Directives to Hospitals in respect of Reporting Requirements under the BPSAA

Transcription

1 DRAFT Directives t Hspitals in respect f Reprting Requirements under the BPSAA Issued By Minister f Health and Lng-Term Care Effective April 1, 2011 DRAFT March 28, 2011

2 Table f Cntents 1. BACKGROUND REPORT ON THE USE OF CONSULTANTS POSTING OF EXPENSES FOR HOSPITALS COMPLIANCE REPORTS ATTESTATIONS... 6 APPENDIX A HOSPITAL REPORT ON CONSULTANT USE... 9 APPENDIX B POSTING OF EXPENSES APPENDIX C ATTESTATION APPENDIX D QUESTIONS AND ANSWERS DRAFT March 28,

3 1. BACKGROUND Preamble: The Brader Public Sectr Accuntability Act, 2010 (the Act) received Ryal Assent n December 8, Under the Act, hspital means: (a) (b) (c) a public hspital, a private hspital that received public funds in the previus fiscal year f the Gvernment f Ontari, and the University f Ottawa Heart Institute As f April 1, 2011, under the Act every hspital, in cmpliance with the directive(s) issued by the Minister f Health and Lng-Term Care (the Minister), is required t: Prepare reprts n the hspitals use f cnsultants Sectin 6 Publicly pst expense claim infrmatin Sectin 8 Prepare cmpliance attestatins Sectin 15 Purpse, Applicatin and Scpe: The purpse f this directive (the Directive) is t utline the requirements with which every 1 hspital must cmply under sectins 6, 8 and 15 f the Act. Every bligatin f a hspital under the Act is deemed t be an bligatin it is required t cmply with under the terms f the service accuntability agreement between the hspital and a Lcal Health Integratin Netwrk REPORT ON THE USE OF CONSULTANTS Backgrund: This Directive utlines the requirements with respect t: (a) (b) (c) the infrmatin that every hspital must include in its Reprts; t whm the Reprts shall be submitted; and the frm, manner and timing f the Reprts. 1 As set ut in the Act (s. 6, 8, 15) 2 As set ut in the Act (s. 18) DRAFT March 28,

4 Preservatin f Slicitr Client Privilege: This legislatin maintains the integrity f slicitr client privilege, litigatin privilege and settlement privilege, and des nt require the disclsure f infrmatin subject t any f these privileges. While hspitals are expected t reprt n their retentin f lawyers and law firms fr the prvisin f cnsulting services, they are nt required t reprt n instances where they have retained lawyers and law firms t prvide legal advice, draft legal dcuments, cnduct litigatin n behalf f a hspital, r therwise fr the purpse f prviding legal services t a hspital. Submissin f Reprts: Every hspital shall submit its Reprts t the relevant LHIN, by June 30 th every year, starting in Reprting Perid: The first Reprting Perid will be April 1, 2011 t March 31, The Reprting Perid fr all subsequent years will be April 1 t the fllwing March 31. Frm f Reprt: A reprt table template is attached t this Directive as Appendix A. Every hspital is required t submit its Reprts using this reprt table. Fr every prject fr which the hspital retained a cnsultant during the Reprting Perid, every hspital is required t reprt n the fllwing infrmatin: 1. Cnsulting Firm Retained by the Hspital: The name f the Cnsulting Firm (e.g. ABC Cnsulting Grup) retained t cmplete wrk n the prject. 2. Name and Title f Cnsulting Cntract: The name/title f each prject listed and the purpse (e.g. Infrmatin Technlgy Refresh). 3. Cntract Term: The start and end-date f each cnsultant cntract entered int by the hspital. If there has been a change in the cntract term, e.g. an extensin, please nte the riginal cntract term and the revised cntract term. Fr example, an IT refresh prject with a cntract term frm August 3 rd t Nvember 9 th, 2011, was extended t January 31, 2012, wuld be recrded as fllws: A: Original cntract term: August 3 Nvember 9, 2011 B: Amended cntract term: August 3, 2011 January 31, 2012 DRAFT March 28,

