The Québec Ombudsman: A New Player and New Levers of Action for Examining Health and Social Services Complaints and Reportings
The Right to Health Symposium, Ligue des droits et libertés de la personne
du Saguenay – Lac-Saint-Jean
Pierre-Paul Veilleux
Deputy Ombudsman – Citizen and User Services
Saguenay
November 15, 2006
I was truly a delight to accept this invitation. Mainly, because this symposium of the Ligue des droits et libertés du Saguenay–Lac-Saint-Jean provides me with the ideal platform to introduce you to a new player in the world of health and social services: the Québec Ombudsman. And also because your theme—“The Right to Health”—is central to our new preoccupations.
As you all already know, the National Assembly recently entrusted the Québec Ombudsman with a new mandate. Since Bill 83 came into effect on April 1, 2006, the office has also taken on the duties of the Health and Social Services Ombudsman, in addition to its own initial mandate.
Bill 83 marks a logical evolution that was strongly encouraged by many within the health and social services network. You no doubt have a number of reasons to be pleased it is now law. Firstly, because this decision gives the Health and Social Services Ombudsman an independence it hasn’t enjoyed until now. Secondly, because it provides the institution with effective leverage, with patients standing to benefit most.
Most of you know the Health and Social Services Ombudsman well, the Québec Ombudsman perhaps a little less so. The institutions were relatives of sorts until last spring and obviously held many values in common. Their incorporating acts were similar, albeit distinct. One differentiating feature was their fields of jurisdiction: the civil service for one, the health and social services network for the other. Now, they have merged into one, single institution whose head, the Ombudsperson, is appointed by the National Assembly and has joint jurisdiction, serving both citizens and patients.
There is no doubt that the efficiency, credibility, and independence of an institution like the Québec Ombudsman are powerful tools for preventing and rectifying situations that are harmful to patients. And this is true whether it involves analyzing complaints or reportings, or giving greater scope to cases it is defending for the greater good of society. The Québec Ombudsman can operate in areas the Health and Social Services Ombudsman couldn’t. Its influence extends not just across the health and social services network and to the ministry, but throughout all government agencies and departments. Its influence on MNAs alone gives it many opportunities to improve the quality of services provided by the health and social services network.
As you can see, the Québec Ombudsman’s new, broader jurisdiction fits perfectly with the theme of this conference. Having a known and recognized institution that cuts across decision-making levels, takes action in several fields at once, and has the real ability to influence decision makers gives real meaning to the right to health.
I called this presentation “The Québec Ombudsman: A New Player and New Levers of Action for Examining Health and Social Services Complaints and Reportings,” which doesn’t leave much to the imagination but at least we all know what we’ll be talking about. And my approach to this topic is just as straightforward: How will patients benefit from such a change?
The Québec Ombudsman’s mission
The Québec Ombudsman constitutes, with its broadened jurisdiction, if not quite a new institution, then at least a transformed one. And as a result, it is facing a huge challenge, perhaps the biggest since its creation in 1968.
I think it is interesting to look at how these changes will benefit patients. First of all, I would remind you that the original mandate of the Québec Ombudsman remains unchanged. It is still tasked with monitoring the Québec government, and as such it helps to strengthen the rule of law and democratic values, which are the foundation of the relationship between the state and its citizens. Now with the addition of the health and social services network, a whole new area has fallen under its responsibility.
The Québec Ombudsman must, on the one hand, ensure that citizens are treated with respect, fairness, and equity by the government. On the other hand, it now has to ensure that patients are treated with respect and that their rights are respected, as set out in the law.
In short, its mission is to correct and to prevent harmful situations and, ultimately, to improve the quality of services on offer.
The Québec Ombudsman’s independence
Health and social services have been part of the Québec Ombudsman’s jurisdiction since last spring, when. two institutions were merged into one to reinforce the available means of intervention.
The Québec Ombudsman is an impartial and accessible form of recourse, independent from political authority. In fact, the Québec Ombudsman was entrusted with the additional responsibilities of the Health and Social Services Ombudsman primarily so that patients could benefit from this independent status. The Québec Ombudsman is represented by the Ombudsperson, an independent public official who reports only to the National Assembly. Since its independence was such a key reason for the transfer of jurisdiction from the Health and Social Services Ombudsman to the Québec Ombudsman, let’s have a look at what makes it so independent.
The appointment process for the ombudsperson is initiated by the premier, who puts forward a name that must then be approved by a two-thirds majority of members of the National Assembly. The current ombudsperson, Ms. Raymonde Saint-German, was appointed in this way on April 13, 2006, for a renewable five-year term. Once appointed, the Ombudsperson advises the government on the appointment of two deputy ombudsmen to assist her with her work. This is how I was officially named Deputy Ombudsman, Citizen and Patient Services last August.
