Background 7.1 Ambulance Services is a program of the Department of Health and Community Services. New legislation (Ambulance Services Act and Regulations) for this program came into effect in October 1992. Standards, inspections and licensing were addressed in this new legislation. 7.2 On 1 January 1993 standards came into effect for: services; personnel; vehicles, equipment and supplies; quality assurance; and communication. These standards are set out in a departmental publication called, “Standards for Ambulance Services” (Standards). “Their introduction, along with inspection and licensing requirements, serve to assure the public and health care personnel that ambulance services of a consistent quality will be available across the province” (the Department’s Annual Report for 1993-94). 7.3 The Ambulance Services Branch (Branch) is responsible for the 56 service providers (Providers) and the 116 vehicles that currently operate in the Province of New Brunswick. Providers with whom the Province has ambulance service contracts include private businesses, non-profit agencies, and hospitals. Inspection is one of several functions performed by the Branch. There are two types of inspections – inspection of the service and inspection of the vehicle. There are two inspector positions in the Branch. 7.4 Our Office began work in the Branch in 1996. The inspection function was selected as an audit project that began in February 1997. This function was selected for the following two reasons: • Ambulance service is a very important service that affects the lives of New Brunswickers. The quality of this service could mean the difference between life and death in an emergency situation. The inspection process ensures the required quality of service is delivered. • We promote accountability. The Branch is responsible for ensuring that Providers meet the Standards. The Branch conducts inspections to determine if these standards are met. Scope 7.5 The main purpose of this audit project was to ensure the Standards are being met. We also wanted to determine if the inspection process actively contributes to the deliverance of an effective ambulance service and to improvement in Providers’ performance. 7.6 Our audit work included the following: • a literature review; • observation of an inspector performing both a service and a vehicle inspection; • interviews with staff in central office and telephone interviews with staff at two provider services; and • review of several inspection files, computer reports and various documents at the Branch. 7.7 The audit field work was done in February and March 1997. Inspections performed after this date were not considered. File reviews and report analyses were completed in April 1997. Results in brief 7.8 Policies and procedures for the inspection function have not been clearly established and documented. Some of the effects of this include a lack of consistency in inspection practices and procedures and a low frequency of inspections. 7.9 Improvement in the scheduling of inspections is needed. Inspections are not done on a regular basis in accordance with a predetermined coverage plan. 7.10 Improvements are needed in monitoring of inspections and their results. Some ambulances did not receive a full, documented inspection before being put into service and the number of Providers not meeting some standards remains high. 7.11 Enforcement action plans should be established to help ensure Providers meet the Standards. In 1997 none of the Services inspected and only a few of the vehicles inspected complied with all the Standards. The Standards for Ambulance Services are not being fully met. 7.12 The Branch needs to improve its information system. 7.13 Inspection results are not integrated with licensing. Licensing could be used as a means to help enforce the Standards. Policies and procedures for inspections have not been clearly established and documented 7.14 Policies and procedures are a useful tool for providing guidance and ensuring consistency in the way things are done. A few years ago, the Branch discussed the need for policies and procedures, however, they have not been formalized and documented. Two of the effects of not having policies and procedures governing inspections are a lack of consistency in inspection documentation and a low frequency of inspections. Inconsistency in inspection practices and procedures 7.15 Each inspector has his own way of doing inspections and documenting them. This was observed when performing a review of inspection files. Inspection documentation varied from a well-organized file to incomplete checklists. It is important that inspections are properly documented. The skill is in the Branch; however, it has not been transformed into formally written policies and procedures for all inspectors to use. Frequency of inspections seems low 7.16 “Provider” refers to the individual or organization that is licensed to operate the ambulance service. There were five Providers who, at the time of our audit, had not yet received a documented service inspection. These services had been operating since September 1996, when St. John Ambulance was replaced. They had been operating for half a year without receiving a full inspection. 7.17 In order to analyze the length of time since current Providers and their vehicles had been inspected, we had to make a list of all current Providers and vehicles with the date of their last inspection. We summarized this data in Exhibit 7.1 to show who had been inspected within twelve months, within twelve to twenty-four months and who had not been inspected in over two years. Only twenty-four of the fifty-six current Providers (43%) were inspected in 1996-97. Sixteen of the fifty- six current Providers (29%) have inspections that are one year old, and eleven Providers (19%) have not been inspected for over two years. The ages of the vehicle inspections are very similar. There are no policies and procedures governing the frequency of inspections. Exhibit 7.1 Ages of Inspections * There are 5 services (9%) which had not yet been inspected that are not included in this table. Recommendation 7.18 Appropriate policies and procedures for the inspection process should be clearly established, properly documented, effectively communicated, and updated on an annual basis. Policies and procedures should include, among other things: • the objective of inspections; • the responsibilities of inspectors; • when an inspection should be done; • how often inspections should be done; • what the inspection should include; • how inspections should be documented; • how the findings should be reported; and • when to carry out follow-up inspections and enforcement actions. Departmental response 7.19 The establishment of a separate inspection unit, appropriately resourced, and with expertise to design operational policies and procedures will allow this to occur. Design work will commence in November, 1997. Better scheduling of inspections is needed 7.20 Inspections are not done on a regular basis and there is not a predetermined coverage plan. The effects of not having a schedule of predetermined coverage include: the inspection coverage seems low, some inspections are very old, and some new services and new vehicles have not yet been inspected. 