Enhanced Leeway and Collaborative Stimulus for Protecting and Defending Users and Their Rights
Training sessions on the complaints management system in the health and social services network
Fostering mutual understanding
Enhanced leeway and collaborative stimulus for protecting and defending users and their rights
Deputy Ombudsman – Citizen and User Services
Montréal: January 19, 2007
Québec City: February 22, 2007
The health and social services complaints management system is like a spotlight shining permanently on the system. And as local and regional complaints commissioners, you are, in many ways, the lighting technicians behind the spotlight. Your job is to shed light on the situations that users and their representatives bring to your attention. It is a task that requires a great deal of thoroughness and care.
I am delighted to participate in this training session. Given the major changes introduced last year, I would like to take this opportunity to present a new player in the health and social services field—the Québec Ombudsman. This gathering represents an ideal opportunity for us to discuss our respective roles and objectives with respect to defending user rights and improving the quality of service.
As you know, on April 1, 2006, the effective date of Bill 83, the Québec Ombudsman assumed the duties of the Health and Social Services Ombudsman in addition to its initial mandate. In doing so, it has become a key player in the area of complaints management in the health and social services field. What difference does it make now that the Québec Ombudsman has taken on this new role? What are the benefits for users? What impact does the change have on your role and your work methods? These are the issues I wish to discuss with you today.
Complaint and service quality commissioners share a common objective with the Québec Ombudsman: to ensure that the rights of health and social services network users are respected and that their legitimate expectations regarding quality service are met. Although the commissioners and the Québec Ombudsman act at different levels using different means, their efforts converge toward the same goal. Therefore, I believe it is in our mutual interest to clarify how they can work in a complementary fashion as they fulfill their respective mandates.
I know that a number of commissioners apprehend possible involvement by the Québec Ombudsman in their cases. I hope that my remarks here today will put their concerns in perspective. For my part, I feel strongly that our recently redefined levels of action open the door to a new era of cooperation. Together, the services we provide can complement each other to serve the best interests of health and social service network users.
Your contribution to protecting user rights is vitally important. Today, as Deputy Ombudsman – Citizen and User Services, I would like to lay the groundwork for constructive and productive collaboration between our respective levels of action. Our challenge is to use the twin-level mechanism as efficiently and effectively as possible.
The Act respecting health services and social services recognizes users’ rights. Those who feel their rights have been violated can seek recourse through the complaint review mechanism. This is a normal way to express dissatisfaction and seek a solution. Under the law, you are the first line of recourse. The law also stipulates that a user can contact the Québec Ombudsman at the second stage of this process.
Dealing with complaints requires time, effort, and energy. And to correct and prevent situations prejudicial to health and social service network users, the Québec Ombudsman and the complaint and service quality commissioners must have ample leeway, be guided by the same spirit, and have access to the full range of tools at their disposal.
The Québec Ombudsman: a politically independent form of recourse
Prior to April 1, 2006, the Health and Social Services Ombudsman was the institution tasked with seeing that users 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. This was all changed by Bill 83.
The Québec Ombudsman is an impartial form of recourse totally 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 users could benefit from this independent status, which is incarnated by the Ombudsperson, an independent public official who reports only to the National Assembly.
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 him or her with his or her work. This is how I was officially named Deputy Ombudsman last August after an 11 month interim as Health and Social Services Ombudsman.
Under the rules ensuring her independence, the Ombudsperson is required to act with utmost caution to preserve her impartiality and prevent political interference. The same goes for the deputy ombudsman and the staff of the Québec Ombudsman’s office.
Those of you who have been commissioners for some time already know that independence enhances your ability to act impartially in dealing with complaints. As a result of Bill 83, the two main forms of recourse available to health and social services network users now offer new guarantees in this regard.
On one hand, local complaints and quality of service commissions no longer report to management at their respective institutions, but rather to their boards of directors.
On the other hand, the merger of the Québec Ombudsman and the Health and Social Services Ombudsman into a single institution similarly enhances the available protection. Should the Québec Ombudsman determine that a health and social services institution has not provided adequate followup to on one of its recommendations, it can report directly to the government or to the members of the National Assembly. This increased independence is an unquestionable advantage at both levels of action.
Greater leeway thanks to intersectorality
You are all experts in matters of complaint. You know that complaints are valuable indicators of the problems affecting our health and social services system. You also know that they teach valuable lessons on how to improve the quality of service.
Québec’s health and social services network does not by any means operate in a vacuum. In fact, it has offshoots extending into numerous sectors of activity. Certain cases brought to your attention require a broader vision and a wider scope of action. Sometimes, you need to knock on several doors to obtain a fair and equitable solution for users. With its well-equipped toolkit, the Québec Ombudsman is a precious ally in this regard. Not only does Bill 83 bring numerous benefits for users, it also generates a stimulating and complementary dynamic between the Québec Ombudsman and the local and regional commissioners. Let me explain.
