Dear Louise and Miranda;
Further to your recent correspondence with Camille Parent of Ontario Cares, Camille has referred these to me, as we collaborate, share objectives on – (1) Stopping, Preventing Abuse, Neglect of RESIDENTS in LONG TERM CARE HOMES and (2) Providing all residents a Quality Life. I support, am a member of Ontario Cares and as needed, requested, act as Communication Liaison for Ontario Cares. Like Camille, I too, have many years experience with a parent in LTC and prior to that many years’ experience with my parent in a Retirement Home. Though my parent did not experience the horrific severity of abuse, neglect, as did Camille’s mother, there is no doubt abuse and neglect are prolific in the care and treatment of our seniors and sadly, particularly rampant in LTC.
With a career background (which I sacrificed to care for my parent for 15 years) in “organizational development”, I spent 25 years, plus, assisting organizations in aligning their Vision, Mission, Values, strategies, goals/objectives; also ensured their employees, had their competencies” i.e. skills, knowledge , attitude to carry out their roles in the organization were in alignment to achieve the organizations’ goals/objectives. This included everyone from top management throughout all organization functional areas e.g. admin, accounting, operations, service delivery etc… Within today’s complex health system, alignment does not exist, as evidenced by the abuse, neglect in Long Term Care homes and the failure of the MOH, OLTCA to take the required actions, especially as the MOH does not really “enforce” the LTC ACT.
An organization cannot simply adjust, change just one dimension without looking at how the adjustment affects every other dimension and every person in the organization. Like throwing a stone in to a river…. one change causes a “ripple effect” throughout all other organizations.
If we look at the LTC as one aspect of a dynamic health system … we definitely have lots of evidence of how badly some are aligned, the results being terrible failure – abuse & neglect and yes, death in some tragic incidents. I know, in LTC, being there daily, for 5 years, I saw unacceptable behaviours, actions and in-actions, by staff, lack of supervision, lack of coaching for staff members, broken communication processes or, little to no communication processes throughout the organization, insufficient staff. From my networking with other caregivers, this situation prevails in many, many, many homes. When you read an organization’s MISSION STATEMENT, their VISION, their VALUES and then compare these to how people “actually live these”, it is quickly apparent there are many disconnects, variances. Net, net, failure to meet their own standards.
Here’s what we know:
-The Long Term Act is being violated and there is lots of evidence of abuse, neglect
-The MOH has inspectors and re-act to family complaints and the media spotlight; they do not prevent abuse, neglect, they inspect after the fact
-MOH inspect complaints, document the violations of the Long Term Care Act – physical and mental abuse, neglect, and submit these to the LTC homes
-LTC homes have the right to appeal their findings, but families do not
-The MOH imposes the same consequence on the LTC home for proven violations of the ACT, regardless of the severity of the abuse, neglect
-The consequence imposed is that the LTC Home write and submit a plan to the MOH, so the abuse does not re-cur
-MOH then have to return to the LTC home at a later date where the violation happened to inspect whether the LTC plan is in effect
-If not, the MOH simply writes up another report to the LTC home, and so the ineffective cycle continues
-We and the MOH know very well this consequence does not deter, prevent or stop abuse, neglect
-If it was having the desired effect of “preventing” abuse, neglect (which an effective consequence should do) then abuses would not still be occurring, as it currently is
-No further abuse is the only acceptable measurement for resident safety quality
-Yet, seniors’ families and advocates are still reporting these incidents
-As per CTV recent reporting, many cases are also unreported
-PSW Unions enable PSWs, who have been proven to violate the LTC ACT and abuse residents to keep their jobs or, to be re-hired
-This Union imposed re-hire, re-instatement “protects” able-bodied staff and impose minimal consequences, if any
-The fact our police cannot criminally charge LTC homes or their staff for proven severe abuse, violation of the LTC ACT is “evidence” the MOH protects the LTC homes
-So who really protects our sick, old, frail, cognitively challenged, vulnerable, defenceless residents?
-Family Caregivers want the standards, rules, regulations the LTC ACT to be enforced and an independent body overseeing PSW’s that will hold them accountable
-We also know the medical/health professionals’ training is regulated and standardized while PSWs training is neither of these
-PSWs spend the most time with residents, (more than regulated medical, health professionals) assisting residents with their daily living activities
-They are in the best position to observe changes, variances in residents’ mental and/or physical status and report these to the RPN’s or other designated LTC home staff
-These resident changes, variances in mental/physical status then move through the LTC home’s established communication processes, and the families, until the status variance is dealt with according to a designated protocol
-I know not all employed PSWS are using the “job required skill” of observing and “job required skill of communicating resident changes to appropriate LTC staff for needed attention (direct experience)
-I also know the skilled PSWs who “do report” issues, that their report is ignored and the resident’s condition is neglected and worsens (direct experience)
-There are also LTC communication processes that are mis-aligned or even don’t exist, because “all” staff responsible for “working together” to care for the resident either, don’t know what their LTC home communication process is, don’t know how to respond to the issue or, simply don’t care.
