THE MANDATE OF THE SUBCOMMITTEE
The Subcommittee on Veterans Affairs was given the mandate to study and report on the state of the health care provided Canadian war veterans and Service personnel following their military service. In partial discharge of this mandate, during the week of December 15th the Subcommittee heard from the major veterans organizations before visiting Sunnybrook Hospital in Toronto, Ste Anne’s Hospital in Ste Anne de Bellevue, and Veterans Affairs Canada in Charlottetown. This, its First Report on the subject, focuses on long-term institutional care, standards of care, federal-provincial relations and two case studies: the Sunnybrook Health Science Centre (Sunnybrook Hospital) and the departmental Ste Anne’s Hospital. Further reports on veterans health care will be submitted as time permits.
RESPONSIBILITY FOR HEALTH CARE AND VETERANS PRIORITY
Although the Constitution Act, 1867 only assigns the federal government exclusive jurisdiction over the military, veterans and the members of the Subcommittee believe their welfare after service is part of the unspoken covenant between a nation and those who die or are prepared to risk their lives on its behalf. At the time of Confederation only the most rudimentary rehabilitation benefits were offered veterans. Even as late as 1938, the eve of World War II, Stephen Leacock could humorously characterize the popular attitude toward war veterans: "When the war ends they are welcomed home under arches of flowers with all the girls leaping for their necks, and within six months they are expected to vanish into thin air, keep out of the public house and give no trouble." However, following 1945, Canada put in place one of the world’s most comprehensive and generous programs of veterans benefits. Canadians have reason to be proud of the way in which Canada has kept faith with her veterans, but in a time of change and cutbacks, we must be ever vigilant that we do not begin to betray the trust of veterans just as old age renders them less capable of defending their own interests.
The Department of Veterans Affairs has primary responsibility for discharging Canada’s responsibility toward war veterans (including their dependants) and the men and women with peacetime service in the Regular Forces. In addition to the commemoration of their service and sacrifice, Veterans Affairs Canada (hereafter, the Department) delivers three primary entitlement programs: disability pensions, economic support and health care. The reports of the Subcommittee will deal with health care, which has become the fastest growing program, a tendency which, barring another war, can be expected to continue until well into the next century as the Department faces mounting health care demands from aging veterans and service personnel.
Health care for veterans is a complex field with both federal and provincial aspects and responsibilities. Although the federal government is responsible for treatment of and compensation for service related injuries and for conditions arising therefrom, veterans are also residents of a particular province and hence are fully entitled to provincially funded health care services. Military service, particularly in a theatre of actual war, has traditionally brought with it entitlement to benefits either not generally available to the public, or to more generous benefits. The cost of providing these additional or more comprehensive benefits is borne by the federal government.
To meet the health care needs of veterans the Department has often "pioneered" new services and treatments. In the years following World War II, most of the health care needs of veterans were provided for by an integrated network of departmental facilities: hospitals, nursing homes, clinics, etc. located across the country. Today, with the exception of Ste Anne’s Hospital, the Department relies primarily on provincial health care systems and on other health care providers to deliver health care services to veterans. The Department reimburses veterans or a health care provider for the purchase of services over and above those covered by the provincial health care programs.
In the competition for increasingly scarce provincial and community health care resources, veterans organizations are concerned that the claim of veterans to priority over non-veterans will be ignored. In conversations with officials from provincial and community services it is often necessary for veterans organizations to explain the reasons why a veteran is entitled to priority over and above a citizen who does not have veteran status. The priority arises, in their opinion, from the implied contract in the Pension Act and the War Veterans Allowance Act under which the federal government undertakes to deliver health care and treatment as well as pensions and allowances. Health care workers outside the Department, however, are motivated by the principle that adequate health care should be available to all Canadians on a non-discriminatory basis.(1) While the Subcommittee fully supports the existence of such an implied contract and the priority it bestows, this subject requires further study and will be dealt with in the final report.
In the meantime, the Subcommittee is concerned that veterans who might be entitled to services and benefits not generally available to other residents of a province receive these services and benefits and not be dependent on the initiative of a health care worker.
- The Subcommittee recommends that Veterans Affairs Canada ensure that all service providers at the provincial and community levels are informed that veterans are entitled to priority in receiving such additional services and benefits as may be provided under federal legislation, federal contracts with the provincial health care system, or with the individual institution.
The main elements of the Veterans Affairs health care program are treatment and other health-related benefits, the Veterans Independence Program, and long-term care. Under the first, the Department provides medical, surgical and dental examination and treatment, prosthetic and related devices, supplementary benefits, treatment allowances and other community health care services. The Veterans Independence Program, or VIP, provides the services necessary to maintain recipients’ health and independence in the home or community. It funds housekeeping services, home care, ambulatory health care, social transportation and intermediate care in a community facility. The Subcommittee views the VIP as a great success in improving the lives of veterans and in postponing their institutionalisation, and strongly supports its extension to the spouses of veterans. Finally, the Department provides intermediate and chronic care in Ste Anne’s Hospital (which is still administered by the Department), and contracts with the provinces for priority access beds in hospitals and community care facilities across the country. The latter element of the veterans health care program is the primary subject of the current report.
