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Friday, 9 November, 2007

Audit exposes Quebec Health Ministry woes

Quebec Auditor General (right) released his latest annual report last week, on November 1. In it, he provides a scathing critique of the way that the province's Ministry of Health and Social Services is governed. His biggest complaint is the lack of accountability of health organizations' boards of directors, he explains (PDF):

In Québec’s health and social services network, some 3,500 members who make up the boards of directors are responsible for the governance of health and social service agencies as well as public institutions. In 2006-2007, these authorities were entrusted with the management of budgets totaling close to $13 billion.

One is forced to admit that good practices in the governance field are not applied sufficiently by the boards of directors. This situation concerns, among other things, their collective skill profiles, their independence, the training of their members and their participation in the strategic exercises of the entity. It follows that the boards of directors do not fully occupy their rightful place, which detracts from their effectiveness.

Moreover, the Ministère de la Santé et des Services sociaux must clarify its expectations, notably those related to the accountability of boards and those pertaining to reporting obligations. It is important to dissipate the confusion that reigns concerning the roles and responsibilities entrusted to the stakeholders. In addition, the Department should do more when it comes to the electoral process pertaining to the appointment of directors of institutions. Indeed, public participation in the last elections was below the 1 percent mark.
You can , or expand this post to read the chapter on health governance.


The following is the full text of Chapter 4 of the Auditor General's report:
Governance in the agencies and public institutions of the health and social services network

Audited Entities:
• Ministère de la Santé et des Services sociaux
• health and social services agencies
• public institutions of the health and social services network

4.1 As a general rule, the concept of governance refers to the processes whereby
organizations are directed, controlled and have to report on their activities.
Based on the principles of transparency, integrity and accountability, governance
deals with the structures and processes related to decision-making,
accountability, control and conduct at the top of organizations.
4.2 In Québec’s health and social services network, some 3,500 members who
make up the boards of directors are responsible for the governance of the
health and social services agencies as well as public institutions. For the
2006-2007 fiscal year, these authorities were entrusted with the management
of budgets totaling close to $13 billion.
4.3 Our objective was to verify that the current structures and processes allow
the boards of directors to ensure good governance. We carried out our work
with the Ministère de la Santé et des Services sociaux (MSSS) and boards
of directors chosen from among the regional authorities and institutions.
Several members, including presidents and executive directors or executive
directors, were interviewed, while other directors were asked to complete
a questionnaire. Our audit, which took place from July 2006 to July 2007,
covers the activities of the 2005-2006 year, but some comments concern
situations before or after that period.
4.4 One is forced to admit that good practices in the governance field are not
applied sufficiently. What is more, the boards of directors do not fully
occupy their rightful place, which detracts from their effectiveness. Similarly,
the MSSS must perfect some of its approaches while making sure that it
clearly makes known its expectations, notably those related to the accountability
of boards and those concerning reporting obligations.
4.5 Here are the main conclusions drawn from our work:
• In the case of both agencies and institutions, the roles and responsibilities
of the board of directors and its committees, as well as of top management
are already defined in relation to one another and in relation to
the upper levels and the minister. Despite this fact, a certain confusion
reigns in reality and it tends to be more pronounced in the case of agencies.
Efforts must be made to ensure that the roles and responsibilities
assigned to stakeholders are well understood and that the actions taken
comply with the Act.
Boards of directors should give themselves the means so that each one
collectively possesses the skill profile, independence and commitment
required to accomplish its duties. As for the MSSS, it should take additional
measures to make better known the electoral process pertaining
to the appointment of directors of institutions by aiming notably to
increase the tangible involvement of the public. Indeed, public participation
in the last elections was below the 1 percent mark.
• The members of boards of directors receive training to variable degrees.
However, since no policy has been adopted to structure the activities
offered, some needs go unmet. Among the subjects warranting special
attention, mention may be made of the roles and responsibilities and the
principles inherent to sound governance.
• Ordinarily, the boards of directors – be it in the case of agencies or
institutions – proceed with the approvals submitted to them. However,
their actions should be reinforced. The effect of this would be to increase
their influence on the performance of organizations. For example, their
contribution in strategic exercises is not optimal. Furthermore, no mechanism
is provided to systematically assess the effectiveness of boards of
directors and that of their committees. It should also be pointed out that
there is little to no reporting on their activities.
• As for the documentation produced at all levels (MSSS, agencies and
institutions) to reflect the objectives aimed for and the results obtained,
there is a lack of integration between the strategic plans, the management
and accountability agreements and the annual management reports.
Furthermore, our work reveals that the upper levels provide very little
feedback on the strategic plans and annual management reports of agencies
and institutions. Moreover, since these documents often have shortcomings,
the interpretation of the overall performance of the health and
social services network and each of its parts often proves difficult.
Recommendations
4.6 This section brings together the recommendations made in our report. It
should be noted that for information purposes, the number of the paragraphs
in question is indicated in parentheses.
(4.37) We recommended to the department that it clearly establish its expectations
regarding the roles and responsibilities of the boards of directors
and the top management of agencies and institutions, notably with
respect to their accountability and their reporting obligations, by considering
what is stipulated in the Act.
(4.64) We recommended to the department that it:
• make the necessary efforts to increase public participation in elections;
• rule on the question of those members who in addition to being on
the boards of directors of agencies sit on the board of directors of
an institution of the same region.
(4.65) We recommended to the boards of directors of the audited agencies
and institutions that they see to it that sound governance practices are
applied, notably:
• devise a strategy in order to be able to benefit from the appropriate
skill profile to fulfill their mandate;
• take steps to ensure that their members represent the entity first
and foremost and that they see to it that the entity’s mission and
objectives are achieved at an optimal level.
(4.73) We recommended to the department that it offer adapted training for
the boards of directors of agencies.
(4.74) We recommended to the boards of directors of the audited agencies
and institutions that they establish a policy in the training field for all
of their members, in particular for newcomers in order to meet their
needs.
(4.94) We recommended to the boards of directors of the audited agencies and
institutions that they reinforce their actions to increase their influence
on the performance of their organization, namely:
• get more involved in the strategic exercises, notably the strategic
plan, the management and accountability agreement, the annual
management report, internal control activities, value for money and
risk management;
• regularly update their internal management by-law;
• rule on the management information that they wish to obtain: form,
frequency and timeframe;
• make an annual assessment of the effectiveness of their board, its
committees as well as each of the members;
• include in the annual management report the reporting of the board
of directors and its committees.
(4.113) We recommended to the department that it:
• make sure that the strategic plans of agencies and institutions are
submitted to the upper levels;
• make sure that the documents pertaining to its performance as well
as to that of agencies and institutions are integrated and coherent;
• make sure that the upper levels offer systematic feedback on the
annual management reports of agencies and institutions;
• make sure that the chosen indicators provide information on the final
purpose of the health care system, namely to improve the health
and well-being of Québec’s population as well as the accessibility,
continuity, quality and safety of care and services;
• make sure that the strategic plans, management and accountability
agreements and annual management reports of agencies and institutions
respect the legal obligations;
• see to it that the management and accountability agreements are
signed in a timely manner.
(4.114) We recommended to the boards of directors and to the top management
of the audited agencies and institutions that they:
• periodically carry out together a strategic planning exercise which
will include the setting of objectives, targets and indicators;
• jointly report on the results according to the objectives of their strategic
plan and their management and accountability agreement in
accordance with the legislation and good practices in this field.
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