacy of federal/provincial fiscal agreements with respect to the handicapped and the elderly was widely acknowledged. Steps began to be taken to change the system of funding so that the matching grants were not, in future, so closely tied to acute care. Prior to this, incentives had been given to develop programs that treated illness. Extended care programs were cost-shared, but no such help was available for intermediate care and nursing homes. By 1977, agreement had been reached between the federal government and the provinces on Established Program Financing (EPF). Under the terms of the Extended Health Care Services Program, some provinces expanded the health system and made possible a continuum of services administered and funded as insured services for the elderly by provincial governments (Government of Canada, 1982; Walker, 1982). Government interest in B.C. in the development of a Long Term Care program (including institutional care) followed a pattern similar to many other North American jurisdictions -- it began as a social welfare service and subsequently took on more of a health orientation. As early 2. See Appendix C for outline of Foulkes1 Report. 57 as 1938 under the Welfare Institutions Act, government regulations ensured the protection and safety of dependent residents in adult and child care facilities, with responsibility shifting over the years between the social service and health ministries. In 1969, with the passage of the Community Care Facilities Licensing Act, jurisdiction was allocated to the Ministry of Health. This Act regulates physical, economic, and social welfare conditions in both profit and non-profit institutions. By 1970, it was felt that the regulatory authority should be with public health under the direction of an interministerial licensing board. By 1975 growing public concern over facility care resulted in the addition of community representation and the development of separate boards (and Regulations) for adult and child care facilities. Concern for quality of care issues was addressed through revisions and amendments to the Act and regulations; for example, the focus shifted in long term care from a custodial to a care-training orientation for mental retardation and mental health clients and from personal care services to include intermediate care services for the el derly. The Adult Care Board was given responsibility to develop a proposal for a Long Term Care Program (LTC),3 which was implemented January 1, 1978 under an order-in-council. This program was to meet standards established by various Provincial Acts Under the terms of reference 3. See Appendix D for the Philosophy and Objectives of the Long Term Care program. 4. See Appendix E for legislation directly affecting Long Term Care Institutions. 58 of the program, non-institutional care was legitimated; i t included such services as homemakers, home-care nursing and physiotherapy, meals-on-wheels, and day care programs. Institutional services were to include those given in private hospitals and in personal, intermediate, and extended care facilities. The program also was given responsibility for the government Mental Health Institutions. The idea was to . . . assist those who have ongoing health-related problems by providing services in the individual's home or in an institution . . . (LTC Manual, 1978). Based on the commitment to the provision of a continuum of services for the elderly in British Columbia, preventive and supportive services meeting health, personal, social and shelter needs -- comprehensive services — for the elderly were to range from independent living through five levels of institutional care: personal care, intermediate care levels one, two and three, and extended care. The concept of a "single point of entry" to the system provided a gatekeeping function -- the prescreening and channelling of potential clients for home care or long term facility care -- administered by government and delegated to public health or social service staff who determined the need for services. This assessment would be monitored on an ongoing basis through a centralized information system. This concept allowed for accessibility either through the acute care system or 59 through community services making it possible for alternate care services to develop. Such a system, if developed to its potential, would be a unique concept in Canada for provision of services for the elderly. DISCUSSION The Long Term Care Program in B.C. was the result of a long historical development. This publicly funded program was the logical result of the efforts undertaken to provide needed services. The movement in long term care towards publicly administered, universal access and a distinct model of Long Term Care service provision moved Canada away from some of the more complex problems experienced in other countries. Movement is also towards integration of services and investigation of improved methods of providing effectiveness (and cost control). Standards-setting, however, is not well developed to maintain and assure continuation of these developments. Government funding as a means to assuring quality services is criticized by Ruchlin (1982) who takes the view that public funding creates an environment in which quality is not deemed a priority. In contrast, Somers (1982) believes that programs not directly addressed through the regular fiscal arrangements of the health care system, such as long term care, must be publicly funded. The latter position is realized in B.C. However, the government funding in B.C. tends to provide basic minimum standards rather than quality standards. Since the program is government financed, the main 60 pressures on i t at the present time are for accountability. But accountability for what? The problem of the balance between cost and quality ar ises, quality services at what price? Ways to obtain a balance between the cost and the quality of long term care services in institutions are being investigated. How can this be accomplished? Who can provide quality care and how can this be regulated? Why are the concerns not dealt with by current regulatory measures? These are questions asked by most North American jurisdict ions as the numbers of elderly people and health and welfare costs increase. 61 CHAPTER VI STANDARDS-SETTING FOR LONG TERM CARE INSTITUTIONAL SERVICES As cost-containment became the major issue in health services planning in the 1980's, concern for the provision of quality health services became increasingly apparent. Over the past century many public health concerns -- such as the control of infectious diseases and the introduction of medical cures -- had been dealt with successfully. Standards-setting activities encouraged acute medical-care and institutional developments. However, as was apparent in Chapter VI, the areas of chronic disease and long term care services were not addressed in the Federal/Provincial fiscal agreements and, compared to acute care services, had received relatively little attention. The technological advances in the medical care outcomes, in fact, tended to aggravate the processes of long term care services leading to extreme problems of a social, moral and ethical nature. The 1970's were noted as a decade of health regulation with increasing concern and intensity of activity in the development of regulatory control of costly institutional services. The Canada Health Survey (1978-79) showed the elderly as using significantly greater numbers of health and welfare services than younger people. A search for alternative approaches to the traditional provision of health services occurred in the belief that community programs would not only improve the quality of life but also save money (Baum, 1972). This explanation of possible alternate services led to the need to address 62 the complex issues around the definition of "quality of life" (and therefore quality services) for the elderly. What was clarified in examining the evaluation of long term care services was the need for more comprehensive services which include the provision of "shelter, financial security, health, recreational, cultural/spiritual and social needs" (GVRHD, 1979) for the elderly population who require these services.1 It has been determined, however, that current health standards-setting developments promote acute care medical developments to the exclusion of alternate services that would allow more comprehensive services to evolve. COMPREHENSIVE LONG TERM CARE SERVICES Provincial long term care programs developed rapidly across Canada since the EPF (1977). These programs varied from province to province in the differences in population served, extent of the program, eligibility patterns and provincial patterns of standards development.z Provincial efforts and the subsequent sharing of information led to the identification of the major issues affecting provision of long term care services across Canada. 1. The elderly have increased in both number and proportion in Canada's population (Stone, 1980). More than 12% of the population in British Columbia is over 65 years of age (Hall, 1984). Of the 15% of the elderly who require long term care services, 7% at present are institutionalized in B.C. 2. See Appendix F for outline of Canadian provincial Long Term Care Programs from the Canadian Report on Aging, 1982. 63 This section examines the nature of long term care services. What makes these services distinct from those provided for acute care medical services? Fundamental to understanding the differences is the need to establish clear objectives for the long term care programs and to define conceptual models for long term care planning and administration. The initial philosophy and objectives of the B.C. Long Term Care Program (1978) outlined in Appendix D, reflected the uncertainty by governments as to the direction of the program. Provincial Long Term Care Associations (1979) evolved to address institutional needs and began to clarify long term care services as distinct from acute care services .3 Basic principles were presented, but the lack of knowledge about appropriate services for the elderly and the lack of planning expertise was apparent. In the attempt to gather information, various provincial efforts at dealing with services for the elderly were shared in 1983 leading to the formation of the Continuing Care Programs of Canada (1983). CONCEPTUAL MODELS Understanding the nature of Long Term Care services begins with defining "quality of life" for the elderly. Research into what constitutes "quality of life" is minimal, however, it is related to meeting the physical, economic and social needs of this group of people 3. See Appendix G. 64 (Penning & Chappell, 1980). Research linking "quality of life" to needed institutional services is beginning to be investigated (Kane & Kane, 1981; Killilea, 1982). The factors that influence the definition of "quality of life" for the elderly in institutions are explored leading to a possible model of care. Ascertaining the health status of the elderly as a basis for planning services is a complex and complicated task. First, health must be defined. The World Health Organization (WHO) defined health as: . . . a state of complete physical, mental and social well-being, not merely the absence of disease or disability (World Health Organization, 1958). This concept considerably expands the traditional medical viewpoint. Its purpose was presumably to encourage people to take a wider view of health than medical care, and therefore of the factors which contributed to i t . In fact, it is widely accepted that various environmental and life-style factors may have more effect on health than medical services. This perception has resulted in an expansion of the medical system into the realm of advising on human behaviour which has taken medicine beyond its proven technical competence (Friedson, 1970). As models for care of the elderly were proposed, more and more attention was given to the social aspects of their environment.4 Lynch 4. See Appendix H for model of Social Support for treatment of Chronic Illness, from Killilea, 1982. 