Have you ever felt powerless in certain situations? Or obliged to admit that in the face of a complex problem, you can only fix one small aspect within your immediate purview?
Problems arising at network establishments or entities may result in part from policy, legislation, or regulations originating within a ministry other than health and social services. Yet the solutions you can offer are limited by the scope of your authority.
With the passage of Bill 83, this has changed. Where you were once limited by the scope of your authority, the Québec Ombudsman, with its extended mandate, can now step in to assist the user in other areas. I believe that this represents a special opportunity for you to reinforce your role as user advocates, because the Québec Ombudsman can use all of its levers for action—and they are powerful ones—to remedy or prevent situations likely to impinge upon users’ rights.
Of course, the Québec Ombudsman, like the Health and Social Services Ombudsman before it, has a duty to review certain decisions you have made. This will not change. What is important to understand is that from now on, the process will not stop there. Starting from the principle that decisions may sometimes be incomplete or unsatisfactory due to the framework governing your actions, I believe that we have an opportunity to establish a new form of cooperation that transcends these limitations in the best interests of those filing complaints. I see this collaboration as being frank and open. From the moment we decide to work in solidarity to achieve this objective, we are on what promises to be a very successful road.
When the solution to a problem extends beyond your jurisdiction, the best decision is to refer the user to a well-known and recognized institution with the ability to influence decision makers from different organizations at various levels. In short, this allows us to examine the complainant’s overall situation and take action with all government departments and agencies to resolve problems in the health and social services network. This is assuredly a plus.
What holds true for individual complaints or incident reports holds equally true for cases where the Québec Ombudsman seeks to defend the greater good of society. With a power of recommendation that extends to all government agencies and departments, a power not available to you, the Québec Ombudsman can also help people who are victims of poorly coordinated programs and policies.
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 and suffers from backlogs.
Users 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 so that these objectives are fully achieved? The Québec Ombudsman has the authority to issue recommendations to both Société d’habitation du Québec and Ministère de la Santé et des Services sociaux. Which means that in a single step, users who feel they have been victims of unfair waits can contact the Québec Ombudsman to seek access to the services they believe they are entitled to.
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 at intellectual disability rehabilitation centers, institutions that report to MSSS.
When the children reach school age, rehabilitation therapy is often interrupted. Yet 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.
Government programs and policies must be coordinated to 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 users face in real life.
The Québec Ombudsman has the flexibility and authority to operate in an intersectoral manner.
Effective tools used wisely
To carry out her duties, the Ombudsperson is backed by a multidisciplinary team of professionals and technicians with expertise in various fields, including law, nursing, physiology, criminology, social work, and administration. Complaints are assigned to these delegates for review on the basis of their areas of responsibility.
Like you, the Ombudsperson and her delegates have the authority to access any information required to assess a situation. This includes the right to contact any person who may be able to provide information that is useful for their investigation. Moreover, local and regional commissioners must always be consulted when a complaint or reported incident involves their institutions or jurisdictions. Similarly, regional commissioners play an important role when problems reported have a regional dimension.
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 it can also act on its own initiative. When a situation is found to be harmful to a number of people in several institutions, 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 or set enforcement guidelines for a regulation, policy, or act in order to prevent inter-institutional or interregional inequities. These actions have a collective impact and are designed to prevent such situations from recurring and to improve the quality of services in a broader sense.
Equity, another major lever for action
Another important aspect of the Québec Ombudsman’s work is its ability to defend and move equity cases forward. Its 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 equity-based solutions in order to obtain corrective measures and improve the quality of service.
Equity is not the opposite of the law, it is an enhancement of the law. It “arises from a natural sense of what is right.” In concrete terms, equity enables the Québec Ombudsman to endorse an exceptional measure as a solution to a particular problem that cannot be satisfactorily resolved by following a law or regulation. Obviously, equitable intervention must not betray the purpose of the law or regulation in question. I am sure you also use this technique in certain special circumstances when it is the only way to render a fair decision that meets the legitimate expectations of users.
The Québec Ombudsman may refer to the principle of equity to correct an overly severe rule, supplement the rule, or interpret it when it is obscure. In the health and social services field, the use of this lever for action, which was also available to the Health and Social Services Ombudsman, has now been extended to reflect the Québec Ombudsman’s broader jurisdiction. The Ombudsman can take advantage of this principle to correct inconsistencies or incompatibilities between agencies and organizations. For network users, this can make all the difference.
A real ability to influence parliamentarians
Health and social services network users 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.
In addition to its power of recommendation, the Québec Ombudsman also has other weapons in its arsenal to educate MNAs. 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.
Lastly, even though it does not seek undue publicity, the Québec Ombudsman can take its concerns public if it feels the situation so warrants. In doing so, it always respects confidentiality.
