Investigation into Cambrian College’s administration of its Health Information Management Program and the oversight provided by the Ministry of Training, Colleges and Universities
"Too Cool for School Too"
André Marin
Ombudsman of Ontario
August 2009
Contributors
Director, Special Ombudsman Response Team (SORT)
Lead Investigator
Investigators
Early Resolution Officer
Senior Counsel
Table of Contents
1 High school students anticipating graduation and planning their futures, as well as more mature students seeking to upgrade their skills and prospects, were drawn to Cambrian College’s Health Information Management program, which began operating in September of 2005. In the first years of the program, prospective students were told in promotional materials and through outreach activities about the exciting possibility of entering the “high demand” field of professional health information management, where there was a national shortage and the potential to work in a variety of settings, including acute and chronic care hospitals.
2 What Cambrian had neglected to mention to these unsuspecting individuals was that it was highly unlikely that Cambrian’s program would ever lead to employment as a health information management professional. Cambrian referred in its promotional materials to its program being based on requirements established by the Canadian Health Information Management Association (CHIMA), which controls entry into the profession through a national certification examination. However, unlike other college programs in Ontario that offer programs in this field, successful graduates from Cambrian’s program cannot write the national professional certification examination. This is because Cambrian’s program has never been formally recognized by CHIMA. Certification provides college graduates with the option of upgrading their two-year diplomas to a university degree in the field if they have the requisite work experience, or of gaining access to secure and well-paid positions in the hospital sector.
3 It wasn’t as if Cambrian was unaware of the significance of CHIMA recognition. Its Health Information Management program had been developed with the intent that the College would seek CHIMA recognition. The program was created based on market research that highlighted the need for certified health information management professionals. The College’s advisory committee and board of governors had approved the program on the understanding that CHIMA recognition would be sought, and this was also what the College told the Ministry of Training, Colleges and Universities when it applied for funding approval for the program.
4 However, despite the fact that CHIMA encourages programs to apply for recognition six months before admitting students, Cambrian did not apply to CHIMA until it had been operating its program for 18 months, just as its first crop of students was preparing to graduate. On top of that, Cambrian’s program had not been designed by someone experienced in the field of health information management; as a consequence, its first program submission fell far short of meeting CHIMA’s recognition standards. After its first failed attempt at recognition, the College tried a year later in 2008, only to be once again rejected. This time, the denial of recognition was based on an impressive list of deficiencies, key of which was the requirement to have a program co-ordinator that was certified in the field, a requirement that the College had been aware of from the outset, but which it had never satisfied.
5 While the College’s Health Information Management program students were initially kept in the dark about the significance of the program’s unrecognized status, as they learned more about the field they began to question the College about its intentions with respect to CHIMA recognition and the implications for their future. In response, College officials repeatedly provided students with assurances that they were working on CHIMA recognition, and that they should stay optimistic. However, all hope vanished by the summer of 2008, when it was evident that Cambrian’s program didn’t stand a chance of recognition without a complete overhaul. By then, it was clearly too late for those who had already graduated.
6 Frustrated graduates, denied the opportunity to attempt the professional certification examination and finding themselves blocked from competing for professional jobs in the hospital sector, began to complain and demand redress. Eventually, the College offered a solution. It would pay towards a portion of the costs of registering in an online course that would enable students to upgrade their skills. However, there was a significant limitation; students would have to successfully complete the program before they were reimbursed.
7 Some students have taken up this offer or pursued the upgrading route on their own. However, many have already incurred substantial debt in attending Cambrian’s course and no longer have the time or money to invest in further education. Unfortunately, others, after what they viewed as inadequate training through Cambrian, have found the online course too daunting, and have been forced to withdraw.
8 For many who attended Cambrian’s Health Information Management program, their dreams of careers in the field of health information management have been dashed forever. For a few, the possibility still remains that they may one day gain entry into the profession, but at an additional financial and personal cost. If these individuals had been provided with accurate and sufficient information in the beginning, they might have made different choices. Perhaps they could have saved some time, money, and heartbreak by choosing to attend another two-year course at a college recognized by CHIMA, instead of a program that has left them discouraged, disillusioned, in debt, and with a diploma they consider to be virtually worthless.