Prior to April 1, 2006, the Health and Social Services Ombudsman was the institution tasked with seeing that patients were treated with respect and that their rights were respected, as set out by law. It was a credible and competent institution; of that there is no doubt. Unlike the Québec Ombudsman, however, the Health and Social Services Ombudsman did not enjoy complete independence from the health ministry, as I have just described. The Health and Social Services Ombudsman, both as an individual and an institution, reported to the ministry and the government as a whole. Bill 83 changed all this.
The Québec Ombudsman’s levers of action
Processing complaints and reportings: accessibility and complementarity
Simply put, a patient whose rights have been violated or who has been denied access to adequate services of an acceptable standard must be able to have the situation corrected. But the means of recourse must be easy to access to be effective, and I’m sure that nobody in this room would claim otherwise. In other words, complex and ineffective recourse is a barrier, not a solution. I would go so far as to say it places insurmountable obstacles in path of those who do not have the socioeconomic means to create an environment and living conditions conducive to the maintenance and improvement of their health.
The health and social services complaint review process in which the Québec Ombudsman is involved is therefore of immense value to patients who don’t want to or quite simply cannot afford to turn to the courts to defend their rights. Recourse to the Québec Ombudsman is free, simple, and accessible. This is important because lack of access to service is often the cause of citizen dissatisfaction, especially in the health sector.
Health and social services network patients who feel wronged therefore have access to a number of complementary appeal mechanisms to protect their rights.
The power of the Health and Social Services Ombudsman, combined with the power of the Québec Ombudsman, thus gives health and social services institutions the means to learn more from the complaints they receive. The adoption of Bill 83 has also confirmed the role of the main people involved, that is to say, the local complaints and service quality commissioners. These commissioners now enjoy exclusive authority and report directly to their boards of directors. The institution of second recourse also had to be independent of the executive branch of government.
Local and regional complaints and service quality commissioners are the first line of recourse for patient complaints and third party reportings.
Since April 1, patients have had a further place to turn. If they are not satisfied with the conclusions of the local or regional authorities, they can send their complaints to the Québec Ombudsman for further examination. Given the Ombudsman’s powers, it’s one more way of considering all possible solutions to problems raised. Why? Because it is highly likely, for example, that the solution will come from harmonizing various programs administered by government departments and agencies. The Québec Ombudsman can investigate and send its recommendations to all government departments and agencies, not just Health and Social Services.
The Québec Ombudsman steps in when it has reason to believe a patient has been or could be wronged. It can also act on its own initiative, without the need for a preliminary local or regional investigation. A problem reported by a third party can also lead to an investigation. It should be noted, however, that complaints of a medical nature do not fall under the Québec Ombudsman’s jurisdiction.
The Québec Ombudsman’s jurisdiction now covers virtually all of the health and social services network, from hospitals and foster families to youth centers and rehabilitation and residential centers.
I should also stress that major progress has been made recently with the addition of private retirement homes, which wasn’t the case before Bill 83.
In the past, the Health and Social Services Ombudsman had no legal right to intervene in such homes. It would, however, receive many reports about them, especially concerning their upkeep and cleanliness and the quality of services they provided. This major shortcoming has been addressed. The Québec Ombudsman is now free to investigate the practices of private residential homes, to visit them and recommend action to be taken, if need be. This is an important development seeing as the people living there have lost their independence and are often isolated, making them particularly vulnerable.
Serving citizens—and society as a whole
As I already mentioned, the Québec Ombudsman can act in response to a complaint or a reporting, but also on its own initiative. When a situation is revealed to be harmful to a number of people, the Québec Ombudsman can ask that corrective action be applied to all of them. In such cases, it can choose to address the cause of the problem by recommending that a ministry or agency amend a regulation, policy, or act for the benefit of society as a whole. This prevents the situation from repeating itself and helps improve the quality of services in a broader sense.
Take, for example, the case where the Québec Ombudsman asked MSSS to review its regulation governing room fees for hospital patients. The regulation dates back more than 25 years. At the time, most treatment was administered in the wards and was therefore free. Since then, the situation has evolved: Babies are born in birthing rooms, and intensive care has become more and more common in private rooms. Patients must therefore pay for a room to receive this type of care without it being a personal choice. As this calls into question the concept of universal access to health care, the regulation no longer corresponds to reality.
Greater efficiency thanks to intersectorality
One of the advantages of combining the responsibilities of the Health and Social Services Ombudsman with those of the Québec Ombudsman is the resulting intersectorality. The Québec Ombudsman is now free to act within the health and social services network while also intervening, for example, with Régie de l’assurance maladie, Le Curateur public, or Ministère de la Santé et des Services sociaux when they are involved. The Québec Ombudsman’s influence and approach give it greater leeway in solving citizens’ problems, which often stem from a lack of coordination between government programs and policies.
A look at patient complaints shows this to be the case. Take, for example, the difficulties persons with permanent physical disabilities have with the Residential Adaptation Assistance Program. The program is administered by Société d’habitation du Québec, which reports to Ministère des Affaires municipales et des Régions. Patients have to wait months, if not years, for their homes to be adapted so that they can go on living there in a safe environment. Program eligibility must be confirmed before work is allowed to begin. Otherwise, no refunds!
