Algoma District Services Administration Board

 

CAO Report – February 2002

 

This report will focus on Emergency Medical Services (EMS) cost overruns in 2001 and the 2002 budget.  The transfer of land ambulance responsibilities from the Ministry of Health to Consolidated Municipal Services Managers occurred across the province between January 1, 2000 and January 1, 2001.  The program transfer in the Algoma District Services Administration Board (ADSAB) jurisdiction occurred on January 1, 2001.  It must be remembered that the EMS downloading included activities previously the responsibility of the Regional office of the Ministry of Health and not simply those activities which occurred at the local providers.

 

Unlike program transfers from the Ministry of Community and Social Services (i.e. Child Care) and the Ministry of Municipal Affairs and Housing (i.e. Social Housing), there was no formal transfer planning or approval process.  Unlike those transfers there was also no intergovernmental transfer team.  There was also not a single dollar of transition funding, again, unlike the other program transfers.  The Ministry of Health not only did not assist the transfer they took steps and made decisions which directly complicated and interfered with the transfer process.

 

Similar to the other program transfers, there were several new obligations imposed by the Province coincidental with the transfer.  These included new educational requirements for paramedics, an increased length of the paramedic educational training course and new response time standards.  The Ministry of Health has done nothing to facilitate this Board or its staff in meeting any of these new obligations. 

 

2000 /2001 Base Budget

 

In February 2001, the Board set a budget based on the identical staffing pattern which had been in place for the seven predecessor services.  Beginning in November 2000, we had attempted to get from the Ministry of Health the approved budgets for each service, the total municipal share levied and the method of cost apportionment.  The Ministry refused to provide this information stating we had no right to information prior to December 31, 2000.  Several requests and a letter on this issue were ignored by the Ministry.  We are thus unable to answer questions of comparison between 2000 and 2001 municipal levies for EMS.

 

It was readily apparent from information received from Board members that the municipal share of the 2001 budget was much higher than that collected by the Ministry in 2000.  A political enquiry by a former Board member resulted in no written response and a confusing verbal response that municipalities should be grateful for reduced levies in 1998, 1999 and 2000 as they were not paying their true share of the actual cost of providing land ambulance. 

 

From our knowledge, it appears that the following items were not part of municipal levies prior to January 1, 2001:

 

Reserve transfers for severance

Purchase of vehicles

Repair of conversion equipment

WSIB – NEER assessments (in 2001 there was a 500% increase in WSIB premiums)

Stretchers

Major patient care equipment

Defibrillators

Insurance

Ministry of Health Regional administration costs

 

2001 Base Budget Submission

 

The budget format provided by the Ministry was followed in detail and a copy of the draft budget was submitted to the Regional Director - Dennis Fournier on January 5.  Mr. Fournier came to our offices on January 12 and went through the budget on a line-by-line basis with the EMS Manager - Tom Johns and the Director of Finance - Keith Bell.  The changes suggested by Mr. Fournier were reflected in the revised budget and the budget was resubmitted January 30.

 

The budget was based on the identical staffing pattern of the preceding seven services and the management structure approved by the Board.  The pay rate was the provincial Adams rate as approved by the Board in September 2000.  The Adams rate was an arbitrated settlement which was matched by most EMS delivery agents prior to the transfer.  No increase in wages was budgeted although a new collective agreement was going to be negotiated for 2001 once the issue of union representation was settled.  The issue of union representation was not settled until mid-year.

 

No additional information was request by the Ministry related to the budget until May 10^th. A meeting was requested and held with Mr. Fournier on May 18th.  He requested that we remove the wages of Supervisors from the operations portion of the budget and the WSIB –NEER assessment.  We disagreed in principle but reluctantly complied and resubmitted the budget on May 18^th.  That budget removed $194,547. from the total budget request as Supervisor salaries were moved to administration which exceeded the arbitrary administration 10% cap.  Their removal was despite the fact they were performing frontline First Response services and despite the fact they were part of the prior years budgets as part of operations. 

 

We gave notice that we would be appealing the exclusion of Supervisors from the operations portion of the budget. No further requests for information or other contact was received related to the 2001 budget.

 

In September, the Ministry unilaterally decreased the base budget again by $60,575 bringing the total down $255,122. from the original submission in January.

