Legislation

The Broader Public Sector Accountability Act, 2010

BPSAA Questions and Answers for Hospitals Expenses, Reporting and Attestation

Note: The Ministry of Health and Long-Term Care is providing the following responses for informational purposes only in order to assist hospitals in complying with the reporting requirements of the Broader Public Sector Accountability Act, 2010 (Act). The reporting requirements with which hospitals are required to comply under the Act are outlined in the Directives issued by the Minister of Health and Long-Term Care.


Procurement Directives

How do the BPS Directives define Consultant and Consulting Services, especially as it applies to professional services provided by e.g., architects and engineers? What about those individuals or organizations providing non-consulting services?

The Procurement and Reporting Directives define "Consultant" as a person or entity that under an agreement, other than an employment agreement, provides expert or strategic advice and related services for consideration and decision-making. Further, the Procurement Directive defines "Consulting Services" as the provision of expertise or strategic advice that is presented for consideration and decision-making.

Whether a service in question is deemed consulting service should be determined by the nature of the service being procured and not by the designated profession being represented.

Services provided by licensed professionals may constitute consulting services. Where an organization is seeking to obtain expertise or strategic advice for consideration and decision-making, notwithstanding the designated profession providing the service, the organization is seeking to obtain consulting services. Under these circumstances, organizations must utilize competitive procurement irrespective of the value of the procurement.

At the same time, procurement of services that in Ontario may, by legislation or regulation, be provided only by any of the following licensed professionals: medical doctors, dentists, nurses, pharmacists, veterinarians, engineers, land surveyors, architects, accountants, lawyers and notaries, does not constitute consulting services. BPS organizations should still clearly delineate between professional services that are providing expertise or strategic advice for consideration and decision-making and professional services that fall outside this scope.

Conversely, individuals or organizations may identify themselves as “consultants”, but provide non-consulting services.  These are services that do not provide expert or strategic advice for consideration and decision-making, but rather deliver a more tangible product/service.  In these situations, organizations must conduct the procurement activities consistent with their requirements for goods and non-consulting services.

It is up to the Organization to determine whether the services they require are consulting services or not.

There are numerous requirements for BPS procurement. Will there be something more specific in terms of reporting procurement compliance rather than just a general statement that we are in compliance?

Hospitals will be required to submit an attestation indicating compliance with the requirements of the BPSAA. The directive also requires the documentation of exceptions to compliance. In addition, hospitals will be required to submit an annual report on consultants that outlines consultant procurement activity, in compliance with the Directive issued by the Minister of Health and Long-Term Care under the BPSAA.

In terms of rationale for following non-competitive process, will government-required deadlines (MOH/CCO) be considered a meaningful rationale for following a non-competitive process? For example, if we are required to put a new reporting process in place by a specific date, and internal resources are not available to do the work and a competitive process will take 3-6 months to complete and result in not achieving the government’s requirements. Any thoughts on that?

Please note that deadline driven initiatives do not constitute non competitive procurements unless they fall under the AIT exemptions. Under the noted circumstance it’s best practice to work with your government representative and outline timelines and issues that would result in going through a competitive vs. non competitive procurement process in order to meet the required timelines.

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Expenses Directive

How do you define public funds?

“Public funds” is defined in section 1 of the Broader Public Sector Accountability Act, 2010 (BPSAA) to mean the public money of the province of Ontario that is provided by the Government of Ontario or an agency of the Government of Ontario, directly to any authority, board, commission, committee, corporation, council, foundation or organization through a grant or transfer payment or other funding arrangement, and, in the case of a school board, includes money received by the school board from taxes levied under the Education Act for school purposes, but public funds does not include,

  1. money that is paid for the provision of goods or services to the Government of Ontario or an agency of the Government of Ontario,
  2. money that is paid by the Government of Ontario or an agency of the Government of Ontario under a fee for service arrangement, or
  3. money that is provided by the Government of Ontario or an agency of the Government of Ontario, by way of a loan or loan guarantee;

This would mean, for example, that for purposes of expense disclosure, public funds would not include money paid by a private sponsor or entity not included in the definition above (e.g. travel paid by a course sponsor or by the federal government).

Does the expense policy (expense rules for allowable expenses) need to be posted on our internal or external website by April 1, 2011?

The expense rules must be posted on the organization’s external website, so they are available to the public. The rules must be available in accessible formats.