9 Cambrian College has consistently denied any responsibility for the plight of its graduates. It has claimed that no promises were made. It charges that students had unrealistic expectations of the program and that CHIMA recognition wasn’t originally part of the plan, but a gratuitous enhancement. It has even suggested that changing CHIMA standards are partially to blame for its failed recognition attempts, and that in any event graduates are overstating the problem and many have successfully found employment in their chosen field.
10 However, my investigation has shown that instead of ensuring that students were provided with enough information to make informed choices, the College through its representations, assurances and indifference has led many individuals to waste time, money and effort on a program with dismal returns. Program documents clearly indicate that seeking CHIMA recognition was not an afterthought, but had been embedded in the program from the beginning. In addition, it wasn’t a matter of CHIMA’s changing its standards that defeated the College’s recognition efforts, it was its own failure to properly construct a program that met fundamental CHIMA requirements. As for the fortunes of Cambrian’s graduates, those working in the field of health information management are either doing so in low-paying clerical positions, which they could have obtained with a high school education, or on the condition that they exert more time, money and effort to obtain CHIMA certification. For many students, Cambrian’s program was their only chance. Some are in substantial debt, unemployed or marginally employed, without much prospect of realizing their goal of a rewarding career in health information management.
11 Ultimately, my investigation has revealed that Cambrian College has failed to live up to its statutory mandate, and has poorly served the students and graduates of its Health Information Management program, which has received hundreds of thousands of taxpayer dollars since its inception. Ontarians are entitled to expect more of their public institutions.
12 When it comes to Ministry oversight of the College, the Ministry is not immune from censure. Cambrian’s disregard for its commitment to seek CHIMA recognition was fostered by a system for college program development and approval that sacrifices the interests of education consumers to the autonomy of educational institutions. Colleges are on the honour system when it comes to program development. While the Ministry sets broad policy directives, it has no effective mechanisms in place to ensure that colleges comply. Even when it was clear that Cambrian’s program was premised on obtaining CHIMA recognition, the Ministry did not consider this significant. It opened the public purse strings and shelled out the cash without taking any steps to ensure that the College followed through. In the end, it was the students and graduates of the program who suffered.
13 In order to redress the maladministration on the part of both the College and the Ministry, I have made a number of recommendations. To address the specific situation at the College, I believe that Cambrian College is responsible for ensuring that graduates of its Health Information Management program are reasonably compensated for the losses they have suffered as a result of program deficiencies, and I am recommending that it do so. In order to deal with the broader systemic issue of the lack of effective oversight at the Ministry level, I am recommending that the Ministry implement adequate safeguards to ensure that colleges fulfill the representations made in program funding approval requests. I have also recommended that both the College and the Ministry report back to me at quarterly intervals on their efforts to implement these recommendations.
14 In responding to my recommendations, the Ministry has been determined to distance itself from responsibility for college program development and administration. It does not agree with my findings that there are systemic problems with the current process for program development and approval. The Ministry has, however, agreed to make one concession. It has undertaken to issue a binding policy directive to help ensure accuracy in advertising and promotion of college programs. While this may assist in preventing misleading advertising in future, it does not address the broader systemic concerns that my investigation revealed.
15 As for Cambrian College, it demonstrated an arrogant disdain for my oversight throughout the investigative process, which culminated in a wholesale rejection of my findings, analysis, opinion and recommendations. The College continues to dismiss the concerns of over half of the graduating classes of 2007 and 2008, and to cultivate a “too cool for school” attitude towards students, who naively placed their trust in a college which, at least with respect to its administration of the Health Information Management program, proved itself to be aloof, indifferent and dismissive.
16 In May 2008, we began to receive complaints from graduates of Cambrian College’s Health Information Management program. They claimed that the program had never been recognized by the Canadian Health Information Management Association (CHIMA) despite repeated assurances by the College that it would be, that they were unable to write the national certification examination for the Health Information Management profession, and remained unqualified to work in health information management in the hospital sector. After initial attempts to resolve this matter, I launched a formal investigation of the College’s conduct in relation to the Health Information Management program on September 12, 2008. On October 24, 2008, the Ministry of Training, Colleges and Universities was notified that we would also be investigating its role in relation to approving and monitoring the College’s program.