 

We were advised we could appeal the 2001 base budget after the revised budget was approved.  We did so on three occasions.  Firstly, in June 2001 as a base budget appeal, secondly on October 1, 2001 as part of the EMS Response Time Framework and finally on January18, 2002 on the suggestion of the provincial Emergency Health Services Director.  We have never had an opportunity to negotiate on this base budget and still do not (as of Feb 15, 2002) have an answer to our appeals.

 

2001 Cost Overruns:

 

Staffing Shortages / Increased Educational Requirements

 

The primary driver of EMS cost overruns in 2001 was the impact of increased educational requirements which lead to immediate and then chronic staffing shortages.  In mid 2000, the Board was advised that effective January 1, 2002, the Board would not be able to employ any ambulance staff who are not Emergency Medical Care Attendants (EMCA).  As part of the hiring process on January 1, 2001, persons who had Emergency Medical Assistant (EMA ) training were advised that effective January 1, 2002, the Board would not be able to continue to employ them.  This lead to some EMA staff leaving the Board’s employ and quickly lead to severe staffing shortages.

 

The EMA qualified staff were essential in meeting the staffing needs in several bases.  These staff were very often employed full time in other occupations. They were essential in assisting the Board by providing coverage in smaller communities outside of the regularly scheduled shifts and on weekends.  Their role was particularly important in being available on a call-in basis for which they received compensation of $2.15 per hour to be on call. The majority of these staff indicated they could not leave their existing employment to be become EMCA certified unless they could be guaranteed regular scheduled shifts at the regular rate of pay following their graduation.  Some would not leave their primary occupation regardless of any assurances.

 

EMCA - Training Requirements

 

In 1999, the length of the EMCA training program was increased from one year to two. This created a province wide situation in which there was one year of no new EMCA graduates.  Unfortunately, this change in educational requirements coincided with a sharp increase in demand for EMCAs driven by new mandatory response time standards. As other areas staff up they are hiring EMCAs and not EMAs.

 

Response Time Standard

 

Implementation of a Response Time Standard in other areas had a direct impact on staffing shortages in the ADSAB jurisdiction. Prior to the transfer, there was no provincially mandated response time standard.  Following the transfer, the imposed standard is 90% of the average response time achieved in 1996.  The Ministry of Health had not been recognizing, in any systematic manner, service demand increases since 1996. As the transfers occurred, the requirement to meet this new standard had huge impacts across Southern Ontario. The impact was greatest in those areas where there was significant population growth.  These areas, primarily the Regions, had the service transfer during 2000 and immediately began to staff up so they could meet the Response Time Standard.  This staffing up process has led to a migration of staff from Northern and rural areas to Southern Ontario. 

 

Staffing Issues

 

At the January 2001 meeting of the Board, several Board members expressed concern that the future of the service was imperiled by the Ministry’s unilateral decision to raise education levels without a reasonable transition period.  Discussion as to different strategies to attract and retain staff with the appropriate requirements began at that time.

 

By the February 2001 Board meeting, the EMS Manager noted that service delivery was in jeopardy due to resignations of staff who were primarily leaving for work in Southern Ontario.

 

At the April 2001 Board meeting, two resolutions passed at the meeting of the Northern Ontario Service Delivers Association were also passed by the Board.  Those resolutions requested a longer implementation period for new EMCA educational qualifications and increased training opportunities.

 

In year changes

 

At the February 2001 meeting, there was a Board approved change which ended the practice of allowing paramedic staff to leave bases for meal breaks during their assigned shift. This practice created a break in coverage in all bases except Elliot Lake and White River. To ensure uniform service across the District, the Board moved to implement continuous coverage by paramedic staff during their assigned shifts.

 

At the March 2001 Board meeting, a request to allow funding for the implementation of a non-emergency transfer service that would serve both Elliot Lake and Blind River was approved for submittion to the Ministry of Health.  Implementation was held pending funding approval.  In the interim, transfers were made using staff at the overtime rate to ensure hospitals could continue to meet their mandate and severely ill patients could receive essential services

 

By the May 2001 meeting, staffing shortages had reached a crisis. The EMS staffing shortage problem was in existence prior to the January 1, 2001 transfer date.  However each week since then, the shortage had increased despite several aggressive hiring initiatives.  The number of new employees hired had been consistently been more than offset by staff leaving for other areas. 

