year ended March 31, 1999
Scope of audit work In addition to the annual audit of Ministry financial
statements, the focus of systems work was to follow-up on selected audit recommendations and to conduct additional review in areas of business planning, performance and
governance reporting, capital assets management, health care registration, physician funding, and preparing equipment and systems for the Year 2000.
Also reported are the results of auditing Ministry financial statements for the year ended March 31, 1999 and the audits of health authorities for the year ending March 31, 1998.
Business planning for health Recommendation No. 36
It is again recommended that the Department of Health and Wellness and health authorities implement a joint strategy for improving the timely implementation of authorized business plans.
Last year we reported that the implementation of business planning was a significant accomplishment. However, the 1998-99 business plans of 13 health authorities were not finalized and approved by the Minister of Health until late in 1998 when more than half the business year was over.
Having authorized business plans in place for health authorities at the beginning of a fiscal year is necessary for setting an agreed basis of action throughout the year. When this does not happen, the value of business plans, as
instruments of accountability, is diminished.
The amount of time to finalize business plans for fiscal year 1998-99 had to do, in good part, with health authorities forecasting deficits in original business plan submissions after initial funding allocations had been made by the Ministry of Health. A series of additional funding
allocations for the health system were then made between March 1998 and October 1998. Subsequently, the Minister approved 1998-99 business plans and health authorities prepared revised budgets. Avoiding the experience of 1998-99 would enhance business plans as instruments of accountability and strengthen the linkage between business plan expectations and budget.
The challenge is to reconcile health system funding with the achievement of balanced budgets by health authorities. To begin, for the past three years the target funding level for each fiscal year of the three-year Ministry business plan have increased for the same fiscal year from one year to the next, one business plan to the next. Within each fiscal year, annual supplementary estimates have been required. For 1998-99 these amounted to $245.7 million, and of this, $127.9 million was additional funding of health authorities.
In view of this, during 1998-99 the Department modified its method of determining budget increases for the next business planning cycle starting April 1, 1999. This was also done to help reduce the need for additional funding after Ministry business plans are prepared and to help avoid delay in finalizing the business plans of health authorities. In addition to a 3% minimum budget increase for 1999-2000, the Department modified basic cost drivers to incorporate additional amounts for population increase (but not aging), for the effects of population-based funding allocations, and for other specific items recommended by committees. The result was an overall budget increase of $386 million for 1999-2000. Of this, $261 million is to go to health authorities.
The Minister provided additional funding on the understanding that health authorities would balance their budgets
The Minister provided additional funding for 1998-99 on the expectation that health authorities would balance their budgets for 1998-99. While this was the expectation, there was no agreement about the definition of a balanced budget at the time when ten health authorities were budgeting operating deficits for 1998-99 totaling $32.4 million after additional funding. Subject to the finalization of all audited financial statements for the year ended March 31, 1999, actual results indicate that 12 health authorities incurred operating deficits amounting to $31.7 million (with seven posting excess of revenues over expenses amounting to
$7.1 million).
Agreement was reached between the Department of Health and health authorities on what defines a balanced budget
In April 1999 agreement was reached between the
Department of Health and health authorities on the definition of a balanced budget (revenue equal to expenses based on generally accepted accounting principles). This should assist in removing uncertainty about the basic measurement of annual budget performance. The Department is currently working on further guidance to health authorities for determining when deficits would be recommended to the Minister for approval.
While a basic definition of a balanced budget has been determined, it is uncertain what would constitute an appropriately approved budget of a health authority as an integral part of approved business plans. For the past two years, health authorities variously reported their budgets as having been approved by the Minister (only), by the board and the Minister, approved by the board and submitted to the Minister, or having been submitted to the Minister (but not necessarily approved). At the same time, health authorities described what budget approvals took place in relation to original business plan submission and additional funding amounts.
As of June 1999, the Joint Alberta Health/Health Authority Business Planning Group was considering factors affecting timeliness of business plans and ways to improve this for the next business planning cycle for 2000-2001. There was not sufficient time to do this for 1999-2000 while also finalizing business plans for 1998-99. As of July 1999, the 1999-2000 business plans of health authorities were in the process of being given final review by the Department of Health in order to recommend them for Minister approval some four months after the start of the fiscal year.
The Joint Business Planning Group is encouraged to find ways of improving business planning
The Joint Business Planning Group is encouraged to find ways of improving business planning. Possibilities include assessing ways to improve the forecasting and control of budgets, aligning resources with business strategies, the sharing of best practices, issuance of a self-assessment tool for health authorities to improve business planning, and clarifying what constitutes an appropriately approved budget.
All of these could contribute to the timely implementation of effective business plans.
In conclusion, while progress is being made, the risk is still present of delay in implementing authorized business plans.