STANDARDS OF INTERMEDIATE AND CHRONIC CARE
A. The Veteran Population
On 31 March 1997, there were approximately 460,000 veterans and it was estimated that, by the end if the fiscal year 1997-1998, this number would have declined to 434,000, 42,500 of whom would be women. The veteran population is expected to decrease to about 383,000 by March 2000 (39,100 women) at which time their average age will be 78. This trend is illustrated in the chart below.
Table 1
Forecast of the Veteran Population (1995-96 to 1999-2000)
Source: Veterans Affairs Canada, 1997-98 Estimates, p. 10.
As recently as 1995-1996, veterans 65-74 years old still outnumbered those 75 years old and older by a significant margin – (248,000 to 217,000); today, those 75 and older number about 256,000 while the younger veterans number 170,000 and, by the year 2000, the oldest contingent of veterans will number 291,000 out of a total estimated veteran population of 357,000. This trend is very important because demographic analysis of the veteran population indicates that veterans requiring departmental services and benefits will become even more dependent as they age. The bar graph below projects this trend over the decade 1995-2006.
Table 2
Aging Trend of Veterans by Age Category
Source: Veterans Affairs Canada, 1997-98 Estimates, p. 11.
B. The "Phantom" Group of Veterans
In May 1996, the Auditor General submitted a report on the Veterans Affairs health care programs.(2) The Report found that the Department did not have an accurate projection of its future client group. While there were an estimated 475,000 veterans, only 153,000 (less than a third) were currently receiving Veterans Affairs benefits. Not enough was known about the remaining two-thirds and the degree to which they might be entitled to, and apply for, benefits after the age of 75 when their health could be expected to deteriorate. Furthermore, the Department had "devoted limited resources to determining the needs of its future client population." Thus, in the opinion of the Auditors, Veterans Affairs "could face significant unplanned costs." The heaviest of these costs would be those associated with providing care in an institution – some $50,000 to $80,000 per annum in a chronic care facility and about $33,000 in a community care facility. The Department would also be responsible for treatment and drug costs.(3) Veterans Independence Program benefits as well might be extended to these veterans.
The Department’s reaction to the report of the Auditor is causing concern to veterans organizations. The National Council of Veteran Associations (the Council), for example, expressed the opinion that the raft of recent studies undertaken by the Department was driven by concern over what to do about the 165,000 overseas service veterans who are not in receipt of benefits because they do not have a service-related disability and are not eligible for the income-tested benefits of the War Veterans Allowance program. What the Council found alarming about the Department’s focus on the overseas veterans was that the only benefit the latter are entitled to under the legislation is a bed if a bed is available. But the total number of departmental and contract beds is only 4,082 and 253 veterans were already on waiting lists across the country as of 16 December 1997:
What scares us is that there is so much time being taken to try to find out what will happen to this phantom group when most of them will not be clients. Second, the only thing they are entitled to under the legislation is a bed. If we only have 4,000 beds and there is a waiting list of well over 200 now, things are off the rails somewhere along the line…(4)
The Subcommittee will address at length the whole issue of the present and future availability of priority beds and community beds, and their provincial and rural/urban distribution in its final report. It believes, however, it is time for the Department to draw some concrete and practical conclusions from the studies on veterans health care already undertaken. These conclusions, which must directly address the issue of this group of 165,000 overseas veterans and the demands their current entitlements may place on the veterans health care program, should be clearly stated and circulated to the veterans organizations and to the Subcommittee. As much as possible, the document should deal with facts and figures, present a number of different scenarios depending on different demographic and dependency assumptions, and cost out these different scenarios.
- The Subcommittee recommends that Veterans Affairs Canada prepare a discussion document setting out in concrete terms the conclusions to be drawn from the studies it has undertaken on the future of veterans health care. The document should
- present a demographic analysis of aging and dependency trends;
- evaluate the increased demands on programs that might arise as overseas service veterans, not currently in receipt of benefits, age and become less independent; and
- be prepared without delay and circulated to veterans organizations and the Subcommittee as soon as possible.
The Subcommittee is very interested in the evolution of our policy toward this large group of veterans who served overseas, were rehabilitated on their return to Canada, and who were so successful in re-integrating themselves into civilian life that they have drawn no benefits since then. As Canadians, we owe them at least our formal thanks for their service and for "a job well done," but should we offer them more in their old age, and if so, what do we owe them? This is an issue to which the Subcommittee, veterans organizations, and the people and government of Canada must turn their attention once the document referred to above has been prepared and discussed.