 

The Board made a decision to take exceptional measures and incurred unbudgeted costs to get the remaining overworked staff to accept call in shifts in their base or other bases. These additional costs included the paying of incentives such as guaranteeing a call-out (6 hours regular time) during the call-in shift.  Exceptional costs also included payment of travel, meal and other expenses when a shift occurred at a base other than the employee’s designated base. 

 

A staffing review completed on May 16, 2001 identified the need for 26 part time scheduled staff across all eight bases.  However, the Board was unable to attract qualified EMCA staff to fill these vacancies unless we were able to guarantee a certain level of work.  There was also no interest in EMCA certified staff accepting only call-in shifts at the rate of $2.15 per hour.

 

The lack of adequate numbers of staff lead to the total inability to cover shifts in some remote communities.  The danger of this occurring had been noted at the Board meeting on April 26.  Staff expected the problem to increase sharply during the summer months.  There was a need to grant vacation to staff who had been working exceptional number of hours to try to offset other vacancies. 

 

At the May 2001 meeting, the Board by resolution decided to:

 

1.    Implement the day crew plan for the Eastern Division as previously approved as part of the Board’s 2001 budget.  Implementation was to occur as soon as adequate staffing had been secured. 

 

2.    Implement a uniform 12 hour regular / 12 hour call-in schedule across all bases except Elliot Lake and Blind River.  Elliot Lake and Blind River would remain on their existing regular time schedules.  The schedule in the other bases would be based on a mandatory consecutive bundling of 12 hours of regular time at the regular rate and 12 hours of call-in time at the call-in rate. The present minimum call-out rate would remain.

 

3.    Any funding shortfall for the above two changes was to be funded from any year end surplus from the Board’s total operations.  If there was an insufficient surplus, the required funds would be covered by the Board’s existing operating reserve.

 

At the June 2001 Board meeting, it agreed that to ensure coverage, the 12/12 schedules will be implemented in Blind River on a trial basis. This action was in response to a potential loss of staff in Blind River. 

 

Also in June 2001, the Board received formal notice that the mandatory EMS Certification Review would occur in September.  Staff began a three month detailed review/upgrading of every aspect of the EMS service in preparation for that review. As part of that process, there were identified a host of equipment deficits and repair costs which had not been budgeted.  These problems were rectified at a cost of approximately $56,999.  and completed prior to the review.

 

By July 2001, it was clear that the new 12/12 schedules and the Eastern Division Inter-facility Transfer Unit  were having a positive impact on attracting staff, reducing overtime and ensuring no loss of service.   The implementation of the 12/12 schedules proceeded in stages across the District and was not fully in place in all sites until September.  The new schedules created more full time positions that were filled with existing EMCA qualified staff.  In addition, these new schedules attracted some EMCA qualified persons from other areas. Nevertheless, several EMCA vacancies still existed and efforts were ongoing to fill these vacancies.

 

By mid August 2001, Ministry officials had advised the CAO that the Ministry would be putting forward an amendment to the Land Ambulance Act relating to educational requirements.  Under the existing legislation only EMCA certified staff would be able to work in EMS after January 1, 2002.  The amendment provided for Emergency Medical Attendants (EMA’s) enrolled in the Paramedic program at a recognized College and in the process of advancing to EMCA to be allowed to continue working.  This extension is for four years. This amendment partially answers the request of Northern DSSABs for a staged implementation of changes to educational requirements.  Although the change did not immediately resolve the overall staffing problem, it did keep EMAs who were interested in the training in the Board’s employ.

 

The change did allow the EMS management staff to focus on working with EMAs who were already in the EMCA training program by continuing to supply work to them.  The Director of Human Resources was in touch with each EMA who was in the training program or had expressed an interest in the EMCA training to ensure ongoing communication related to progress in the course and to provide work commitments.

 

On August 14 2001, the CAO called the Regional Director to indicate we had still not received the 2001 budget approval. The Regional Director indicated the budget had been approved with the provincial share being $1,988,838.  It was noted that the Eastern Division Inter-facility Transfer Unit request and the 12/12 Scheduling Change request were not approved as part of the base budget but would be considered under additional funding.

 

By September 2001, in the Eastern Division sites now had the minimum staff complement.  This was resulted from several new hires and linked to the new 12/12 schedules . Nevertheless, additional part time staff were still needed for vacations and sick leaves.