-Unfortunately the PSWs, who are closest to the residents issues bear the blame for abuse, neglect and yes, sometimes they are responsible, accountable, but there is enough incompetency, misalignment in how the LTC homes operate and how well they conform to their own established and posted quality standards to go around
-MOH requires lots of documenting by the LTC homes on their “Quality Indicators”, i.e. what they want measured and how; the MOH measures “quantities” of many things, but unfortunately not quality of staff communication skills, approaches to residents, how well the LTC homes are conforming to established standards
-MOH do not track/measure the “quality of the staff/employee competencies i.e. the skills, knowledge, attitude required by LTC homes’ management teams or staff, so abuse/neglect can be prevented.
-Homes have in-service training and regular staff meetings to address residents’/families concerns re abuse/neglect which should stop/prevent abuse
– But it’s not effective as the same issues of abuse, neglect re-cur, again and again, many times by the same individual, so the effectiveness – “quality” of in-service training has to be questioned (my and other caregivers’ direct experience)
-No amount of collaboration by Family Councils with their loved one’s LTC home’s management team to correct issues leads to better conditions (my and other caregivers’ direct experience)
-The LTC management team says – the MOH doesn’t give us sufficient funding to train or, hire more staff
-How are caregivers, residents supposed to change that?
-The LTC homes do their own hiring of PSWs, so aren’t “they” responsible, accountable for their own hiring successes or failures, PSWs’ supervision, coaching if the PSW is either unable or unwilling to improve? And why shouldn’t they be allowed to terminate a non-compliant employee after all avenues for improvement have been exhausted?
-Do the LTC homes and the MOH lower the standards so incompetent people can keep their jobs?
-The staff ratio to residents is high.. approx 1 staff member to 13 + residents
-The residents being admitted to LTC today are older, sicker, frailer, have more chronic issues, more cognitive (dementia, Alzheimer’s) issues, and take much more time to assist with their “daily living activities” (DLA)
-The MOH has not only ignored ensuring that the right people are certified to become PSWs, how well the LTC homes conform to quality standards, they have no knowledge of the amount of increased time needed for each resident, so the ratio which may have worked years ago, is definitely NOT working today for this aging, sicker, frailer population
-And the top performing PSWs are getting burned out emotionally and physically, (having to do the work of the incompetent PSWs) so workers compensation benefits have undoubtedly soared, adding to the health care costs
-How seriously does the MOH really take LTC residents?
Three years ago, May 30, 2011, I facilitated a meeting with some members of the MOH Compliance Department and family caregivers of the Family Council Association Network. The purpose of the meeting was to ensure the MOH Compliance Department understood family’s concerns re LTC abuse, neglect of their loved ones. As a result of providing a clear understanding to the Compliance Team (much evidence was presented) the outcome we desired was they (MOH) would take specific and appropriate “Action” steps to enforce the LTC ACT in homes. Rachael Kampus of the MOH Complaints Dept responded with ACTION plans she said MOH would take. Yet, these had no direct relation to or on stopping/preventing abuse. In 2015 the abuse, neglect continue. How seriously did they take our seniors & their caregivers?
Prior to this meeting with the MOH’s Rachael Kampus & her team, the MOH itself initiated 2 commissions to uncover the LTC problems and make improvement suggestions; one logically concluded this initiative was undertaken so the MOH would fix the right problems with the right solutions that would work. There was the Starkey Report in 2007 and another initiated in 2011 by MOH Deb Matthews. Both reports confirmed the exact same issues that families have been telling the MOH for years – LTC homes need to be better operated, staff better trained, increased staff. Families also wanted enforcement of the Long Term Care ACT but the commissions, sidestepped this issue. And the abuse continued!
Current LTC STATUS
Eight years after the Starkey report, 2015, with 8 more years of family complaints, media exposure and we still have problems of abuse, neglect which have and will continue, to escalate, get worse, because this aged population is growing. Unless the MOH identifies and fixes the “RIGHT” root causes of the problems and develops the right solutions and effectively implements them, we are doomed. It won’t matter if lots of jobs are available, our children, like I and others have, will be doing the work of the MOH and LTC homes at NO charge.