A broader approach to health and social services
Health is one area where the government is in frequent contact with citizens. The Québec Ombudsman’s independence, intersectoral approach, tools, powers, and zone of influence facilitate its efforts to deal with both the sources and the consequences of the problems it is asked to address. More than ever, the levers for action that I have described for you today allow for a broader approach to the health and well-being of the general public.
The area of health prevention is a good example. Clearly, prevention must play a part in a comprehensive and integrated approach to health and social services. This requires the ability to 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 the conditions of imprisonment and social reintegration that many citizens have to deal with. Such actions are at the core of the Québec Ombudsman’s mission.
The Québec Ombudsman already shares the values of social justice and equity underpinning the delivery of health and social services by government ministries and agencies, including MSSS. The reason for a complaints management system within the health and social services network is to provide citizens with the tools they need to defend their rights. Free, flexible, and readily accessible, this system facilitates access to services that help users maintain and improve their quality of life. Indeed, 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.
Local and regional commissioners play a crucial role
In this light, the fact that the Québec Ombudsman’s can go further and take broader action in defending citizens’ interests does nothing to lessen the importance of your role. On the contrary, an effective first-line appeal mechanism is crucial to remedying most problems at the source and highlighting problems as experienced in the field.
Those who feel lost in the labyrinth of the health and social services network and discouraged by perceived unfair treatment or a lack of consideration and respect need to be able to make their voices heard. What can you do for them?
Resolving complaints means looking at issues from a user’s point of view. When you are wholly or partially convinced that a complaint is justified, it is up to you to make your case to management at your institution or organization. At all levels, complaints must spark reflection and action.
Your credibility with users lies in providing them with readily available services that are well known, fast, confidential, and transparent. With your skills, you can resolve most problem situations. When you cannot, users must have all the information they need to seek other remedies. For this reason you should systematically refer them to the Québec Ombudsman when you believe it could do more to assist them.
The Québec Ombudsman: first or last resort?
In situations involving two levels of recourse, the first level is generally compulsory. In principle, users or their representatives must file a complaint with the local or regional complaints and service quality commissioner before contacting the Québec Ombudsman. I say “in principle” because there are exceptional circumstances in which the Québec Ombudsman may act on a complaint or report without an initial investigation at the local or regional level. In such cases, the needs and vulnerability of the user take precedence in triggering immediate and direct intervention by the Québec Ombudsman.
For example, fears or incidents of reprisal constitute serious grounds for immediate action, and a complaint or report to this effect automatically triggers an intervention by the Québec Ombudsman.
Also, the Québec Ombudsman can always intervene on its own initiative when it feels that the rights of a user or groups of users have been violated.
As with the Health and Social Services Ombudsman before it, however, complaints of a medical nature do not fall under the Québec Ombudsman’s jurisdiction.
Good relations foster cooperative and complementary action
As you can see, the Québec Ombudsman fulfills a vital role. It is neither a stand-in for political or administrative decision makers, nor a judicial authority that replaces the courts. Its mission is to protect citizens and users against abuse, errors, rights violations, negligence, and inaction on the part of the public service and the health and social service network. It is a remarkable remedy because of its power to recommend rather than impose, its straightforward procedures, ease of access, and the flexible alternatives it suggests as ways for dealing with unreasonable decisions.
Thanks to the Québec Ombudsman’s newly broadened mandate, a new voice is speaking out in the health and social services field. Neither a competitor nor an enemy, it is a unique institution born of Québec’s democratic institutions. The Québec Ombudsman’s jurisdiction now extends throughout the network, from hospitals and foster families to youth centers and rehabilitation and long-term care facilities.
As the theme for today’s training session suggests, the two mechanisms must evolve in a spirit of “mutual understanding,” as we familiarize ourselves with our respective roles to better protect the rights of users. By combining our efforts, we can help improve the quality of the services provided through Québec’s health and social services network.
As complaints and service quality commissioners, you have intimate knowledge of the user environment and are in a privileged position to understand user needs and decode user expectations. You perform your duties with enthusiasm and professionalism that deserve generous praise.
For its part, the Québec Ombudsman has significantly expanded the range of tools available for dealing with complaints in the health and social services network. With its expanded jurisdiction, it has the ear of government ministries and agencies, which ensures that its vision and influence will reach more decision makers. Its powers enable it to address problems at their root and prevent situations that may be harmful to users.
With proper coordination, our respective actions will allow us to develop systemic solutions to recurrent problems. I believe that we need to maintain close ties and share our techniques and strategies. This spirit of openness already exists, since complaints and service quality commissioners meet regularly to share information with representatives of the Québec Ombudsman and various health and social services network organizations.
In this regard, the Ombudsperson, her delegates, and I, in my capacity as deputy ombudsman, are firmly committed to maintaining the quality relations that already exist between us. We are convinced that frank and constructive ongoing dialog will foster cooperation and complementary action that benefits all users.