65 (1979) linked social aspects of caring with morbidity data and showed a correlation between social s tabi l i ty and the incidence of heart disease. Cassel (1975) showed that strengthening social supports effectively reduced i l lness - - acting as a "buffer" to l i f e stresses. Social Support is defined as . . . that set of personal contacts through which the individual maintains his (or her) social identity and receives emotional support, material a id , services, information and new social contacts (Syme, 1975:17). During the past decade social support has been linked to a variety of mental and physical pathologies (see Pi l isuk and Froland, 1978; Cobb, 1979; McKinlay, 1980). Perhaps most in f luent ia l , because of i t s large population and longitudinal design, the Alameda County study of Berkman and Syme (1979) is regarded as the most general indication of the impact of social contacts on health (Hammer, 1983). These researchers demonstrated an inverse relationship between social support and morbidity and mortality. Wan and Weissert (1981) have shown that social support plays an important role in mitigating the effects of deteriorative health status, thus reducing the risk of inst i tut ional izat ion, and that those who were most l ike ly to improve in physical and mental functioning had stronger social support networks. I t has been determined that factors other than physical influence admission to inst i tut ions, and that institutional l iv ing correlates highly with " l i v ing alone" without social supports, resulting in mental 66 and physical deterioration (Wan & Weissert, 1981). These writers appeal for research directed toward identifying societal (macro) and individual (micro) determinants of institutionalization of the chronically i l l . Myles (1980), in support of institutions suggests that the image of dependency and loss of self in institutions identified by Goffman (1961) may only be a reflection of wider societal attitudes. Whether or not these needs can be addressed through provision of a continuum of services in the long term care program remains an empirical question. A basic premise of the study is that institutional services are an integral part of the comprehensive services needed for the elderly in British Columbia. Jesion and Rudin (1983) proposed the social model for Long Term Care Institutional services as distinct from the medical model (see Chart II on page 67). A combination of the elements from social and medical approaches in varying proportions -- based on the level of resident independence — will likely evolve. ORGANIZATIONAL ASPECTS WITHIN LONG TERM CARE INSTITUTIONS Professional Organization While it has been recognized that gerontological studies cross disciplinary lines, there are no institutions which bring together applications of this research in the way that hospitals bring together medical peers engaged in clinical work to review what they are doing. There is no structuring of standards-setting in long term care as there is in acute care settings. Scott (1982), however, has presented an 67 CHART II CHARACTERISTICS OF INSTITUTIONAL CARE IN THE SOCIAL MODEL VS. THE MEDICAL MODEL SOCIAL MODEL Primary social needs More generalized care Resident's overall needs primary Quality of l i f e pr ior i t ies Focus on quality of l i f e for quality assurance Admission for social factors by se l f , family, doctors, Negotiate for consent Various organizational arrangements - simpler Less expensive Hospital administrator's role more pivotal and central agent Accreditation standards -should be increased "emphasis on quality of l i f e , " (e .g . , resident councils) Future: Resident contracts for a l l ac t i v i t i es , including medical ac t i v i t i es ; resident has access to medical care as he/she would at home MEDICAL MODEL Primary medical needs More specialized care Professional service primary, patient need is limited medical Technology and "cure" priori ties Focus on medical care for quality assurance Admission for physical and physiological factors by doctor Consent prescribed by l e g i s l a -tion Institutional organization arrangement - complex More expensive Hospital administrator's role - "tradit ional" Accreditation standards -evaluation by doctors, peer review and medical record audit, etc. Future: increased emphasis on psycho-social care From Jesion and Rudin, Health Management Forum, Summer 1983. 68 interesting conceptualization of a professional organization within long term care institutions. He describes the "conjoint professional organization" as a possible rather than an existing model of professional organization that fits with a matrix organizational structure. It supports a focus on care and decentralization of decision-making. It is possible to visualize the conjoint professional model as a series of concentric circles with settings for care and professional interests at the centre. Managers and support systems form the next layer, with general administrators facing out to the environment more than into the institution -- responding as a "buffer" to environmental influences and building bridges to the care level from the policies developed (Pfeffer & Salancik, 1978). This conjoint professional organization represents an approach that recognizes an autonomy of the professionals as well as the increasing interdependence of the work they perform. Organizational Structures The matrix structure5 is the most functional organizational framework for long term care settings (Steward, 1963; Beckhard, 1977). The traditional hierarchical structure in place in acute care institutions focuses on specialization (differentiation of tasks) (Neuhauser, 1972) with integration of services occurring on a project 5. See Appendix I for analysis of the matrix organizational structure in health care. 69 basis. In long term care institutions the focus is on integration of services with specialized tasks having minor significance. Integration and differentiation of tasks are needed by both long term care and acute care institutions but the proportions are different. Rotate the acute model shown below and the long term care organizational structure results (see Chart III on page 69). Basic organizational contrasts listed in Chart IV on page 70. The conceptual models presented focused on both the aspects of care and organization of long term care institutional services. They reflect the nature of long term care services providing what Margulies & Adams (1982) described as, . . . a consistency of design of the organizations with the appropriate models of care reflected at all levels of the institutions (p. 369). CHART III ORGANIZATIONAL MODEL OF ACUTE CARE DISCIPLINARY FUNCTIONS for DIFFERENTIATION Of TASKS Hierarchical structure MULTI-DISCIPLINARY PROJECT FUNCTIONS for INTEGRATION of TASKS Matrix Structure 70 CHART IV ORGANIZATIONAL MODEL FOR LONG TERM CARE MULTI-DISCIPLINARY FUNCTIONS for INTEGRATION of TASKS Matrix Structure DISCIPLINARY PROJECT FUNCTIONS for DIFFERENTIATION of TASKS Hierarchical Structure CHART V BASIC ORGANIZATIONAL CONTRASTS ORGANIZATIONAL DIMENSION (DISCIPLINARY) BUREAUCRACY (MULTIDISCIPLINARY) MATRIX Authority Hierarchical Participative Command Unitary Multiple Integration Vertical Vertical/Horizontal Change Rigid Fl exible Power Administrative Expert Tasks Routine Non-routine Loyalty Organization Team Organization Functional Proj ect Rules Str ict Loose Orientation Maintenance Change Decision-making Control 1ed Discretionary Adapted from Theodore Walden, 1981. 71 IMPLICATIONS FOR STANDARDS-SETTING . . . curing disease is not the same as promoting health and well-being. If health is seen, as it once was, as successful adaptation to one's situation or overall environment, we can help the elderly achieve this by different types of services and different methods of delivery from what we now offer them (Dubos, 1979:11). The difference between acute care and long term care services is that the latter is not so much about outcomes as about processes. Since the outcome of long term care is likely to be death, the appropriate standards for long term care must address processes of care. Chart VI on page 72 begins to clarify these differences. Reliance on the medical-professional aspects of care and the mechanisms that maintain this focus is incomplete particularly for the elderly. This approach results in the medicalization of needs (McPhee, 1977), with old age often seen in this society as synonymous with sickness (Shanas, 1968). This is inappropriate for the provision of comprehensive services that include the approaches to health care outlined in this chapter. The appropriate standards-setting for long term care must address processes of care — not only the medical-professional aspects but also the administrative (governmental) and organizational aspects of service delivery. 72 CHART VI DEFINITION AND GENERAL CHARACTERISTICS OF THE SOCIAL MODEL VS. THE MEDICAL MODEL SOCIAL MODEL Psychosocial services such as educational, creative, sensory awareness, religious act iv i t ies provided by social workers, chaplains, recreationists, community volunteers, and others. Psycho-social - capability orientation - finding solutions to problems which interfere with social functioning Psychiatric/behavioural characteristics Focus on social relationships and purpose/meaning to l i f e More generalized Focus on overall needs Care emphasis (process) Long-term - chronicity More community-based Medical problems are multiple and complex Team MEDICAL MODEL Organic/physical problems with physical methods, rehabil itation and treatment using doctors, nurses, and rehabilitation staff Medical-disease orientation Physical, physiological, and rehabil i tat ive characteristics Focus on inst i tut ion More generalized Focus on limited needs (medical) Cure emphasis (outcomes) Short-term - acute care Institution-based Medical problems are uni-dimensional Doctor-patient (Key for decision making) From Jesion and Rudin, Health Management Forum, Summer 1983. 73 CHAPTER VII ADMINISTRATIVE ASPECTS IN HEALTH CARE STANDARDS SETTING COMPARATIVE DEVELOPMENTS Government intervention into health care systems in the form of reimbursement policies varies from country to country. The historical developments outlined in previous chapters support a view of trends, identif ied by Roemer & Roemer (1981) across five countries that developments are towards increased organization of services, both in terms of economic support and control over patterns of delivery. In addition, as the demand for accountability by governments increases, there is increasing tension between federal and provincial governments, between professionals and government and between the professionals themselves. This chapter explores where Canada stands in health care standards-setting compared with the two countries that have most influenced Canadian developments - - the United Kingdom and the United States. This provides a continuum on which Canadian developments find an intermediate posit ion. The Br i t ish influence has affected Canadian administrative and funding structures. By the end of the 19th century, the United Kingdom had la id the groundwork for a national health insurance system. The emphasis of government had been on funding problems. When the Second 74 World War led to the need for reconstruction policies, among these were the development, not only of a social insurance system, but also a tax supported health care delivery system. The Beveridge Report (1942) proposed policies and programs that resulted inter alia in the formation of the National Health Service (1946) in Britain. As Crichton (1976) explained, this welfare state philosophy had some appeal in Canada. The organization of Canadian society was very different from that of Britain. By virtue of the Canadian Constitution, standards for health care were set by the provinces. In the 1930's, when Federal/Provincial involvement was examined generally, it was considered unconstitutional for the Federal government to become involved in health care matters. As a result of the Rowel 1-Sirois (1940) investigation, it was decided to amend the constitution in order to enable the Federal government to develop a social security and health insurance system. A national health service was not initiated in Canada. Canada was not a homogeneous, industrial country. It was characterized by a federal system of government, heterogeneity of population, pluralism of culture and widespread rural populations. It had not suffered from the rigours of war at first hand in such a way that all its citizens had become convinced of the need for a comprehensive social security program and State intervention in social planning (Crichton, 1976:60). The health insurance plan was introduced very gradually through federal-provincial negotiation, as described by Taylor (1976), and with many glances across the U.S. border. 75 In the United States, attempts by Roosevelt to establish a "national health bi l l " as part of the New Deal - to give grants to the States for health insurance plans -- were interrupted by World War II. The Wagner-Murray-Dingell bills failed, but they had much the same effect as Canada's post war proposed program of enacting comprehensive national health insurance - they stimulated the further rapid growth of voluntary insurance. National Health insurance never did arrive in the U.S., although the passage of Medicare and Medicaid (1965) are seen as moves in that direction. The Canadian proposals took twenty years to complete. The U.S. Congress attempted to produce hospital and medical treatment appropriate to an industrial nation. The Hi 11-Burton Act of 1946 facilitated long-range planning and hospital construction in the less populated states, and the Hi 11-Harris Act of 1964 directed hospital construction away from rural areas to urban areas that had been neglected. Short term developments in Canada followed closely upon the American legislation with respect to hospital construction under the National Health Grant Program, 1948. The American influence was transmitted through communication between the various international professional associations and accrediting bodies. Neither system however - Canada with its Federal Insurance plan or the U.S. with numerous planning acts - improved the coordination of construction plans or services among hospitals and other health services. Changes occurred in an incremental, disjointed fashion. 