Avoiding, acknowledging and fixing mistakes: investigation of a complaint about the Australian Community Pharmacy Authority

This investigation into the approval process for pharmaceuticals produced findings with broader lessons for Commonwealth agencies about the importance of proper program design, sharing information necessary to ensure proper outcomes and about service recovery arrangements when things go wrong. Foreword This is a report on the Ombudsman’s investigation of a complaint from a pharmacist about the Department of Health (DoH) and the Department of Human Services (DHS). The complainant contacted our office because he believed that a neighbouring pharmacy had been incorrectly approved to dispense medications under the Pharmaceutical Benefits Scheme (PBS). He told us the neighbouring pharmacy had relocated from its original site to one closer to his pharmacy than the rules allowed and this affected the viability of his business. He had unsuccessfully attempted to find out from DoH and DHS how this had happened, and was frustrated in his attempts to obtain a resolution. The approval process, jointly administered by DoH and DHS, relies upon the pharmacist applying for approval to provide evidence of the distances between their new location, old location and any other nearby pharmacies. There was an error in the measurement of the distances between the pharmacies. This error had come to the attention of the DoH before the approval was finalised, but the information was not relayed to DHS, which granted the approval without knowing that the application did not meet the location requirements. We found problems in the design of the pharmacy approval program, which focussed primarily on the interests of the applicant pharmacist without considering how to protect the interests of other pharmacies in the area. The program was delivered by two separate agencies, without sufficient regard to the need to share information in a timely way to ensure the integrity of the scheme. When it became apparent to DoH that DHS had made a decision based on wrong information, it initially failed to consult with DHS about how to put things right. In our view, DoH responded to the mistake in an inappropriately defensive way. Finally, when someone affected by the error complained about it, they were met by an unwillingness to explain or admit fault, and told their only option was to go to court. We were unable to obtain a remedy for the complainant. However, DoH agreed that, if the complainant makes a claim for compensation including evidence of loss, it will refer that claim to its Minister for consideration. We note that DoH has already implemented changes to its administrative procedures to address some of the problems that this complaint revealed. At the conclusion of this report we make four recommendations that we believe will further strengthen those arrangements, and provide a more open and responsive complaint process. While this complaint is about a very particular set of factual circumstances, we believe it holds broader lessons for Commonwealth agencies about the importance of proper program design, sharing information necessary to ensure proper outcomes and about service recovery arrangements when things go wrong

Investigation into allegations of improper conduct by officers of VicRoads

The investigation found that that some VicRoads enforcement officers routinely exceeded the speed limit in VicRoads vehicles without displaying lights or sirens, as required by the road rules. Foreword This report sets out the investigation into a protected disclosure complaint referred by IBAC to the Ombudsman in October 2014. The discloser alleged that it is “normal practice” for VicRoads Transport Safety Services staff caught speeding in VicRoads vehicles to avoid a fine by claiming unjustifiable exemptions. In effect, the allegation was that some VicRoads staff break the road rules with impunity. Victorian road rules are clear: road users may not exceed the speed limit, unless the special exemptions for drivers of police, emergency, enforcement and escort vehicles apply. The rationale for both the road rules and the exemptions is unarguably about public safety. Not only did some staff routinely break the rules, the process for investigating infringements and approving exemptions was seriously deficient. Exemptions were approved on no or minimal evidence, and with no or minimal rationale. Senior staff responsible for approving exemptions were not even aware that lights or sirens were necessary. &nbsp

