I am very pleased to be here today to talk about our audit ‘In Sickness and in Health: Healthy Workplaces for British Columbia’s Health Care Workers.” However, before I do, I thought I would take a few minutes to provide you with a brief overview of the work of my Office and highlight in particular audits examining the work environment.

I am an independent Officer of the Legislature, meaning I do not report to the Premier or any agency of government but rather the Legislative Assembly. The work of the Office is governed by the Auditor General Act.

Within the mandate provided in the Act, we allocate our resources and energies to three lines of business:

• Firstly, we attest to the reliability of the financial statements of government as a whole as well as many individual provincial public sector organizations.
  
  
• Secondly, we review the quality of the broader performance information reported by the provincial public sector. In British Columbia, ministries and agencies must publish three-year service plans and then report annually against their plans. Our Office issues a report on the quality of the annual reports using a set of reporting principles developed by a joint working group of staff from our Office and government, and which have been approved by the Public Accounts Committee.
  
  
• Our third line of business assesses how well organizations manage the key risks they face in achieving their planned results.

There are three dimensions to this third line of business.

The first dimension is governance – how well government is doing as the steward, an example of our work in this area was our review of the performance agreements between the Ministry of Health Services and the Health Authorities.

The second component is program management – how well programs are meeting their objectives, examples of our work here are the review of the Alternative Payments Program in the Ministry of Health Services and a current audit examining the Pharmacare program.

The third dimension is capacity building – how well programs care for and develop their people.

We started our work on this third dimension by assessing whether training and development was being used strategically to maintain the human capital of the British Columbia Public Service.

We found that the human capital of the Public Service was at risk and that training dollars were not being used strategically to protect its human capital. This audit also identified leadership as an issue and in particular its impact on the work environment from a learning perspective.

Thus this piece of work led us to conduct an audit examining the work environment of the public service. I believe a well performing government, one that meets the service expectations of British Columbians, can only be achieved through a strong, highly competent and committed public service.

However, from our audit work we concluded that the work environment in the public service was being weakened by a lack of strong leadership in the executive ranks. The result being employees who were only moderately engaged in their work and a culture that did not encourage employees to question current practices or to continuously improve the services they provide to British Columbians.

The findings and conclusions in this audit were based primarily on the result of a government-wide survey of over 6,000 public service employees in government ministries. We received a 74% response rate.

We have just repeated this particular audit and will be releasing the audit report in January.

So from this you can see my Office has a particular interest in the work environment, which led us to think about the health care work environment.

The health and well being of the health workforce is key to a well-functioning and sustainable health system. Care delivery and patient outcomes are impacted by the health of the care providers.

Yet, we know that health care workers are one and half times more likely to miss work because of illness and disability than the average employee in other work places. We also know that the healthcare environment is a difficult one to work in. Staff are at high risk of injury; and they have little control over their workload or work schedules in an environment that is physically and emotionally demanding. They also can be exposed to noxious agents and subjected to violence.

In recent years they have also had to endure numerous reorganizations, which research has shown, can in part have a negative effect on staff.

It is safe to say that an unhealthy work environment costs employers, employees, patient care and patients.
In fiscal year 2002 – 2003 the direct costs for illness and injury related absences in the health authorities totaled approximately $247.1 million. This breaks down as follows:

• $83.5 million for contributions to the Workers Compensation Board
  
  
• $60.4 million for contributions to the Health Care Benefit Trust (the long-term disability insurer), and
  
  
• $103.7 million for short-term sick absences in five of the six authorities. One authority was unable to provide this information without a significant investment of staff time.

None of the health authorities were able to provide any dollar amounts for indirect costs due to illness or injury. Nor is their accounting for the cost of presenteeism – the concept of decreased productivity when staff attend work but are not feeling well. Estimates for indirect costs vary from 2 – 10 per cent of total employee costs and for presenteeism from 2 – 4 per cent of direct costs.

A report in 2004 by the Healthcare Benefit Trust estimated that in the year 2000, direct & indirect costs and presenteeism cost the BC health care system $1 billion dollars.

It is against this back drop that we began asking how well the health authorities are managing the workplace to ensure a healthy work environment for their employees.

However, before attempting to answer that question we first had to know what were the attributes of a healthy work environment. The literature seems to suggest there are three:

• First a safe and healthy physical environment – one in which employees are protected from, injury, violence, hazardous substances, ergonomic stress, and other hazards. It is also a place that gives all employees (including those with health-related restrictions) access to the tools and other resources they need to do their job.
  
