Ontarios transport medicine provider, Ornge, is under fire. In early December 2011, the Toronto Star launched a series of stories that took aim at the private, not-for-profit charitable organization, which provides patient transfers via helicopter, fixed-wing aircraft and land-based vehicles for Canadas most-populated province. In return for its services, Ornge receives grant funding from the provincial Ministry of Health and Long-Term Care (MOHLTC) under a performance agreement. 

The Stars first story on Dec. 5 focused on the issue of executive salary disclosure. Although Ornge receives $150 million Cdn in tax funding a year, the reporter wrote, the salaries of at least five of its top executives are shielded from the sunshine list the province publishes annually to help make government accountable. According to Ontarios Public Sector Salary Disclosure Act, organizations that receive funding from the province must publish the names, positions, salaries and total taxable benefits of anyone earning $100,000 or more annually. 

The salaries that were not disclosed at Ornge were those of Dr. Chris Mazza, then-president and chief executive officer, along with at least four other top executives, reported the Star. 

In a statement also published on Dec. 5, Ornge fired back that the executives in question were actually employed by for-profit private entities created within the Ornge group of companies and that only the salaries of operational staff at Ornge Ontario (the transport medicine division) must be reported.   

Ornge maintained that it had complied with provincial law, and that disclosing the salaries of employees who fall outside the operational scope of Ornge Ontario could be a breach of confidentiality. It also said that no public funds had been spent on its for-profit enterprises.

Ontarios auditor general had begun probing Ornges operations in early 2011, as part of a regularly scheduled audit cycle. On Dec. 6, the Star reported that Auditor General Jim McCarter had requested more time to complete his report, and that it was now targeted for a late-February-2012 delivery. 

Then, on Dec. 19, Canadas largest daily newspaper published a story saying Ornge Global Solutions (one of the private, for-profit affiliates under the leadership of Mazza) had struck a multi-million-dollar deal in 2010 to provide “marketing services” to AgustaWestland, the Anglo-Italian helicopter company that had manufactured Ornges fleet of AW139s, which were purchased in 2008 (see p.8, Vertical, Oct-Nov 2008).

Ornge reportedly refused to discuss the deal when contacted by the Star. A representative was quoted as saying that Ornge Global is a private company and its business agreements are not open for public discussion. 

By Dec. 21, the provincial health minister, Deb Matthews, was on the record as strongly encouraging Ornge to co-operate fully with the auditor general, as well as the MOHLTC, in an investigation launched in response to the issues raised by the Toronto newspaper. 

The next day, the Star published Mazzas salary: $1.4 million a year. That same day, Ornge released a statement indicating Mazza had gone on indefinite medical leave. In the statement, Rainer Beltzner, then-chair of the Ornge board of directors, said the organization had fully complied with all requests from the MOHLTC and would support the auditors work at Ornge.

In late December, the Star also raised questions about the level of service provided by Ornge. The newspaper reported that a lack of paramedics at the Thunder Bay base during the period of February to November 2011 resulted in the helicopter air ambulance being grounded a total of 1,300 hours, with the average unavailability time being five hours.

In an email to Vertical, Ornge spokesperson James MacDonald said Ornge has always had two paramedic crews in Thunder Bay, but the difference now is that they have stationed a second Pilatus PC-12 at the base, in response to increased demand for fixed-wing transport. He wrote that by doing so, Ornge has transported 57 percent more patients over the same time period from the previous year (paramedics are cross-trained to work in rotary-wing, fixed-wing and land-based vehicles). 

Vertical attempted to clarify Ornges reasons for not hiring a third paramedic crew, so that all aircraft would be staffed, inquiring directly if this would not be the most efficient use of resources. 

Steve Farquhar, Ornges vice-president of operations, replied via email to our question: The reality is that we dont have the operating funding to add a third paramedic crew in Thunder Bay. We added the fixed-wing [aircraft] with no additional dollars from the province in order to maximize the use of resources within our operating budget. It may not be ideal, but… its the best we can do for patients in northwestern Ontario in the current environment.

A separate Star story, also in December, examined Ornges helicopter launch policy (the second-most-recent revised version of which went into effect June 27, 2011), raising questions about dispatch procedure and response time in at least one specific case.  