2009 Annual Report to Congress

[Excerpt] Enacted in 2004, Public Law 108-375 also created an Office of the Ombudsman (the Office) and urged the Secretary of Labor to take appropriate action to ensure that it be an independent Office within the Department of Labor (DOL), including independence from the other officers and employees of the DOL engaged in activities related to the administration of the provision of the EEOICPA. See 42 U.S.C. § 7385s-15(d). The Secretary of Labor appointed an Ombudsman in February 2005, and the Office submitted its first report to Congress covering calendar year 2005 on February 15, 2006. When initially created, the duties of the Office only extended to Part E. On October 28, 2009, Public Law 111-84, the National Defense Authorization Act for Fiscal Year 2010, expanded the authority of the Office to also include Part B of the EEOICPA. The day to day activities of the Office are driven by two goals; 1) to provide information and assistance to claimants and potential claimants regarding the EEOICPA; (2) to provide opportunities for claimants and potential claimants to express their complaints, grievances, and requests for assistance concerning this program. In achieving these goals, the Office: Engages in outreach – We sponsor town hall meetings, as well as attend other meetings, forums and workshops where we discuss the EEOICPA and its requirements. This year, with the assistance of the efforts of a task force comprised of many of the agencies involved with the EEOICPA we were able to attend 20 outreach meetings in 11 different cities. Clarifies/explains documents and procedures – The EEOICPA can be very complicated and decisions are oftentimes based on very technical medical, scientific and/or legal concepts. We are contacted by claimants who find it difficult to comprehend these concepts. In addition, there are a many nuances to this program – for example for many of the “rules” there is at least one exception. Some claimants need assistance “steering the right course” as they proceed with their claim. Receives complaints, grievances and requests for assistance – Individuals with pending claims; individuals whose claims were denied; as well as some individuals whose claims were awarded, contact the Office or attend our town hall meetings, to voice complaints and grievances with this program. We are also contacted on occasion by claimants who have complimentary comments concerning the program – usually complimenting the services provided by individuals associated with the program. Provides assistance – It is rare when we are contacted by an individual who simply wants to voice a complaint. Most individuals contact us because they are seeking assistance with their claim. In some instances, we are asked to explain a word or decision. On other occasions, we are asked to provide assistance locating necessary records, or our input is sought on how to proceed with a claim. Inasmuch as many claimants do not have access to computers, we also frequently provide public information such as copies the Site Exposure Matrices; Site Profiles; listing of the 22 cancers covered for purposes of Special Exposure Cohorts, etc. Within the limits of our authority and resources, we assist claimants however we can. The report that follows is a synthesis of the many e-mails, letters, telephone calls, faxes, and face to face conversations that members of this staff had over the past year

2012 Annual Report to Congress

[Excerpt] Public Law 108-375 not only repealed Part D and established Part E it also created the Office of the Ombudsman (the Office). The law urged the Secretary to ensure the independence of the Office within DOL, including independence from other officers and employees of DOL engaged in activities related to the administration of the provisions of EEOICPA. Public Law 108-375 also contained an express sunset date, terminating the requirement for the Office on October 28, 2007. On October 22, 2007, shortly before the sunset provision was to take effect, former Secretary Chao issued a Memorandum determining that the Department of Labor should continue to have an Office of the Ombudsman in the event that the statutory requirement expired. This Memorandum took effect on October 28, 2007. Subsequently, on January 28, 2008, Section 3116 of the FY08 Defense Authorization Act, Public Law 110-181, effectively reinstated the statutory requirement for the Office by extending the sunset date until October 28, 2012. On October 24, 2012, shortly before the October 28, 2012 sunset date, former Secretary Solis signed a Memorandum continuing the Office under the authority of the previous Memorandum signed on October 22, 2007. EEOICPA outlines three duties for the Office: Provide information about the benefits available under Part B and Part E and on the requirements and procedures applicable to the provision of such benefits; Make recommendations to the Secretary regarding the location of resource centers for the acceptance and development of claims under Part B and E; and Carry out such other duties as the Secretary specifies. See 42 U.S.C. §7385s-15(c). In addition, 42 U.S.C. §7385s-15(e) requires the Office to submit an annual report to Congress setting forth: The number and types of complaints, grievances, and requests for assistance received by the Office during the preceding year, and An assessment of the most common difficulties encountered by claimants and potential claimants during the preceding year