While the word “quality” and the term “quality improvement” are used everywhere by the MOH and others in the health system, I have yet to see defined what they (MOH/others) mean. As a Quality Management facilitator for years, the first thing to learn about “quality” is the definition and that everyone must share the same understanding of the word quality.
Otherwise it is chaos. And all “health stakeholders” involved with or, who support the LTC homes in providing QUALITY, need to also share this same understanding, analyze their organizations to see how they are currently performing, identify the root causes of non conformance to quality standards, develop and then implement solutions so quality is the ultimate result. Everyone agrees this is needed, wanted, so why is it not happening?
Thousands of organizations have implemented QUALITY MANAGEMENT to transform their organizations successfully and deliver quality. I’ve used his approach to assist several organizations and wonder what Quality Approach the MOH, LHINS, CCACs, LTC homes are using. Clearly whatever their approach is, they do not have a shared understanding because we still have a broken system with abuse and neglect continuing.
The definition of quality, is easy to understand: “ Quality is Conformance to Standards” . So if all organizations in the health system have standards, the solution to providing quality care and specifically preventing resident abuse is first, people must “conform to job standards”. If the LTC ACT is a standard, then the MOH needs to act and enforce the standards.
I researched the standards set in the LONG TERM CARE ACT. I researched the MOH standards about LTC homes. They are clear. I also researched the PSW job standards by reviewing their Curriculum for certification and here’s what I found:
The PSW curriculum is accredited by the Ministry of Colleges Training and Universities. Louise, as per looking at the OPSWA website, youdeveloped the PSW curriculum & have also taught the program to PSWs. Your description on the OPSWA website is sound, covers the relevant skills/knowledge, we, as families want as credentials for the PSW’s caring for our loved ones. The ON Ministry of Training/Colleges website, has a more in-depth, comprehensive PSW job description which contains, in much detail, the objectives, knowledge and skills PSWs will have by the end of their course, when they are certified.
All looks great!
So, if the curriculum makes sense, has and teaches what PSWs need to know and be able to do and, if the PSWs pass the accredited certification course, why do we still have abuse, neglect in the homes?
I have to ask –
-What are the standards the colleges have for accepting someone in to their program who wants to be certified as a PSW? Or, do they admit ANYONE, regardless of basic abilities, standards?
-Are there any standards? Are they the right standards? If none, then the candidate, who perhaps doesn’t have the right basic skills is more likely to fail, because they did not have the foundational standards
-To develop standards for candidates to be certified to perform any job, the first step is to analyze the “job” requirements that the certification training program supports; then you know from that analysis what the basic standards are for someone to be successful in the training program and subsequently successful in the PSW job or, ANY job in an organization.
Then I wondered:
-Is the curriculum that is taught in all the colleges, standardized and regulated by the Ministry of Colleges and Training and by the MOH?
-How is the curriculum being taught to PSWs by the college instructors? Do the colleges have standards for all PSW certification instructors in all the colleges/organizations who offer PSW certification?
-Are the instructors certified and monitored for the quality of their instruction? What are the “quality standards” for the instructors?
-Who monitors, vets these instructors, coaches them if they require improvements? Just the colleges? MOH?, Ministry of Training? ???? Who’s responsible for overseeing the instructors’ performance so they are conforming to the PSW certification quality standards?
-If the PSW is certified as having passed, acquired the right competencies- i.e. skills, knowledge, attitudes by a college/organization, then,
-WHY is it that they lack such basic skills i.e., how to talk/listen/communicate to residents, families, colleagues demonstrating “respect and dignity”, how to problem solve, how to think, and prevent the abuse of residents?
These are basic standards needed in the job of a PSW! If they do not have a strong comprehension of the English language, how do they even acquire the knowledge, skills, taught in the certification program ? To learn you first must understand, then, you are able to perform!
And the basic of basics in communications – are: understanding, comprehending, speaking the English language – (I had daily problems at my dad’s home with staff who’s English was barely understandable, unless I repeated and repeated questions until I understood; my poor dad who was hard of hearing never could understand those who did not speak/understand English) – he was very hearing impaired, so he’d just smile and nod his head) The colleges must ensure their PSWs meet a high enough standard in English language competency to be able to “learn” and show proficiency in all they need to learn to be successful in their job as a PSW. Language proficiency is a JOB requirement in this role, not something nice to have, or the LTC homes hope PSWs learn as they go along. In LTC, our parents lives are at stake!
If an individual does not meet the basic established standard for English, (required by the job analysis), then the potential employer has the responsibility, if they want to hire them, to provide them English language training, including comprehension, listening and speaking skills first, before they care for residents. To admit PSWs to certification when handicapped by not having a good command of the English language is a disgrace…. the colleges, LTC homes are responsible, accountable for treating everyone equitably, not making it more difficult to do a quality job! This is a terrible dis-service and is also disrespectful to all potential PSWs or any employee.