Ornges then-acting-president, Tom Lepine, explained the helicopter launch policy to the Star: if a call comes in and a land ambulance is less than 10 minutes from the scene, the helicopter is readied but not dispatched until the land ambulance crew confirms it is needed. 

MacDonald confirmed to Vertical that if a land ambulance is more than 10 minutes from the scene, and the patient meets transport guidelines, policy says the helicopter will be launched. 

David Jensen, media relations coordinator at the MOHLTCs communications and information branch, explained to Vertical that Ornges staged-launch policy for helicopter deployment was instituted last summer in response to recommendations from the Office of the Auditor General of Ontario, recommendations that were originally presented in the auditors 2005 annual report. Ornge officially assumed responsibility for the provincial air ambulance system in January 2006. 

In a follow-up issued two years later, as part of its 2007 annual report, the Auditor Generals Office included a section pertaining to air ambulance services. The percentage of helicopter calls being cancelled after the helicopter had already been dispatched had been increasing, from about 27 percent in the 2003/04 fiscal year to 33 percent in 2004/05, said the report. The ministry had not formally analyzed the reasons for the high level of cancellations to determine whether changes to the dispatch process were required. Aside from the costs of cancelled flights, dispatched helicopters are generally unavailable to respond to another call, and therefore reac-tion times for subsequent patients may be increased. 

The auditor general recommended, in part, that MOHLTC take action to minimize the unnecessary dispatch of aircraft. 

In an August 2011 interview, for a previous story (see p.xx, Vertical, Oct-Nov 2011), officials at Ornge said the transport medicine provider had been actively searching for efficiencies within its operations to stretch funding dollars as far as possible. We have to be very efficient in the way we reach the patient, said Lepine, who was at the time chief operating officer at Ornge (and is now again after his brief stint as acting president).

Under the terms of its performance agreement with MOHLTC, Ornge receives a set amount of funding each year and must determine how to best divide that money to cover all operational aspects of its patient transfer services. 

According to Jensen at MOHLTC, Ornge determined that by delaying helicopter takeoff in situations where a land-based paramedic crew was within 10 minutes of the scene who could subsequently confirm the need for air ambulance transport the number of cancelled calls could be reduced; thereby saving money, assisting Ornge in providing its services within its funding envelope, and allowing aircraft to remain available to transport another critically ill or injured patient.

Ornge spokesperson MacDonald told Vertical in an email that Ornge reviewed statistics for scene calls that came in between June 27, 2011, and Aug. 29, 2011. One hundred and fourteen scene calls were documented as meeting the new scene-call response criteria: scene-call request and land ambulance within 10 minutes of the patient, he wrote. Of 114 requests, 24 patients were transported by Ornge and 90 were cancelled by land EMS [emergency medical services] upon arrival on the scene. Of the 24 patients transported, there were no adverse events or clinical deterioration that could have been related to any delay in launching the aircraft for response.

  

One senior member of the provincial network of ambulance dispatch communication centers expressed concern over the revised helicopter response policy. He told Vertical, under condition of anonymity, that the biggest change Ornge had made is in the way they deploy the helicopters. He explained further: What used to happen is that if there was an accident on the highway, they would re-route the helicopter to that accident. Now, what they say is if a patient is in the hospital and they have a known condition, they wont re-route the helicopter [from them] to an unknown condition. . . . If theres a head-on collision on a highway, the likelihood of a trauma patient being involved is significant. But they dont consider that, its an unknown, and they dont re-route the helicopter to that accident. 

Ornge VP of operations Farquhar responded to the dispatchers comments by email: Ornge physicians assess each case individually and make triage decisions based on fully-disclosed information. With respect to an on-scene response (such as a car accident), there are typically few patient details available to our physician. When the accident happens, the only information provided to dispatchers typically comes from non-medically trained bystanders. It would be irresponsible, for example, for a physician to triage a helicopter away from a call for a critical patient in a hospital to a car accident based on no more than bystander information. If, however, there is credible, medical information being fed back from the EMS crew on the scene, a physician will then make a triage decision to determine which patient is the highest priority.