76 In Great Britain government became directly involved not only in funding but also in the delivery of health services. In Canada, governments gradually got more and more involved in funding but, on the whole, were not much involved in service delivery. This was delegated to subsidized, entrepreneurial professionals and "voluntary" institutions. Although in due course Canadian institutions became almost totally funded by governments, they retained their delegated powers. Accountability has not been tight, although improving this has recently become a focus. In the U.S., both funding and service provision remained outside government control, except for some planning activities related to construction, and the funding of the two programs for the elderly and for poor people - Medicare and Medicaid. MODELS TO COMPARE DEVELOPMENTS Four models have been identified which help to conceptualize the relationship of Canada to the United States and United Kingdom regarding their national health systems -- the models proposed by Lowi (1964), Spiers (1975), Illich (1975), and Johnson (1972). Lowi (1964) The government activities model proposed by Lowi (1964) is useful in examining developments across countries. The distribution of prerogatives, regulatory activities, and redistribution of rights by government are placed on a continuum. 77 Distribution Functions Regulatory Functions Redistribution Functions Sabatier (1981) wrote of the U.S. system that: Distributive and redistributive policies are less likely to meet with opposition as they focus on benefits to people, whereas regulatory policies focus on modifying behaviour and are more likely to have functional rivals. Spiers (1975) The second model, proposed by Spiers (1975), provides a continuum of four major kinds of planning along a scale of control, ranging from free enterprise at one extreme to near complete planning at the other. Government Activities: The position of planning by countries is identified by: a. The degree of control sought. b. The quantity and kind of information required by the planning authority to make the plan effective. c. The type of sanction used by the planning authority to make the plan effective. d. The focus of the control . Limited Free Enterprise Indicative Planning Limited Dirigism Pure Diri gism 78 Illich (1975) The third model, proposed by Illich (1975), arose out of a questioning of the efficacy of the traditional role of the doctor. He described medical care as having become "perverse" - its objective being not to further the health of the general population, but to promote the well-being of those who provide care. He went as far as to describe it as promoting "clinical, social, and technical iatrogenesis" (1975:27). Johnson (1972) Illich's model is best understood in conjunction with Johnson's model (1972). He focuses on categories that describe the relationships of the medical profession to the rest of society - stage of patronage, collegiality, and mediation. Tensions develop as health care policy evolves through these stages. As the producer-consumer relationship was changed by the increasing use of technology and changes in funding to third-party payment schemes, the common area of shared experience and knowledge was reduced. Illich's interpretation leads to a more radical view of what Johnson proposed. Mediative System Patronage Coll egial ity or Perverse System Illich's model of the control of health services by the professionals supports the findings in this chapter. The fact remains that the medical professional strives to maintain a self-regulating position (Illich, 1975), while the trend appears to be towards mediative 79 measures by third-party payers in all countries. The following chart illustrates the chronological development of these stages: CHART VII MODELS FOR HEALTH CARE DEVELOPMENTS Government (Lowi Model) Distributive Regulative Redistributive Dates C 1800 1867 I9I0 I 1977 I 1980 Profession (Johnson model) Patronage Col 1egi ali ty Medi ati on/Col 1 egi al i ty At first, government involvement in prepayment schemes introduced more money into health care systems, which enabled more to be spent on patients, on technological developments, and on health workers' pay. The system displays a continuing demand for increased payments, and at a time of economic restraint this has led to increased tensions between government and the health care system. The dominant professional groups have challenged the distribution of resources and the total amount devoted to health care, which they argue is insufficient to maintain good standards. The self-regulated medical profession receives substantial public support when it speaks out on quality assurance issues, yet the elected officials have to find the money to support the system. This is the classic situation of responsibility without authority, hardly a stable mechanism. 80 THE PATTERN OF HEALTH INSURANCE DEVELOPMENT (CANADA) Governments in Britain, Canada and the United States are drawn more and more into redistribution and regulation and, as they react to increased costs, they became concerned to improve quantitative and qualitative controls. This leads to increased politicization of the health care system. Weiler (1976) discussed the progression from a narrow to a broad conception of the range of forces that operate in health policy formation - the movement from micro-issues relating to physicians and legislation to macro-issues of organizational control of expenditures. He took the many suggestions of the 1970's and identified points where government could intervene. As with various other analyses at this time -- provincial reports, and the like -- he appealed for acceptance of more comprehensive models of care. The financial consequences of introducing these broad ideas were not considered. The evolution of health insurance financing follows a pattern. This can be established from the examination of historical developments. Mandatory health insurance programs are first introduced in response to political pressures to achieve greater equity in health services, while patterns of health care delivery are left untouched in the face of conservative opposition to change. The subsequent rise in expenditures and their social visibility then generate a whole new series of regulatory controls, among which are deliberate strategies to restrict the growth of health care resources, and the introduction of new patterns of health care delivery. The 1977 E.P.F. Act in Canada was 81 designed to intensify the force of this second stage. The third stage overlaps with the second; in response to continued cost-control pressures, sweeping changes are made in the structure of the health care delivery system to achieve greater efficiency and effectiveness within acceptable cost limits. Depending on the health insurance system the amount of regulation and need for accountability varies, but the trend is towards accountability by all funding bodies. This movement, however, leads to opposition by professionals who have profited by leaving things ambiguous. CONTROL OF THE MEDICAL PROFESSION BY GOVERNMENTS The consequences of introducing increased accountability for health services delivered must be considered. A number of writers have examined the political, economic and legal powers of the medical profession. Political power has helped doctors to shape relevant legislation, licensure, and regulatory activities (Krause, 1977). Economic power derives from the medical profession's monopoly status (Reinhardt, 1975). Legal power gives dominance to medical activity by statute (Dolen, 1980). Parsons (1952) considered how the 'gatekeeping' functions of the profession were social control mechanisms. Watkins (1975) described how personal service professions have always emphasized skills and underplayed other professional activities (economic/political) to keep them indeterminate. McKinlay (1981) and a number of others have 82 discussed the usefulness of neo-Marxist explanations to the development of the capitalist state. Because of the gatekeeping power of the medical profession in rationing and allocation of services (Parker, 1967), attempts to control medical/technological developments met with resistance. As Marchak (1975) stated, doctors tolerate government only as a regulatory organization permitting the professionals to provide the services they consider appropriate. Friedson (1982) recently remarked, however, that the position of the medical profession is changing and that the trend is for government to gain more control of doctors' activities. To accomplish this it is advisable to employ cooptation rather than confrontation, as confrontation (or perceived threat to professional autonomy) has historically provoked strong resistance to change. RESISTANCE TO CHANGE The British Columbia government has a traditional policy of non-intervention in most health matters. It has deemed itself a funding body, delegating service decisions to regulated professional associations and institutions. The legal and administrative process established by government sets the framework for the health care system, but has interfered very little in the day-to-day conduct of service associations and institutions. The system is essentially medically dominated, supported by government financing. Canadian governments, however, have moved towards the third stage outlined above: accountable redistributive policies. Such policies 83 pose a threat to established "regulated entrepreneur!"al ism", so adherents of this ideology resist change (Crichton, 1980). Two accounts of resistance to government control are explored by Thompson (1962) and Badgley and Wolfe (1967). The Thompson Report (1962) showed that doctors were not sufficiently involved in the planning process when health insurance was introduced in Saskatchewan and this led to strong political repercussions. Badgley and Wolfe (1967) discovered that provincial governments, even with a clear political mandate, could not make unilateral decisions to systematize health care. In both situations, the legitimacy question was assumed to have been settled. As Crichton explains, Unless all groups who have veto power are involved in the legitimation process, they may decide to undermine the feasibility of a project (1976). Canadian governments have found that increased regulation of the medical profession has not been advisable (Bennett and Krasny, 1977). Blishen (1969:14) reported a situation which remains apparent today: "efforts at regulation lead to inactivity and strong attempts by both parties to maintain the status quo." Professional associations and health service institutions were regulated by public statute and by established accrediting bodies which pre-dated public insurance and were, at first, not significantly challenged to be accountable. Since the E.P.F. Act (1977) this has changed. Federally, government moved into block funding, seeking more accountability within the provinces. Political resistance from the 84 provinces resulted in the Canada Health Act (1984) which returns total responsibility for health expenditures to the provinces as long as they meet the criteria of the Medical Insurance Act (1966). WHAT IS APPROPRIATE STANDARD SETTING FOR CANADA? Given these briefly outlined but salient concerns that arise as accountability for health funding increases, standard setting becomes an art. Experiences from other countries may help us to understand what decisions are appropriate for the Canadian health care system. The study of health manpower policies across five countries by Roemer and Roemer (1981) provided a comparison of the general effects of national health systems on shaping health care developments. Weiler (1974), and more recently Evans (1983), have examined Canadian Federal/Provincial arrangements in more detail and described the potential for conflict over increased regulation. The Economic Council of Canada presented a special report on Reforming Regulation (1981) concerned with the use of monopoly power by the professions. These discussions revolve around the issue of relating quality to costs and the need for rationing and priority setting, issues which have not been considered properly by the peer-review groups which have focussed on individual cases. THEORIES ON REGULATION Theories that establish patterns relevant to regulation of a health care system fall into two categories, dominant interest group theories 85 and participatory interest group theories. The dominant interest group theory states that: "the regulated desire regulation for the benefits they expect it to bestow upon them and demand it as it is in their best self-interest" (Bernstein, 1955:155). Posner (1974), another American writer, accepts this hypothesis but views regulation somewhat differently: "the regulated and the regulator jointly dominate the regulatory process at the expense of the public" (p. 135). In a later work, Bernstein (1970) discussed participatory group theories that describe the nature of regulation as a process -- as experienced in the U.S. specifically by the long term care industry. He described the cycle that participatory groups go through when they desire to introduce mandatory regulation. The initial phase involves public pressure for action with regard to specific social programs. This continues until an agency of regulation is introduced to take control of attempts to refine regulatory goals and policies. Instead of pursuing a plan, this agency reacts to the issues. Resistance is shown by the providers of care and public support decreases. In the third phase, the agency adjusts to the conflict atmosphere and functions more as a manager than a regulator, which begins the process explained under dominant interest group