17 By January 2009, our Office had received 13 complaints, 11 from graduates and two from former students of Cambrian’s Health Information Management program. Ironically, at a later date we also received a complaint from a graduate who had been referred to us by the College to substantiate its claims concerning the quality of the program.
18 The investigation was assigned to the Special Ombudsman Response Team (SORT). The Director of SORT, three investigators and an Early Resolution Officer, assisted by senior counsel, conducted the investigation.
19 During the course of the investigation, interviews were conducted with 14 former students of the College’s Health Information Management program, members of the Canadian Health Information Management Association, the College’s President, Vice President of Academics, Dean of Health Sciences and Emergency Services, the Program Co-ordinator and a former instructor for the Health Information Management program. We also interviewed an official from the Credentials Validation Service, officials from a hospital health records department, program co-ordinators from two CHIMA-recognized college health information management programs, as well as Ministry staff responsible for approving new college programs for funding.
20 All formal interviews were tape-recorded. Relevant documentation was obtained from the College and the Ministry, and reviewed. While we generally received good co-operation from the Ministry, an issue did arise at the outset of the investigation regarding the College’s understanding and compliance with our investigative process.
21 Initially, the College insisted that its own external legal counsel be present during our interviews with witnesses from the College. It was explained to the College’s counsel that we conduct administrative investigations into allegations of government maladministration and make recommendations directed at remedying maladministration and achieving systemic improvement. In accordance with the Ombudsman Act, my investigations are conducted in private. Officials and employees of governmental organizations are required to co-operate with our requests for information and production of documents. In order to encourage witness candour and maintain the integrity of the investigations process, we do not permit officials or counsel on behalf of a governmental organization to attend individual witness interviews. It was also explained that prior to any final report being issued, the College would have an opportunity to review and respond to a preliminary report setting out initial findings, conclusions and recommendations. However, in accordance with our procedure, letters of complaint and records relating to witness interviews would not be provided to the College.
22 Unfortunately, the College through its counsel continued to provide resistance, advising that we could expect its co-operation only if the College’s legal counsel was in attendance at interviews with College witnesses, and asserting that the College had no faith in the fairness of our investigative process.
23 Once again, we attempted to explain the nature of Ombudsman proceedings and the rationale behind our investigative process to the College’s counsel. We noted that the Ombudsman does not have decision-making authority, but makes non-binding recommendations and relies on moral suasion and the goodwill of the government institution to comply. Given the limits on this authority, my Office is not subject to the same procedural rules that apply to administrative or judicial decision makers. We also emphasized that we have a statutory obligation to keep investigations and complaints confidential. These provisions ensure that the Ombudsman can find out what is happening in government organizations without public servants feeling intimidated by the risk of retaliation or pressure from their employers. The only way to protect this interest is to keep employers and managers out of interviews and to keep what is said confidential.
24 Undeterred, counsel for the College continued to challenge the legitimacy of our investigative process. She mischaracterized investigator attempts to set up witness interviews as “contacting her clients directly” and wrongly suggested that we had failed to grant an extension of the time for the College to disclose documents. In fact, a College official had suggested that it be given another week to produce documents that we had requested because it wished to better organize and catalogue them. At the time, my staff had assured the College that this step was unnecessary, and requested that the available documentation be sent by the date we had set for disclosure. Even then, the College delayed months before sending some of the documents it had assembled.
25 Begrudgingly, the College’s counsel eventually indicated that her client would not stand in the way of our interviews, but she continued to insist that the College disagreed with our investigative procedure. Ultimately, she signalled that the College would not accept the results of my investigation, commenting:
… given the lack of transparency and the lack of process, any conclusions reached should not and cannot be relied upon as having any basis in fact.