According to Farquhar, Ornge often re-routes helicopters to higher-priority patients based on decisions made by its physicians.  

In response to the service level concerns raised by the Toronto Star, Ornge has committed to a vigorous review of current practices and process, and improved communications regarding outcomes according to an internal Dec. 23 message, sent by Lepine and other senior executives to Ornge staff, that was made public by the Star on Dec. 27. 

In the meantime, MOHLTCs Jensen commented that, in addition to the auditor generals regularly scheduled value-for-money audit of Ornge, the transport medicine providers operation is also the focus of a forensic audit team, recently deployed through the Ontario Ministry of Finance with the mission to follow the public dollars and determine how public dollars have been used.

With regard to the forensic audit team, MacDonald told Vertical that Ornge welcomed the investigators arrival and is fully co-operating with them in an open and transparent manner.

On Jan. 11, 2012, Ornge released the news that its board had accepted a recommendation from MOHLTC to appoint senior public service member Ron McKerlie as its new interim president and CEO. According to the government press release on the same topic, McKerlie has a track record of bringing greater transparency and accountability to the public sector. In addition, the Ornge board announced it was resigning as soon as a new volunteer board could be put in place. 

But, that wasnt the only bombshell dropped by Ornge in its Jan. 11 press release. The transport medicine provider also announced that Ornge Global Solutions, the for-profit branch that had been under the direction of former Ornge president and CEO Mazza, was winding down.  

A day after taking the helm at Ornge, McKerlie sent an open message to staff: I am here to work with you to make Ornge a model organization as it relates to accountability, transparency and integrity of operations. 

But McKerlies appointment and the resignation of the Ornge board didnt end the related media investigations. The Star turned its focus to an empty hangar in Hamilton, Ont., leased by Ornge in December 2010 at a cost of $50,000 a month, but which has sat unused since that time. The delay has apparently been caused by a difficulty in procuring supplies needed for hangar renovation, but chief operating officer Lepine told the newspaper the goal is to open the base by this April. 

Meanwhile, auditors continued digging into Ornge records, following the trail of public money. But, the Star has also revealed that the Ontario Premiers Office and MOHLTC had in fact received a briefing from Ornge in January 2011 a briefing that outlined in detail Ornges plans to leverage the expertise of the public service through a group of for-profit entities. In return, Ornge executives promised the government that three percent of gross revenues from those spin-off companies would be returned to taxpayers, with the lions share being retained by Ornge executives and investors. This is the very structure that is now being investigated by auditors. Health Minister Matthews reportedly told the newspaper that Ornge had unequivocally assured the government that public dollars would not be spent on the private ventures. But, the government apparently did not make any further inquiries into Ornge operations subsequent to that briefing one year ago.

Then, on Jan. 16, another bombshell: the Toronto Star revealed that public money had indeed gone into funding much of Ornges private ventures. Although funds for Ornges new aircraft, office building and other expenses had in fact been contributed by private investors, the newspaper revealed that those investors receive interest and principal payments from the $150 million public purse that Ornge receives annually. In the same article, it was noted that Ornge had purchased 12 AW139 helicopters, but only needed 10. The other two surplus machines are in storage, listed for sale.

The Globe and Mail national newspaper then joined the fray, revealing on Jan. 18 that MOHLTC is investigating 13 incidents, some involving deaths, that mostly relate to Ornges response times or the adequacy of its helicopter fleet. In a Jan. 19 article, The Globe and Mail said that questions have been raised about the stretcher pedestal in the AW139, which reportedly is too high. When the stretcher is oriented in the lengthwise position, which it must be for takeoff and landing, there is not enough clearance space to perform CPR. The lifesaving procedure may be executed if the stretcher is in a cross-wise or transverse position, and Ornge is reportedly seeking a Transport Canada exemption to allow the stretcher to be in that position for taxi, takeoff and landing. 

The ongoing saga concluded (at least for the purposes of Verticals deadline) on Jan. 20, when the Star announced that Ornge had changed its helicopter launch policy once again. Helicopters will now be dispatched when the original 911 call goes out, if emergency services think a helicopter is required. The change was made, Ornge spokesperson Gannon Loftus reportedly said, after a review of the old policy found unexpected delays in helicopter response.