Are we required to post our draft expense policy on April 1, 2011, even if we are working on a new one?

Yes, please post the most current expense policy with a caveat that it is a draft version. Once your organization has a board approved version, this should replace the draft version on the website.

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Reporting on Consultants

In our report on the use of consultants are we required to include consultants paid in April 2011, or later, whose engagement was approved prior to April 2011?

If the contract work carries over after April 1, 2011, the contract must be included in the report on the use of consultants. The contract term must be noted and the amount paid for the reporting period (April 1, 2011 to March 31, 2012) must be captured.

Do we need to report on consultant contracts involving work completed prior to April 1, 2011, if payment was made on the contract after April 1, 2011?

No. If the contract work is completed prior to April 1, 2011, the contract does not need to be included in the report.

Our hospital has engaged a lawyer/law firm to provide an analysis of whether our current governance structure complies with the requirements of the Public Hospitals Act. Do we need to report on our retention of this lawyer/law firm under the MOHLTC's Report on Use of Consultants Directive?

No – since you have engaged this lawyer/law firm to provide you with legal advice, you do not need to report on the terms of your agreement.

Our hospital has engaged a consulting firm to prepare a report on the efficiency of our patient intake procedures as compared to those in other hospitals. While we are not seeking legal advice from this consulting firm, a number of members of the consulting team possess law degrees. Do we need to report on our retention of this lawyer/law firm under the MOHLTC's Report on Use of Consultants Directive?

Yes – Since you are purchasing consulting services rather than legal services, you would need to report on your agreement with the lawyer/law firm for this project.

Our hospital has retained a lawyer/law firm specializing in labour relations to provide advice on potential layoffs resulting from the consolidation of food services. Do we need to report on the retention of this lawyer/law firm under the MOHLTC's Report on Use of Consultants Directive?
No – since you have engaged this lawyer/law firm to provide you with legal advice, you do not need to report on the terms of your agreement.

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Posting of Expenses

I am a designated individual required to post expenses. I recently attended an out of town meeting where I was required to rent a car and stay overnight. What do I need to report on?

Hospitals must post the cost reimbursed for: the vehicle rental and any travel incidentals such as insurance; accommodation; and any meals.

I incurred an expense, and submitted an expense reimbursement claim, for a meal in September 2011, yet it will not be approved or reimbursed until October. Will it be reported in the first semi-annual posting that has to be publicly posted by November 30th?

No. Each posting must include all expenses approved and paid during that period. If an expense is incurred in one period (say September) and approved in another (say October), the required information about that expense must be included in the posting for the period in which the expense was approved. Therefore an expense incurred in September (April to September reporting period), but approved in October (October-March reporting period) would be posted in the October – March reporting period.

I attended a meeting where I traveled by air. My hospital uses a centralized booking service for this purpose. Does this have to be reported?

Yes. Even though you are not being reimbursed directly for the expense, the required information about travel for designated individuals obtained through a centralized booking service must be posted.

I am a lawyer and my professional fees are reimbursed by the hospital I work for. Do I have to report these?

No. Professional fees or licensing costs do not have to be reported.

My hospital provides meal chits if we have to work late. I have been working on a project that has required me to use these during the current fiscal quarter. Do I have to report these?

No. Things like meal chits and subway/bus tickets/tokens that may be used by designated individuals do not need to be reported.

I purchased a stapler and some office supplies for my use, which the hospital reimbursed me for? Do I have to report these?

No. Travel, meal and hospitality expenses are the only types of expenses for which the required information must be posted.

Do costs reported include HST?

Yes, please report the total approved amount, including HST.

Would travel expense reporting include costs such as mileage and tolls?

Yes, this would be included.

If a board requests its CEO to attend a golf tournament for networking purposes, would this expense be reportable if the CEO were reimbursed for this expense by the hospital?

If the hospital considers the cost of attendance/participation at a golf tournament to be an allowable expense, then yes, this expense would need to be reported on as a hospitality related expense.

In our hospital, some staff who are not senior management report to the president/CEO. Are they “designated individuals”, whose expense information must be posted?

Only senior executives reporting to the president/CEO are “designated individuals”, whose expense claim information must be posted. Senior executives are members of the management group of the hospital that report directly to the hospital’s chief executive officer (or, if there is no chief executive officer, to anyone who holds a position equivalent to chief executive officer, regardless of title.) This includes the Chief Nursing Officer and the Chief of Staff, if a direct reporting structure is in place.