5 4. Ttal Prcurement Value ($) / Ttal Paid: The value f the riginal cntract, the value f any amendments, and the ttal amunt paid t each cnsulting firm by the hspital. This ttal amunt must include the amunt paid t the firm during the riginal cntract term, and, in the event that the cntract is amended, any subsequent amunts paid t the firm. Fr example, an IT Refresh prject had an riginal cntract price f $65,000. Hwever, the length f the cntract term was changed, and the ttal value changed t $90,000, shuld be recrded as: A: Original Prcurement Value: $65,000 B: Amended Prcurement Value: $25,000 A+B=C C: Ttal Prcurement Value: $90,000 If cntracts term extends beynd the Reprting Perid, the hspital must indicate the amunts paid t each cnsulting firm up until the end f the Reprting Perid (e.g. if a cntract term is fr August 2011 t July 2012 the hspital s Reprt fr the perid frm April 1, 2011 March 31, 2012 must include the amunt paid n the cntract fr the perid frm August 2011 t March 2012). 5. Cnsultant Selectin Prcess: The Selectin prcess used: Invitatinal cmpetitive Open cmpetitive Nn cmpetitive (if nn-cmpetitive, please prvide an explanatin) Other 6. Mdificatins t Agreement: Indicate whether the cntract term, r the value, f any cnsultant cntracts have been mdified (Yes r N). If Yes, indicate whether the relevant prcurement dcuments (i.e. a prvisin t extend the cntract is in the cntract dcuments) allwed fr this (Yes r N). If N, please ensure the mdificatin is captured in the Cmpliance Reprt -Attestatin Please see Q s and A s in Appendix D (pg.14) fr further infrmatin. DRAFT March 28,

6 3. POSTING OF EXPENSES FOR HOSPTIAL Backgrund: The Minister has issued this Directive under the authrity f subsectin 8(2) f the BPSAA, and every hspital must pst infrmatin abut expense claims n its public website in a manner that cmplies with the requirements set ut in this Directive. Types f Expense Claims that Must be Psted: Every hspital must pst the required infrmatin abut expense claims made, fr the fllwing types f expenses: Travel Vehicle rental r wn use (mileage) Train r air travel Taxi r public transprtatin Accmmdatin Travel incidentals (insurance, parking, tlls) Meal Hspitality Whse Expense Claim Infrmatin Must be Psted: Every hspital must pst the required infrmatin abut expense claims made by the fllwing individuals (the Designated Individuals): Every member f the Bard f Directrs; Chief Executive Officer/President/Administratr/Superintendent; Every member f the hspital s senir management that reprts directly t the CEO/President/Administratr/Superintendent. Infrmatin Abut Expense Claims That Must be Psted: Every hspital shall pst the fllwing infrmatin in respect f each travel, meal and hspitality expense claim made by a Designated Individual: Type f Expense Claim Date n which expense was incurred Amunt claimed Descriptin Frm, Manner and Timing f Psting: Every hspital must pst the required infrmatin abut expense claims in an area n its public website that is clearly and readily accessible t the public. Every hspital must pst the required infrmatin n a semi-annual basis beginning in the 2011/2012 Fiscal Year. Expenses must be psted n later than 60 days fllwing the end f the semi-annual reprting perid. Each psting must include the required infrmatin in respect f all expenses apprved within the applicable quarter. DRAFT March 28,

7 Fr example, and as set ut in the table belw, this means that every hspital must pst the required infrmatin abut expense claims made frm April 1, 2011 t September 30, 2011, by Nvember 30, If a claim is incurred between April and September but nt apprved until Octber, the expense shuld appear in the next psting. Every hspital shall cntinue t make the required infrmatin available n its public website fr a perid f 2 years frm the date n which the expense was psted. The annual public psting cycle is as fllws: Reprting Perid Public Psting date April 1 t September 30 By Nvember 30 Octber 1 t March 31 By May 31 Every hspital must cmplete an expense reprt, in the frm shwn in Appendix B fr each Designated Individual, and pst the cmpleted frm n its public website. 4. COMPLIANCE REPORTS ATTESTATIONS Pursuant t sectin 15 f the Act, every hspital is required t prepare attestatins, attesting t: The cmpletin and accuracy f reprts required n the use f cnsultants (s. 6 f the Act) Cmpliance with the prhibitin n engaging lbbyist services using public funds (s. 4 f the Act) Cmpliance with expense claim directives issued by the Management Bard f Cabinet (under s. 10 f the Act) Cmpliance with prcurement directives issued by the Management Bard f Cabinet (under s. 12 f the Act). Subsectin 15(2) f the Act requires that the fllwing individuals make the attestatins, which must be apprved by the hspital s bard: In the case f a public hspital, the administratr In the case f a private hspital, the superintendent In the case f the University f Ottawa Heart Institute, its chief executive fficer. This Directive is issued by the Minister f Health and Lng-Term Care under the authrity f subsectin 15(3) f the Act. Every hspital is required t cmply with this directive. As required by subsectin 15(5) f the Act, the hspital must pst its attestatins, after they have been apprved by the hspital s bard, if it has ne, n its public website. DRAFT March 28,

