Ombudsperson - Terms of Reference

The Office of the Ombudsperson
Status
Mandate: Consideration of Individual Complaints
Mandate: Baycrest Policies and Procedures
Reporting
1. Annual Report
2. Protection of privacy in public reports
Files
Review

1. The Office of the Ombudsperson

Baycrest provides the services of an independent and impartial Ombudsperson to assist Baycrest: in protecting the rights of its clients¹ ; in fulfilling its obligations to its clients; and in achieving its mission to enrich the quality of life of the elderly guided always by the principles of Judaism.

The Ombudsperson provides an impartial and confidential service to assist clients of Baycrest who have been unable to resolve their concerns about their treatment by Baycrest authorities. The work of the Ombudsperson is devoted to furthering procedural fairness and just and reasonable outcomes. While the Ombudsperson does not have the authority to over-rule decisions, she/he can consider complaints, make informal enquiries, carry out formal reviews, draw conclusions and recommend actions to be taken by Baycrest to address the nature of the complaints.

2. Status

The Ombudsperson is appointed by the President and Chief Executive Officer on the recommendation of a search committee that is representative of the Baycrest community including clients, family and staff representatives of Baycrest; reports directly to the President and Chief Executive Officer; makes recommendations to the President and Chief Executive Officer, and issues annual reports to the attention of the President and Chief Executive Officer. The Ombudsperson has unrestricted access to all Baycrest authorities and is independent of all existing administrative structures of Baycrest.

3. Mandate: Consideration of Individual Complaints

3.1 Appropriate stage for consideration of a matter by the Ombudsperson

The Ombudsperson considers complaints from clients and their families (a) when they have been unable to resolve their concerns through the usual process; or (b) when they have encountered unreasonable delays in the consideration of their concerns through the usual processes; or (c) when they are unable, because of other factors that are reasonable in the circumstances, to determine or to follow the usual processes. The Ombudsperson shall not normally consider complaints that are in the process of being dealt with through established processes, apart from (a) situations of unreasonable delay or (b) situations where, given special circumstances, additional assistance is warranted. The Ombudsperson shall not consider complaints that are before the courts of law or are pending at or before any administrative tribunal outside Baycrest.

3.2 Impartiality

In considering complaints, the Ombudsperson shall act in an impartial fashion, acting neither as an advocate for the individual client or family representative nor as a defender of Baycrest, but rather seeking procedural fairness and reasonable outcomes.

3.3 Confidentiality

The services of the Ombudsperson are provided on a confidential basis. The Ombudsperson shall hold all initial consultation in strict confidence. Where an individual decides to ask the Ombudsperson to deal with a complaint, the name of the individual and the substance of the complaint shall be disclosed only to those staff members who need to know the name to respond. Those staff members shall hold the matter in strictest confidence with any breach of confidentiality to be addressed as a performance issue.

Where the outcome of an individual complaint is a formal report, that report shall be regarded as confidential by the Ombudsperson and by all recipients, although any policy implications of the reports may be made public without disclosure of the complainant’s name(s). Where, in special cases, the Ombudsperson reports on a matter that has become public, the Ombudsperson may, with the written permission of the affected persons, publicly disclose names and findings. In all cases, confidentiality is also subject to disclosure required by law or where, in urgent situations, there is a real risk to health and safety.

3.4 Eligibility and Jurisdiction

The services of the Ombudsperson shall be available to anyone who receives or is representing someone who is receiving care or service from Baycrest including residents, in-patients, out-patients, clinic patients, day program participants, family members of residents and patients, and client research participants.

The services of the Ombudsperson shall not be available to members of the public with complaints about the actions of Baycrest authorities unrelated to the provision of care and service to current clients.

3.5 Consideration of an individual matter at the request of a Member of Baycrest Management

A member of Baycrest management may request that the Ombudsperson consider a matter. The Ombudsperson may do so provided: (a) that the matter has not already been brought to the Ombudsperson as a complaint by an individual Member of Baycrest (in which case it will be dealt with in the usual manner); (b) that the other parties/party consent/s to the Ombudsperson’s consideration of the matter, and (c) that for any matters requiring a significant commitment of resources, it be subject to the approval of the President and Chief Executive Officer to whom the Ombudsperson is accountable.

3.6 Process for Consideration of Individual Complaints

The normal process for the Ombudsperson’s consideration of individual complaints is informal enquiry and fact-finding, proceeding if appropriate to further fact-finding and informal intervention, and thereafter if appropriate to a formal review and report.