Therefore, we repeat the recommendation that the Department of Health and health authorities should implement a joint strategy for improving the timeliness of business plans. Until strategic direction and expectations are established in a timely manner, the accountability system is not working as well as intended.
How well the accountability system is working should also be evident in the way results are measured and reported. The following section makes further observations and
recommendations in this regard.
Performance measurement and reporting
Recommendation No. 37
It is again recommended that the Department of Health and Wellness and health authorities implement a plan to improve performance measurement and reporting, including better reporting of results achieved compared to plan.
In 1997 it was recommended that the Department encourage health authorities and boards to improve the reporting of performance in annual reports in terms of measuring results and linking them to performance expectations established in business plans. In 1998 it was further recommended that the Department of Health and health authorities collectively implement a plan to improve performance measurement and reporting. In particular, service output and patient outcome measurements were not visible compared to indicators of process activity and resource inputs.
Annual reports do not yet fully link results achieved with the goals and strategies set out in business plans
To gauge progress, we analyzed five annual reports of health authorities for 1998 as representative samples. The chart below shows that annual reports do not yet fully link results achieved with the goals and strategies set out in business plans.
Links between Annual Reports and Business Plans
0 50 100 150 200 250 300
Measures relate to 1997/98 year Targets / Explanation of performance variances Targets Performance Measures Goal Statements
criteria
discrete count of criteria Annual Report Business Plan
Note: This chart has been prepared on the basis that performance measurements contained in business plans for 1997-98 were to be reported for that year unless otherwise specified that results are only to be reported in future years.
The first pair of bar lines indicates that goals stated in business plans compare closely to annual reports. The second set indicates the total number of performance
measures in business plans and the extent to which they were included in annual reports. The third set compares those performance measures that had a target (number, date, or other) in business plans to the reporting of performance against the target. The fourth pair of lines indicates the extent to which there were variances from target that were explained. The last set indicates for all performance
measures the extent to which actual results for the fiscal year have been reported using 1997-98 data.
As the chart indicates, the loop of accountability needs to be closed by better reporting of results achieved compared to expectations set out in business plans. Closing the gap to improve accountability will require changes in setting
expectations and in the reporting of results compared to plan.
An annual report should disclose actual results against targets in the business plan. In total for the five health authorities analyzed, measurements for 69% of the targets identified in health authority business plans were not
included in annual reports for 1998. Therefore it is difficult to determine if results were what was intended and whether they require corrective action.
Business plans and annual reports indicate that several performance targets are missing and need to be determined.
These include, for example, lists for seniors waiting
placement, number of health promotion initiatives available for seniors, acute care average length of stay and number of patient separations. If a target can not be determined, management should consider whether the goal is clearly stated or that a better measure of the goal exists.
Too many measures may create confusion and there is a need to sort out what is most relevant
There is a risk that too many measures create confusion and there is a need to sort out what is most relevant for health authorities to report and for the Department of Health to report. Three health authorities each reported up to 65 measures or indicators in an attempt to cover all of the health authority’s business planning goals, including measures required by the Department of Health as part of business planning. The reporting in these cases can be further improved by highlighting those measures which are key in assessing performance or by indicating which measures are influenced by factors within or beyond the control of the health authority. This type of description would help a reader understand the measure’s relative importance to the organization.
There is risk of confusion about what requires a performance target and when a variance from target ought to be explained by health authorities. The Department of Health makes the differentiation that a performance measure requires a target but an indicator does not. We understand this is done so that information on items of interest is reported even though a performance target is considered not possible or advisable.
Also, indicators allow monitoring of trends in order to help determine goals and strategies (as would be contained in business plans) and possibly set performance targets in the future.
Where there are no performance targets (or variance limits
for indicators) the question becomes at what point are
corrective steps to be taken or should performance targets be established using indicator information. Also, given the volume of measures, there may be benefits in clarifying when particular performance measures are best reported rather than reporting all measures each year, and to give more emphasis to targets that require measurement.
In general, annual reports up until 1997-98 did not contain management discussion of performance using information such as cost of outputs and patient outcomes, analysis of financial operating results, or assessment of financial condition and risks.
It is expected that
performance measurement and reporting will improve
While making the preceding observations, it is expected that performance measurement and reporting will improve.
Health authorities are aware of the need to improve
performance information and the Department assists them by providing data for use in preparing business plans and annual reports.
New indicators for access to health care were introduced in April 1999 as part of reporting requirements for health authorities during 1999-2000. Quarterly reporting to the Minister is intended to monitor the impacts on access to health services as the results of increased funding to health authorities. These do not set performance expectations to be achieved (targets) but will indicate change in, for example, home care clients served, wait lists for long term care, surgery cancellations, and people waiting for major joint replacement. However, health authorities are expected to set performance targets. When this takes place, the particular results to be achieved from increased funding should be more certain.