26 When the dust had settled, the interviews of College witnesses proceeded smoothly. However, the College made it clear that it would not respect my findings, and appeared to be operating under a misapprehension concerning the nature of my Office. An Ombudsman investigation is not an adversarial process. The Ombudsman’s role is not to represent the interests of any particular complainant or governmental organization. I have been appointed as an independent Officer of the Legislature with a mandate to carry out impartial investigations. My only interest is in ensuring that governmental organizations serve the public objects they were intended to fulfill in the interests of Ontario’s citizens. Unfortunately, the College’s conduct throughout my investigation continued to demonstrate a misapprehension of and lack of respect for Ombudsman oversight.
27 Whether through incompetence, inadvertence or sheer contempt, the College failed to disclose a number of relevant documents to my Office. On September 12, 2008, we sent a letter to the College requesting that it produce a list of identified documents as well as “any other documents that may be relevant to this investigation.” In accordance with s. 19(1) of the Ombudsman Act, College officials were required to comply with this request. However, it wasn’t until January 26, 2009, after we had made a specific and additional request, that the College produced a copy of the Program Advisory Committee meeting minutes of October 14, 2009, in which approval of the Health Information Management program was documented. Even then, the College continued to withhold significant information. Despite our multiple requests during the investigation for placement and employment data for graduates of the program, it wasn’t until May 19, 2009, after our Office requested further support for the College’s response to my preliminary investigative report, that the College presented this information. Similarly, a number of other documents, including Roundtable Discussion Meeting Minutes from October 14, 2004, concerning consideration of the Health Information Management program, did not materialize until May 19, 2009. We also received numerous email transmissions between CHIMA and College officials, which were produced not by the College, but by CHIMA. While I cannot conclude that the College deliberately withheld this information, at the very least this suggests that the College’s recordkeeping was less than desirable.
28 Despite repeated attempts to instruct the College as to the nature of my investigations, in its April 21, 2009 response to my preliminary report, counsel on behalf of the College continued to protest against my investigative process and cast aspersions on its integrity. The College would not relinquish its belief that an Ombudsman investigation should be an adversarial adjudicative process entitling it to traditional due process, including the right to question witnesses and to full disclosure. The College submitted that it was hampered in responding to the evidence set out in my report because of “the lack of transparency and procedural fairness” in the investigation. In fact, rather than produce timely, consistent, clear and objective evidence to support its position, the College appeared to opt instead to rely on a deliberate strategy of attacking our investigative process, and making broad allegations, without apparent factual foundation. We addressed a number of the College’s criticisms after receiving its response to the preliminary report, including rather dramatic and exaggerated assertions. For instance, counsel for the College accused investigators of “high-handedness and bad faith” for failing to send a recording of her client’s testimony. While counsel had been advised that a copy of the recording could be provided as long as the details of the interview and the recording were not shared until the investigation was complete, she had never followed up with our Office to obtain a copy of the recording. Once this matter was brought to our attention, a copy of the recording was duly provided.
29 On further probing of the College’s submissions, it became apparent that they reflected, for the most part, superficial posturing rather than factual reality.
30 The College’s contemptuous attitude towards my investigation is regrettable, and I believe it reflects a failure on its part to embrace a true spirit of public service. Its position is also consistent with the self-righteous and dismissive approach it appears to have adopted when faced with student concerns over its administration of the Health Information Management program.
31 In order to understand the context in which student complaints arose, it is useful to briefly review the College’s history and the development of its Health Information Management program.
32 Established in 1967, Cambrian College in Sudbury is one of 24 colleges of applied arts and technology in Ontario. It is a corporation without share capital operated by a board of governors. In accordance with the Ontario Colleges of Applied Arts and Technology Act, 2002, the College’s objects are:
to offer a comprehensive program of career-oriented, post-secondary education and training to assist individuals in finding and keeping employment, to meet the needs of employers and the changing work environment and to support the economic and social development of … local and diverse communities. (s.2(2))
33 With its motto “Responsibility with Excellence,” Cambrian College serves a full- time student population of over 4,400 and an additional 8,000 students annually in part-time personal, professional and human resources development courses and seminars. It offers approximately 90 full-time programs.