I have seen a Ministry of Government Services document requiring that, in addition to senior staff, expense claims of the five employees with the largest expense claim amounts must also be posted. Is this a different requirement?

Yes. The public posting of expenses requirements under the BPSAA are different than the rules set out in the Public Sector Expenses Review Act, 2009. Currently, under the BPSAA, hospitals are only required to publicly post expense claim information about “designated individuals”, as described in the Directive issued by the Minister of Health and Long-Term Care. There is no requirement under the BPSAA, or the Directive, for hospitals to post expense claim information about the five employees with the largest expense claims, unless these employees are “designated individuals”.

Our LHIN is reimbursing the expenses of our hospital CEO to attend a meeting. Who is responsible for reporting these expenses?

A hospital is only required to post information about expenses that are reimbursed by the hospital; therefore, since the hospital is not reimbursing the CEO’s expenses, the hospital does not need to include information about the expenses in the CEO’s expense posting. The LHIN would not need to post information about these expenses either. This is because the hospital CEO is not employed by the LHIN and not a “designated individual” for whom the LHIN is required to post expense claim information.

Are we required to post an expense that has been reimbursed by a publicly funded entity that is not part of the hospital, such as a board or advisory committee? Should the expense be reported by the hospital or the other organization?

No, the hospital is only required to post expense claim information about designated individuals, where the expenses are reimbursed by the hospital.

We are a small hospital and our chief of staff (COS) is on a small stipend for part-time services. Are we required to report on the COS's expense claims even though he/she is not an employee of the organization?

If your COS is a “designated individual” under the Directive, then you are required to report on the COS's expenses.

Do expenses incurred by the President of the Medical Staff Association need to be reported? This position does not report to the CEO but is an ex-officio member of the board.

No, as this individual does not report to the CEO, he or she is not a designated individual, and his or her expense claim information does not need to be posted.

Are we required to post all expenses related to travel, hospitality and meals, regardless of the method of payment (central or reimbursement)?

A hospital is required to post information pertaining to any travel, meal or hospitality expense claim made by a designated individual, if the expense is reimbursed by the hospital.

This means that the information must be posted even where payment for the expense is made by the hospital centrally on a corporate travel card. A hospital must also post the required expense claim information for any meal, travel or hospitality expense for which the hospital reimbursed a designated individual directly.

Do the costs of conference/courses need to be posted?

Registration costs for conferences and courses do not need to be posted; however, if a designated individual is reimbursed for meal and/or travel costs incurred to attend a conference or course, these expenses must be posted.

Should expenses be reported in the period in which they were incurred or in the period in which they are approved?

Expenses will be reported in the period in which they were approved. The report will include information about the date on which the expenses were incurred.

How much detail is required for each designated individual for each reporting period? Should expenses be posted by item or is a monthly total for each category sufficient?

Expenses should be posted by category, and by specific event or key date, and not be summarized into totals. For example, if the CEO attended a board meeting on June 12, 2011 out of town, the expense reporting would capture the expenses incurred for that event broken out into the required categories (i.e. travel, accommodation, etc.). Please refer to the Directive, which sets out all of the requirements for public posting of expense claims.

If a designated individual is on the payroll of hospital A, but hospital B reimburses the payroll hospital (Hospital A), which hospital reports the expense claim information of that designated individual?

The expense report for a designated individual must be posted on the public website of the hospital that pays the individual (i.e. Hospital A).

Does information about expenses for home office need to be posted?

Only information about expenses claimed for Travel, Meal and Hospitality need to be reported.

Can I modify the format of the Posting of Expenses Form?

No. In order to ensure consistency of reporting, the template noted in Appendix B of the Directive must be used.

As an alliance, my hospital shares administration costs with another hospital. Are we required to report on multi-hospital web sites in total or only relevant portion to that corporation?

Information about expenses claimed by designated individuals must be posted on the public website of the hospital where the designated individual is employed.

Does a hospital need to include the amounts on a designated individual’s T4 for auto taxable benefits, in its expense report?

The amount on the T4 slip may not be consistent with the cost of the actual car rental (it may be higher as required by CRA). This is a travel expense, so it would be best practices to include the actual car lease cost as a disclosable item, but the hospital would need to make this determination.

Some of our executives travel regularly between a number of hospital sites. Can we report all six months together as travel - mileage?