8 Timing f the Attestatins and Submissin t LHINs: Reprting Perid: Hspitals will be required t submit attestatins n an annual basis. The reprting perid fr which a hspital is required t submit an attestatin is April 1 t the fllwing March 31. Submissin f Reprts fr Attestatins: Every hspital is required t submit t the relevant LHIN, the required attestatin, apprved by the hspital s Bard, cvering the Reprting Perid (i.e. April 1 t the fllwing March 31), by June 30 th f every year. Frmat f the Attestatin: Every hspital is required t cmplete the attestatin in the frmat set ut in the attachment t this Directive (Appendix C). Infrmatin t be included in Attestatins: Every hspital is required t prepare an attestatin, in which the individual required t make the attestatin, attests t the fllwing: 1. the cmpletin and accuracy f reprts required in sectin 6 f the BPSAA n the use f cnsultants; 2. the hspital s cmpliance with the prhibitin in sectin 4 f the BPSAA n engaging lbbyist services using public funds; 3. the hspital s cmpliance with the expense claims directive issued under sectin 10 f the BPSAA by the Management Bard f Cabinet; and 4. the hspital s cmpliance with the prcurement directive issued under sectin 12 f the BPSAA by the Management Bard f Cabinet. If there are material exceptins t the hspital s cmpliance with any f these requirements, the attestatin is required t list the exceptin(s), and prvide a ratinale/explanatin fr each incidence f nn-cmpliance, and describe what, if any, actins the hspital has taken t address the incidents f nn-cmpliance. Public Psting: Every hspital is required t pst its Bard apprved attestatins n its public website by August st 31 f each year. Attestatins shuld remain n main public websites fr a perid f ne year, after which time they may be mved t the archive sectin f the website. DRAFT March 28,

9 APPENDIX A HOSPITAL REPORT ON CONSULTANT USE Sample - Draft Hspital Reprt n Cnsultant Use Name f Hspital: LHIN: Reprting Perid: April 1, 2011 t March 31, 2012 N. Cnsultant Firm Name(s) Name and Title f Cnsulting Cntract Cntract Term If the cntract term has been extended please include the riginal cntract term and the amended cntract term Prcurement Value (A) Original value plus (B) Value f amendments and (C) Ttal prcurement value ($) / Ttal Paid Cnsultant Selectin Prcess (Open Cmpetitive, Invitatinal Cmpetitive, Nn-cmpetitive) If nn-cmpetitive, please prvide an explanatin Mdificatins t Agreement (Yes/N) If N please ensure the mdificatin is captured in the Cmpliance Reprt/ Attestatin 1. ABC Cnsulti ng Grup Infrmatin Technlgy Refresh - Refresh administrative IT systems Original Cntract Term: August 3 t Nvember 9, 2011 Amended Cntract Term: A Original Prcurement Value $65,000 B Amended Prcurement Value $25,000 Open cmpetitive Yes August 3, 2011 t January 31, 2012 C Ttal Prcurement Value $90,000 A+B=C Ttal Paid fr reprting perid - $90,000 (Nte if cntract term extends beynd the Reprting Perid, indicate ttal paid during the reprting perid f April 1 t March 31) Preservatin f Slicitr client privilege: This legislatin maintains the integrity f slicitr client privilege, litigatin privilege and settlement privilege, and des nt require the disclsure f infrmatin subject t any f these privileges. While hspitals are expected t reprt n their retentin f lawyers and law firms fr the prvisin f cnsulting services, they are nt required t reprt n instances where they have retained lawyers and law firms t prvide legal advice, draft legal dcuments, cnduct litigatin n behalf f a hspital, r therwise fr the purpse f prviding legal services t a hspital. DRAFT March 23,

10 Appendix B Psting f Expenses Draft Frm r Template Frm Name: Title: Reprting Perid: Date Amunt Expense Categry Descriptin April 10-12, 2011 $ Travel Meals Cnference April 10-12, 2011 $ Travel Accmmdatin Cnference April 16, 2011 $16.00 Travel Mileage Bard meeting Definitins: Date(s): - when expense(s) were incurred Amunt: - the value f the apprved expense Expense Categry: - the type f expense incurred: Travel Vehicle rental r wn use (mileage) Train r air travel Taxi r public transprtatin Accmmdatin Travel incidentals (insurance, parking, tlls) Meal Hspitality Descriptin: Ntes explaining the cntext in which the expenses were incurred, r any ther relevant details. DRAFT March 23,