I’ve worked in Human Resources and this is NOT discrimination – ENGLISH comprehension & being able to communicate with respect and dignity towards residents in LTC is a JOB REQUIREMENT SKILL. This skill minimizes mistakes, makes safety possible and treats “seniors” with dignity and respect. If PSW candidates speak more than one language, wonderful; they will be a tremendous asset. Remember, our official languages in Canada are English & French. English in Ontario IS a JOB REQUIREMENT!
The health “system” has many components; LTC is but one component. However, if the LTC homes (1) understand and (2) want to (both mandatory) to operate effectively, they need to analyze their whole organization and ensure everyone in their organization shares the same understanding of their Mission, Vision, Values and that the following elements are aligned: their Leadership, their systems, policies, procedures, their hiring competency standards and promotion practices, their training practices, their measurement of productivity, and their rewards and recognition programs.
Workers who belong to Unions have that right; established Unions have represented workers for years. Yet, Unions need to be aware of “the quality job standards” required by those workers they represent. When LTC residents are abused to the extent which many have been e.g. Mr. Parent’s mother and found guilty of abuse, then Unions must respect the job quality standards and acknowledge the worker has violated them and lost their right to job protection. Who negotiates Union contracts? The Unions and employers? Then responsibilities for and terms of the contracts agreed upon, rest equally with both parties. Ultimately, LTC residents must be protected by all stakeholders, including Unions.
WHERE to START
Because the PSWs are critical care service providers, who see residents the most during their shift, we as consumers, funders, families, need to have answers to all the questions asked above about them and their certification– then we can look at who they report to and if those supervisors understand the PSW job, and if they have the skills to provide effective feedback to PSWs (not punish them) the coaching skills needed to assist the PSWs in improving in delivering quality care.
The journey of a thousand miles begins with the first step! Acknowledging families need to be engaged.
Having reviewed your website, and the content of your emails, here are my comments, perspectives and concerns:
-The MOH, the LTC homes do not enforce the LTC ACT, despite pleas from families to do so for years; therefore what power or, authority might they confer on OPSWA that would enable your association to improve the situation any more than they (MOH) currently do?
-Yes, PSWs should have their own association but not to govern their performance, or their conformance to quality standards, or compliance with the LTC ACT;
-The LTC homes that hire and supervise all staff, are responsible for the governance, accountability, penalties for non compliance with conformance to standards and proven violations of the LTC ACT;
-As an outside group very far removed from the LTC homes where incidents occur, the OPSWA would simply be another level of bureaucracy
-OPSWA does not need to set a “higher standard” for PSWs; the “quality standards” already exist, as described above; the LTC homes are the ones who interview, select, hire their RN’s RPN’s, PSWs, operations staff etc.. according to their quality standards
-All ON LTC homes are under the same LTC rules and regulations, set by the MOH as well as the LTC ACT
-The wide variances in LTC employee, staff performances, and their operations we observe, experience should not exist. These variances indicate clearly, that all LTC homes do not, have either the right quality standards or, are not effectively implementing, enforcing these standards, or do not have the right people in the positions required.
-This is misalignment
-The LTC homes, like any employer, need to ensure all staff, including PSWs meet the existing PSW quality standards as set out by the Curriculum for the colleges (though that should be reviewed too) and be held accountable to the LTC home and families of residents who are just as critical a customer for the LTC homes – the family caregivers make decisions for loved ones when loved ones cannot speak for themselves
-MOH already do inspections, and unsatisfactorily, because they are re-active; residents and families are entitled to prevention, not anafter-abuse, negligence inspection when an already vulnerable resident’s condition worsens or dies, due to abuse, neglect. After the incident, “re-active inspections” will not restore a resident’s condition to pre-abuse status, improve a resident’s life, or relieve a family’s fears/anxieties about the safety of loved ones nor, bring the resident back to life, if death occurs as a result of their violations – “after” the incident is not Quality CARE
-The fact is the PSWs are caring for vulnerable, sick, older people with physical & mental challenges who require “health care”, are receiving it by “health care personnel”, in a facility dedicated to “safety and health care” of their residents
-PSWs play a vital role through their daily tasks, and responsibilities which include observations of the residents’ health status and their responsibility to inform/communicate to the appropriate personnel in the LTC home who are the ones designated to “take appropriate actions.”
-While your site states OPSWA will have a complaints process, why is this (a mandatory process) not described on the OPSWA website; what is the OPSWA’s discipline process? Where is the transparency, the support of family caregivers’ concerns on your web site?