The Ombudsperson shall have such access to all Baycrest files and Baycrest Officers, staff and representatives as she/he deems necessary in the pursuit of official duties and Baycrest Officers, staff and representatives are required to provide prompt and full responses to the Ombudsperson’s enquiries.

In dealing with individual complaints, the Ombudsperson shall not seek to replace established legislative, judicial or administrative rules or procedures or to make a judgment that will replace Baycrest policy. The objective shall be to determine whether the established legislative, judicial or administrative rules or procedures have been carried out fairly and appropriately and to determine whether a Baycrest policy, in the case under review, had an unintended outcome that is unfair or unreasonable.

In considering individual complaints, the Ombudsperson may decline to proceed with a matter if she/he determines that the complaint is frivolous or vexatious.

If the consideration of an individual complaint proceeds to the stage of a formal review and report, a draft of the report will be provided in advance to the member of Baycrest management responsible for the matter, who will be invited to provide a formal written response. That response will be included in the final report, which is submitted to that member of Baycrest management, to the Vice-President(s) responsible and to the President and Chief Executive Officer.

4. Mandate: Baycrest Policies and Procedures

In the course of considering complaints, the Ombudsperson may become aware of possible deficiencies in Baycrest’s policies and procedures. Where the Ombudsperson perceives such deficiencies, she/he shall expeditiously draw them to the attention of the appropriate Baycrest authorities. It shall be the special concern of the Ombudsperson to draw the following matters to the attention of the appropriate Baycrest authorities:

any situations where the rights and responsibilities of members of the Baycrest community of clients are not adequately defined and promoted; and any situations where information on proper procedures for problem-resolution is not readily understandable and readily available;
any gaps and inadequacies in existing Baycrest policies and procedures that affect the ability of individuals to function as members of the Baycrest community or that might jeopardize their human rights and civil liberties;
any situations in which the problems of members of the Baycrest community of clients are not addressed with reasonable promptness; and
any deficiencies in procedures used to reach decisions or in criteria and rules on which the decisions are based.

In carrying out this responsibility, the Ombudsperson shall not purport to make Baycrest policy or to replace established legislative, judicial or administrative rules or procedures. Rather the Ombudsperson shall draw problems to the attention of the appropriate Baycrest authorities and recommend a review of the policy or procedure. Where the Ombudsperson wishes to do so, she/he may recommend specific improvements.

While it is anticipated that the Ombudsperson will become aware of potential deficiencies in Baycrest’s policies or procedures or in their application as the result of complaints, it is recognized that such potential deficiencies may come to the attention of the Ombudsperson by other means. In such cases, the Ombudsperson may give consideration to the matter; may draw problems to the attention of the appropriate Baycrest authorities; may recommend a review of the policy or procedure, and may recommend specific improvements to the policy or procedure.

5. Reporting

5.1 Annual Report

The Ombudsperson shall issue a written annual report to the attention of the President and Chief Executive Officer, as well as such other special recommendation reports as may be required.

5.2 Protection of privacy in public reports

The Ombudsperson, in all such written annual and special reports, shall protect the privacy of clients and staff of Baycrest who use the services of the Office in accordance with the Personal Health Information Protection Act, 2004 and other legislation, as applicable.

6. Files

6.1 The Ombudsperson shall maintain suitable records of complaints, findings and recommendations and these shall be accessible only to the Ombudsperson and members of the staff of the Office of the Ombudsperson.

6.2 Each file and record will be maintained for a period of ten years from the date on which the Ombudsperson deems the case to be completed. At the end of the period of ten years, the file or record may be destroyed; however, no destruction of the file or record will take place while any proceedings are pending at Baycrest, and/or the Courts or any outside tribunal and until after all rights of appeal are exhausted or times of appeal have expired.

6.3 The Ombudsperson shall not release any information regarding personal and personnel records, unless written permission has been received from the affected persons for releasing the information.

7. Review

The Office of the Ombudsperson shall be reviewed on a regular basis at the direction of the President and Chief Executive Officer. The President and Chief Executive Officer may commission a review committee, state its terms of reference and appoint its membership, subject to approval by the Program and Quality Committee of the Board. The report of the review will be presented to the President and Chief Executive Officer and through him/her to the Program and Quality Committee of the Board, for consideration and action as they deem appropriate.

November, 2007

Baycrest gratefully acknowledges the original policy framework provided by the University of Toronto (Terms of Reference for the Office of the University Ombudsperson) for the purposes of adaptation by Baycrest.

¹ This term, throughout this document, is intended to be inclusive of residents, in-patients and out-patients, clinic patients, day program participants, family members/representatives of patients/residents, and client research participants.