The long-term spouses of entitled veterans constitute another group which has a strong claim to consideration as the department reviews the future of veterans health care. In an earlier report the Subcommittee strongly recommended that the Department’s forthcoming "housekeeping" bill include provisions to clarify the right of surviving spouses to apply for an increase in the assessment of a disability of a deceased veteran, regardless of the level of the disability prior to the veteran’s death. The Subcommittee also recommended that, under certain circumstances, the spouses of veterans should be eligible for a continuation of Veterans Independence Program benefits following the death or permanent institutionalisation of the veteran. The Subcommittee reiterates its support for these recommendations: implementation of the recommendation about the re-assessment of a deceased veteran's disability prior to his or her death involves little, if any, additional expense and should be proceeded with without further delay.
As noted earlier, institutionalisation of a seriously disabled veteran costs the Department $50,000-$80,000 per annum. This is the annual value to the government of Canada of the work and sacrifices of a spouse who tends a disabled veteran in the home, sometimes over a period of decades. Even after institutionalisation, many spouses continue to participate faithfully in the care of their mates. A representative of the Royal Canadian Legion (the Legion) told the Subcommittee about one such woman:
There is a lady who attends the Rideau Veterans home every night to feed her husband. She uses a walker and weighs approximately 160 pounds and she has emphysema. She feels if she does not feed him, he would not have a meal. That lady has been married to her husband since before the Second World War. She was separated during the Second World War. She goes home by bus every night. She has served her husband well, yet she has no income other than what she gets from his pension. So she has the problem coming to her, who will look after her? Should it be the responsibility of Veterans Affairs Canada, or should it be the responsibility of the provincial government? That lady is in a difficult circumstance.
Second, if she must be put into a facility because of her condition, where will she go? Will she join her husband? In most cases, no. Once again we are separating loved ones...(5)
The Subcommittee believes that the Canadian people and government can no longer "abandon" in old age the spouse who has spent decades looking after a severely disabled veteran with no more than a survivor’s pension. While it is possible for them to remain in the home they should be entitled to assistance from the Veterans Independence Program, and when infirmity or old age forces their institutionalisation, they should be entitled to the assistance of the Department.
What form should this assistance take? Ideally, in cases where their mates occupy a veterans bed, every effort should be made to find them a bed in the same facility. In cases where their mates die before they require institutionalisation, they should be entitled to the assistance of the Department in finding a bed.
- The Subcommittee recommends that Veterans Affairs Canada adopt an integrated approach to the health care needs of the spouse of a severely disabled veteran in the years following the death or permanent institutionalisation of the veteran.
As it continues to discharge its mandate, the Subcommittee will press the Department to address the health care and other interests of the spouses of deceased and permanently institutionalised veterans in any substantive amendments to the legislation brought forward.
NATIONAL STANDARDS OF VETERANS HEALTH CARE?
As already mentioned, until the 1960s the Department of Veterans Affairs administered a comprehensive and national network of hospitals, homes and clinics dedicated to providing veterans with the medical treatment and services they required. This not only allowed the Department to pioneer the special services and treatments that veterans needed, but also to ensure that veterans enjoyed roughly the same quality of care across the country. The decision of the government to discontinue the direct provision of health care services to veterans and to negotiate the transfer of its facilities to the provinces is still controversial. At the time, however, Canada was implementing a national but provincially based system of comprehensive hospital and medical benefits for the whole population, and the continued existence of federal institutions was considered inefficient and unnecessary. The federal government had agreed to make large contributions to the costs of building up the health care systems in the provinces, and to make continuing contributions to their costs in return for compliance with the minimum standards set out in the Canada Health Act. Today, all the federal institutions have been transferred with the exception of the Ste Anne’s Hospital complex outside Montreal, and negotiations are underway that may lead to its transfer to the government of Quebec.
One of the reasons why the Subcommittee has grave reservations about the transfer of Ste Anne’s, the last federally administered, chronic care facility, is that, lacking national, clearly stated and enforced standards of institutional care for veterans, Ste Anne’s remains an invaluable benchmark of an acceptable level of care. Such a benchmark has become essential, given the increasing disparities between the health care programs of one province and another. These differences have become so substantial that one can no longer say that the Department is dealing with a national health care system; instead, it must negotiate with and adjust to the strengths and weaknesses of ten distinct provincial systems.
As provinces cut back on their funding of medical care (and as federal cuts to transfer payments to the provinces bite deeper) individual hospitals are faced with the reality of reduced resources, are forced to close beds, reduce staff and eliminate or reduce the cost of services. The result is that unacceptable differences might emerge between the quality of care in facilities within the same province, and even within the same institution.
In their appearance before the Subcommittee, Veterans organizations decried the lack of national standards. The Royal Canadian Legion is in a particularly good position to evaluate trends in the institutional care of veterans across the country. They have a national structure and Legion provincial command representatives are responsible for arranging that volunteers regularly visit hospitals and nursing homes where veterans live. These are not just social visits. The Legion plays a strong active role in support of veterans in the different facilities, providing funding, furniture, television sets and even cable TV.(6)
Regular and systematic visits to long-term care facilities and regular and systematic contact with the veterans who live in them and with the family members of veterans allow the Legion to speak with authority about the issue of a declining quality of care in some facilities and the need for detailed standards. In their opinion, the quality of the care veterans receive is at risk:
Mr. Annis: I do know that the veteran’s care across Canada does vary, and regrettably it varies with provincial health authorities running the things Veterans Affairs Canada used to run itself.