Yes, expenses for similar purposes can be grouped within the same period. Example for regular travel would be “Routine travel for the six month period from XXX to YYY”.

On the Posting of Expenses Form, do I add my expenses and show one total for each category or am I required to show amounts for each category by trip?

Expenses should be posted by category and by specific event or key date and not be summarized into totals. For example, if the CEO attended a board meeting on June 12, 2011 out of town, the expense reporting would capture the expenses incurred for that event broken out into the required categories (i.e. travel, accommodation, etc.).

Should expenses be broken down by individual?

Yes. Expenses should be broken down by designated individual, as indicated in the Directive.

What if several designated individuals attend the same conference?

Expenses should be broken down by designated individual, as indicated in the Directive. If several designated individuals attended the conference, the associated travel, meal and hospitality costs would be captured under each individual’s expense report for the appropriate reporting period.

Many executives participate in hospital-related committees or organizations where some or all of the expenses are paid for by sources external to the hospital (OHA committee, CAHO, CCO, etc). In some cases, the executive is paid by the hospital and the hospital is reimbursed by the external party. In other cases, the external party reimburses the executive directly. Do these expenses need to be reported?

A hospital is only required to post expense claim information about expenses that are reimbursed by the hospital using public funds.

Are the rules for hospitals the same as for government? Could you point us to the aligned policies and public reporting guiding the OPS?
Under the BPSAA, do hospitals have to report to the Office of the Integrity Commissioner?

No, hospitals will be submitting reports required under the BPSAA, to their respective LHINs.

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Compliance and Attestation

The 2011/12 Multi-sectoral Service Accountability Agreement (M-SAA) that we are asked to sign has different compliance declaration requirements. For example, Schedule C shows a Declaration of Compliance Report being due on October 30, 2011. If this is not changed, hospitals having an M-SAA will have additional reporting requirements. Can these requirements be aligned?

The ministry has raised this question with the LHINs. The LHINs have agreed to align the reporting requirements. Any questions regarding your hospital’’s Service Accountability Agreements should be addressed with your LHIN.

Who makes and approves the Attestation?

The attestation must be made by:

  • In the case of a public hospital, the administrator
  • In the case of a private hospital, the superintendent
  • In the case of the University of Ottawa Heart Institute, its chief executive officer.

The Board of Directors of the hospital is required to approve the attestation that will be provided by the Hospital to the Board of Directors of its respective LHIN. The Board of Directors must approve the attestation prior to sending it to the LHIN.

Which hospitals complete the attestation?

The BPSAA defines hospital”, and all hospitals falling within this definition are required to prepare and submit attestations in accordance with s. 15 of the Act. Under the BPSAA “hospital means:

  • A hospital within the meaning of the Public Hospitals Act
  • A hospital within the meaning of the Private Hospitals Act that received public funds in the previous fiscal year of the Government of Ontario; and

The University of Ottawa Heart Instititue/Institut de cardiologie de l’Université d’Ottawa

Are there any requirements for submitting the attestation to the LHIN?

The attestation must be sent by email (scanned copy) or fax or mail, to the attention of the Chair of the Board of Directors of the LHIN to which the hospital reports.

What happens if a hospital has exceptions?

Every hospital is required to identify all material exceptions in Schedule A of their attestation (i.e. incidents of non-compliance with the requirements of the BPSAA) and to provide a rationale/explanation for each exception. A hospital may be contacted by its LHIN in the event that an exception has been listed to obtain additional information or clarification.

What is a material exception?

A material exception is any incident of non-compliance with the requirements of the BPSAA that is significant. For example, if the hospital extends a contract, where the original contract does not contain a provision allowing for the term of the agreement to be modified (in contravention of Mandatory Requirement #18 of the Procurement Directive).

Are the attestations to be made public?

Yes - Every hospital must post its attestations on its public website. The hospital should post the attestations in a location and manner that is readily and easily accessible. Every hospital should post its attestation after submitting it to the LHIN.

How long will the attestations remain on the website?

Attestations should remain on main public websites for a period of one year, after which time they may be moved to the archive section of the website.

What happens in the case of a private hospital that does not have a board?

In the case of a private hospital that does not have a board, then signature from the Administrator/Superintendent/CEO who made the attestation is sufficient. The hospital must comply with the remaining requirements in the directive.

Is there any additional funding available to meet the added compliance costs of the BPSAA?

The ministry will not be providing any additional funding to organizations for operational costs associated with BPSAA.

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