theory. The fourth phase includes abandonment of the agency by the public, who opt for safety in policy decisions and for funding through legislation. This pattern of development in the U.S. provides insight into the public scrutiny of the health care industry (p. 476). The arguments about Canadian regulation are different. Evans (1983) believes government intervention is required and that a mediative 86 role is necessary because the subsidized entrepreneurial professionals in a monopoly position have "lost sight of reality" (p. 4). Their emphasis on quality care for each individual who comes under their charge misses the main point - that there are limits to the country's ability to pay. Challenged by this, physicians fall back on their legal position, saying that they will be sued if negligent. Like many others, Baldwin (1974) disagrees with self-interest theories and feels that the process of decision making is not controlled by regulations. Blishen (1949) sees much of the Canadian medical professionals' behaviour as a response to stress, not self-interest. What, then, is likely to happen? McLachlan (1976), a British writer, indicated that with greater financial involvement requiring more accountability, less government regulatory involvement in determining standards is necessary. A NEW CONCEPT OF QUALITY ASSURANCE In order to be effective a quality assurance program must focus on the professional, administrative and organizational aspects of care (Australian Council on Hospital Standards, 1977). An expanded conceptualization of a quality assurance program that included other than the professional aspects of care was not considered in North America. The idea that quality assurance is about expanded models, such as aggregate models (Kane and Kane, 1981) was discussed in Chapter IV and quality management certainly has been introduced as necessary (Slee, 1982). The result, however, is still a focus on 87 (micro) clinical aspects of care and aggregates of this. As determined in the previous section, the professional aspects of care influenced standards-setting to focus on the medical outcomes of treatments or curative aspects of health care. Essentially the micro-clinical aspects — concern about delivery of quality service to individual patients --often neglected the macro concerns about equity and distributional aspects. Certainly the need for alternate systems of health care delivery and quality of care standards was addressed in the 1970's in the various Provincial Reports; however, attempts to introduce multi-service programs were short lived. Why was this? Lowi's (1964) discussion of the administrative aspects in health care showed how government involvement in redistributive policies changed the context in which standard-setting occurred. Is it possible that government must be involved with health care standards-setting (with all the inherent difficulties) if multi-service health care delivery is the objective? SECTION IV Conclusions and Recommendations 89 CHAPTER VIII  CONCLUSIONS AND RECOMMENDATIONS The purpose of this study was to examine the process of standards-setting in the Canadian health care system to determine how quality health services are assured and maintained for the elderly population who require care. The question may not be "what are the appropriate mechanisms for setting standards for Long Term Care developments?" but, rather, "what is the most feasible and appropriate mix of mandatory and voluntary mechanisms which is l ike ly to eliminate unnecessary quantity and stimulate high quality long term care services?" This study set out to examine qualitative standards-setting in the Canadian health care system. I t was concluded that standards-setting in Canada moved from a focus on structure to a preference for peer-review mechanisms as the means of control — the movement from macro- to micro-concerns. However, the focus on professional aspects of care emphasized the outcomes of acute care treatments. Since the outcome of long term care is l ike ly to be death, the appropriate standards-setting for long term care must address the processes of care (quality of l i f e processes) which include not only the professional aspects (peer-review), but also takes into account the administrative and organizational aspects of service delivery. The general development of qualitative standards-setting revealed the unsatisfactory nature of regulatory activity in Canada. When resources were unlimited and the population overwhelmingly young in age, 90 the professional (micro-) aspects of care were less likely to impinge on the macro-aspects relating to distribution and equity. But the situation changed in the sixties as technology advanced and population structures changed. Concern for the rising costs of health services led to increased regulation in the seventies. Standards-setting, however, promoted normative practices that tended to escalate costs and provide the wrong incentives for acute and long term care services. The study investigated the interrelatedness of all aspects affecting the provision of quality health care services: the professional, administrative, and organizational aspects. The debate ranged from the belief that administrative-government involvement was essential for the provision of quality services for groups such as the elderly (Somers, 1982) to the belief that government involvement decreased professional incentives for the provision of quality services (Ruchlin, 1978). Regardless of the approach to regulation -- the United Kingdom with the National Health Service to the United States with the proliferation of regulatory activity -- costs continued to increase and conflicts arose between the professional and administrative aspects governing care. The recognition in this study of the presence and legitimacy of this conflict led to the need for identifying a political-bureaucratic model for introducing change (Marmor, 1973). Alternatives to the traditional medical system were suggested as a means of improving the quality of life for Canadians in the 1970s. The alternatives, such as preventive programs, focussed on the processes of care rather than on the outcomes of medical treatments, yet developments were not maintained. The existing standards-setting mechanisms ensured 91 the maintenance of the medical institutions which created them. From legislative standards to quality assurance program standards, the focus was on medical outcomes that led to the medicalization of needs and the increasing fragmentation of services. The difference between acute care services and long term care services is that the latter is not so much based on outcomes of treatment as on the processes of care. Programs that require process care were not addressed through existing standards-setting mechanisms. Attempts to modify and redesign existing mechanisms have been poorly directed efforts. This is in part due to the lack of clarity and definition of objectives, conceptual models and appropriate organizational structures for long term care services. Based on the provision of process care, standards appropriate for guiding long term care developments must reflect the nature of these services at all levels of standards-setting. The examination of long term care services in British Columbia has revealed gaps in the provision of services for the elderly. Long term care developments have illustrated how the existing mechanisms for setting qualitative standards did not directly address the health needs of this group of people. In fact, the standards developed to assure quality in acute care institutions were perverse in long term care settings. They encouraged the medicalization of the needs of the elderly thus promoting the "sick role" and dependency on institutionalized services. The elderly require a continuum of services that would enhance the quality of life in later years. For this development to occur, i t became evident that in the Canadian health care 92 system, government involvement was necessary for assuring comprehensive services to the elderly. Government became directly involved with program development for long term care services in 1978. Movement toward a mixed provider system avoided many of the concerns for quality long term care services experienced in other jurisdiction; however, government has only addressed efficiency issues. The assurance of quality services to meet the health needs of the elderly who require services has not been addressed. As Somers (1982) suggests, what is needed is a policy that takes change in total health needs and family structure into account, and acknowledges that the quality of life in later years is at least as important as the quantity. What is needed is a mixture of mandatory and voluntary mechanisms which are likely to eliminate unnecessary quantity and stimulate high quality long term care services. Long term care services are less technical than acute care services and understandable to the general public; therefore, the Canadian system, with its political-bureaucratic model for assuring health care changes, must move toward mobilizing the informal voluntary mechanisms. The plan for this is essentially an educational one. Once the process standards are set, the more formal voluntary mechanisms that are effective in achieving compliance, namely accreditation and continuing education, can be used to ensure that the changes are instituted. Based on the findings of the study, the recommendations on qualitative standards-setting for Canadian process (long term care) services are summarized as follows: 93 that assessment of professional, administrative and organizational aspects governing care delivery are necessary for assuring quality process (long term care) services; that a multidisci piinary task force (including consumers) be formed to define and c lar i fy the direction of process (long term care) services; then, that appropriate standards be developed that reflect a consistency of design at a l l levels of health care delivery; that educational programs be developed for professionals and consumers; that mandatory professional standards should reflect the dist inct nature of process (long term care) services as compared to acute care services; that mandatory administrative standards, both Federal and Provincial , shoul d provide financial incentives for the development of process services; that formal voluntary mechanisms (Accreditation and Continuing Education) should be modified and adapted to reflect process standards; and used to achieve compliance to the health care standards developed; and 94 that informal voluntary mechanisms be used to monitor and develop the quality of process services. 95 BIBLIOGRAPHY Abel-Smith, B., The Hospitals, 1800-1948, London: Heinemann, 1964. 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Zola, I., "Medicine as an Instrument of Social Control", in D. Tuckett, and J . Kanfert (eds.), Medical Sociology, London: Tavistock Publications, 1978. 122 APPENDICES NAME AND B R I E F D E S C R I P T I O N E V A L U A T I O N OF Q U A L I T Y D E V E L O P M E N T & E N F O R C E M E N T OF S T A N D A R D S C o m m i s s i o n o f I n q u i r y o n H e a l t h a n d S o c i a l W e l f a r e ( " C a s t o n g u a y R e p o r t " ) A b r o a d I n q u i r y I n t o a n I n c o m e , h e a l t h a n d s o c i a l s e c u r i t y s y s t e m f o r t h e P r o v i n c e o f Q u e b e c . ( 1 9 7 0 ) W h i t e P a p e r o n H e a l t h P o l i c y ( M a n i t o b a " W h l t e P a p e r " ) . A " W h i t e P a p e r " p r o p o s i n g b r o a d p o l i c i e s f o r M a n i t o b a h e a l t h a n d s o c i a l s e r v i c e s f o r d i s c u s s i o n w i t h p u b l i c a n d p r o f e s -s i o n a l s . ( t 9 7 2 ) R e p o r t o f t h e H e a l t h P l a n n i n g T a s k F o r c e ( " M u s t a r d R e p o r t " ) A p l a n f o r o r g a n i z i n g , w i t h i n a v a i l a b l e f i s c a l r e s o u r c e s , a c o m p r e h e n s i v e h e a l t h p l a n f o r O n t a r i o . ( 1 9 7 4 ) H e a l t h S e c u r i t y f o r B r i t i s h C o l u m b i a n s ( " F o u l k e s R e p o r t " ) P r o p o s a l s f o r t h e r a t i o n a l i z a t i o n o f h e a l t h c a r e s e r v i c e s i n B r i t i s h C o l u m b i a . Two v o l u m e s a n d 13 c o m m i s s i o n e d s t u d i e s . ( 1 9 7 3 ) I n f o r m a t i o n s y s t e m r e q u i r e d . B a s e d o n c e n -s u s , r e g u l a r s u r v e y s , h e a l t h r e c o r d s , s p e c i f i c s u r v e y s a n d s p e c i a l r e g i s t e r s . E v a l u a t i o n t o m e a s u r e s t a t e o f h e a l t h , o p e r a t i o n o f s y s t e m , o u t p u t o f h e a l t h p l a n . P r o v i n c e s u p p l i e s t e c h n i c a l ' b a c k - u p f o r d i s t r i c t s a n d r e t a i n s o v e r a l l r e s p o n s i b i l -i t y . P r e c i s e m e c h a n i s m s n o t s p e l l e d o u t . ( a ) O n - g o i n g m a t c h i n g o u t c o m e s t o o b j e c -t i v e s ; m o n i t o r i n g r e s o u r c e s u s e d . ( b ) A u d i t : e x t e n s i o n o f m e d i c a l a u d i t o f p a t i e n t r e c o r d s t o p r i m a r y c a r e g r o u p s a n d s e c o n d a r y c a r e p r o g r a m s . ( c ) R e v i e w : e x t e r n a l p e e r r e v i e w b y t e a m s I n c l u d i n g l a y m e n ; u s e o f a u d i t a n d O H I P d a t a ; I n t e r n a l p e e r r e v i e w m e c h a n i s m s t o b e e s t a b l