Mr. Margerum: We have facilities now that are combined veterans and community beds. The … comment we hear is that the veterans will get as good care as the community bed resident. We have a concern with that because under the legislation, veterans were given a particular level of care by the government for their services to the country, and we are finding that that service is being reduced to what provincial standards have become. Consequently, in our opinion, veterans across the country as a whole are not getting the level of care that they were promised by the government of the day and by legislation.(7)
The most universal and demoralising symbol of the decline in the quality of care was the resort, as a cost cutting measure, to "rethermalized" food, that is, food that has been prepared in bulk off site, frozen in large bags and shipped to the hospital or facility. There it is thawed out, divided into portions and put on plates which are put in special holding trolleys similar to those used on aircraft. The trolleys are wheeled to the ward and plugged in. The Legion characterized what emerges as being "atrocious":
It is pretty hard to have three square meals a day that you would enjoy. I would invite anyone to go there, eat the food for three weeks. I am sure they would realise rethermalization of food is a disaster. They should go back to home cooked meals.(8)
The most common complaint involved the quality of the "rethermalized" toast which could be hard enough to break teeth and had to be dipped in coffee or some other liquid before eating. But the system could not be depended upon to keep hot foods consistently and safely hot, or cold foods adequately chilled. Portions could be watery, mostly gravy or too small.
Although the veterans the Subcommittee spoke to at Sunnybrook and Ste Anne’s hospitals felt their food was good, as was the meal sampled by members of the Subcommittee, the question of "rethermalized" food will be kept under study.
On its visit to the Sunnybrook Health Science Centre in Toronto, the Subcommittee also learned about the discrimination that can result from provincial funding levels and the lack of definite federal standards for veterans. At Sunnybrook, two wings of the hospital are devoted to veterans- the Kilgour Wing (K Wing) for veterans requiring chronic care and George Hees Wing (L Wing) for those needing intermediate care.
K Wing is the older of the two wings and, although the veterans living there require a higher level of care and more constant attention, most are crowded into four-bed wards that were not designed to store today’s medical equipment, wheelchairs, scooters and walkers. Almost all their beds are the old fashioned hand cranked models with heavy side rails that they cannot adjust themselves. Instead, they must wait until a staff member can find the time to adjust it for them. The hospital is not replacing these beds on an urgent basis, but as funds become available – a few each year. In other words, most of the veterans in this wing may not live long enough to occupy more appropriate and safer beds.(9) The question of the beds concerned members of the Subcommittee because it involves safety as well as comfort: the shortcomings of these old beds were responsible for the broken arm of one veteran in K Wing and may be implicated in the unexplained death of another.
Veterans in the much newer L Wing are not crowded. Rather, they occupy two-bed and private rooms with adequate storage space. The halls are wide enough to allow for both wheelchairs and ambulatory residents and staff. Since the Wing opened, residents have also enjoyed the luxury of electric beds which they can adjust themselves.(10) The physical differences between K and L wings may be unavoidable, but the injustice of the two different levels of equipment in the same institution, in the opinion of the Subcommittee, is unacceptable and underscores the need for definite standards.
The differences between the conditions on K Wing and L Wing are almost entirely due to their difference in funding. K Wing is funded by the hospital out of the funds provided by the province, and reflects the provincial level of care and the federal-provincial agreement on priority beds. L Wing, on the other hand, is entirely funded by the Department of Veterans Affairs and reflects the level of care the Department deems appropriate for veterans.
A difference between the fire safety standards of hospitals in different provinces should also be noted here. Although Ste Anne’s Hospital in Ste Anne de Bellevue, Quebec, was opened earlier than the Kilgour Wing of Sunnybrook, it has always been equipped with a modern fire sprinkler system; it has taken the unnecessary deaths of three veterans to spur the installation of a sprinkler system at Sunnybrook.
In 1990, the Department undertook an evaluation of its institutional care program. As a result of this work, a set of minimum standards known as the core program was developed to define the expected level and quality of care to be provided to clients. However, the Core Program was not officially adopted or implemented, a decision which was implicitly criticised in the 1996 Report of the Auditor General.(11) Nor in the years since then does the Department seem to have made much progress toward adopting detailed and specific standards of long-term care for veterans.
The Department has evolved a 13 point "Action Plan for Institutional Long Term Care" which embodies three "Quality Assurance" paragraphs. The most important of the latter promise an annual visit/contact by the Department staff to all veterans in long term care facilities. The other two talk of cooperating with the Ontario Ministry of Health to implement a "pilot project to look at assessment of resident care outcomes, and measurement of resident satisfaction levels with quality of care" and identifying "other provincial approaches to measure resident care outcomes and satisfaction levels" and identifying opportunities to develop a joint provincial departmental approach to monitoring care.