And yet MSSS policy advocates keeping people in a safe living environment. Not only that, it seeks to prolong home care for as long as possible to prevent putting people into institutionalized care earlier than necessary. Should the program not be more closely tied to policy?
There are also complaints about situations affecting children who suffer from a pervasive developmental disorder. Between the ages of two and five, a number of these children undergo rehabilitation therapy as part of an intensive behavioral intervention program. The program is offered by the Intellectual Disability Rehabilitation Center, an institution that reports to MSSS.
When the children reach school age, rehabilitation therapy is interrupted because—theoretically—the children have been successfully integrated into the school system. But sometimes they are not quite prepared for school life. If the decision to put an end to the rehabilitation program is based on their age rather than individual needs, we risk slowing their school progress.
A truly preventive approach requires that government programs and policies be coordinated. It must ensure that agencies and departments, as well as the health and social services network, are more focused on the individual rather than program management and administration. This requires the flexibility to deal with individual problems patients face in real life. That, too, is part of the right to health. With this in mind, the Québec Ombudsman, which has now taken on the duties of the Health and Social Services Ombudsman, is a new tool that allows us to go further than ever before.
Acting on the grounds of reason and equity
A little earlier, I spoke of the need for citizens and patients who felt wronged to have a means of recourse. I mentioned that with the two Ombudsmen now sharing the same duties and responsibilities, the result was a new complementarity that was to the benefit of patients. I would now like to talk about another aspect of this that I didn’t touch upon earlier: the Québec Ombudsman’s ability to defend and move equity cases forward in order to rectify a situation and improve services.
Unlike the courts, the Québec Ombudsman’s scope of action is not limited to the legality of the acts and decisions of the bodies under its jurisdiction. It can be called on to investigate unreasonable, unfair, or abusive acts committed by an organization. In assessing the situation, it may intervene and recommend corrective measures or remedies based on equity.
Equity “arises from a natural sense of what is right and not from positive law.” It has a triple role: correcting an overly severe rule, supplementing the rule, or interpreting it when it is obscure.
By its very nature, equity-based action is for situations of exception. When it takes such action, the Québec Ombudsman must…
- Respect the lawmaker’s intent
- Assess the extent to which the citizen has been wronged
- Make a reasonable recommendation
A real ability to influence parliamentarians
Health and social services network patients will now also benefit from the role the Québec Ombudsman plays in advising parliamentarians. To fulfill its oversight role, the Québec Ombudsman systematically studies all new bills and draft regulations. It analyzes them to determine their administrative, economic, and social impact—and their potentially harmful impact on citizens. It can then propose changes likely to improve them and prevent situations arising that could prove harmful to citizens.
The Québec Ombudsman also has other weapons in its arsenal, in addition to its power of recommendation, to sensitize MNAs. In particular, it can elaborate on cases in special reports or in its annual report and, when it believes it to be in the public interest, publicly comment on these reports.
The Québec Ombudsman, a key player in defending the right to health
Given its mode of operation, governing principles, and new jurisdiction, the Québec Ombudsman is most certainly a key player in fashioning a society that pays more than lip service to the right to health.
In this respect, the recent changes significantly contribute to an accessible and impartial appeals process for patients. The single institution that has resulted from the merger of the Québec Ombudsman and the Health and Social Services Ombudsman offers many benefits. More than ever, a broader approach to the public’s health and well-being is needed. Health is one area where the state is in regular contact with citizens. The Québec Ombudsman’s new jurisdiction provides it with a unique opportunity to advance the right to health. The challenge may be great, but the cause is just!
Clearly, prevention must play a part in our overall approach to health and social services, which must be integrated. This will require that the Québec Ombudsman act on a number of factors that influence an individual’s environment. I have in mind, for example, policies on social housing, social aid, or conditions of imprisonment that many citizens have to deal with. Having an efficient, accessible, and impartial appeal mechanism for patients is also part and parcel of this approach and another step in the right direction. Socioeconomic status has a dramatic effect on an individual’s ability to make healthy choices, as those who work daily in this field know only too well.
The Québec Ombudsman already shares the values of social justice and equity that underpin the ministry’s organization of health and social services for the population. This shared value system must also be reflected in how complaints are handled and in all the efforts undertaken to improve the quality of care and ensure that patients are treated with respect. The Québec Ombudsman’s powers of intervention in the health and social services sector are in keeping with this goal:
- Act beforehand on bills, draft policies, and draft regulations to prevent situations that may be harmful to patients
- Correct inequities after they happen and protect patient rights
A new voice is speaking out in defense of patients’ interests and rights, a voice that speaks not only to institutions in the health and social services network, but also to government departments and agencies and all members of the National Assembly.
The Québec Ombudsman is an institution like no other, working tirelessly to improve the quality of health and social services.
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