i s h e d f o r g r o u p s a n d p r o g r a m s . E v a l u a t i o n c a r r i e d o u t b y R e g i o n a l B o a r d s a l o n g p r o v i n c i a l g u i d e l i n e s ; m o r e f u n d s n e e d e d f o r e v a l u a t i o n a n d l o n g r a n g e p l a n -n i n g . P r o v i n c i a l t a s k s : I n s p e c t i o n o f i n s t i t u t i o n s , l i c e n s i n g o f p r o f e s s i o n a l s , d e v e l o p i n g s t a t i s t i c a l c o n t r o l s , e s t a b -l i s h i n g b a s e l i n e s a n d n o r m s . R e g i o n a l t a s k s : f o l l o w - u p e v a l u a t i o n r e s u l t s , i m -p l e m e n t r e s e a r c h . L o c a l t a s k s : I n t e r n a l e v a l u a t i o n o f r e c o r d s . I n t e r n a l p e e r r e -v i e w . P r o v i n c e r e t a i n s o v e r a l l r e s p o n s i b i l i t y w i t h i n a d e c e n t r a l i z e d s y s t e m M i n i s t e r o f H e a l t h u l t i m a t e l y r e s p o n s i b l e ; s h o u l d c o o r d i n a t e a n d f i n a n c e a n e v a l u a t i o n s y s t e m . S t a n d a r d i z e d r e c o r d s y s t e m s h o u l d b e e s t a b l i s h e d . A C o u n c i l o f H e a l t h t o a d v i s e M i n i s t e r a n d a H e a l t h D i s c i p l i n e s B o a r d t o o v e r s e e p r o f e s s i o n s 3> TD "O fD 3 CL j. X 3> -o -s o < 2 o —i. DJ 73 fD O -$ rt-A P r o v i n c i a l r e s p o n s i b i l i t y c a r r i e d o u t t h r o u g h t h e S t a n d a r d s B r a n c h o f M i n i s t r y w h i c h s h o u l d d e t e r m i n e l e v e l s o f c a r e . A b e t t e r d a t a s y s t e m n e c e s s a r y ; s t a n d a r d r e c o r d s a n d I n f o r m a t 1 o n ' s y s t e m s n e e d e d f o r m o n i t o r i n g a n d p l a n n i n g . H e a l t h D i s c i p l i n e s B o a r d t o e n s u r e s t a n d a r d s a n d a c c o u n t a b i l i t y o f p r o f e s s i o n s . c CD f< o o DJ -5 fD A New P e r s p e c t i v e o n t h e H e a l t h o f C a n a d i a n s ( " L a l o n d e R e p o r t " ) A w o r k i n g p a p e r o u t l i n i n g f u t u r e h e a l t h p r o g r a m s , p a r t i c u l a r l y I n t h e p r e v e n t i v e a r e a . ( 1 9 7 4 ) U r g e s d e v e l o p m e n t a n d u s e o f new m e a s u r e s o f e f f e c t i v e n e s s ( e . g . c a u s e s o f I l l n e s s ) t o d e t e r m i n e w h a t p r o g r a m s a r e m o s t e f f e c -t i v e . N e e d f o r b e t t e r a n d m o r e a c c u r a t e I n f o r m a t i o n . C a l l s f o r a way t o d i s c o v e r 111 h e a l t h In t h e p o p u l a t i o n t r e a t e d o u t -s i d e h o s p i t a l s , t h e n u m b e r s o f c h r o n i c a l l y d i s a b l e d , t h e a m o u n t o f s e l f - l i m i t i n g o r s e l f - t r e a t e d d i s e a s e , e t c . S t a n d a r d s t o b e d e t e r m i n e d f o r f o o d , w a t e r , a i r , n o i s e a n d s o i l p o l l u t i o n ; l e -g i s l a t i o n a n d r e g u l a t i o n f o r a d v e r t i s i n g a n d s a l e o f h o u s e h o l d p r o d u c t s , c o s m e t i c s , e t c . L e g i s l a t i o n t o b e c h a n g e d w h e r e n e -c e s s a r e a n d p o s s i b l e ( e . g . s e a t b e l t s ) to p r o v i d e " n e g a t i v e " I n c e n t i v e s . T h e C o m m u n i t y H e a l t h C e n t r e I n C a n a d a ( " H a s t i n g s R e p o r t " ) , > A d i s c u s s i o n o f C o m m u n i t y H e a l t h C e n t r e s a n d t h e i r p o s s i b l e s o c i a l a n d e c o n o m i c I m p a c t o n t h e C a n a d i a n H e a l t h C a r e S y s t e m . O n g o i n g e v a l u a t i o n a c r i t i c a l e l e m e n t o f s y s t e m ; e x i s t i n g m e t h o d s o f d e l i v e r y m u s t b e a p p r a i s e d a n d a l t e r n a t i v e m e t h o d s d e -s i g n e d a n d a s s e s s e d . S u f f i c i e n t f u n d s m u s t b e a l l o c a t e d f o r t h i s t a s k b o t h i n p r o v i n -c i a l a n d d i s t r i c t b u d g e t s . A r e c o r d a n d c o m m u n i c a t i o n s s y s t e m m u s t b e d e s i g n e d f o r a n d e m p l o y e d t h r o u g h o u t a l l l e v e l s o f t h e h e a l t h c a r e s y s t e m . B a s i c a l l y a p r o v i n c i a l r e s p o n s i b i l i t y t o b e d e c e n t r a l i z e d a s f a r a s p o s s i b l e PO Co Appendix B. B .N .A . Act « ? 6 CONSTITUT IONAL DOCUMENTS OF C A N A D A 4. N O V H Scotia and Nuw Brunswick. Omsi iu j i ions $S. T h e Constitution of the Legislaturo of each of the Provinces of N o v a oi L*p>«lstnrer Scotia end New Brunswick shall, subject to the provisions of this A c t . cont inue » n d X^r*Bn2^ 8 5 i l a t " , e Un ion until altered under the Author i t y of this A c t ; and the wick. House of Assembly of New Brunswick existing at the passing of this A f t sha l l , unless sooner dissolved, continue for the period fur which i l was elected. 5. Ontar io, Quebec and N o v a Scot ia . Firet E^ciions. E * r " ° ' , t i e L ieutenant-Governors of Ontar io , Quebec, and N o v a Scot ia , shall cause 'Writs to be issued for the first E lect ion of Members of the Legislat ive Assembly thereof in such form and by such person as he thinks fit. and at such l ime and addressed to such noturning Oll icer as the Governor -General directs, and so that the first E lect ion of a Member of Assembly for any E lectoral Dist r ict <T any subdivision thereof shall be held at the same time and at the same places as the Elect ion for a Member to serve in the House of Commons of Canada for that Electoral Distr ict . C. The Four Provinces. OO. T h e following provisions of this Act respecting the Parl iament of C e n a d a , tie^rl™*" n a n i d y . — p r o v i s i o n s relating to appropriat ion and tax Bi l ls , the r e c o m -provisioni mendation of money votes, the assent to Bil ls, the disallowance of A c t s , 1 e n d u,e signification of pleasure on Bills reserved,—shal l extend and opply to the moufj T 0 ^ - Legislatures of the several Provinces us il those provisions were here re -enacted " and made applicable in terms to the Tespt -c l ivc Provinces and the Legislatures lhereoL wi th the substitution of the L ieutenant -Governor of the Prov ince for the Governor-General , of the Governor-General for the Queen and for a Secretary' of Stale, ol one year for two years, and of the Province for Canada. V I . D I S T R I B U T I O N o r L E G I S L A T I V E P O W E R S . Pourrs cf liic Parliament.1 91. It shall b e lawful for the Queen, b y end with the advice und consent of .^Pf^^', the Senate a n d House of Commons, ICP make laws for the |>eacc, order a n d pood Fw£j .n!eLi n; government of Canada in relation to all matters not coming within the classes C « n f c J t <if subjects b y this A c t assigned exclusively to the Legislatures of the P r o v i n c e s ; » n d fur greater certainty, but not so « s to restrict the generality of the foregoing t » r m s of this Section, it is h e r r h y declared that (notwithstanding any th ing In this Art) the exclusive Legislative Authur i ty of the Parliament of Canada e x t e n d i i o all matters coming within the classes of subjects next hereinafter enumerated , ihttl i s tu s a y : — 1. T h e Publ ic Debt a n d Property : 2. The regulation ol Trade B n d Commerce : 3. T h e raising of money by any mode or system of T a x a t i o n : 4. T h e borrowing of inonry on the Publ ic Credi t : h. Portal Service: C. T h e Census and Stat ist ics : , 7. Mi l i t ia , Mil itary and Naval Service, and Defence: 8. The fixing of and providing (or the Salaries and Allowances of C i v i l a n d ether Officers of the Government of C a n a d a : 9. Beacons, Buoys, Lighthouses, and Sable Is land: 10. Navigat ion and Sh ipp ing : 11. Quarant ine and the establishment and maintenance e l Marine H o s p i t a l s : 12. S ta Coast and Inland Fisheries: 13. Ferries between a Province and any Brit ish or Foreign Country , or between two Provinces: 14. Currency and Coinage: 15. Bank ing , Incorporation of Banks, and the issue of Paper M o n e y : 16. Savings B a n k s : 17. Weights and Measures: 18. Bills of Exchange and Promissory Notes : IS. Interest: 20. Legal T e n d e r : 21. Bankruptcy and Insolvency: 2"i Patents of Invention and Discovery : •il. Copyr ights : " 4 . Indians and l ,ands reserved for the Indians: "5. Natural ization and Al iens : ?f>. Marriage and Divorce: 27. The Cr iminal Law , except the Constitut ion of the Court* of Cr imina l Jurisdiction, but including the Procedure in Cr iminal Matters: 05. T h e establishment, maintenance and management of Penitentiaries: 29. Such Classes of Subjects as are expressly excepted in the enumeration of the Classes of Subjects by this A c t assigned exclusively to the Legislatures of the Provinces: • Per th* d b u J l ' o f provincial MU, t-e Kenm-dr, Cmtevru*. cf C n a b , pp. «" e -Jmtrmmt tf Cmy^ralin Lrfiiiaium, J V U u k r j , IH34, pj,. H C. » Fir * A eiLsu9Xic mimtukry of U* mLryirt •J.'JL^ li\ ll.r coorte of •rttttrafi W ** . _* ' «*» Lift™, Canada i fnierai Iffsinn <lf )Sj, a^d L e l i o j »Dl) Ktauriy, Trrmu «•» C « » ^ « « " O " " * -ftjinMt Xo» (19)8). Sisof W( tlx UiWrjiTditlmi must I * n*upo! i i tW l»« fcryort* A n d nny mat lor coming within any of tin: Classes of S u b j e c t enumerated in this section shall not I* deemed Io Conic wit)tin tin- Class of matters of a local or private nature comprised in the Enumerat ion of I he. C l a r e s of Subjects by this Act assigned exclusively to the. Legislatives of the Provinces. Exclusive PoiKn of Provincial Legislatures. h i each 1'rovincc the Legislature may exclusively make, laws in relation Fui.iccuoi to ma i le rs coining within the Classes o i Subjects next hereinafter enumerated ; J * c ; u s i ™ that is to s a y : — l«Si»ii.uou. 1. T h e amendment f rom time to l ime, notwithstanding anyth ing in this A c t , of the Constitution of the Province, except as regards the Oflice of L ieutenant -Governor : 2. Direct Taxat ion within the Province in order to the raising of a Revenue for Provincial Purposes: 3. T i i c borrowing of money on the sole credit of the Prov ince : 4. T h e establishment an<1 tenure of Provincial O/lices, and the appointment a n d payment of Prov inc ia l officers: o. T h e management and sale of the Publ ic Lands belonging to the Province, and of the timber a n d wood thereon: 6. T h e establishment, maintenance, and management of public and reforma-tory prisons in and for the Prov ince : 7. T h e establishment, maintenance, and management of Hospitals , Asy lums, Charit ies, and E leemosynary Institutions in and for the Provinces, other than Marine Hospi ta ls : 8. Munic ipa l Institutions in the Prov ince : 9. Shop , Saloon, T a v e r n , Auctioneer, and olber Licenses, in order to the raising of a Revenue for Provincial , Loca l , or Munic ipal purposes: 10. . L o c a l works and under lakings,olhert l ian such as are of the following classes: (o) L ines of Steam or other Ships, Rai lways, Canals, Telegraphs, and other works and undertakings connecting the Province with any other or others of Uie Provinces, or extending beyond the l imits of the Province. (ol L ines of Steam Ships between the Province end any Br i t ish or I-'orcign Count r y : (e) Such works as, al though wholly situate within the Prov ince, are before or after their execution df-i lared by the Parl iament of Canada to be for the general advantage of Canada or for the advantage of two or more of the Prov inces : 11. T h e Incorporation of Companies with Provincial Objects: 12. T h e Soluniitualiun of Marriage in the Province: 13. Property and civi l rights in tiie Province: 14. T h e Administrat ion of Justice in the Province, including the constitut ion, maintenance, and oigani74ilioii of Provincial Courts, both of C iv i l and of Cr imina l Jurisdiction, and including procedure in c iv i l matters in those Cour ts : 15. T h e imposition of punishment by fine, penalty, or imprisonment for enforcing any L a w of the Province made in rrlHlion to any matter coming w i lh in any of 1 lie clas*-e= of subjects enumerated in this Sect ion : 10. General ly all matters of a merely local or private nature in the Prov ince. SP 2 Ref: S t a t u t e s , T r e a t i e s and Documents o f the Canadian C o n s t i t u t i o n 1713-1929, W. Kennedy ( E d . ) , Oxford U n i v e r s i t y P r e s s , T o r o n t o , 1930. Health Security for Appendix C. Br i t ish Columbians, the Foulkes Report 1973 The basis of i t s approach to improving the health care system was stated: (1) a W.H.O. definit ion of health, (2) consumerism, (3) systems approach to health care, (4) equal access based on needs, (5) regionalization of services for public participation and rat ional izat ion of services, (6) a government role in health planning, financing, monitoring, research, and education, The Foulkes Report described the existing health care system of the province, and proposed a number of changes: reorganization of the Ministry of Health; decentralized funding; Community Human Resource and Health Centres: Councils to interface with other govern-ment ministr ies, the public, and health professionals/workers; establishment of 7 - 9 regions for health planning. More specif ic concerns were also addressed by the report, and the scope of i t s recommendations included health manpower issues, teaching hospitals, emergency services, rehabi l i tat ion, occupational health, environ-mental health, preventive medicine, mental health, alcohol, native peoples, the aged, children's dental needs, housing and health, etc. Many of the points or issues raised in the report are s t i l l appl ic-able in B.C. and in this sense the Report serves as a useful refer-ence for health planners. 