-Nor does the OPSWA website describe how the OPSWA will hold PSWs to account or, what consequences will be imposed for the specific types of incidents that violate the LONG TERM CARE ACT
-The OPSWA site provides no process, action steps for how a registry would work; how would it ensure the public, LTC homes and others of the PSWs performance, if the PSW has ever been found guilty of violations; a transparency issue, again
-While it was, as stated, in your email “a recommendation that PSWS be governed by a group of their peers“, from long time experiences, we know, it is not the most effective proven idea. The evidence on peer colleges that exist for nurses, doctors, lawyers etc… have many problems which have been exposed in the media. Peer colleges’ complaints and discipline processes, have failed. The work involved by individuals to register a complaint, the time it takes to have issues responded to, let alone heard and resolved are all very problematic, very time consuming and take considerable effort. And it is also costly to the individuals that bring forward and pursue resolution of their complaints. Canadians who pay for our health system, are entitled to transparency, ease of use of any process and “impartial people” involved making decisions – peer colleges are neither truly impartial nor, unfortunately, objective.
The number of family caregivers who provide care to their loved ones and are at the LTC homes daily, at their own expense, sacrifice careers, time with their own children, spouses because of the incompetence in LTC homes and the MOH’s refusal to take meaningful actions when they have “hard” evidence
-This avoidance of direct effective actions and the “health speak” for years, is no longer acceptable, nor credible; trust is long gone. We are simply tired of the inadequacies in the Ontario and across Canada provincial health systems; we’re tired of the phrase “we take seniors’ issues very seriously and tired of the long winded wordiness and obtuse language in the MOH and other like-minded government & organization responses
-That is why families do not trust, believe, and can hardly respect the words spoken by the government and MOH any longer; all this proves is that “the best indicator of future performance is PAST performance”, because that is the “hard evidence”.
-That is why families are advocating and will continue to advocate for engagement, to be heard, for changes, the RIGHT changes
-Our seniors, residents in LTC built this country, in many cases fought for this country, worked hard, paid taxes, raised and educated families, contributed much to their communities, while our various provincial and federal government representatives have squandered and mismanaged we, and LTC residents (tax payers) financial contributions
-We no longer tolerate abuse, neglect of this population nor, ourselves – we too are aging
Let us get at the root problems. Let’s have evidence that Families’ perspectives matter, are a vital piece of the health system are invited to the discussion table, are engaged as partners in discussing these issues directly affecting loved ones, us, identifying the root causes and developing, implementing solutions and involved in the monitoring of the performance of the LTC system, in collaboration with the health professionals, organizations. One-sided perspectives i.e. PSWs, health professional organizations, government, like the MOH, OLTCA, CMA, CNA etc.. unfortunately, only ever have their OWN perspectives, which, is of course, is very understandable. If the only tool you have is a hammer, then everything looks like a nail. Residents entering LTC today are in most cases unable to speak for themselves on problems the families witness, so we will speak for them.
In summary, I am sure your intent is sincere. However, I join Camille Parent, in saying, we cannot support your plan, as OPSWA, has not articulated nor demonstrated a comprehensive understanding of family caregivers perspectives, least of all family members who volunteer countless hours of care to their loved ones, sacrifice their careers and have their own earnings eroded because of an incompetent LTC health system. We need to first, identify the “root causes” of the problems and engage all stakeholders equally, i.e. especially, family caregivers.
There are dedicated, talented, knowledgeable, compassionate PSWs who deliver “QUALITY” each and every time they interact with a resident. I know some who met and exceeded standards. I am forever indebted to these few and have expressed my gratitude, many times. Yet, I quit my career to provide daily care at the LTC home of my parent, because the variance among all PSWs on any one shift in terms of their competencies, skills, knowledge, not to mention inability to communicate in English with me, let alone my hearing impaired parent, did not meet quality standards required by the job. I could not and did not trust they would “all” treat my dad well. Experiences taught me that. Despite numerous complaints, discussions with the home where my dad resided for 5 years, nothing was ever really remedied. It was like playing WHACK A MOLE – you think you have the problem solved, then WHAM, it re-appears a few weeks later with same people each time. PSWs and all other staff who don’t meet or who are either unable or, unwilling to meet quality standards must be weeded out; LTC homes not having processes, policies, hiring, training, etc must be held accountable when violations happen under their roofs.
I believe we all want the best for our LTC residents – safety, a quality life, peace and serenity, comfort and pain management; the real challenge is how and with whom we will accomplish this.
Communication Liaison & Member, Ontario Cares,
Publisher, Our Health Care, Our Choices