11 APPENDIX C - ATTESTATION Draft Attestatin Frm Prepared in accrdance with sectin 15 f the Brader Public Sectr Accuntability Act, 2010 (BPSAA) TO: FROM: Date: RE: The Bard [insert Name f Hspital], (the Bard ) [insert Name] Administratr/Superintendent/CEO [insert Name f Hspital] [insert date] [insert dates f reprting perid] ( the Applicable Perid ) On behalf f the [name f hspital] (the Hspital) I attest t: the cmpletin and accuracy f reprts required f the Hspital pursuant t sectin 6 f the BPSAA n the use f cnsultants; the Hspital s cmpliance with the prhibitin in sectin 4 f the BPSAA n engaging lbbyist services using public funds; the Hspital s cmpliance with any applicable expense claims directives issued under sectin 10 f the BPSAA by the Management Bard f Cabinet; and the Hspital s cmpliance with any applicable prcurement directives issued under sectin 12 f the BPSAA by the Management Bard f Cabinet, during the Applicable Perid. In making this attestatin, I have exercised care and diligence that wuld reasnably be expected f a [select applicable title: hspital administratr/superintendent/ceo] in these circumstances, including making due inquiries f Hspital staff that have knwledge f these matters. I further certify that any material exceptins t this attestatin are dcumented in the attached Schedule A. Dated at [insert city], Ontari this [insert date], 20xx. [insert name f [select applicable title: Administratr/Superintendent/CEO]] [insert title: Administratr/Superintendent/CEO] [insert: Name f Hspital] DRAFT March 28,

12 I certify that this attestatin has been apprved by the bard f the [insert Name f Hspital] n [insert date]. [insert: Name f Bard Chair] Chair f the Bard [insert: Name f Hspital] DRAFT March 28,

13 SCHEDULE A t Attestatin Instructins [please delete instructins nce yu have cmpleted the Schedule]: If, n behalf f yur Hspital, yu have n material exceptins t declare, please include a n knwn exceptins statement in each sectin t this schedule. If, n behalf f yur Hspital, yu have material exceptins t declare with respect t any f the matters set ut belw, please: a) list them accrdingly b) prvide a ratinale fr each exceptin in respect f why the Hspital did nt cmply with the requirement, and c) describe what actins have been, r will be taken, t address each exceptin. 1. Exceptins t the cmpletin and accuracy f reprts required in sectin 6 f the BPSAA n the use f cnsultants; 2. Exceptins t the Hspital s cmpliance with the prhibitin in sectin 4 f the BPSAA n engaging lbbyist services using public funds; 3. Exceptins t the Hspital s cmpliance with the expense claims directive issued under sectin 10 f the BPSAA by the Management Bard f Cabinet; and 4. Exceptins t the Hspital s cmpliance with the prcurement directive issued under sectin 12 f the BPSAA by the Management Bard f Cabinet. DRAFT March 28,

14 Slicitr - Client Privilege: Appendix D - Questins and Answers 1. Our hspital has engaged a lawyer/law firm t prvide an analysis f whether ur current gvernance structure cmplies with the requirements f the Public Hspitals Act. D we need t reprt n ur retentin f this lawyer/law firm under the MOHLTC s Reprt n Use f Cnsultants Directive? N since yu have engaged this lawyer/law firm t prvide yu with legal advice, yu d nt need t reprt n the terms f yur agreement. 2. Our hspital has engaged a lawyer/law firm t prvide strategic business advice n a majr IT prject that we are abut t undertake. D we need t reprt n ur retentin f this lawyer/law firm under the MOHLTC s Reprt n Use f Cnsultants Directive? Yes since this lawyer/law firm has been retained t prvide business cnsulting services, rather than legal services, yu wuld need t reprt n yur agreement with the lawyer/law firm fr this prject. 3. Our hspital has engaged a cnsulting firm t prepare a reprt n the efficiency f ur patient intake prcedures as cmpared t thse in ther hspitals. While we are nt seeking legal advice frm this cnsulting firm, a number f members f the cnsulting team pssess law degrees. D we need t reprt n ur retentin f this lawyer/law firm under the MOHLTC s Reprt n Use f Cnsultants Directive? Yes Since yu are purchasing cnsulting services rather than legal services, yu wuld need t reprt n yur agreement with the lawyer/law firm fr this prject. 4. Our hspital has retained a lawyer/law firm specializing in labur relatins t prvide advice n ptential layffs resulting frm the cnslidatin f fd services. D we need t reprt n the retentin f this lawyer/law firm under the MOHLTC s Reprt n Use f Cnsultants Directive? N since yu have engaged this lawyer/law firm t prvide yu with legal advice, yu d nt need t reprt n the terms f yur agreement. Cmpliance Reprts (Attestatins): 1. Wh makes and apprves the Attestatin? The attestatin must be made by: In the case f a public hspital, the administratr In the case f a private hspital, the superintendent In the case f the University f Ottawa Heart Institute, its chief executive fficer. The Chair f the Bard f Directrs f the hspital is required t apprve and sign-ff n the attestatin that will be prvided by the Hspital t the Bard f Directrs f its respective LHIN. The Bard f Directrs must apprve the attestatin prir t sending it t the LHIN. DRAFT March 28,