7.21 The results are that the Branch is not complying with the legislation requiring that all new vehicles be inspected before licensing, and that the Providers are not meeting the Standards because they are not regularly inspected with consequences for non-compliance. Exhibit 7.2 Inspection Coverage Note: Figures for 1997 do not include the results of inspections done in March 1997. The inspection coverage seems low 7.22 Actual inspection coverage for the past four years is presented in Exhibit 7.2. The number of inspections for 1996 and 1995 is lower than reported in the Department’s annual report for those years. The Department agreed that the number shown in the annual reports for 1996 and 1995 was incorrect. The chart shows the following. • The percentage coverage was virtually the same for both services and vehicles. • The highest coverage was in 1994, when 85% of the services and vehicles were inspected. The lowest coverage was in 1997, when only 50% and 52% respectively were inspected. • The coverage has steadily declined since 1994, the first year with the Standards. • Although the number of services has greatly declined in 1997, and to a lesser extent the number of vehicles has also decreased, the inspection coverage did not increase. With fewer services to inspect, one would expect a higher coverage. Some new vehicles do not have a documented inspection 7.23 We reviewed the Branch’s records for grants to Providers for new vehicles in 1996 and 1997 to determine if these new vehicles were inspected promptly. It was difficult to determine the date the vehicle was put in service and the date of the inspection of the vehicle. However, our review indicated that there was no documented inspection for four vehicles in service at the time. We believe this indicates that the legislation requiring that new vehicles be inspected before being approved for use is not being fully complied with. Recommendation 7.24 An inspection schedule should be compiled on an annual basis, and updated as needed. Departmental response 7.25 Policies in regard to licensing and inspection frequency, criteria, and timing and terms will soon be implemented. These policies will be approved and monitored by the Director. Monitoring of inspections and their results needs improvement 7.26 Monitoring of the inspection function needs to be improved. In general, insufficient monitoring often causes the following: 1) work does not get done, and 2) problems do not get identified and addressed. In our opinion, these effects have occurred in the inspection function. Work does not get done 7.27 The following observations are examples of inspection work not being done. • Some service inspections date back to 1993 and 1994. • Twelve vehicles have not been inspected since 1993 and 1994. • There are a few Providers who have never been inspected. • Exhibit 7.2 shows that only 50% of the current Providers and 52% of the vehicles were inspected in 1996-97. These are the lowest inspection coverage percentages since the Standards were introduced. • New vehicles are not always promptly inspected. Problems are not being identified and addressed 7.28 We identified two problems that are not being properly addressed. Both problems involve compliance with legislation and Standards. 7.29 The first is that the Branch is not complying with legislation that requires all new vehicles be inspected before approving them for use. 7.30 The second is that Providers are not complying with all of the Standards. “Infraction” is the term used by the Branch to denote non-compliance with a Standard. Infractions are discovered when inspections are performed. Exhibit 7.3 deals with service infractions. It shows the percentage of the services inspected that did not meet a specific Standard. To interpret this exhibit properly, it is important to understand that infraction means non-compliance with the Standard; it does not necessarily mean that an item is missing. An item could be present, but if it is lacking in the quality or quantity required by the Standard, an infraction would be recorded. 7.31 Recent infraction reports for vehicles show improvement for some of the Standards that in the past had high rates of non-compliance. On the other hand, some Standards had a higher infraction rate in 1997 than in the past. In 1997, reports show that approximately 40% of the inspected vehicles had infractions relating to fire extinguishers, 30% had infractions relating to short spine boards, and 20% had infractions relating to portable suction. 7.32 In our opinion, the level of non-compliance with the Standards, the severity of the infractions, and the repetitiveness of specific infractions are problems. Recommendation 7.33 A means of monitoring the inspection function should be established and performed regularly. Possible methods of monitoring include: • director’s approval of inspection schedule; • director’s periodic review of inspection files; • regular review of inspection reports generated by the Branch’s computer system by both the inspectors and the director; and • tracking of time spent doing inspections. Departmental response 7.34 The Branch has implemented monthly Inspection Unit meetings between Unit staff and the Director to address inspection activity, results, and plans, and to address administrative issues such as policy administration, long-term trends, and effects on other units within the Branch….. A long-term management approach to ensuring compliance will be designed and implemented. Exhibit 7.3 Frequent service infractions - top five infractions for each of the past four years Notes: 1) 1997 figures are as of 28 February 1997. They do not include the results from three inspections done in March 1997. 2) “*” indicates the infraction was not in the report for the given year. Enforcement of Standards 7.35 The Branch is not fully enforcing the Standards for ambulance services. In 1996-97, four years after the Standards became effective, none of the twenty-eight Providers inspected complied with all of the service Standards, and only eight of the sixty vehicles inspected complied with all the Standards. The Provider for one area, who has been operating the ambulance service for several years, was inspected in February 1997. The inspection revealed over seventy infractions for the service and its four vehicles. During the same year, another Provider with four vehicles had fifteen infractions. 