Having listened to departmental officials outline the plan, the Subcommittee can agree with its "client-centred approach," and can agree that it may be worthwhile as a complement to detailed standards of care, to ensure that standards remain up-to-date and relevant. It does little, however, to ensure the quality of care for the increasingly large number of patients who suffer from one form or another of cognitive impairment and cannot speak for themselves. Aged and long-term residents can become isolated from their surviving family and friends as a result of the latter’s age and infirmities. It must also be remembered that the detailed interviews have not yet taken place, and that the other elements of the plan involve no more than an effort to find other ways of measuring "resident outcomes."(12)
The Subcommittee does not agree that the quality assurance provisions of the Action Plan "address concerns about the uniformity of quality of care" as the Department assured us. Nor do we agree with the somewhat cavalier dismissal of stated standards of care that tend to be related to the availability of nurses, doctors, specialists, nurses’ aids, etc. and how many there are per patient. Rapid and complex change in this respect, the "dumbing down" of the qualifications of staff who actually deal with veterans, in the opinion of the Subcommittee, all point to the absolute need for definite, if flexible, federal standards to assert the interests and rights of the veterans against those who would erode quality in the name of cost reduction. Such standards are the necessary benchmark by which change can be negotiated in the interest of veterans, rather than to their detriment.
In a similar vein, the Subcommittee does not accept the suggestion that the Department should not second guess the institutional managers of some 800 institutions and the 76 on contract to the Department unless the "resident outcomes" it favours as a standard are precise, are clearly spelled out in its agreements with the provinces and individual facilities, and are rigorously enforced.(13)
- The Subcommittee recommends that the Department establish a detailed federal standard of care for implementation in long-term care facilities. This standard must meet the needs of veterans to the same or a higher degree than was the case before the Department transferred its facilities to the provinces. Regardless of whether the standard is expressed in terms of patient outcomes or in terms of hours of care per resident per day etc., it must be readily understandable;
- The Subcommittee recommends that the standards referred to above specify that all chronic care palliative care wards in which the Department contracts for veterans beds be equipped with a sprinkler system; and
- The Subcommittee recommends that the Department negotiate updated Transfer Agreements with the provinces that enshrine the departmental standards referred to above.
Standards can exist only on paper, unless effective steps are taken to implement and enforce them. Veterans organizations complained that, in their opinion, departmental officials did not visit the institutions where veterans lived often enough. The commitment to visit and interview every veteran at least once each year partially addresses this concern as does the need to make a formal audit of the facility, but the regional officials of the Department, and even officials from headquarters in Charlottetown, should adopt a policy of making informal, "drop in" visits, particularly at mealtime. It is important for veterans that both they and their day-to-day care givers experience first-hand the concern of the Department that veterans receive the highest possible level of care. In the opinion of the Subcommittee, these informal visits, perhaps lasting only an hour and focused on the care of only a few randomly selected veterans, would also serve to keep officials, and even senior officials, in touch with their clientele.
- The Subcommittee recommends that the Department make formal visits to facilities where veterans reside at least twice a year, and that its officials make informal visits as frequently as possible.
SUNNYBROOK HOSPITAL AND STE ANNE’S HOSPITAL
To evaluate the working of federal-provincial health care agreements for veterans and differences in the level of care experienced by institutionalised veterans, the Subcommittee chose to undertake two initial case studies. Members of the Subcommittee were able to spend the better part of a day at each hospital: Sunnybrook Hospital in Toronto and Ste Anne’s Hospital outside Montreal. Sunnybrook has 570 veterans beds and Ste Anne’s, 606 so that together these two hospitals account for about 28% of the 4082 departmental, priority and contract beds spread across the country. Both institutions offer veterans a superior level of care and recreational amenities, but Sunnybrook has recently been marked by tragedy – the death of three veterans in a fire set by a fourth veteran, and in a separate incident, the death of a veteran in unknown circumstances.
SUNNYBROOK HOSPITAL
The Subcommittee’s overall favourable impression of Sunnybrook is substantially owed to the very favourable impression made by the testimony of the delegation of residents who asked to meet with it. The first of the issues that the residents wished to raise, the lack of electric beds in Kilgour Wing for chronic care, has already been referred to. According to the residents, about 250 manual beds should be replaced with electric beds at a cost of about $750,000. Since a very high proportion of the residents on K Wing require staff assistance in adjusting their beds several times a day, the purchase of the electric beds will help save the time of the staff almost as much as it will make the veterans more comfortable. Nevertheless, the residents’ request is being given the usual bureaucratic treatment:
Unfortunately, the hospital says they do not have the money. Veterans Affairs says that it is not their problem, it is a capital problem for the hospital. In between you have the veterans or the residents being held hostage. It is a no-win situation.(14)
The Subcommittee is convinced that important issues of resident safety are involved as well as comfort and believes that the deadlock must be broken. Together, the Hospital, the Department and the veterans organizations should be able to come up with a way to equip K Wing with electric beds. Perhaps the Department could purchase the beds and the hospital could rent-to-purchase them with the assistance of veterans organizations and even of the families of the veterans.
