Embarrassed and shocked by the large numbers of deaths in certain long term care facilities largely in 4 provinces, the Federal government is now calling for Long-Term Care Reform or the creation of National Standards for Long-Term Care.
A bit late, don’t you think? For a half century, public policy experts have been observing the growing population of aging baby boomers and forecasting that the health and long-term care system would be distressed at unprecedented levels. But in much of that 50 years, while health care has seen a boom in expensive new services, much of the approach to caring for that small segment of the senior population deemed to be frail or compromised by multiple chronic diseases seems to have progressed little. We do have an unprecedented number of long-term care facilities, many superb, that have grown more by accident than by design. Long-term care has morphed into a significant industry in the absence of consistent regulation.
When one major facility (not in Atlantic Canada) had its awful Covid-19 outbreak well over 8 months ago, I went directly to the inspection reports that are published on line. News flash: when you see the same violations repeated several years in a row, you know there are problems! Not an ownership problem but a regulatory problem. Unlike the airline industry, on which we rely for safety, there are vulnerabilities in the inspection and regulatory process. I would hope that an airline, cited for significant violations, would be grounded until fixed.
In the airline industry, personnel with flight training and experience play a key role in the regulatory process; that is how the regulators know what is important or not. Having a degree in aeronautics engineering will provide a theoretical base but the experience of flying a plane, with all that is involved, is ignored to the peril of the regulator and passengers.
In Long-Term Care, placing persons in regulatory roles who have had no training or experience in care management puts the regulator at risk. And therein is one explanation for some of the “surprises” during the pandemic. Issues that have been communicated to regulators for months and years prior to the pandemic are central to some of the shock and surprise experienced during the pandemic.
The federal government has no jurisdiction in the home care, hospital care, medical care, or long-term care under the Canadian Constitution. What the federal government has historically done is use its powers of taxation and revenue generation to provide cost-sharing, as they do with the Medicare, Hospital, and Affordable Housing Programs. In so doing they can prescribe certain basic standards that direct the way in which services are delivered.
The federal government can play a significant role, if they choose to, in providing seed money for major system change. They have taken some steps by awarding $75 million to New Brunswick that seems to be trickling out to projects of interest to academics and government. Thus far funds seem not to be targeted to the real core issues of effective and efficient senior care.
In the wake of the initial outbreaks, the spokespersons for some advocacy groups and unions got much media attention by calling for an end to “for profit long-term care”. The NDP, federally, have made that a major issue but like so many other surface issues, that phrase has nothing whatever to do with quality long-term care. Nothing! If you were to be consistent in applying the principle of ridding the health and long-term care system of profit motive, you would have to close doctors’ offices, dentist offices, drug companies, suppliers of all the products on which our health and long-term care sector are based.
The issue, as with the airline industry, is with regulation. Digging a bit deeper into what it takes to create and maintain excellence, you look to practices of the superb organizations as opposed to those that are in the news negatively.
The practice of housing frail seniors 3-4 to a room was a practice decades ago to which modern design and knowledge standards have all but eliminated. In long term care, when one frail person contracts the flu or a contagious infection, pretty soon it is spread to many in close proximity. Staff who have been rigorously trained will see and isolate the condition fairly quickly, but the condition can worsen and spread fairly quickly.
In great facilities, staff training and continuing education are priority; staff resonate to being well trained and not only does it improve their job satisfaction but it increases the probability of staff remaining with that employer for the longer term. In long-term care, that training includes all the principles of eldercare, infection control practices, safety, fire safety and more.
The culture of the workplace is absolutely critical in these facilities. In situations in which staff are reported to abandon their work, you can bet your bottom dollar that the workplace culture would be found to be woefully deficient.
Staffing standards in long term care are all over the map across the country with some provinces digging in and doing good research and development with others not so much. Indeed, even in New Brunswick there are glaring differences in staffing standards between special care and nursing homes and other forms of residential care. And what is the right mix of staff? As we learned in hospitals in the 1980’s, it is more than a numbers game. There are some objective, measurable criteria to be applied but there is, equally importantly, the need for judgement executed by wise, mature managers who balance cost and care on every decision they must make.
One of the major issues in the regulatory process is the ambiguous nature of the jobs of regulators. In the airline industry example, the regulators do not fly planes, nor do they manage hospitality, train pilots, ground crew, or ticket agents. Theirs is to regulate; others do training, hiring, management, flying, making passengers happy.
The regulators job, first, is to ensure that regulations represent state of the art, current, consistent with law, science and best practice including the international community. They do that by having a well-oiled policy research team that reaches out to and collaborates with people and organizations that provide service. That process will engage, no doubt, the research arms of the academic community, as well.
With long-term care service providers, the common message is micro-management by the regulator. It should not be the job of the regulator to respond to operational questions that start out with “can I…?” But that is the way it works; hours and hours of time with untold frustration of regulators and operators engaged in discussions that should not be happening.
The regulator must concentrate on the issues that count: what is the process of facility inspection? Is it based on current knowledge? What are the qualifications of the persons doing the inspection? Does the inspection focus on matters material to good and safe care for elders? Are there infractions that are repeated from the last inspection? If so, why and what is the remedy? Is this a facility in which I would feel safe leaving my mother? Who follows up on inspections with infractions? Who follows up on repeat infractions?
Up to date standards, rigorous inspection processes, staff with rigorous training, applying standards fairly, consistently, equitably regardless of who the owner/operator is. That, and more, will yield a long term-care system dependable, reliable, and capable of responding to the next outbreak.
Ken McGeorge,BS,DHA,CHE is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News and author of Health Care Reform in New Brunswick. His email address is firstname.lastname@example.org.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.