34 Colleges of applied arts and technology are stewards of a significant portion of taxpayer dollars. In the case of Cambrian College, the Ministry has advised that it was provided with just over $45 million in operating funds for the 2005/2006 fiscal year, just over $48 million for the 2006/2007 fiscal year, and just under $55 million for the 2007/2008 fiscal year.
35 Cambrian College, like other colleges of applied arts and technology in Ontario, is largely responsible for the content of its own curriculum. Under the present system, colleges have relatively broad scope with respect to the courses they choose to offer.
36 According to the Ministry of Training, Colleges and Universities, the Ontario college system was established in 1965 to offer occupation-oriented programs designed to meet the needs of the local community. The system has developed into a network of 24 colleges providing a wide variety of programs and services in communities throughout Ontario. In March 1999, the Ontario Jobs and Investment Board Report emphasized that quality education and training was a top priority for sustainable economic prosperity. One of the recommendations of this report was for a new “charter” for the colleges to allow them to be more market-driven and flexible. In addition, in December 1999, the Report of the Advisory Panel on Future Directions for Postsecondary Education recommended that colleges operate within a less regulated environment to encourage institutional differentiation and specialization.
37 In June 2000, the Association of Colleges and Applied Arts and Technology (now known as Colleges Ontario) submitted a report to the Minister entitled Ontario’s Colleges for the 21st Century; Capacity and Charter Framework, recommending a new charter for colleges that included common system-wide elements as well as flexibility for colleges to specialize, increased authority within a broad governance accountability framework, and permanent permission to grant degrees.
38 Following these reports and after conducting its own internal research, the government introduced the Ontario Colleges of Applied Arts and Technology Act, 2001 on December 4, 2001. In introducing the legislation, the then Minister of Training, Colleges and Universities stated:
The current legislation treats all colleges the same. However, the characteristics of Ontario’s 25 colleges vary considerably in size and the nature of the local communities they serve. They vary in the range of programs they offer, they vary in the partnerships they have with local business, industry, and other education institutions, and they vary in the way in which they deliver programs and courses – whether in the classrooms, through apprenticeship, over the Internet, in remote communities, by day or by evening. We want to enable colleges to be better able to respond to the different circumstances of their communities, their student bodies, their local economies or their unique areas of specialization.
Regarding accountability, she said:
Modern accountability relationships focus on public reporting against projected outcomes… The role of government in day-to-day operations of institutions should be limited.[1]
39 The Ministry has advised that the Act is based on a model that combines the oversight of governing boards made up of members of the local community, quality measures agreed upon by both the sector and government, and performance contracts between government and the college. It has stated that:
The approach recognizes that the locus of expertise in matters of program selection, quality, delivery and review rests primarily with colleges, working closely with their broader communities.
40 The Ontario Colleges of Applied Arts and Technology Act, 2002, which came into force in April 2003, ushered in a new era of increased self-regulation and autonomy for Ontario’s colleges, in recognition of their institutional “maturity.” Prior to its implementation, the Ministry of Training, Colleges and Universities was involved not only in approving funding for college programs, but also in reviewing program titles and credentials. Today the Ministry has a much more limited role..
41 Under the Act, the Minister has the authority to issue policy directives in relation to the manner in which colleges carry out their objects and conduct their affairs (s. 4(1)). However, colleges retain substantial discretion with respect to their operations, including with respect to program development.
42 The Ministry has issued Binding Policy Directives relating to the creation and funding of college programs. However, these provide only general direction. This is consistent with the Ministry’s approach, which places the primary responsibility for creating and assessing programs on the colleges themselves. One of the guiding principles of the Ministry’s Framework for Programs of Instruction is that:
A college is best positioned to determine the programs of instruction it should offer based on its own strategic direction and the needs of its community. A college is also best positioned to ensure the ongoing relevance and quality of its program of instruction.