 

In the Northern Division, Hornepayne and Wawa also had the minimum staff complement.  White River would only reach that position when two paramedics arrived from Nova Scotia.  Exceptional funds were approved for relocation costs for these new employees.

 

Dubreuilville remained seriously understaffed.  Service was primarily maintained through moving staff from other bases.  Keeping this base operating lead to exceptional overtime and travel costs.

The ongoing staff shortages in EMS continued to create huge overtime costs as staff were brought in to cover understaffed areas, for vacations and for sick leave.

 

By early September 2001, Ms. Cindy Widawski, Training Supervisor had identified a shortage of training openings in the community college system and she worked to create new training seats.  Despite requests, no support was received on this problem from the Ministry of Health.

 

On October 1, 2001, a thirty page document was submitted by the EMS Manager seeking additional funding for a number of activities which had already been implemented under the Response Time Framework.   The Board hoped to be funded for activities related to improving response time and improving service quality.  These were submitted by the due date.  Despite formal written enquiries in December 2001, we have still not received any written response to this submission beyond an acknowledgement in January 2002 that the submission had been received and was complete.  We have been verbally advised, in February 2002, that only a fraction of the $100 million in requests under this framework would be approved due to Ministry restraint.

 

In October  2001, it was noted that the staffing shortage had also lead to untaken vacations which would need to be paid out  at year end.  This payout, which occurred in early January 2002 for the 2001 budget year, cost $35,245.

 

It was noted that by this time, several EMA staff were already involved in the community college program leading to EMCA designation.  Under updated provincial legislation, effective January 1, 2002 the Board could only employ EMS staff who were either qualified EMCA or, alternatively who were presently involved in the community college program leading to EMCA designation.  It should be noted that using this latter group is only acceptable for part time employment and only if they are enrolled in the EMCA course.  The legislative provision to use staff in EMCA training expires December 31, 2006. 

 

At the October Board meeting, a new collective agreement was ratified by the Board.  That agreement covered all staff including EMS.  It replaced the original (CUPE) agreement for Ontario Works staff which had remained unchanged since 1992, the provincial (OPSEIU) agreement covering Social Housing transferred staff and the seven separate collective agreements with three separate unions (CUPE, CAW, SEIU) covering EMS staff.  For all unionized staff the increase was 3% in 2001, 3% in 2002 and 3% in 2003.  For EMS staff only, there is an wage opener in February of 2002 and February 2003 which assured those in demand staff that they would be paid the average rate in pay for their classification between the City of Thunder Bay, Sault Ste. Marie DSSAB, Cochrane DSSAB and City of Greater Sudbury.  This wage opener article for EMS staff was deemed essential to prevent further loss of staff. Nevertheless, staff losses still occur due to the significant rate differences between Northern and Southern Ontario and rate differences in the North.

 

By late December 2001, additional community college seats in the EMCA program had become available locally. These additional community college spaces came about through direct action of Board staff working with community college representatives. The Director of Human Resources and the EMS Manager noted there were efforts underway to get an additional group of up to fourteen persons in these courses prior to year end.  However, it was not clear this could be accomplished by year end. The Director of Human Resources noted that all the potential candidates may not be enrolled by December 31.

 

On December 11, 2001, a letter was couriered to the Minister.  It reflected the staffing situation in EMS as of that date and the resolution passed by the Board on November 30.  The correspondence was shared with the Land Ambulance Implementation Steering Committee (LAISC). LAISC is a joint committee of AMO and the Ministry of Health.  It formally notified the Minister that the Board would employ, contrary to the Ambulance Act, non-EMCA paramedics who were not currently enrolled in or had committed to a college program rather than having to close one or more ambulance bases as a result of the current staffing shortages and lack of sufficient college programs.

 

 

2002 Budget

 

The 2002 budget for EMS was created based on the existing staffing patterns in place on December 31, 2001.  It does not include any funds for any changes to any bases or changes to any schedules.

 

It contains reduced travel costs and no avoidable capital costs beyond the ambulances ordered in 2001 for delivery in 2002.  The municipal share is based on no increase in the provincial grant from 2001 to 2002.

 

The EMS budget increase is mainly driven by two factors.   The first factor is increased paramedic wage and benefit costs as previously outlined.  The second factor is the refusal of the Ministry to recognize true costs in 2001 and any increased costs in 2002.