127 Appendix D. P h i l o s o p h y and D e f i n i t i o n of Long Term Care ( S o u r c e : Government Manual f o r Long Term C a r e , J a n . 1976.) P h i l o s o p h y 1. The a d v o c a t e s of a s t r u c t u r e d program f o r l o n g term c a r e i n the P r o v i n c e have f o r y e a r s bemoaned the absence of a framework t h a t c l e a r l y i l l u s t r a t e d the range of s e r v i c e s r e q u i r e d of t h i s t y p e of c a r e . A l t h o u g h the e ssence of a system f o r i t s d e l i v e r y was p r e s e n t , the i n g r e d i e n t s were . f r a g m e n t a l l y p r o v i d e d by many w i d e l y s e p e r a t e d groups who, more o r ' l e s s , worked i n i s o l a t i o n of t h e t o t a l need. Moreover, th e m i n i s t e r i a l r e s p o n s i b i l i t y f o r the c o n t r o l of t h i s c a r e was d i v i d e d because of the absence c f an a c c e p t a b l e d e f i n i t i o n f o r l o n g term c a r e . 2. The P r o v i n c e of B r i t i s h C o l u m b i a has acknowledged the need f o r l o n g t e r m i n s t i t u t i o n a l c a r e . However, the c a r e f o r t h o s e who a r e a b l e t o and d e s i r i o u s of r e m a i n i n g i n t h e i r homes i n s p i t e of h e a l t h r e l a t e d p r o b l e m s , has l e f t much t o be d e s i r e d , r e s u l t i n g i n the i n s t i t u t i o n a l i z i n g of many who, i f t h e y had been a b l e t o o b t a i n h e l p , would have remained i n t h e i r own homes. 3. The need t h e r e f o r e i s f o r the g a t h e r i n g t o g e t h e r of t h o s e f o r m a l and i n f o r m a l segments of h e a l t h r e l a t e d c a r e and t h e i r i n t e g r a t i o n i n t o a f o r m a l c o h e s i v e s t r u c t u r e t h a t w i l l p r o v i d e a c o m p r e h e n s i v e and u n i v e r s a l s t a n d a r d  of c e r e t h r o u g h o u t t h e P r o v i n c e . 4. The Program f i r m l y b e l i e v e s t h a t most p e o p l e want t o s t a y , i n t h e i r homes and r e c o g n i z e s the i n h e r e n t r i g h t of an i n d i v i d u a l to remain i n h i s or her own home f o r as  l o n g as i t i s d e s i r a b l e and p r a c t i c a b l e . The support p r o v i d e d must be based on the premise that people are  r e s p o n s i b l e and d e s i r o u s of c a r i n g fo r themselves and  t h e i r f a m i l i e s f o r as l o n g as they are capab le of do ing s o . C o n s e q u e n t l y , on l y when p e r s o n a l and f a m i l y r e -sources f a i l to meet t h e i r need w i l l the Program assume r e s p o n s i b i l i t y . F u r t h e r m o r e , the program must not on l y r e s p e c t the r i g h t of the i n d i v i d u a l s to r e q u i r e d care when the f a m i l y i s unable or u n w i l l i n g to h e l p b u t , the r i g h t of. the f a m i l y to request the t r a n s f e r of i n d i v i d u -a l s from the f a m i l y ' s home to approved f a c i l i t i e s in the community, when t h a t i n d i v i d u a l s c o n t i n u e d presence i n t h e i r home i s d e t r i m e n t a l to the h e a l t h of t h e i r f a m i l y . 5 . I d e a l l y the many f a c e t s of long term care must be immed-i a t e l y a v a i l a b l e l o c a l l y f o r those assessed as be ing i n need , and i n c l u d e i n a d d i t i o n to home support c a r e , i n s -t i t u t i o n a l c a r e a t the p e r s o n a l , i n t e r m e d i a t e and ex -tended care l e v e l s . D e f i n i t i o n 1 . Long Term Care i s t h e r e f o r e to be i n t e r p r e t e d as c o m p r i -s i n g a cont inuum of ca re s e r v i c e s fo r those people who are unable t o l i v e i n d e p e n d e n t l y w i thout h e l p , because of h e a l t h r e l a t e d p r o b l e m s , which do not warrent admiss ion to an acute h o s p i t a l . 2 . Lcr-c Term Care Program (1978) w i l l range from home sup -p o r t s e r v i c e s and p e r s o n a l care to the more i n t e n s i v e c a r e s e r v i c e s p r o v i d e d at the i n t e r m e d i a t e and extended care l e v e l s . Appendix E. 130 L E G I S L A T I O N F o l l o w i n g a r e t h e m a j o r A c t s i n B . C , t h a t a f f e c t l o n g t e r m c a r e o r g a n i z a t i o n s . A l c o h o l a n d D r u g C o m m i s s i o n A c t A n n u a l a n d G e n e r a l H o l i d a y A c t C h i r o p r a c t o r s A c t C o m m u n i t y C a r e F a c i l i t y A c t C o r o n e r ' s A c t E m p l o y m e n t S t a n d a r d s A c t E s s e n t i a l S e r v i c e s D i s p u t e s A c t •- H o s p i t a l I n s u r a n c e A c t Human R i g h t s C o d e o f B . C . L a b o r C o d e o f B . C . L i m i t a t i o n s A c t M e n t a l H e a l t h A c t O c c u p i e r s * L i a b i l i t y a c t Ombudsman A c t P a t i e n t ' s P r o p e r t y A c t P u b l i c T r u s t e e A c t S o c i e t y A c t T r u s t e e A c t V i t a l S t a t i s t i c s A c t W o r k e r s ' C o m p e n s a t i o n A c t COMMUNITY C A R E F A C I L I T I E S A C T (19 7 9 ) : g o v e r n s t h e l i c e n s i n g a n d o p e r a t i o n o f c o m m u n i t y c a r e f a c i l i t i e s c l a s s i f i e d u n d e r t h e H o s p i t a l A c t , S c h o o l A c t , F a m i l y a n d C h i l d S e r v i c e s A c t , C o r r e c t i o n s A c t o r M e n t a l H e a l t h A c t . P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 S 2 B R I T I S H C O L U M B I A SASMTOCXAN MANITOBA mi BRUNSWICK NOVA S C O T I A P R I N C E EDWARD I S L A N D NEWFOUNDLAND Y U 1 P N T E R R I T O R Y NORTHWEST T E R R I T O R I E S A D V I S O R Y A N D C O N S U L T A T I V E M E C H A N I S M S COUNCILS AND COMMISSIONS DEPART-MENTAL OFFICES AND CONSULTANTS INTERDEPART-MENTAL CO-ORDINA-TION Consultants ln Gerontology & Geriatric s(3) Provincial Senior Citizens Advisory Council!}) Senior Citizens BureauO) Interdepartmental Co-ordinating Committee on Senior CltizensO) Planning Committe< on Programs/ Services for Older Persons»(3) Sask. Senior Citizens' Provincial CouncllO) Provincial GerontoIoglst(3) Interdepartmental Task Forco(3) Man. Council on AgingU) Provincial Gerontologist (3) Services to Seniors, Dept. of HealthO) Council Liaison Officers(3) Ont. Advisory Council on Senior Cltlzensf.4) OnL Seniors Secretariat^) Policy Services to Adults and Senior Citizens, Dept. of Social AffalrsU,3) Community Based Services for Seniors, Dept. of Social Serv!ces(3) N.S. Senior Citizens' CommlssionO) N.S. Senior Citizens' Secretarlat(3) C O M M U N I T Y S U P P O R T COMMUNITY Community Community Health Community Health Public Health Health Units(l) Local Community Public Health ' Community Health HEALTH Physiotherapy Nursing ServicesU) Nursing Ho me makers & Service Centres Nursing(l) NursingU) SERVICES ServicesU) Program(l) Senior Citizen Servlces(l) Nurses (1) Senior Citizen Community Health Public Health -Health Neighbourhood Serv.cesU,ll) Nurses Services Clinics ServicesU) NursingU) Information Health U) (ruraiX3) Community Special Care & Counselling Centres(3) Physical Fitness: Nutrition Services in Senior "Kino-Quebec "(3) ServicesU) (ruralXl) Centre s(3) -Home VlBtting(l) COMMUNITY Community Family & Community Age & Home HandyhBlp Legal Aid(l,10) Community Based Friendly Visiting SOCIAL Human Resources Community Services Opportunity Programs(4,ll) Support Program Services for (Red CrosaX3) SERVICES** A Health Support Services (grantsXl) Centre, Inc.(4) Intergenerational for Voluntary Seniors(3) Legal Aid Program Centre a(l) -Home He!p(l) Home Care Services Daily HelloO) Programs(4) Organizations Friendly Visiting (1,10) Oeath & Dying -Home maker -Handyman Home Legal Aid Ont. (1) to Seniors Me a la-on-Wheels Counselling (1) Services(l) Servlce(l.ll) Economlats(l) (1,10) -Meals-on-Wheels (Red CrossX3) (1,11) Family -Meals-on-Whee Is -Meals-on-Wheels Legal Aid Man. Link Skills (1,11) Protection Wheels-to-Meals Counselling (1) (1) (1,11) (1,10) Exchanged) Services to (1,11) Home Repair -"Outreach" -Nursing(l) Meals-on-Wheels Meals-on-Wheels, Seniors(3) 5ervlces(3) ServicesU) Seniors (1,11) Diners' Clubs Legal Aid(l.lO) Assisting Services to (4,11) Seniors' Seniors! 3) Seniors(3) Other Home Counsellor Support Projects Program(3) (4.11) Skills Exchange Senior Volunteers (3) In Serviced) Division of Services to the Aging, Dept. of Social Servlces(4) Division of Services to Senior Citizens, Dept. of Social 5ervlces(o) Audiology Program(l) Occupational Therapy(l) Physiotherapy(l) Public Health Nursing Program(l) Speech Therapy(l) Provision of Personal 5ervlces(4) Home Care Program -Public Health Nurses or VONU) Occupational Therapy(l) Physiotherapy(l) Community Based Services -Crime Prevent ion(4) -Friendly Visiting(4) -Meals-on-Wheels (4) -Volunteer Centre in St. John's(4) -Wheets-to-Meais (4) Social ServicesU) Services for Seniors! 3) Co-ordinated Home Care Program -Home Nursing ServicesU ,11) -Other Professional ServicesU,11) Co-ordinated Home Care Program -Meal s-on-Wheels (1,11) -Ne ighbourhood Services(l,ll) T3 -5 O a ~i n> in in Department of Hospitals and Medical Care and Department of Social Services and Community Health. Including meals-on-wheels, counselling, friendly visiting, senior volunteers, legal aid. NUMERICAL KEY 1. Total general population 2. Special group (e.g^handicapped) 3. Aged 6$ end over a. Aged 60 and over From: Canadian Report on Aging, 1982, page 161 5. Aged 60 to aged 64-6. Aged 55 and over 7. Aged 45 and over B. Adult to aged 64 9. Widowed persons who meet certain stated conditions 10. Income or needs tested 11. Fee for some services 12. No fee for aged 65 and over 13. No fee for aged 65 and over and dependants P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 1 2 BRITISH QXLM3LA ALBERTA SASKATO0XAN MWTTOBA CXTARIO OUEBBC NE* BRUNSWICK MDVA SCOTIA PRINCE EDWARD ISLAM) nOTOMJLAND YUKON TB9UT0RY rOmffEST TOOUTORJES COMMUNITY SUPPORT (Cont.) DAY C A R E SERVICES Long-larm Can Program -Adult Day Cere(l,ll) Dm Service In Edmonton(6) Senior Cans Centre sO) Continuing Car* Program (Home Care) -Adult Day Care(l,ll) Adult Day Care (6,11) Respite Care (4,11) Day Care Centred 1) Adult Day Care In Community Settlng(l) Day Cere Programs In Nursing Homes (3) Day Centre at Bracken House (4) Day Programs at Other Homes for the Aged(4) Day Programs et Senior Citizens' Homes (limited) (4) Day Care Program at LodgesO) H O M E C A R E / SUPPORT SERVICES Long-term Cere Program -Home Cere Servtcea(l,ll) -HomemaUer Co-ordinated Home Care Program -Nur*lng(l,ll) •Rehabilitation (1,11) Home Care Services -Homemaklng(l,ll) -Nurslng(l,ll) Continuing Cera Program (Homo Cere) -Hamemaking(l) -Homo Therapy Acuta Home Care(l) Chronic Home Care(l) Home makeri & Home Care Program(l) Homemaker ServlceeU) Community Baaed Services for Seniors(3) Extra-mural Hospital Home Care Demonstration Pro]ectsU,ll) Homemaker 5ervlce*0,ll) Home Care Program(l) Homemaker ServlceeU, 1L) Home Care ProgramU) Homemaker ServLceeU.ll) Respite Cared) Co-ordinated Homo Care ProgremO,11) ServlceeU,ll) -Support ServlceiU.il) (vie Community Therapy ServlcesXD -Nursing (via Community or VONX1) -Respite Care Nurses Services (1,11) Home Support Projecuj(4,ll) Institutional Home Care(l) Respite/ Vacation Care (4.11) ProgrBm(6) Long-term Home Care Program(3) Short-term Home Care ProgremO) (limited XI) SENIOR CITIZEN CENTRES AND CROUPS* Senior Citizen CentresO) Alta. Council on AgingO) Facility Grant Program(3) Family A Community Support Services -Grantt to 35 San lor Central (3) 41$ Senior Activity Contrasts) Senior Citizens' Croups(grantiX3) Age A Opportunity Centre, Inc. (7 centresXo) Brandon Civic Senior Citizens Inc. (4) Selkirk Senior* Centre(4) Services to Senlort(4) Elderly Persona' Centres(6,H) Leadership Training Programs(6tn) Senior Citizens' Clubs(6) Community Centres for the Retired otPro-retlred(3) Senior Citizen Centre s(3) Continuing Education Servlca*(3) District Service Counclls(4) Nfld. A Labrador Association for the Aglng(4) Nfld. A Labrador Pensioners A Senior Citizen* F ederatlon(4) 2 Senior CentresO) TRANSPOR-TATION SERVICES Free B.C. Ferry ServlceO) Free Driver ExamO) Hendy-Dart, Indlvlduel Transport Progrem(2) Reduced Licence FeesO.ll) Reduced Metro. Transit Feet (5,11) Sub*Id 1 ted But Paw Program (3,10) Minimal Foe Bua Passe s(»me centre«X3,ll) Special Transportation Services for Elderly and Handicapped Persona (grantiX2,3) Community Trans-portation Services (grantsX2,3) Discounted Travel Faros Tor Seniors (3,11) Handicapped Transit Asslstance(2) Senior Driver ProgremO) Transit for the Dlsabled<2) Handl-Tranait (Winnipeg A BrandonX2) Program of Transpor-tation of Handicapped Persons In Rural Man.