Feedback for Proposed Revisions to By-law No 3 — Fees & Public Register

Ontario Hospital Association  ·  Nov. 23, 2015

The Ontario Hospital Association (OHA), on behalf of its members, appreciates the opportunity to provide comments to the Ontario College of Pharmacists’ (College) on its proposed revisions to By‐Law No 3 – Fees and Public Register. The proposed By‐Law amendments include the proposed fee model for application, issuance, and renewal of certification along with public register in response to the Drugs and Pharmacies Regulation Act (DPRA), which will enable the oversight of hospital pharmacies by the College.

Ontario hospitals are deeply committed to providing high‐quality patient care and ensuring compliance with legislation, standards, and accepted safeguards. Further to the Ministry of Health and Long‐Term Care’s (Ministry) commitment to support implementation of the recommendations of the Review of Oncology: Under‐dosing Incident Report, the OHA is committed to working collaboratively with the College, the Ministry, and other health system stakeholders to establish an appropriate role for the College in the oversight of hospital pharmacies.

Reflecting on input from our member hospitals’ Directors/Managers of Pharmacy and Leadership Councils, the OHA has significant concerns related to the proposed fees and respectfully submits that the proposed framework is not a viable fee structure. With this in mind, we have outlined a number of recommendations and would be pleased to discuss these further with you.

1. Proposed College Fee Structure

The draft College By‐Law proposes an initial application fee of $3,000 and issuance fee of $3,000 per site for hospitals; and, additionally, an annual renewal fee of $5,000 per site, to support a cost‐recovery model and cover the $1.1 million in expenses the College’s current model would incur annually.

Ontario hospitals are experiencing significant and sustained budget constraints with a wide range of cost pressures and competing priorities. This is the fifth year where hospitals have not received any inflationary increase to meet growing financial pressures. Despite these challenges, hospitals have remained committed to improving patient care. Today, hospitals are at a critical juncture where they must make difficult resourcing decisions around continuing programs and services for patients. Hospital oversight strategies, such as that proposed by the College for pharmacies, must be designed to be respectful of this challenge and share stewardship for the financial capacity of the province’s hospitals.

Ontario hospitals are remarkably diverse in their size and structures. Some small, rural and northern hospitals have fewer than 20 beds. Others are multi‐site corporations with differing pharmacy requirements and services across different sites. Across all hospitals, the fees proposed by the bylaws represent yet another cost pressure and will only add to the financial pressures elsewhere in the hospital.

The OHA respectfully requests that the College consider the following options:

Recalibrate the Scale of the Oversight and Licensing Program

Hospitals are regularly faced with difficult program design decisions. We respectfully request that the College reconsider aspects of the design of its hospital oversight program (e.g., budget, staffing, travel) in order to sustain achievement of core objective through resources that the province and hospitals can afford. It is our understanding that the initial thrust of work to complete baseline assessments in all hospitals in one year, while commendable, would not be a true reflection of future work requirements. The OHA supports a more viable fee structure that allows hospitals to focus resources toward the implementation of standards and future safety practices, rather than paying administrative fees.

Seek Ministry Funding and Nominal Hospital Application/Renewal Fee

With the Ministry committed to supporting the new role for the College and the licensing of all Ontario hospital pharmacies, the OHA supports the creation of a dedicated budget that would be provided to the College to support the infrastructure and ongoing inspection/licensing requirements associated with this work. This separate budget would ensure that the costs would not require offset hospital fees, as it would in the current proposal. With this preferred fee structure, hospitals would pay a nominal initial application fee and then an annual renewal fee. For instance, in British Columbia, the OHA understands that this fee is $1,331 per hospital site.

Amalgamate College Infrastructure and Fee Schedule for Hospitals and Community

The current fee structures associated with hospital pharmacy oversight is many times greater than the fees charged to community pharmacies. Not‐for‐profit hospitals do not have capability to raise additional revenue to offset additional fees. Closer alignment of the hospital and community programs would better leverage the expertise and economies of scale currently being achieved in the community sector and divide the total budget among all pharmacies.

Delivery Through a Regional Peer‐Surveyor Model

Based on member feedback, one additional consideration toward the model that may support the College with decreasing its annual budget requirements is a regional peer‐surveyor model, similar to Accreditation Canada. Pharmacy leads from Ontario hospitals would support review, inspection and ongoing peer mentoring of peer and local hospitals; and in addition, the review and update of standards related to the practice. With consideration to this model, the staffing and travel requirements for the College may not need to be as extensive.

Utilize Differentiated Licensing and Fee Structures

While a number of hospitals in Ontario are comprised of one site, there are many situations where a hospital corporation has numerous sites. In the case of community and small hospitals, many of these sites have pharmacies, but many do not participate in high‐risk pharmacy activities (e.g., chemotherapy drug preparation). As such, we would also recommend consideration to differentiating hospital pharmacies licenses and fee structures.

2. Communicating the College Inspection Results through a Public Register

The OHA is supportive of a public register that would outline details similar to the current public register (e.g., accreditation number, corporation name, address, status of accreditation). It is important to consider the best way to capture hospital site‐specific information within the fields that relate to the broader hospital corporation. Additionally, the inspection criteria and the standards that hospitals are being assessed against should be posted; however, individual hospital summary reports would not.

The OHA recommends the College specify how they will address situations where a hospital may receive a “pass with conditions” or a potential “fail” as it would be critical for the hospital to address the areas of concern, liaise with the College for an update to the inspection report, and continue to provide pharmacy services to meet patient care needs at the hospital. It is our understanding that an inspection report would be effective immediately, and, as such, we request further clarity on the process and next steps that would be considered.

3. Additional Operational and Implementation Considerations

The OHA wishes to raise a number of other operational and implementation issues related to the inspection and accreditation of hospital pharmacies:

  • While the OHA support appropriate oversight of hospital practices we must draw attention to situations where duplication of efforts contributes to inefficient use of valuable time and resources. There is significant overlap with the emerging work of the College and that of Accreditation Canada’s standards, which include a specific set targeted at medication management. In moving forward with the accreditation of hospital pharmacies by the College, it would be helpful to clarify the scope of accreditation and how the overlap of accreditation between the two organizations will occur. For instance, to prevent duplication of assessment on the same criteria, having Accreditation Canada defer to the College’s inspection results, where accreditation was recently assessed and completed. 

  • In consideration of the baseline assessments that have been completed, there are a number of resource requirements needed for hospitals in order to meet the standards outlined in the inspection templates to support accreditation. A number of hospitals are faced with challenges related to implementing these standards – for example, concern has been raised with the cost of the estimate for implementing USP 795 and 797 standards, which the OHA understands could range from anywhere from $100,000 to more than $1 million per hospital site. Further, several members indicated that the renovations required to fully implement these standards may be physically impossible given the current size and structure of their facilities. 

  • Acknowledgement of the number of different quality initiatives currently underway in the province and the need for a service‐based prioritization and provincial‐level plan to address the areas with a realistic outlook regarding the standards, timelines and outcomes we wish to achieve.

Conclusion

We are committed to working with the College, the Ministry and our member hospitals to establish an appropriate role for the College that balances oversight with fiscal realities hospitals are facing, and also support the prioritization of work such that legislation/regulation and standards are successfully and consistently implemented across the sector.

The OHA would like to thank you once again, for the opportunity to provide feedback on the draft proposed By‐Law. We would be please to meet and speak further on the recommendations outlining our suggested alternative models above at any time.

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