  
• The second element is a healthy psychosocial environment, which provides individuals some control over their workload or work schedule, and offers positive peer and manager relationships. One model notes that the optimal work environment includes: demands that fit the resources of the person, a high level of basic predictability, good social support, meaningful work; high level of influence at work; and a balance between effort and reward.
  
  
• Thirdly, healthy lifestyles – the role for the organization in this area is to support a positive lifestyle through encouragement, education and opportunity.

With these attributes in mind we looked to see if the health authorities were:

• Providing leadership
  
  
• Promoting a healthy work environment, and
  
  
• Monitoring and reporting on the health of their employees and the work environment.

Overall, we concluded that health authority leaders need to focus more attention on creating a healthy work environment for their employees.

I will now talk about some of our findings in the three areas previously mentioned.

Looking at leadership, we found health authority leaders spoke about the importance of staff and a healthy work environment, but there was limited explicit acknowledgement of this in either the mission or value statements of the authorities. One authority did capture this importance in their mission statement while others stated it either directly or indirectly in their value statements. Even within the organizations’ human resource plans or occupational health and safety plans, we found that the value of employees was not clearly stated.

We found health authority leaders to be focused on meeting their fiscal targets by controlling the costs of injuries, sick absences and overtime, and while this may benefit employee wellness to a degree, it is focused on symptoms of an unhealthy work environment and not the causes.

In fact we found that only one authority was asking employees about their work environment. Without good information about the health of their employees and the work environment, it is difficult to ensure that the health and wellness plans that were being developed by the authorities were going to address work environment issues important to staff.

We also found that the health and wellness plans mainly focused on addressing the physical aspects of the work environment, with minimal attention paid to the psychosocial or healthy lifestyle aspects.

In addition to leadership and good information, creating a healthy work environment requires investment. However, because investment is needed across a broad spectrum of activities from management development, to equipment, renovations and safety training it was difficult to determine the amount of money the authorities directed to creating a healthy work environment. We did find that the health authorities received additional funds and in kind support from the Occupational Health and Safety Agency for Health Care in British Columbia, as well as the HealthCare Benefit Trust and WCB. For example, both the Occupational Health and Safety Agency and the Workers Compensation Board have provided funds to the health authorities for purchasing equipment and training staff to support the “No Lift Programme.”

In the area of leadership we recommended that the health authorities:

• Ensure that the health of the work environment is included in the performance appraisal of all senior and frontline managers.
  
  
• Demonstrate in word and action that employee health and well being are important to organizational success.
  Put in place appropriate mechanisms to gather data on employee health indicators and work environment conditions. The health authorities should then incorporate the information into their human resource plans.
  
  
• Develop costing information for the initiatives in their human resource and occupational health and wellness plans in order to understand their return on investment.
  
  
• Ensure, in conjunction with partner agencies, that all initiatives are well coordinated to maximize both the funds and effort being directed to creating a healthy work environment.

In promoting a healthy work environment. We found that the authorities have policies and programs in place, which are directed at preventing and reducing the impact of illness and injury on staff and on the organization. These efforts are showing some success as the average injury rate for health care workers in British Columbia is declining, although it remains higher than all other industries. Contributions by the health authorities to the Workers Compensation Board are also beginning to reflect this decline, in 2002 – 2003 health authority contributions totaled $83.5 million decreasing to $76.7 million in 2003/04.

We also found that musculoskeletal injuries as a percentage of all active long-term disability claims have been declining across all authorities for the period 1997 to 2002. Although in recent years there has been a slight increase in claims, among some authorities.

Mechanisms for addressing issues in the psychosocial environment are primarily directed at developing leadership and management capacity, which was identified as a key issue by all health authority senior management. While positive, there also needs to be attention paid to workload, scheduling and interpersonal relations.

Focus groups we held with frontline staff in most authorities identified consistent areas of concern that fit within the context of psychosocial well being, such as lack of flexible scheduling, heavy workloads, poor communication, intimidation and bullying. Frontline managers interviewed also expressed some of these same concerns. These managers seemed extremely stressed and felt that their capacity to manage the expectations of executive management and frontline staff had reached its limit. They believe that executive staff continues to introduce change without acknowledging that implementation always falls to the already heavily burdened frontline manager. They also felt that they had limited input into changes and decisions. Managers also said their span of control in many instances was not workable, that they had no time to interact with staff in a meaningful way. Span of control was also acknowledged by executive management to be an issue and two health authorities in fact, had initiatives underway to assess and address it.