(2) Winnipeg Metro. Transit DlscountiO.il) Reduced Transit Fee« (Metro. Toronto A other centres) (3,11) Wheel Trens-Servlcea/Busea for Disabled A Elderly Per*on*(2,3,ll) Reduced Transit Fares for Senior Citlrens (Montreal A QuebecX3,ll) Special Public Transportation (7 urban centresX2,3) Municipal Services for Elderly 4 Handicapped Persona (F rederlcton) (2,3) Reduced Ferae on Public Translt(3,ll) Bus Fare Discount (HaI l fa«X3 ( l l ) Free Dartmouth Ferry(3) Special Transportation ServlceaU) Handy Bus Progrem(2,3) Reduced Transit Fare* (Whltehorte) (3,11) ro * Including Qrantl and connjltlng Mfv leM. P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 8 2 BRITISH COLUMBIA ALBERTA SASKATOOAN MANITOBA ONTARIO QUEBEC NEtf BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAND NBVrTWDLAND YUKON TERRITORY NORTHWEST TERRITORIES ECONOMIC SUPPORT INCOME SUPPLEMENTS Guaranteed Available Income for NeedCGAIN) for the Handicapped (2,10) GAIN (or Senlors(4,10) GAIN Supplement (3,10) Alta. Assured Income Plan (3,10) Assured Income for the Severely Handicapped (2,10) Sask. Income Plan(3,10) Man. Supplement for Pensioners (6,10) Family Benefits •Guaranteed Annual Income System (GAINS)-0188610(1(2,10) -SenlamU.lO) GAINS-Aged (3,10) Soldiers' Aid Comml8slon(l,10) Municipal Social Assistance(3,10) Special Social Asslstance(3,10) Senior Citizens' Beneflts(3,10) INSURANCE ASSISTANCE Principal Residence Policy Program (dlscountsX3) Senior Citizen Automobile Insurance Grant(3) Tenants' Package Program(3) Pension Pak (insurance discounts) (3,10) Discounts on Property Insurance & Insurance on Po8session8(3) Criminal Injuries Compensation a) PUBLIC PENSION PLAN" Quebec Pension Plan(l) RENT ASSISTANCE Renters' Tax CredltU.lO) Rent Supplement (1,10) Shelter Aid for Elderly Renters(3,10) Renter Assistance Credit(8,10) Renters' Assistance to Mobile Homeowners (3 & 5,9) Renters' Grants (3 & 5,9) Shelter Allowences for Elderly Renters (6,10) Rent-Geared-to-Income for Senior Citizens Program -Rent Supplement (4,10) Housing Grant Program(3,10) Rental Assistance for the Elderly (3,10) Rental. Assistance(a,10) Social Assistance (1,10) SOCIAL ASSISTANCE GAIN Program (1,10) Social Allowance Program(l,10) Sask. Assistance Plan(l.lO) Municipal Assistance (1,10) Social Allowances (1,10) Family Benefits (1,10) General Welfare Assist once (1,10) Social Aid (1,10) Social Assistance (1,10) Family Benefits (1,10) Municipal Social Aaslstence(l,10) Welfare Assistance (1,10) Social Assistance (1,10) Social Assistance (1,10) Social Assistance (1,10) TAX PROVISIONS a) PROPERTY AND SCHOOL TAX ASSIS-TANCE •• Homeowner Grant (2,3) Land Tax Deferral Scheme(2,3) Property Tax Rebate for Senior Citizen Homeowners (3 & 5,9) Property Tax Reductlon(3) Property Improvement Grant(l) Renters' Property Tax Rebated) Senior Citizens' School Tax Rebate(3) Pensioners' School Tax Asslstance(6) Property Tax Credit(l.lO) Property Tax Deferral Program(3) Special Senior CreditO) General Property Tex Credit (8,10) Munlclpel Property Tax Ald(3) Ont. Seniors* Property Tax Grant(3) Real Estate Tex RefundU.lO) Property Tax Rebate(4,10) Property Tex Deferral System(3) Social Assistance (1,10) Home Owners' Grant(l) Home Owners' Property Tex Rebete(l) Property Tax Deferrals (3,10) * All other provinces and territories are participants In the Canada Pension Plan. • • Renters and/or homeowners. P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 8 2 BRITISH COLUMBIA ALBERTA SASKATCHEWAN MANITOBA. ONTARIO QUEBEC NEW BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAND NEWFOUNDLAND YUKON TERRITORY NORTHWEST TERRITORIES E C O N O M I C S U P P O R T ( C o n t . ) (Cont.) b) OTHER T A X PROVISIONS WORKERS' COMPENSA-TION Political Contributions Tax CredltU) Provincial Personal Income Tax CredltU,10) Worker*' CompensatlonU) Political Contribution Tax CredltU) Workers' Compensatlon(l) Low-Income Tax ReductlonU.lO) Senior Citizens' Tax Reductlon(3) Workers' CompensatlonU) Cost of Living Tax CredltU) Political Contribution Tax CredltU) Workers' CompensatlorKI) Ont. Retail Sales TBX Grant{3) Political Contribution Tax CredltU) Retail Sales Tax Credlt(B,10) Workers' Compensation(l) Workmen's CompensatlonU) Political Contributions Tax CredltU) Workers' CompensatlonU) Political Contributions Tax CredltU) Workers' CompensatlonU) Workers' CompensatlonU) Workers' CompensatlonU) Workers' CompensatlonU) Workers' CompensatlorKI) E D U C A T I O N A N D R E C R E A T I O N ADULT EDUCATION COURSES Courses at Several InstitutionsU) Knowledge Network (universities) (1) Nelson Summer University for Seniors (U. Victoria) (3) Further Education Services -Non-credit Courses(3) -Sessions far Seniors at 2 UniversitlesO) Tuition Fees Waived at Post-secondary Instltutlons(3) Most Tuition Fees Waived at 2 Universities & Community CollegesO) Elderhostel ( M D English aa a Second Languege(l) Institute for Continuing Development in Retirement^) Nominal or No Tuition Fees at Several Institutions (3,11) Elderhostel ( M l ) English as a Second Lenguage(l) Free Correspondence Courses(l) Reduced or No Tuition Fees at Most Institutions (3,11) Geriatrics & Gerontology Courses at Some CEGEPs & Universities (1) Elderhostel (3,11) Free University Tu[tiorr(3) "University du Troiaieme Age" (U. of More ton) (3) Community School ProgramsU) Elderhostel (3,11) Free University Tuitlon(3) Local School Board Programs U) Community School Programs(l) Elderhostel (U.P.E.I.X3,11) Free University Tuition (U.P.E.I.X4) Gerontology Courses at Holland College (1) Nominal or No Tuition Fees at Several Institutions ( M D INFORMATION SERVICES a) LIBRARY AND RESOURCE SERVICES Large Print Books, Talking Books, Book-moblleU) Publications AvaliableU) Large Print Material. Talking Books, Home Delivery of Booka(l) Large Print Material, Talking Books(l) Workshops for Librarians on Needs of Seniors d ) Public Library Servlcesd) -Grants, Large Print Material, Talking Books, etc. Public Library Servicesd) -Grants, Large Print Material, Talking Books, etc. Municipal Library Depots in Day Care Centresd) Resource Materials AvaliableU) Free Library Shut-in Services(2,4) b) OTHER INFORMA-TION SERVICES" Consumer CounselllngU) Financial Planning 6t Investment ConsultatlonU) Pre-retirement PlermlngU) Zenith Information LlnesU) Consumer Help(l) Local Information Services for SenlorB(3) Pre-retirement Programed) Senior Citizens Bureau(3) Pre-retirement Programed) Consumer Assistance & Translated Series for Consumer Protectlon(l) Home Economics InformationU) Income Tax Servlce(3) Pre-retirement Planning for Rural Residents (1) Seniors' Hour, TV(3) Community Information Centresd) Leadership Training -Seniors' Clubs & Retirement (6,11) Radio Open College Prog rams( 1,11) Retirement Llteretured.H) TV OntarloU) "Communication-Quebec" -Information & Reference Servicesd) Retirement Preparation Course s(l) Financial Plannlng(l) Information Services to Senlors(3) Pre-retirement CounselllngU) Consumer InformationU) Continuing Education Servicesd) Pre-retirement Semlnars(l) Community Awareness Programs(l) Pre-retirement Seminars(l) Pre-retirement Counsellingd) '* Including pre-retirement counselling. P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 S 2 BRITISH COLUMBIA ALBERTA SASMTCHEMAN MANITOBA ONTARIO QUEBEC NEW BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAND NBfRTUNDLAND YUfc.'! TERRI,JRY NORTfMEST TERRITORIES EDUCATION AND RECREATION (Cont.) RECREATION PROGRAMS AND SERVICES Camping Subsidy (2,3) Hunting & Angling Licences for Senior Citizens (3) Recreation Programs(3) Sports Events(3) Consulting ServicesU) Keepsake Readers' Theatre Program(l) Local Recreation Services Including 2 Senior Recreation CentresO) Senior Citizens' Sports A Recreation Associatlon(3) Senior Summer Games(3) Community Recreation Grents(l) Free Entry to Provincial Parks, Recreation Sites, A Trans-Canada CempgroundsO) Free Fishing Llcences(3) Golden Green Tours of Provincial Parks(3) Reduced Golf Permit Rates(3) Free Access to, & Camping In, Provincial Parks(3) Free Fishing A Gameblrd Llcenslng(3) Guided Tours (2,3) Recreation Program Development(l) Reduced Golf Fees(3) Community Recreation Grants(l) "A Guide to Travel in Ont. For Senlors"(3) Leisure A the Older Adult(l) Ont. Senior Citizens' Privilege Card(3) Recreation Program Development (6,11) Reduced Fees to Provincial Parks, Galleries, Ont. Science Centre, etc. (3,11) Aid to Senior Citizens' Programs In Outdoor Recreation Centre B(3) Aid to Special Institution B(1) Aid to Vacation CampaO) Discover Quebec Program(l) Free Camping In Certain Government Campgrounds(6) Vacation Resorts(6) HEALTH Free Entry to Provincial Parks(3) Special Swimming A Fitness Classes(3) Improvements to Facilities -Little Red Schoo lhouse Program & Regional Fitness Development Program(l) Information Program(l) Local Recreation Programs(l) Senior Citizens' Drama Club(3) Fun A Fitness Programmed CrossX4) Recreation A Social Events(servlce ctubsX4) Reduced Golf Permit Rates (some areasX4) Community Recreation ProgramsQ) Grants to Organ IzatlonsQ) AMBULANCE AND OTHER TRANSPOR-TATION SERVICES B.C. Medical Services Plan(l) Alta. Blue Cross Benefits (1,11,13) Air Ambulance(l) Road Ambulance(l) Northern Patient Transportation Program(l) Ont. Health Insurance PIan(l,ll,12) Free Ambulance Servlces(3) Ambulance Services (grantsXD Ambulance Service s(l,H) Air Ambulance(l) Road Ambulance(l) Travel Assistance for Medical Treatment(l) Travel Assistance for Medical Treatment(l) DAY HOSPITAL SERVICES 4 Day Hospitals (1,11) Day HospitalsU) Day Hospitals(l) Day Hospitals(l) Geriatric Day Hospitals(2,3) Day Hospitals (6 in Montreal, Quebec & HullXD Day Hospital (Miller Centre) (1) Day Hospitals (1,11) EXTENDED HEALTH BENEFITS* Basic Health Cere Services (4,10) Dental Care Plan (1,10 4 3,11) Hearing Aids & Speech & Hearing Program(l) Extended Health Benefits Program (3,13) -Hearing Aids, Dental Care, Medical A Surgical Supplies, etc. Health Benefits for Social Assistance Recipient s{l,10) Sask. Aids to Independent Llving(l) Sask. Hearing Aid Plan(l) Medical Supplies A Home Care Equipment Program(l) Social Allowances (3,10) Genera] Welfare Assistance, 1,10) Special Assistance to Seniors (3,10) Social Aid -Special Need B(1,10) Community Based Services for Seniors(3) Supplementary Health Coverage(l,10) Home Oxygen Therapy Program (Metro. XI) Sickroom Equipment Supply Program(l) Financial Assistance Available for Special Equlpment(l,10) Sickroom Equipment Supply Program (Red Cross)(4) Social Assistance -Special Needs (1,10) Social Assistance -Special Needs (1,10) Co-ordinated Home Care Program -Equipment Loans(l) GERIATRIC ASSESSMENT CENTRES Geriatric Assessment A Treatment Centres(3) Geriatric Assessment Centre (Edmonton)(3) Geriatric Assessment Unit A Day Hospital (SaskatoonX3) Geriatric Assessment Units at Health Sciences Centre A Extended Treatment Units (3) Geriatric A Psychogerietrlc Assessment Unlts(2,3) Geriatric Assessment A Day Hospital (Miller Centre) (1) * Including hearing aids, dental care, medical and surgical supplies end equipment. P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 8 2 BRITISH CDLUCIA ALBERTA SASKATCHEWAN MANITOBA ONTARIO QUEBEC NEK BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAND NEWHXNDLAND YUKON TERRITORY NORTHWEST TERRITORIES HEALTH (Cont.) HEALTH EDUCATION Health Education Programed) Senior Chef, TV(3) Health Education (1) Health Education Programs(l) Nutrition Counselling & Health Education(l) Public Health UnltsU) Red Cross-St. John Ambulance(l.ll) Health Education (1) Health Education (1) Health Promotion & Education(l) Health Promotion & Educatlond) Senior Chef, TV(4> Health Education (1) MEOICAL AND HOSPITAL INSURANCE B.C. Hospital In8urence(l,ll) B.C. Medical Services Pland.ll) Alta. Health Care Insurance Plan (1,11,13) Sask. Hospital Services PlanU) Sask. Medlcare(l) Men. Health Services Insurance Plan(l) Ont. Health Insurance Pland ,11,12) Que. Health Insurance Pland.ll) Extra-mural Hospital PrDgram(l) N.B. Hospital Servicesd) N.B. Medicare(l) N.S. Hospital Insurance Program(l) N.S. Medical Services Insurance(l) P.E.I. Health Servicesd) P.E.I. Hospital Servlces(l) Nfld. Hospital Insuranced) Nfld. Medical Care Insurance (1) Yukon Hospital Insurance PlanU) Yukon Medicare Plan(l,13) N.W.T. Health Care Plan(l) MENTAL HEALTH SERVICES Mental Health Servlces(l) Regional Mental Health ClinlcsU) 2 Alta. Hospltals(l) Psychiatric Servicesd) Mental Health Servicesd) Mental Health Servicesd) Paychogerlatric Unlts(3) Psychogerlatrlc Servlces(3) Mental Health Services including Cllnlcsd) Psychogerlatrlc Services (N.S. HospltalX3) Community Mental Health Teams(l) Mental Health Servicesd) PLACEMENT AND REFERRAL SERVICES Social Services, B.C. Hospitals (I) Placement Services in 3 Urban Centresd) Continuing Care Program Assessment for Home Care & Placement(l) Placement Co-ordination Servicesd) Social Service Centresd) Nursing Home Assessmentsd) Provision of Personal Services (4) Social Services (1) Seniors Placement Commlttee(3) PRESCRIPTION ORUG PLANS Pharmacare (1,11) 1,10; 2! 3) Alta. Blue Cross Benefits (1,11,13) Prescription Drug Pland.ll) Pharmacare(l,ll) Ont. Drug Benefit Plan (1,10 & 3) Drug Plan (2,3 & 3,10) Prescription Drug Program (2,3) Pharmacare Plan (2,3) Financial Assistance Available for Drugs(l.lO) Pharmacare Program(3,10,ll) Yukon PharmecareO) Pharmacare (1) PROSTHETIC AND ORTHOTIC SERVICES Basic Health Care Services (4,10) Sask. Aids to Independent Llvlngd) Social Allowances (3,10) General Welfare Assistance(l,10) Special Assistance to Seniors(3,10) Que. Health Insurance Plen (1) REHABILITA-TION SERVICES AND OTHER TREATMENT Aid to the Handicapped(2) B.C. Alcohol & Drug Commission (1) Vancouver Hospice Program (2) Alta. Alcoholism & Drug Abuse Commlssiond) Cancer Services (1) Sask. Alcoholism Commissiond) Sask. Cancer Foundationd) Alcoholism Foundation of Man.