43 Under the Framework for Programs and Instruction, college boards of governors are responsible for approving programs of instruction consistent with the college’s mandate and overall strategic direction, the economic and social needs of local and diverse communities, and government directions and priorities. Boards of governors are made up of 12-20 external community members appointed by the College Compensation and Appointments Council and elected representatives from faculty staff and students. Colleges must also establish and be guided by a program advisory committee that is made up of experts in the field, faculty members, industry leaders in the community, students and employers. All programs of instruction with similar outcomes and credentials must have the same title. If the Ministry has established a program standard for a particular course of study, it must also be met.
44 The Minister has also issued a Binding Policy Directive with respect to Funding Approval of Programs of Instruction, which provides:
The approval of programs for funding purposes is intended to promote access to a range of programs that respond to provincial economic and societal needs, in the context of limited public dollars.
Funding decisions related to programs of instruction offered by colleges of applied arts and technology are made in relation to the overall college system and the mandate of the colleges, collectively and individually.
45 In accordance with the funding Directive, a college must ensure that a number of elements have been addressed with respect to a program of instruction prior to submitting a request for funding approval to the Ministry. These are:
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The program must have been approved by a college board of governors;
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The program must be consistent with the Minister’s Binding Policy Directive;
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The program is compliant, where applicable, with all regulations and legislation pertaining to a regulated field of practice; and
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The program is deemed to meet an identified economic or societal need.
46 In reviewing a program for funding under the Directive, the Ministry is required to consider:
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The need to provide public support to a new program field or for further program offerings in a given field, and to provide the available funding to support college activities through the general purpose operating grant, taking into account government directions and priorities and the availability of existing educational and training opportunities in the field in question.
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The broader public policy issues raised by the program in question; and
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The regulated entry to practice requirements for any field, where applicable.
47 Once a college board of governors approves a program of instruction, an application is submitted directly to the Credentials Validation Service. The Credentials Validation Service is run by Colleges Ontario, an advocacy organization for Ontario’s colleges. The Service refers to the Ontario Qualifications Framework, which is based on internationally recognized descriptors, and maps the overall structure of post-secondary qualifications in Ontario, outlines the standards or expectations that each is designed to meet and describes how the qualifications compare to one another. The Service validates whether the level of credential proposed by a college for a course fits the learning outcomes – for instance, diploma, certificate or applied degree – as well as whether the course title is consistent with similar programs. It does not validate the content of courses or contact professional or accreditation bodies to verify program or course content. These remain the responsibility of the individual colleges seeking approval.
48 Once the Service approves the program’s application, the college may choose to apply to the Ministry for funding. The Ministry’s Funding Approval of Programs of Instruction Procedures requires that when submitting a program approval request, the president of a college must attest that six criteria have been evaluated and met for the proposed program. These are:
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The Credentials Validation Service has confirmed that the proposed program of instruction conforms to the Credentials Framework and is consistent with accepted nomenclature.
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The Credentials Validation Service has confirmed that the proposed program of instruction conforms to the Credentials Framework and is consistent with accepted nomenclature.
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There is a demonstrated labour market or societal need and student demand for the program.
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A relevant program advisory committee has recommended the program.
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The program content and delivery will be compliant with all requirements of regulatory bodies responsible for the field of study or other regulatory bodies related to the field of study.
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The program meets the relevant program standards where they exist and essential employability skills and general education requirements; and
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The board of governors has approved the program of instruction.
49 Once a request for funding is received, the Ministry will review the program for funding purposes. It will ensure there is no “public policy” rationale for refusing a request, and if it relates to a regulated field, the Ministry will ensure that the proposed program meets the requirements of the regulator. While the Ministry monitors whether a proposed program meets regulatory standards, it does not concern itself with issues such as voluntary accreditation with professional organizations. Ministry officials advised that they receive about 200 program funding requests a year and that it is very rare for the Ministry to refuse approval for a program.
50 Once the Ministry gives a college program the green light for funding approval, the Ministry may designate funds for the program within the college’s annual operational budget. In addition, in order for students to be eligible for the Ontario Student Assistance Program, they must attend programs that are approved for funding by the province.