15 2. Which hspitals cmplete the attestatin? The BPSAA defines hspital, and all hspitals falling within this definitin are required t prepare and submit attestatins in accrdance with s. 15 f the Act. Under the BPSAA hspital means: A hspital within the meaning f the Public Hspitals Act A hspital within the meaning f the Private Hspitals Act that received public funds in the previus fiscal year f the Gvernment f Ontari; and The University f Ottawa Heart Instititue/Institut de cardilgie de l Université d Ottawa 3. Are there any requirements fr submitting the attestatin t the LHIN? The attestatin must be sent by (scanned cpy) r fax r mail, t the attentin f the Chair f the Bard f Directrs f the LHIN t which the hspital reprts. 4. What happens if a hspital has exceptins? Every hspital is required t identify all material exceptins (i.e. incidents f nncmpliance with the requirements f the BPSSA, and t prvide a ratinale/explanatin fr each exceptin. A hspital may be cntacted by a LHIN r the relevant ministry f the Gvernment f Ontari in the event that an exceptin has been listed t btain additinal infrmatin r clarificatin. 5. What is a material exceptin? A material exceptin is any incident f nn-cmpliance with the requirements f the BPSAA that is significant. Fr example, if the hspital extends a cntract, where the riginal cntract des nt cntain a prvisin allwing fr the term f the agreement t be mdified (in cntraventin f Mandatry Requirement #18 f the Prcurement Directive). 6. Are the attestatins t be made public? Yes - Every hspital must pst its attestatins n its public website. The hspital shuld pst the attestatins in a lcatin and manner that is readily and easily accessible. Every hspital shuld pst its attestatin after submitting it t the LHIN. 7. Hw lng will the attestatins remain n the website? Attestatins shuld remain n main public websites fr a perid f ne year, after which time they may be mved t the archive sectin f the website. 8. What happens in the case f a private hspital that des nt have a bard? In the case f a private hspital that des nt have a bard, then signature frm the Administratr/Superintendent/CEO wh made the attestatin is sufficient and bard apprval is nt required. The hspital must cmply with the remaining requirements in the directive. DRAFT March 28,

16 Expense Reprting: 1. I am a designated individual required t pst expenses. I recently attended an ut f twn meeting where I was required t rent a car and stay vernight. What d I need t reprt n? Hspitals must pst the cst reimbursed f: the vehicle rental any travel incidentals such as insurance; accmmdatin; and any meals. 2. I incurred an expense, and submitted an expense reimbursement claim, fr a meal in September 2011, yet it will nt be apprved r reimbursed until Octber. Will it be reprted in the first semi-annual psting that has t be publicly psted by Nvember 30th? N. Each psting must include all expenses apprved in that perid. If an expense is incurred in ne perid (say September) and apprved in anther (say Octber), the required infrmatin abut that expense must be included in the psting fr the perid in which the expense was apprved. Therefre an expense incurred in September (April t September reprting perid), but apprved in Octber (Octber-March reprting perid) wuld be psted in the Octber March reprting perid. 3. I attended a meeting where I traveled by air. My hspital uses a centralized bking service fr this purpse. Des this have t be reprted? Yes. Even thugh yu are nt being reimbursed directly fr the expense, the required infrmatin abut travel fr designated individuals btained thrugh a centralized bking service must be psted. 4. I am a lawyer and my prfessinal fees are reimbursed by the hspital I wrk fr. D I have t reprt these? N. Prfessinal fees r licensing csts d nt have t be reprted. 5. My hspital prvides meal chits if we have t wrk late. I have been wrking n a prject that has required me t use these during the current fiscal quarter. D I have t reprt these? N. Things like meal chits and subway/bus tickets/tkens that may be used by designated individuals d nt need t be reprted. 6. I purchased a stapler and sme ffice supplies fr my use, which the hspital reimbursed me fr? D I have t reprt these? N. Travel, meal and hspitality expenses are the nly types f expenses fr which the required infrmatin must be psted. DRAFT March 28,