(l) Man. Cancer Foundationd) 1010 Sinclair (rehabilitation) (2) Palliative Care (cancer-hospice careXl) Rehabilitation Services In Reception CentresO) Drug Dependency Program(l) Addiction Servicesd) Rehabilitation Program(l) Alcohol & Drug Addiction Foundatlon(l) Rehabilitation Centred) Rehabilitation ProgramCl) P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 8 2 BRITISH COLUMBIA ALBERTA SASKATCHEWAN MANITOBA ONTARIO QUEBEC NEW BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAND NEWKUCLAND YUKON TERRITORY NCKnWEST TERRITORIES HOUSING HEATING AND INSULATION PROGRAMS "Warm-up" Sask. Program(l) Man. Home Owners' Insulation Loan Program(l,ll) Ont. Temporary Home Heating Grant(3,10) Temporary Home Heating Tax. Credlt(B,10) Home Insulation Loan Program(l) Pioneer Utility Grant(3 & 5,9) HOME ADAPTATION PROGRAMS Home Adaptation ProgramU) Home Adaptation Programs(2) Sheltered Housing Project(l) Critical Home Repair Program (2) General Welfare Assistance -Some General Asslstance(2,10) Access a Home Program(2) HOUSING INFORMA-TION Senior Citizen Housing Registrles(3) Office of the Rentalsman(l) Community Information Centres(l) Local Housing Authorities^) Ont. Seniors Secretariat^) Municipal Housing Offices(l) LOW-INCOME/ PUBLIC HOUSING Senior Citizens' Housing Construction Program(3,10) Subsidization of Social Housing (1,10 & 3) Self-contained Apartments(3,10) Public Housing Program(l,10) Elderly Persons' Housing Program of Man. Housing & Renewal Corp. (4,10) Ont. Housing Corp Apartments(4,10) Public Housing (1,10) Rent-Geared-to-Income for Senior Citizens ProgramU, 10) Municipal Senior Citizens' Residences (3,10) Subsidized Houaing(l,10) Public Housing for Senior Citizens (3,10) Apartment Conversion ProgramU) Public Housing (1,10) Rental Assistance Program(1.10) Senior Citizens' Program(3,10) Senior Citizens' Units(4) Senior Citizens' Subsidized Apartment8(4,10) Self-contained Apartments(4) Senior Citizens' Homes(3,10) NON-PROFIT HOUSING Provincial Rental Assistance Program(6,10) Rent Supplement for Non-profit Socletles(6,10) Residential Subsidy -Glenshlel 4 Brentwood Houses(6,l0) Interest Subsidies on Loans to Homeowners to Build Rental Sultes(l) Senior Citizen Capital Grant Program(3,10) Co-op Houslng(l) Non-profit Housing for Senior Citizens Program (3) Grants to Non-profit Housing Units(4) Rent Supplement, Elderly & Infirm Persons' Houstng(4,10) Grants to Non-profit Housing Units(4) Limited Dividend Housing (church, ethnic, service club groups) (4,10) Rent Supplemen-tation, Elderly & Disabled Persons' Housfng(2,3,10) Aid to Co-op Housing (1,10) Rental Subsidy Program(l,10) RESIDENTIAL REPAIR AND REHABILITA-TION PROGRAMS Alta. Pioneer Repair Program (3,10 & 5,9,10) Residential Rehabilitation Program(l,10) Senior Citizens' Home Repair Program(3) Critical Home Repair Program -Low-Income Families' Program(B,10) -Pensioners' Program(3,10) Ont. Home Renewal Program(l,10) Home Restoration Aidd.10) Home Improvement Loans for Senior Citizens (4,10) Provincial Housing Emergency Repair Program (1,10) Senior Citizens' Assistance Program(3,10) Small Loans Assistance Program(l,10) Provincial Contribution to Seniors for Mater tals(ft,10) Community Development Program(4,10) Programs in Native Communities(2) Dwelling Restoration Program(l,10) P R O V I N C I A L / T E R R I T O R I A L G O V E R N M E N T A L P R O G R A M S A N D S Y S T E M S , 1 9 * 2 BRITISH COLUMBIA ALBERTA SASWTOEKAN MANITOBA OWAPJO qUEBBC NW BRUNSWICK NOVA SCOTIA PRINCE EDWARD ISLAM) YuTON TERRITORY TERRITORIES INSTITUTIONAL CARE INSTITUTIONAL Long-term Care Alta. Nursing Construction Grants Adult ToSter Adjuvant Proqram Foster Families Extended Health Homes for Chronic Care Government Homes 2 Lodges(l) Extended/Chronic CARE* Program Heme Program for Special Care Home«(3,n) (4) (3) Care(l) Special Care Unl t ( l , l l ) for Special Care Type I A Care Unlts(l) -Extended Care (1,11) Homes(l, l l) Extended Chronic Hospital Long-term Cere Foster Homes -Homes for Nursing Homes M) n Care(l) Nursing Homes Hospitals Auxiliary Government-funded Treatment Care( l , l l ) Hospltala(l) ProgramCl) the Aged(J) (4,11) Interfalth and (1,11) (1,11) HoapltaIs(l,ll) Special Care Hospltals/Unlt) Extended Health Pavllllons(3) Nursing Home -Nursing Homes(l) Provincial Homes Church-ope rated Personal Care -Government Extended Care HomeaU.ll) (1) Care Program Reception Services -Residential Care for the Aged Homeed) Un!ts(3,U) Hospitals Centresd,10 Level IV Care(l) Personal Cere (1,11) Centres(3,ll) Programd.l l ) Facilltlea(l) (menorsX4,ll) Licensed Boarding (1,U) Homes for Special Personal Needa Home Program Homes for the Special Care Special Boarding Home 8(1) -Other Care (deficit Allowance for (1,11) Aged(4,10) Homes(l) Homes(l) Institutions fundlngX3.il) Residents In Residential Homes for (1,11) Lodge Program Special Cere Care Facilities- Special Care (3,11) Homes(2) (Ilcensure (ex-psychiatric) onlyX2,3,ll) (1) -Social Nursing Homes Allowance for (1,11) Residents Satellite or (2,3) Faster Homes (4,11) O T H E R , INCLUDING LABOUR AND EMPLOYMENT EMPLOYMENT Edmonton 6t Senior Citizens' Sheltered SERVICES** Calgary Senior Job Bureau Workshops Centres(3) (4) (1,11) "Over 45" Special Program Counsel!ing{6) (Edmonton At CalgaryX7)HUMAN B.C. Human Alta. Human Sask, Human Man. Human Ont. Human Que. Human N.B. Human N.S. Human P.E.I. Human Nfld. & Labrador RIGHTS Rights Right* Rights Rights Rights Rights Rights Rights Rights Human Rights Commlsslon(l) Commisslon(l) Commlssiond) Commlssiond) Commlssion(l) Commlsslon(l) Commlsslon(l) Commiaalon(l) Commisslon(l) Commlssiond) Ombudsrnan(l) Ombudsman's OmudsmanO) Office(l) PENSION Pension Ont. Seniors INFORMATION Commission of Secretariat^) SERVICES Man.(l) Pension Women's Bureau Commission (1) of Ont.(l) CO CO * Including nursing homes, hornet for the aged, long-term care hospitals, etc. *• Including apprenticeship programs. Appendix G. Some fundamental d i f f e r e n c e s between acute care and long term care models: [B.C. Long Term Care Assoc. Philosophy & Objectives (Unpublished Jan. 1981).] C h a r a c t e r i e s t i c H o s p i t a l Community Care F a c i l i t y F a c i l i t y .As defined under the H o s p i t a l Act •As defined under the ^ Community Care F a c i l i t i e s L i c e n s i n g Act •Designed and c o n s t r -ucted as a h o s p i t a l •Often designed and construc-ted f o r some other purpose • and r e q u i r i n g renovation to meet standards • E x i s t s p r i m a r i l y to r e s o l v e a s p e c i f i c h e a l t h problem • E x i s t s as one s o l u t i o n to ,3 a s o c i a l and medical problem • B u i l t f o r use by a l l c i t i z e n s when r e q u i r -ing treatment f o r s p e c i f i c medical problems • B u i l t f o r populations with s p e c i a l needs, who q u a l i f y ' 1 f o r Long Term Care • -•A temporary place to v i s i t f o r the d i a g -nosis and r e s o l u t i o n of a h e a l t h problem •Becomes the new Home of the r e s i d e n t and a l l of h i s or her problems •A c l e a n , s t e r i l e a t -mosphere i s the norm .A home-like atmosphere i s L encouraged .Segregation of p a t i e n t s according to d i a g n o s i s i s the p r a c t i c e . I n t e g r a t i o n , i n t e r a c t i o n and t o l e r a n c e between 2<b r e s i d e n t s i s encouraged C l i e n t e l e .Commonly r e f e r r e d to as a p a t i e n t .Commonly r e f e r r e d to as ^ a r e s i d e n t •Of varying age groups .Ages o f t e n s i m i l a r u • •Of varying h e a l t h problems, although each p a t i e n t i s o f t e n being t r e a t e d f o r one primary d i a g n o s i s .Resident i s often experien-cing a number of and a v a r i e t y of complex diagnoses, some of which are health r e l a t e d and f o r which no z " . cure i s a v a i l a b l e S t a f f .Large numbers r e q u i r e d • Small numbers the norm .Have p r e s c r i b e d academic p r e p a r a t i o n .Variable academic prepara-2 £ t i o n and s p e c i f i c upgrading o f t e n r e q u i r e d •Have h i g h l y t e c h n i c a l , s p e c i a l i z e d s k i l l s .Are u s u a l l y g e n e r a l i s t s , Z1 and q u a l i f i c a t i o n s vary .Have s p e c i a l i z e d r o l e s i n the h o s p i t a l .Usually have diverse rolesjc. w i t h i n the f a c i l i t y . F a l l under the Master Agreement .Many s t i l l non-unionized 1 Budget .High per diem r a t i o .Low per diem r a t i o / . L i s t of necessary accounts d i v e r s e and l a r g e • L i s t of necessary accounts fewer, but r e l e v a n t to ? Z community care f a c i l i t i e s Appendix H. 140 In Context of Everyday Strain. Acute Illness Episodes and Stressful Life Events Quality of Life in Specific Social Settings Professional or Non-Professional Intervention : t Points of Maximum Leverage Family and Personal Social network Family and Personal Social Network Network Orientation Network Orientation AFFECTIVE INSTRUMENTAL Z X -•COGNITIVE 1 Community Resources —INFORM AL*-Models of Articulation —FORMAL*— Coping Strategies Coping Strategies Helping the Helpers to Help j Supporting the Supporters Social and Community Support Systems Programming Social and Community Support Systems  Interuention Model in Management of Chronic illness K i l l i l e a , 1982:195 Appendix I. 1 4 1 A N A L Y S I S O F M A T R I X I N H E A L T H C A R E B e c k h a r d p r e s e n t s a n i n t e r e s t i n g d i s c u s s i o n o f s t r u c t u r e s t h a t a r e a p p r o p r i a t e f o r t h e h e a l t h t e a m c o n c e p t : i n h e a l t h d e l i v e r y s y s t e m s , t h e p r a c t i t i o n e r s ( t h e d e l i v e r e r s o f h e a l t h c a r e ) t e n d t o b e l o c a t e d a t t h e b o t t o m o f t h e o r g a n i z a t i o n a l t o t e m p o l e . E v e r y b o d y e l s e i n t h e o r g a n i z a t i o n i s t h e r e t o s u p p o r t t h e i r e f f o r t s . Y e t t h e o r g a n i z a t i o n i s t h e t r a d i t i o n a l , h o s p i t a l o r i e n t e d r e p o r t i n g s y s t e m . E a c h s p e c i a l i s t d i r e c t l y r e p o r t s t o h i s f u c t i o n a l c o u n t e r p a r t . T h i s s t r u c t u r e d o e s n o t s u p p o r t t h e t e a m w o r k t o b e d o n e . R a t h e r i t m a i n t a i n s t h e s e p a r a t i o n o f t h e v a r i o u s m e m b e r s b y h a v i n g t h e m r e p o r t u p f u n c t i o n a l l i n e s . I f t h e c h a r t i s r e d r a w n f r o m t h e p o i n t o f v i e w o f t h e s e r v i c e d e l i v e r y , t h e m e m b e r s o f t h e h e a l t h t e a m ' r e p o r t ' t o t h e m a n a g e r o f t h e i r t e a m o r u n i t . H e i s t h e a d m i n i s t r a t i v e b o s s . H i s j o b i s t o f a c i l i t a t e t h e t e a m d e l i v e r y o f h e a l t h c a r e . T h e c h i e f s o f s e r v i c e a r e s u p p o r t s - t e c h n i c a l a n d e d u c a t i o n a l r e s o u r c e s a v a i l a b l e t o g u i d e , c o u n s e l , u a n d p l a n w i t h a l l t e a m m e m b e r s . T h e r e a r e t w o m a j o r t y p e s o f s t r u c t u r e : " F u n c t i o n a l " , b a s e d o n t e c h n o l o g y ( M e d i c a l s p e c i a l i t i e s ) ; a n d " P r o d u c e / S e r v i c e " , b a s e d o n " m a r k e t " ( c l i e n t ) n e e d s a n d d e m a n d s . T h e n a t u r e o f t h e r e q u i r e m e n t s f o r s e r v i c e i n c l u d e p r e v e n t i v e c a r e , t r e a t m e n t c a r e , a n d i m p r o v e m e n t o f s o c i a l c o n d i t i o n s , w h i c h p r o b a b l y m e a n s t h a t a t h i r d o r g a n i z a t i o n s t r u c t u r e o r d e s i g n i s r e q u i r e d . T h i s m a t r i x s t r u c t u r e i s u s e d i n c o m p l e x o r g a n i z a t i o n s w h e n t h e i n t e r -d e p e n d e n c i e s o f t h e w o r k a r e s u c h t h a t n o s i m p l e r e p o r t i n g s t r u c t u r e w i l l d o . A m a t r i x s t r u c t u r e c o m p r i s e s a s e r i e s o f o p e r a t i n g u n i t s a l o n g w i t h a s e t o f c a p a b i l i t i e s . T h e o p e r a t i n g u n i t s a n d t h e c a p a b i l i t i e s m u s t i n t e r a c t r e g u l a r l y f o r t h e w o r k t o b e a c c o m p l i s h e d . A v a r i e t y o f c o m b i n a t i o n s o f p e o p l e w i l l b e n e e d e d t o c o l l a b o r a t e o n s p e c i f i c t a s k s . T o m a k e m a t t e r s e v e n m o r e c o m p l i c a t e d , a l l o f t h e a b o v e -m e n t i o n e d r e p o r t i n g l i n e s r e f e r o n l y t o t h e d e l i v e r y o f s e r v i c e s - t h e w o r k o f t h e o r g a n i z a t i o n . I n a d d i t i o n , a s e p a r a t e r e p o r t i n g l i n e i s n e e d e d f o r c a r e e r p l a n n i n g a n d p e r s o n a l d e v e l o p m e n t . F o r t h i s p u r p o s e , a f u n c t i o n a l h i e r a r c h y i s u s u a l l y a p p r o p r i a t e . O n e m o r e c o m p l i c a t i o n i s t h e n e e d f o r a s e p a r a t e o r g a n i z a t i o n a l s t r u c t u r e f o r p l a n n i n g a n d d e v e l o p m e n t . . M a n y n o n -m e d i c a l o r g a n i z a t i o n s h a v e a s e p a r a t e c h a r t o f o r g a n i z a t i o n f o r f u t u r e p l a n n i n g . O r g a n i z a t i o n s a r e , i n f a c t , m u l t i - s t r u c t u r e d . R e a l i s t i c m a n a g e m e n t s r e c o g n i z e t h i s a n d e x p l i c i t l y d e s i g n t h e i r s t r u c t u r a l c h a r t s t o r e f l e c t i t . M u l t i p l e o r g a n i z a t i o n a l s t r u c t u r e s a r e n e c e s s a r y i n h e a l t h c a r e i n s t i t u t i o n s . B e c k h a r d , o p . c i t . p . 2 9 9 

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