As recommended in 1998, the Department continues to work on developing a strategic approach for performance reporting and discussing priority areas for developing expectations and measures for both itself and health authorities. Because of the importance of this, we repeat the recommendation of last year, adding that a better link should be made between planned performance and actual results reported.
The next sections on managing equipment and planning health facilities also illustrates the need for better
information and the integration of business planning with
other systems.
Managing capital assets As at March 1998, health authorities collectively report
$216 million in equipment and $2.2 billion in property (land and buildings). There are about 350 buildings housing all types of health services and programs in Alberta that provide more than two million square metres of floor space. The cost to construct similar capacity today could exceed
$5.5 billion.
In 1998 it was recommended that the Department of Health provide guidance for establishing an appropriate equipment and building base for each health authority
In 1998 it was recommended that the Department of Health provide guidance for establishing an appropriate equipment and building base for each health authority. It was further recommended that the Department work with health authorities to improve systems for planning and funding capital assets.
We reviewed the steps taken by the Department in response to these recommendations and conducted further review of systems at the Department of Health for planning health facilities. We did not examine the management of capital projects by Public Works, Supply and Services (PWSS) nor did we review the capital management systems of individual health authorities.
This section first deals with equipment and then health facilities.
Meeting equipment needs Recommendation No. 38
It is recommended that the Department of Health and Wellness assess the impact of new requirements for managing equipment and determine whether they have sufficiently diminished the risk of health authorities not meeting equipment needs.
Last year we reported on the issue of how the Department of Health and health authorities would ensure that sufficient capital funding was in place to meet equipment needs. In particular, since health authorities did not include equipment amortization in determining a “balanced budget”, there was a risk that health authorities would not accumulate sufficient funds for needed equipment purchases.
New requirements now expect the business plans of health authorities to include a comprehensive capital equipment plan
Progress has been made on the audit recommendations made in 1998. New requirements now expect the business plans of health authorities to include a comprehensive three-year capital equipment plan including strategies to replace internally and externally funded equipment. Health
authorities are to inform the Minister of the funding available to support acquisitions and how any funding shortfall will be financed.
Further, the Department and health authorities agreed in April 1999 on the basic definition of a balanced budget. The definition adopted means that the annual allowance for depreciation of assets is to be considered in achieving a balanced budget. This could potentially enable the creation of reserves for replacing equipment.
However, a proposal to set financial reserve targets was not accepted by health authorities. While the Department would set expectations and a reporting process, it was agreed that each health authority should decide how to ensure necessary equipment will be available as part of planning services and preparing business plans. There is still a question of what should health authorities do to accumulate revenues in excess of expenses so they are in a sound financial position to make capital acquisitions.
It was agreed that health authorities will annually set aside cash
As a minimum it was agreed with the Department of Health that beginning in 1999-2000 health authorities will annually set aside cash (or cash equivalent) amounting to a minimum of the annual internally funded capital equipment
amortization not reinvested in capital equipment. That is, if a health authority does not purchase equipment at a cost at least equal to the amount of annual depreciation of
equipment it previously acquired with its own money, it should put the difference aside for future equipment purchases.
New requirements may not be sufficient
The risk of not meeting equipment requirements is reduced by these new requirements. However, they may not be sufficient to ensure that an equipment base is sustained.
Reasons include:
• The setting aside of cash to replace equipment would likely only cover up to 50% of equipment in use since about half is externally funded.
• The high cost associated with newer technology,
inflation in the cost of equipment replacements, or more growth in services would not necessarily be covered by money that health authorities set aside.
Accordingly, in addition to our recommendation made last year and as part of ongoing communication with health authorities, the Department of Health should monitor the effect of recent system changes and assess whether the risk of not meeting equipment needs has been reduced.
Planning health facilities Health authorities are responsible for deciding services and allocating operating resources including the planning and running of facilities. PWSS (now Alberta Infrastructure) and the Department of Health are jointly responsible for the review and prioritization of capital funding and for
recommending capital grants for the upgrade, expansion or replacement of health facilities or the construction of new facilities within funds available.
In 1995, a planning manual was issued by the Department and PWSS as a guide to approving new capital projects. This was part of a process for planning and assessing capital needs where health authorities are asked to develop
infrastructure plans linked to service and financial plans and to support requests for major capital projects. Requests by health authorities are subject to review by the Department of Health for approval by the Minister of Health. PWSS works with health authorities to confirm the needed scope and cost of proposed projects.
In 1996, a policy was introduced stipulating requirements and conditions for the disposal of surplus property (buildings and land) owned by health authorities. And, in 1998, an extensive condition survey of all public and voluntary health
In 1996, a policy was introduced stipulating requirements and conditions for the disposal of surplus property (buildings and land) owned by health authorities. And, in 1998, an extensive condition survey of all public and voluntary health