7.36 Exhibit 7.3 shows the frequency of specific infractions for services. Exhibit 7.3 shows that in the past four years, four infractions have repeatedly been in the top five. In our opinion this indicates that Providers are not taking corrective action on reported infractions and that the Standards are not being enforced. The Providers of ambulance services in New Brunswick do not consistently meet the quality of service required. 7.37 The current inspection process only verifies compliance with the Standards. It does not ensure compliance. The physical inspection of the vehicles and services only verifies whether or not the Standards are being met. The follow-up of infractions and the enforcement of the Standards are two other important components of ensuring compliance. 7.38 Inspectors have the legal authority to enforce the Standards. However, in practice the Branch does not have a real ability to enforce the Standards because there are no penalties for non-compliance. They do not have a plan to replace the service or other forms of enforcement action. 7.39 The legislated requirements and the “Standards for Ambulance Services” were established to ensure a certain quality of service. If the inspection process does not ensure compliance, then the expected and required quality will not be achieved. Without a plan to replace the service, the Providers do not feel threatened; there are no immediate repercussions to not meeting the Standards. Follow-up inspection work 7.40 Follow-up on Providers and vehicles that failed to comply with the Standards is very limited. Letters are sometimes sent and re-inspections are rare. 7.41 From our review of a sample of inspection files, we noted that one Provider, who was inspected in May 1993, had eleven service infractions and thirty-seven vehicle infractions. This Provider has not received a service inspection since May 1993, despite the poor results from its last inspection. Recommendations 7.42 The Branch should ensure compliance with all set Standards and with legislation. 7.43 Enforcement actions should be established. These actions should be used to ensure compliance with the Standards. 7.44 Follow-up inspections should be done to determine if identified deficiencies have been corrected. Departmental response 7.45 The Department has a clearly documented compliance process which defines timeframes and conditions under which ambulance services are tracked and monitored. …… With adequate resources, linkages to financial incentives and disincentives and a mechanism to temporarily replace an ambulance service in cases where a license was terminated or suspended, this…….is being addressed. 7.46 Authority to enforce standards is discrete from the ability to do so. The Department has chosen to provide motivation to ambulance services by linking financial incentives/disincentives to service contract performance. Linkages to license status and an ad-hoc ambulance replacement system will take place, the ability to effectively enforce standards will be established. Reporting of inspection results The computer system rates only fair at meeting users’ needs 7.47 The computer system is not user-friendly, has operating problems, and in our opinion rates only fair at meeting users’ needs. The programmer is called regularly for help. The system does not have conventional word-processing abilities, so editing is not simple. When inputting inspection results, one can only exit at the end of the program. Inspectors become frustrated when they have problems using the system. The system generates only pre-designed reports and cannot respond to ad hoc inquiries. Inspectors must manually prepare the “Infraction Report”. 7.48 These problems with the computer system cause delays in getting inspection results to the Provider. Our file review indicated that, in 1996-97, it was common to find a time lag of one month or more between the inspection date and the date on the “Infraction Report”. Recommendation 7.49 The problems with the computer system should be formally identified and addressed, by either updating or replacing the current system. Departmental response 7.50 Development of a strategic information plan for the Ambulance Services program…..is underway. The integration of inspections with the licensing function 7.51 The Ambulance Services Act states that all Providers must have an operator’s license and that all vehicles must be approved before being used as an ambulance. In the Branch, licensing could be a useful tool to ensure compliance with the set Standards and legislation. Currently, inspection results are not formally integrated into the annual licensing process. The licensing process is an independent, routine, administrative task that is not tied into the Branch’s inspection monitoring system. Recommendations 7.52 Licensing should be used as a means of enforcing the Standards. The licensing and inspection functions should work together. Inspection results should be reviewed as part of the licensing process. 7.53 The Branch should develop alternatives (ex. probational licenses, temporary suspensions) to the current automatic annual license renewal practice. Departmental response 7.54 See paragraphs 7.45 and 7.46. General departmental comments 7.55 [We] find your review to be substantively accurate; however, it is important to note certain contextual issues which are not included within your report. The fiscal year 1996-97……was a period of significant transition in the Ambulance Services program. St. John Ambulance-New Brunswick Council unexpectedly withdrew…..service in 26….communities and was successfully replaced. Work was underway on a comprehensive ambulance services funding and administrative policy, and work was accelerated to bring this forward to government. 7.56 ………your review notes some areas for improvement which the department had identified during its own internal assessment, and on which action had already been initiated prior to your review. This does not diminish the importance of the matters noted; however, it does serve to note that the Department was aware of and was addressing these matters. 7.57 Certain steps towards addressing these issues were announced in February 1997. These actions....., which have already been accomplished, include.....re-organization of the Branch to provide a separate Inspections Unit. This will provide 2.0 full-time equivalents dedicated to the inspection and regulatory processes. Previously, each inspector held various administrative functions.....reducing the availability of inspection time to 1.0 or less full-time equivalents.