51 The Ministry has adopted a passive approach to the quality of college programming. Program quality control is left to the individual college board of governors as well as to Colleges Ontario. The Ministry does not actively monitor the provision of approved programs by colleges. Instead, colleges are required to provide information to the Ministry concerning “Key Performance Indicators.” Statistical information about general graduate employment rates, graduation rates by program and Ontario student loan default rates are collected by the Ministry through an external consultant. The data is then analyzed and consolidated into employment profiles for high school guidance counselors. It is also posted in aggregate on the Ministry’s website.
52 Individual colleges are also required to have built-in quality assurance mechanisms to monitor their programs. The Ontario Quality Assurance Service, which operates within the structure of Colleges Ontario, and is responsible to a separate management board, also conducts Program Quality Assurance Process Audits for a fee as a service to all Ontario colleges on a five-year rotational basis.
53 Cambrian College began development of its Health Information Management program in 2004 while the system for program review was still in transition. According to the Program Co-ordinator, the program was created in the wake of the demise of another records management program that had seen waning enrolment.
54 On March 25, 2004, Cambrian College suspended its Records and Information Management Technology program because of declining student interest. This left that program’s Co-ordinator scrambling to fill a void in the College’s calendar. She advised us that she was told that she would have to come up with a replacement program, and was left with the impression that if she did not, her future employment was uncertain. She turned to the field of Health Information Management for inspiration. At the time, the Canadian Health Record Association (now known as the Canadian Health Information Management Association or CHIMA) was promoting development of college programs in professional health information management, and there were three such programs in operation in Ontario, all formally recognized by CHIMA.
55 CHIMA is a membership-based organization of approximately 5,000 health information management professionals. It is not a regulatory body, but a professional association. CHIMA members are employed across Canada to manage the security, privacy and accuracy of health records in hospitals, community health and extended care sectors, government, health and education institutions, and in the private sector including insurance and pharmaceutical companies, technology vendors and consulting firms. Health information in hospitals is recorded using a complex coding system for identification of diseases, in which certified CHIMA professionals receive standardized instruction as part of their training. Coded information is submitted to the Canadian Institute for Health Information, an independent non-profit organization whose data is used by government bodies, hospitals, health authorities and professional associations to assess the effectiveness of different parts of the health system and plan for the future. Graduates of CHIMA recognized programs qualify to write a national certification examination, and if successful, they may refer to themselves as certified HIM professionals and use the designation CHIM (certified in Health Information Management). CHIMA certification is most significant when it comes to obtaining employment in hospitals. According to CHIMA, while some hospitals might take on uncertified individuals during periods of acute shortage, generally hospitals will only hire such individuals to do clerical work, and not for records management.
56 In the spring of 2004, the Co-ordinator set about developing a proposal for a new program at Cambrian based on George Brown College’s CHIMA-recognized Health Information Management curriculum model. She consulted with George Brown College, and she and other Cambrian College officials also discussed the prospect of a new health information management program with Timmins and District Hospital staff.
57 As she drafted the program specifications, the Co-ordinator envisioned that the program would obtain recognition through CHIMA, which requires health information management programs to satisfy a series of standards. As the process of obtaining recognition often requires more than one submission before a program is approved, CHIMA encourages colleges to apply for recognition at least six months before students are admitted. It charges increased application fees – a surcharge of 50% – for programs that operate before they are formally recognized.
58 From the outset, the program proposal documents prepared by the Cambrian Co-ordinator reflected intent to obtain CHIMA recognition. For instance, in a spring 2004 version of the program outline, it was noted:
This is a newly proposed program with plans to seek recognition from the Canadian Health Record Association (CHRA) [now CHIMA], and if recognized, graduates would be eligible to write the Canadian Health Record Association national certificate examination. After successfully completing the national exam, students would become a Health Record Practitioner (HRP).
59 In a September 3, 2004 presentation on the proposed program, a June 4, 2004 conference call between Cambrian College and the Timmins and District Hospital is referenced, in which CHIMA recognition was referred to as something that the program must have.
60 One of the Ministry requirements for program development is that a relevant program advisory committee must recommend the program. On October 14, 2004, Cambrian College’s Records and Information Technology Management Advisory Committee[2] met to consider the proposed “Health Information Technology Management” program.