Although all authorities had policies in place outlining their expectations regarding work conduct, focus group participants felt that interpersonal relations were deteriorating and that there was increased intimidation and bullying. Some managers also echoed these concerns.

Some of these issues may be reflected in long-term disability claims for mental health, which are increasing as a percentage of all active claims in all authorities.

Although this trend may not be confined to healthcare workers. A recent report of the Global Business and Economic Round Table on Addiction and Mental Health found that in Canadian companies mental illness is now the leading cause of employee disability.

All authorities had in place such programs as disability management, employee assistance and occupational health & safety. Yet, for focus group participants the most concerning occupational health and safety issue was violence, and although they acknowledged that steps had been taken to address the issue it remained a major concern.
Looking at healthy lifestyles: We found that the health authorities placed very little emphasis in this area. There were specific health-issue promotions, such as helping workers to stop smoking and encouraging them to get flu shots but there was not an overall strategy for the promotion of a healthy lifestyle. In fact, focus group participants felt that their work environment actually contributed to unhealthy lifestyles — from cafeteria and vending machines that sold food of little nutritional value to the heavy workloads imposed on staff and the impact that this had on work-family balance.

Our recommendations in the area of promoting a healthy work environment, were that the health authorities should:

• Ensure that their actions are consistent with communications to staff.
  
  
• Review the extent of manager’s control and ensure that it is not beyond a limit to be effective.
  
  
• Assess the work environment for risks to staffs’ mental health and develop an action plan to mitigate the risks.
  
  
• Consider ways to promote a healthy lifestyle among their employees.
  
  
• Ensure their appointees to the Joint Occupational Health and Safety Committees attend meeting regularly and recognize occupational health and safety as part of their responsibilities.
  
  
• Assess the work environment for risk of violence to staff safety and security and develop an action plan to mitigate the risks.

Looking at monitoring and reporting, we found that there was variation in what was reported and how often.

Information systems or rather the lack of systems impede the collection of comprehensive integrated data about the health of the work force and the work environment. Acutely aware of the need for better information, steps are being taken by the authorities to move ahead with human resource information systems.

As there are no mandatory or agreed upon standards or indicators on a healthy work environment, we found that internal reporting to the health authority boards varied significantly across authorities. Some boards had identified specific indicators to be reported on, while others received narrative reports describing a wide variety of issues and activities under the heading of human resources.

This quote from Dr. John Evans, Chairman of the Board of Torstar emphasizes the importance of a Board receiving information about the work environment. Dr Evans says,

“In my judgement, any Board that doesn’t insist on having environment, health and safety — with special emphasis on mental health — on its agenda is not discharging its governance responsibility.”

The health authorities, under the Occupational Health and Safety Regulations of the Workers ‘ Compensation Act, are required to report all work-related disease and injury to WCB. However, there is no such requirement that obligates the authorities to report to the Ministry of Health Services about the work environment. The authorities do report some information but it is only focused on all employment-related compensation costs such as overtime and leaves. However, we believe there should be more formal and comprehensive reporting by the health authorities on employee and workplace health to ensure greater accountability to the ministry, legislators and the public.

For monitoring and reporting we recommended that the health authorities should:

• Implement a human resource information system that will provide the data needed for developing a comprehensive picture of employee and workplace health.
  
  
• Ensure that all initiatives include an evaluation component.
  
  
• Have senior management work with their Board members to determine what employee health and work environment indicators are important to collect and report on a regular basis, and how to evaluate if current policies, programs and resources are meeting employee and workplace needs.
  
  
• Determine in conjunction with the Ministry of Health Services, what indicators of employee and workplace health should be reported publicly on a regular basis.

In closing, a healthy work environment contributes to the sustainability of our health system, by supporting the delivery of good patient care and outcomes. It also supports cost-effective resource use, the retention of current employees, and the ability to attract new employees.

Earlier this week, we presented our report to the Public Accounts Committee. The Committee endorsed our recommendations.

The next step in this process will be for my Office to complete a follow-up review in about twelve months time to assess the implementation status of the recommendations that we made. The report of our follow-up assessment is also presented to the Public Accounts Committee.

Thank you for this opportunity to provide you with an overview of our examination of the work environment within our health system. Now, I will try to answer any of your questions or listen to your concerns or suggestions.

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