- The Subcommittee recommends that the Department immediately take the lead in finding a way to equip the veterans on K Wing of the Sunnybrook Hospital with electric beds.
A second issue raised by the residents has to do with staffing levels in K Wing and with the fact that as veterans age they become increasingly less mobile and capable of doing things for themselves. As they become more bound to their beds, a greater burden is placed on staff who must regularly adjust their beds and change the resting position of the bedridden residents every 3-4 hours. Unless staffing levels are increased to take this into account, the result is overworked staff and/or a reduction in the quality of care offered residents. Equipping K Wing with electric beds would relieve some of the pressure on staff, but residents believe there is a need for another staff member in each unit to bridge the two meal times by coming on duty at noon and working until 8:00 p.m. After 11:30 p.m., only two nurses are left on duty in each unit (nine look after a unit during the day, and five during the afternoon). They must administer any medications required and change the position of most residents every 3-4 hrs throughout the night. If a patient dies or needs to be sent to the emergency ward, one of the nurses must accompany him, leaving just one nurse to cope with the whole unit. The residents believe that provision should be made for a rover to move between the units as necessary during the night, replacing absent nurses and helping turn over residents.(15)
- The Subcommittee recommends that the Department review with officials of Sunnybrook Hospital the staffing levels on Kilgour Wing and ensure that these are adequate to meet the needs of the veterans resident there.
The veterans representatives were very proud of the way they were treated and were particularly appreciative about the great range of activities available to them. The quality of the food, which was being prepared at the airport while the kitchens of the hospital were being re-built, had improved and the work of the new caterer was appreciated. This was particularly satisfying for officials of the Hospital because just two or three years ago the quality of the food was one of the biggest sources of complaint in a survey of residents.
The nurses that work in gerontology are different from those who work in the operating room or in general surgery. In periods of nurse shortages it can in fact be difficult to recruit nurses who are willing to work with the elderly. Nursing the elderly who are also cognitively impaired is even more challenging; nevertheless, until very recently nursing the elderly and cognitively impaired did not require special training. In discussions with officials of the hospital the Subcommittee discovered that last year’s cutbacks to the budget of Sunnybrook Hospital had led to wholesale staff changes in the Wings occupied by veterans.
The cutbacks resulted in the closure of acute care beds. Under the terms of the Hospital’s contract with the Ontario Nurses Association, the nurses threatened with layoff can use their seniority and choose to work somewhere else, "bumping" a nurse with less seniority who occupies the position. In this way, the disruption caused by layoffs spreads far beyond those whose positions become redundant. Unfortunately, the most junior nurses were in the cognitive support area on the third floor of Kilgour or K Wing. In one unit, all ten nurses who were experienced in the treatment of the cognitively impaired elderly were replaced by ten full-time nurses with no such experience, and on the other unit, five out of ten nurses were replaced. These new nurses needed time to learn gerontological nursing, then they had to learn how to work in the cognitive support area, and finally, to understand how to function as a primary nurse.(16)
The nurses on the cognitive support units could not have been bumped if special credentials or courses in the treatment of the cognitively impaired had been required to work on the ward. Courses leading to such credentials have now been developed and instituted.
- The Subcommittee recommends that the Department, as part of the standards referred to above, ensure that a high percentage of nursing staff that deal with cognitively impaired veterans hold credentials that prevent their being "bumped" by nurses that have no training or experience in the field of cognitive support.
The cognitive support nurses were bumped in April 1997. By the time the Subcommittee visited the hospital in mid December 1997, both K Wing and L Wing seemed to be running smoothly and residents had got used to their new nurses. In the meantime, however, tragedy had struck. On 4 June 1997, a fire in Kilgour Wing took the lives of three veterans; a fourth veteran confessed to setting the fire. Within a couple of weeks another veteran was found on the floor beside his bed. He was put back in the bed and checked by a doctor, but died soon thereafter.
The Subcommittee was completely frustrated in its efforts to learn what chain of events had led to these incidents and who or what should be held responsible. Hospital officials had obviously been told by lawyers to say as little as possible and patient confidentiality prevented the disclosure of other information. In both cases, ongoing official investigations were major barriers to obtaining authoritative information.
With regard to the fire, hospital officials themselves had not received a copy of the report of the investigating Fire Marshal. They knew that although the hospital lacked a sprinkler system prior to the fire, Kilgour Wing met or exceeded the standards of the fire code. They had been told that the inquest could not be held until the criminal case against the veteran who is alleged to have set the fire had been completed. According to their information the earliest date that an inquest can be held will be the fall of 1998. Finally, the hospital had been told not to hold an internal safety review of the incident until after the inquest had investigated the origin of the fire and brought in its verdict.