2010 Annual Report to Congress

[Excerpt] Public Law 108-375 which was enacted by Congress in 2004 also created an Office of the Ombudsman (the Office). Pursuant to this law, the Secretary of Labor was urged to take appropriate action to ensure the independence of the Office within the Department of Labor, including independence from the other officers and employees of the Department of Labor engaged in activities related to the administration of the provision of the EEOICPA. See 42 U.S.C. § 7385s-15(d). The Secretary of Labor appointed the first Ombudsman in February 2005, and the Office submitted its first report to Congress covering calendar year 2005 on February 15, 2006. When created in 2004, the Office was scheduled to sunset on October 28, 2007. However, in January 2007, Congress passed the National Defense Authorization Act of 2008 extending the Office until October 28, 2012. Moreover, while the Office initially only had authority with respect to claims filed under Part E of the EEOICPA, the National Defense Authorization Act for Fiscal Year 2010 expanded the authority of the Office to include Part B of the EEOICPA. The statute outlines three duties for the Office: To provide information on the benefits available under Part B and Part E and on the requirements and procedures applicable to the provision of such benefits; To make recommendations to the Secretary regarding the location of resource centers for the acceptance and development of claims for benefits under Part B and Part E; and To carry out such other duties as the Secretary shall specify. See 42 U.S.C. § 7385s-15(c). In addition to these specified duties, the statute also provides that the Office is to submit an annual report to Congress setting forth: a) The number and types of complaints, grievances, and requests for assistance received by the Office during the preceding year, and b) An assessment of the most common difficulties encountered by claimants and potential claimants during the preceding year

2007 Annual Report to Congress

[Excerpt] The Energy Employees Occupational Illness Compensation Program Act (EEOICPA) was passed by Congress in 2000, and amended in 2004, to compensate American workers who put their health on the line to help fight the Cold War. In the course of doing their jobs, many of these workers were exposed to radiation and other toxic substances and, as a result, developed cancer and other serious diseases. The purpose of this program is to acknowledge the sacrifice of these workers and to compensate them in some small way for their suffering and loss. As originally enacted in 2000, EEOICPA included Part B (administered by the Department of Labor (DOL)) and Part D (administered by the Department of Energy (DOE)). In October 2004, Congress repealed Part D and enacted Part E of the Energy Employees Occupational Illness Compensation Program Act, effectively transferring responsibility for administration of contractor employee compensation from the DOE to the DOL. The 2004 amendments also created the Office of the Ombudsman for Part E and directed that it be an independent office, located within the Department of Labor, charged with a three-fold mission: To conduct outreach to claimants and potential claimants to provide information on the benefits available under this part and on the requirements and procedures applicable to the provision of such benefits; To make recommendations to the Secretary of Labor about where to locate resource centers for the acceptance and development of claims; To submit an Annual Report to Congress by February 15, setting forth the number and types of complaints, grievances and requests for assistance received by the Ombudsman, and an assessment of the most common difficulties encountered by claimants and potential claimants under Part E during the previous year

2006 Annual Report to Congress

[Excerpt] The Energy Employees Occupational Illness Compensation Program Act (EEOICPA) was passed by Congress in 2000, and amended in 2004, to compensate American workers who put their health on the line to help fight the Cold War. Many of these workers developed cancer and other serious diseases because, in the course of doing their jobs, they were exposed to radiation and other toxic substances. They and their families have paid dearly for their role in protecting our democracy; the purpose of this program is to acknowledge their sacrifice and to compensate them in some small way for their suffering and loss. As originally enacted in 2000, EEOICPA included Part B (administered by the Department of Labor (DOL)) and Part D (administered by the Department of Energy (DOE)). When Congress repealed Part D and enacted Part E of the Energy Employees Occupational Illness Compensation Program Act in October 2004, effectively transferring responsibility for administration of contractor employee compensation from the DOE to the DOL, it also made provisions for creation of the Office of the Ombudsman for Part E. Congress directed that the Office of the Ombudsman be an independent office, located within the Department of Labor, and charged it with a three- fold mission: To conduct outreach to claimants and potential claimants; To make recommendations to the Secretary of Labor about where to locate resource centers for the acceptance and development of claims; To submit an Annual Report to Congress by February 15, setting forth the number and types of complaints, grievances and requests for assistance received by the Ombudsman, and an assessment of the most common difficulties encountered by claimants and potential claimants under Part E during the previous year. See 42 U.S.C. § 7385s-15(e). During 2006, the Office of the Ombudsman undertook outreach efforts to many claimants and potential claimants, principally focusing upon areas of the country to which we had not traveled during 2005. Throughout 2006, we also focused upon responding to the many letters, emails and telephone calls we received, requesting information or assistance, or expressing concerns about various aspects of the Part E compensation program. The concerns expressed to us ranged from issues with the statute itself, and/or the implementing regulations, policies and procedures, to general administrative issues. In responding to complaints, grievances and requests for assistance, we regularly meet with and consult the staff of the Department of Labor’s Division of Energy Employees Occupational Illness Compensation (DEEOIC). These meetings and consultations are fruitful. During the course of 2007, the Office of the Ombudsman expects to: Conduct additional outreach, traveling to meet with claimants and potential claimants to hear, firsthand, of their concerns and difficulties in obtaining Part E compensation. Respond to emails and telephone calls from claimants, potential claimants, and other members of the public. Continue our interactions with DEEOIC. This report is a short summary of the comments that this Office has received as a result of the personal contacts, the emails, and the telephone conversations from claimants erns about various aspects of the Part E compensation program