The incident of the fire leaves a whole series of questions unanswered. How is it that the Board and senior officials of the hospital, according to testimony before the Subcommittee, never proposed that a sprinkler system be installed prior to the fire? How did the fire start? How was it that a cognitively impaired veteran was apparently allowed to possess a source of fire and allowed to mix freely with other veterans? Where was the person hired through an agency to baby-sit this veteran at the time of the fire, and why is the agency still under contract to supply personnel to the hospital? How quickly did staff respond to the emergency? Given that many nurses were new to K Wing, how well had they been trained and drilled about evacuation procedures and the location of emergency equipment? Why did the fire claim a victim in a room some distance from its source?
When the Subcommittee visited the hospital in December 1997 the coroner still had possession of the medical record of the veteran who had fallen out of bed just prior to his death; consequently, hospital officials could not be definite about the nature of his injuries. Police had made an investigation at the request of the family of the veteran following the incident, but no witnesses to the fall had been found. According to the coroner, the autopsy was unclear as to the cause of death (the veteran was 92 years old and in poor health). Lacking any indication of an unnatural death, the coroner had not ordered an investigation. Hospital officials could not carry out an internal investigation until the coroner returned the patient’s medical chart and sent them a copy of the autopsy. It seemed clear to members of the Subcommittee, however, that the hospital did not have clear policy guidelines about the handling of a resident who has fallen and the circumstances under which a doctor must be called before the patient can be moved or put back in bed.
Reviewing these two incidents the Subcommittee finds it extraordinary that six months after they occurred, it was still impossible for hospital authorities to investigate the causes of, and events leading up to, the tragedies, the responsibility of staff members on duty at the time, and the quality of their reaction to the events.
- The Subcommittee recommends that the Department, as part of the standards referred to above, specify that all contract hospitals with veterans’ beds have clear and precise guidelines about handling patients who have fallen and the circumstances under which a doctor must physically check them before they are moved or put back in bed and that all staff members be made aware of and respect these guidelines.
Having questioned hospital officials, and reviewed the two studies of the safety of Kilgour Wing that were completed in the months following the two incidents, the Subcommittee fully supports the decision to establish a behavioural care unit within the cognitive support patient service area.(17) This unit would be a specifically-designed, self contained unit with specialised programs developed for residents with moderate to severe dementia and aggressive behaviours. The Subcommittee believes that it is a mistake to mix such residents with either physically or cognitively impaired residents.
- The Subcommittee recommends that the Department, as part of the standards referred to above, specify that cognitively impaired residents with aggressive patterns of behaviour should not be mixed with physically or cognitively impaired residents.
STE ANNE’S HOSPITAL
The Subcommittee was very impressed by the departmental staff of the Ste Anne’s hospital and by the quality of care and special programs they offer veterans.
The average age of the residents is about 80 years old. The hospital has a special psychiatric program because over 100 of the veterans suffer from a psychiatric condition and it also offers psychogeriatric care. Two closed units treat residents with Alzheimer disease who wander, but other patients suffering from dementia who do not wander are on regular wards.(18) The aggressive treatment of elderly residents who are cognitively impaired is a speciality, and is one of the programs that makes the hospital exceptional.
Although it is not a teaching hospital, its Department of Psychiatry has strong ties to McGill University, both through the latter’s Department of Psychiatry and through its School of Nursing. This allows the hospital to draw on the intellectual resources of the university to maintain and upgrade the qualifications and training of staff as well as to contribute proven, practical experience to students, some of whom are allowed to take elective rotations with the hospital. A nurse clinician with post-graduate education is responsible for the standard of nursing care and for the ongoing, in-service training of nursing staff. This allows for a very rapid response to a problem involving the treatment of a patient.(19)
The Subcommittee believes that the treatment of cognitively impaired geriatric residents at Ste Anne’s Hospital sets a standard against which the programs of other hospitals should be judged.
- The Subcommittee recommends that the Department ensure continued support for the psychiatric and psychogeriatric programs at Ste Anne’s Hospital.
The Subcommittee was given a further example of the quality of Ste Anne’s attention to detail and interest in improving the living conditions of residents. Beginning in the early 1990s, the hospital found that the health of patients suffering from Dysphagia (a condition which leads to dehydration, malnutrition and weight loss because it makes chewing and/or swallowing difficult) improved markedly if they were given thickened beverages. Experimentation spread from thickened beverages to the development of puréed and minced foods with the appearance and taste of normal foods to encourage patients on consistency modified diets to eat better meals. During its visit, the members of the Subcommittee were treated to a full course dinner of attractively presented, natural looking foods and drinks developed at Ste Anne’s, including thickened beer and coffee, main courses, vegetables and deserts.
- The Subcommittee recommends that the Department continue to support further research and development at Ste Anne’s Hospital into advanced nutritional care for Dysphagia, and that the Ste Anne techniques and products be made available at hospitals under contract to the Department.
Unlike Sunnybrook Hospital, at Ste Anne’s the nursing staff dealing with the cognitively impaired are hired and promoted on merit and, should staff reductions become necessary, the layoffs would also be based on merit, not seniority; that is, the best and most experienced staff would be kept and there would not be a sudden influx of nurses with no training or experience in working with elderly patients suffering from different kinds of dementia. The merit principle and the absence of bumping, in the opinion of the Subcommittee and hospital staff, is an invaluable benefit of the hospital’s federal status. The Quebec provincial health system, however, like that of Ontario, has negotiated agreements with unions which accept seniority, not merit, as the main basis for reducing staff; consequently bumping might take place if Ste Anne’s is transferred.(20)
- The Subcommittee recommends that the Department ensure that the principle of merit, not seniority, remain the basis of staffing actions at Ste Anne’s Hospital.
The Subcommittee questioned officials of the hospital about the safety record of the hospital and about their safety programs. Other than the occasional "fire" in ash trays, and a minor fire in the kitchen, to the best of the officials’ memory, the fire safety record of the hospital is commendable. Smoking by the residents is strictly limited and supervised. Volunteer fire-fighters are stationed at the hospital whose director of security meets regularly with the surrounding fire departments. The Subcommittee was briefed about fire drills, the evacuation training of staff and the special equipment at their disposal, and how the patients would be moved, should a fire break out.
A senior doctor at Ste Anne’s is charged with the responsibility of managing risk. Despite their age and mental and physical condition, residents of the hospital are kept as mobile as possible. This mobility brings with it an increased risk of falls, but the risk management program has led to the hospital having a substantially lower percentage of falls each year – 3.3% - than other long-term facilities which average about 4.3%. This is despite the age of the residents and the presence of psychiatric wards where falls are more common.(21)
The Subcommittee believes that Ste Anne’s programs and training to ensure the safety of residents are both thorough and complete and would be useful in establishing federal standards of safety for facilities in which veterans are resident.
The major problems of Ste Anne’s Hospital are that the number of its residents is declining and that its wards are badly outdated. The decline in the number of residents and the closure of units of beds that this entailed led to the fear that before too long there would be too few veterans to justify keeping the hospital open. Consequently, Veterans Affairs Canada decided to open negotiations with the Province of Quebec to see whether an agreement could be reached that would keep the hospital open by transferring it to the province. Almost all the 606 residents of Ste Anne’s live in open wards with 10-16 beds and with common bathrooms and showers. There are only a few semi-private and private rooms. Most of the veterans have spent years and even decades on these wards and do not object to their lifestyle. Nevertheless, current standards for long-term facilities call for two-thirds of the rooms to be private, and the remainder to be semi-private and Ste Anne’s will have to be completely modernized.
The Subcommittee has always viewed the veteran and his or her spouse as a unit and on many occasions has reminded the Department and the Government of Canada how much they, and the people of Canada, owe to the spouses who have devoted most of their lives to the care of veterans who were stricken in the service of their country. Now an increasing number of these spouses are themselves in need of institutionalisation. Rather than close more beds, the Subcommittee believes that the federal legislation should be amended to admit the spouses of disabled veterans, living or deceased, to veterans beds, and that the federal government should modernize Ste Anne’s with this in mind.
Overall, and despite its outdated wards, Ste Anne’s Hospital, in the opinion of the Subcommittee, sets excellent standards in the care of its residents, in providing them with a safe and caring environment in which to live, and in offering a wide range of recreational and entertainment activities. The dedication of the professional staff to maintaining and improving an already high level of treatment programs is obvious in the quality of the training support offered staff and in the urge to research and experiment with new treatments for the cognitively impaired and/or physically disabled. The Subcommittee strongly believes that continued departmental control over at least one facility such as Ste Anne’s is essential to the future health care of veterans across Canada. Ste Anne’s Hospital must be retained, to contribute not only to the development and evolution of standards of care, but also to the development and evaluation of new treatments and new programs.
- The Subcommittee recommends that the Department indefinitely postpone the transfer of Ste Anne’s Hospital to the Province of Quebec, that the Department amend veterans legislation to permit the spouses of disabled veterans to occupy beds reserved for veterans, and that Ste Anne’s Hospital be gradually modernized to this end.
In its future work related to the discharge of its mandate relating to health care, the Subcommittee will study forthcoming omnibus veterans legislation to ensure that the needs of spouses of deceased veterans are not overlooked. It will continue its study of standards of care for veterans resident in provincial institutions by undertaking additional case studies across the country. It wants to evaluate a number of changes to health care policy in the fields of pharmacare, dental work, hearing loss, the supply of prosthesises, etc. It must also continue to monitor the development of policy toward the "Phantom Force" of overseas veterans, their eligibility for various veterans benefits and the priority these veterans should be assigned.