Investigation into SSC conduct of MFAT leaks inquiry

This investigation was triggered by a complaint about an inquiry by the State Services Commission (SSC), which culminated in the publication of the Report to the State Services Commissioner on the Investigation into the Possible Unauthorised Disclosure of Information Relating to the Ministry of Foreign Affairs and Trade (the Final Report). The complainant, Derek Leask, was a former New Zealand High Commissioner to the United Kingdom. He retired in November 2012, after more than 40 years’ service at the Ministry of Foreign Affairs and Trade (MFAT). Mr Leask was the subject of significant criticism in the Final Report. He complained to the Ombudsman that he had been treated unfairly. This review has identified numerous flaws in the inquiry, undertaken by Paula Rebstock on behalf of the Commissioner, in relation to Mr Leask. He was not responsible for the leaks that prompted the inquiry. Publication of a flawed report caused significant damage to Mr Leask’s reputation and resulted in serious, unwarranted and adverse professional, personal and financial consequences for him. The review recommends that SSC offer a public apology to Mr Leask, reimburse him for actual and reasonable expenses, compensate him for harm to reputation and review its guidance for future inquiries under the State Services Act 1988, in light of this report

Building a system-wide approach to community relationships with the findings of a scoping review in health and social care

Purpose: For leadership and management of western health systems, good quality relationships are a fundamental cornerstone of organising health and social care delivery, delivering benefits across organisations and communities. The purpose of this work is explore the extant management, health and social care literature, grounded in older people care, to reveal behaviours, processes and practices that if readily identified across a context will support healthy relationships across the ‘whole system’ of stakeholders. Design/methodology/approach: An academic/practitioner group designed and guided a scoping literature review of the health and social care and broader management literature to identify and extract important behaviours, processes and practices underlying the support of high quality relationships. A search strategy was agreed and key health and management databases were interrogated and 51 papers selected for inclusion. Working with the practitioners, the selected papers were coded and then organised into emergent themes. Findings: The paper outlines the relational behaviours, processes and practices elements that should be present within an older peoples care community, to support a healthy relational environment. These elements are presented under the five emergent literature themes of integrity, compassion, respect, fairness and trust. These five topics are examined in detail. A way forward for building statements using the review material, that may be developed to reveal relational patterns within older people care, is also explored and outlined. Research limitations/implications: All literature reviews are subject to practical decisions around time, budget, scope and depth restraints. Therefore potentially relevant papers may have been missed in the review process. The scoping review process adapted here does not seek to make any major considerations with regards to the weighting of evidence behind the primary research. Originality/value: This work contributes to a growing need for designers of health systems to more fully understand, measure and draw on the value of relationships to help bridge the gap between diminishing resources and the expanding demand on health and social care services

Palliative care in UK prisons: practical and emotional challenges for staff and fellow prisoners

Despite falling crime rates in England and Wales over the past 20 years, the number of prisoners has doubled. People over the age of 50 constitute the fastest growing section of the prison population, and increasing numbers of older prisoners are dying in custody. This article discusses some of the issues raised by these changing demographics and draws on preliminary findings from a study underway in North West England. It describes the context behind the rise in the numbers of older prisoners; explores the particular needs of this growing population; and discusses some of the practical and emotional challenges for prison officers, health care staff, and fellow prisoners who are involved in caring for dying prisoners in a custodial environment