61 Cambrian’s Records and Information Technology Management Advisory Committee included community representatives from the Shared Services Bureau, Ontario, and the Cambrian Foundation, as well as ARMA, a non-profit professional association involved with records information and management. The Co-ordinator explained to the committee that the proposed program had been modelled after George Brown’s. The minutes of the meeting specifically note:
Curriculum will meet the standards for accreditation[3] to allow students to become certified Health Information Practitioners. The program could be articulated with Ryerson University – Bachelor of Health Administration Degree or other universities with Commerce/MBA programs, Library Science, Computer Science/Information Technology. George Brown College, CHIMA, ARMA and St. Lawrence College support this proposed program.
62 The minutes also confirm that the Advisory Committee moved to approve the proposal for the program as presented.
63 The program proposal then went forward to the College’s Executive Committee for its review.
64 The College’s Executive Committee considered the new program proposal at a meeting on November 3, 2004. At that time, the Co-ordinator explained to the committee that program graduates would have employment opportunities in diverse fields, including acute and chronic care facilities. She also explained that the curriculum would meet standards for CHIMA recognition, allowing students to become certified, and that the course could be articulated with Ryerson University or other university programs allowing students to work towards a degree in the field. In a presentation prepared for the meeting, the Co-ordinator noted under the title Stakeholders’ Recommendations that the proposed program should “be recognized by the Canadian Health Information Management Association (formerly Canadian Health Records Association) CHIMA.”
65 In support of the program, the Co-ordinator referred to the comments of other colleges operating CHIMA-recognized courses. She quoted George Brown College as saying “Health records practitioners are currently very much in demand” and St. Lawrence College, which had remarked: “Advancement in information technology and changes in health regulations have resulted in an increased demand for, and a national shortage of Health Records Technologists (HRTs).” She also referred to CHIMA, noting that it had conducted a national human resources survey in 2002 that reported vacancies in all areas of health information management. She quoted CHIMA’s Executive Director, who in commenting on the need for Health Information Management professionals, had observed:
We believe that you are in an area of significant shortage of personnel in health information management. Not only is there a shortage now, but the expectations are that the field will continue to grow and the demand for graduates will be constant for the foreseeable future.
66 Minutes from the November 3, 2004 Executive Committee meeting indicate that it endorsed the new program. It was recommended at that point that the program start in September 2006, and that the Program Co-ordinator be placed on a reduced workload during the 2005/06 academic year to upgrade her skills.
67 Following the Executive Committee’s approval, the proposal was presented to the board of governors for its approval in accordance with the Ministry requirements for program development.
68 On November 25, 2004, a presentation concerning the program, by then titled “Health Information Management,” was made to the College’s board of governors.
69 While it had been initially contemplated by the Executive Committee that the new program would start in September 2006, the draft program proposal considered by the board of governors referred to a start date of September 2005. The proposal once again referred to stakeholder recommendations for recognition by CHIMA, and referenced comments in support of CHIMA-recognized programs. It indicated that CHIMA recognition would be sought and that program graduates would be able to sit the national certification examination, as well as have the option of completing a Health Information Management Bachelor of Health Administration Degree through Ryerson University. Minutes from the board of governors meeting indicate that the program was approved as presented.
70 After the board of governors approved the program, the College prepared and submitted a request for program approval to the Ministry. The Ministry, in turn, referred the request on to the new Credentials Validation Service, which had become operational on February 1, 2005.
71 The College’s “Request for New Program Approval – Transitional Form” was signed by its president on January 31, 2005. It indicated that the Health Information Management program was a two-year diploma program. On the form, the President attested to the following:
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There is a demonstrated labour market or societal need and student demand for the program.
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The relevant program advisory committee has recommended the program as proposed.
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The program admission requirements for this program are consistent with the requirements outlined in the Credentials Framework.
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The Board of Governors has approved the program as proposed.
72 The following note appeared above the President’s signature:
Note: An application for recognition will be submitted to the Canadian Health Information Management Association.
73 In the “Program Description” on the form, there is also reference to CHIMA. It is stated:
This new program will be evaluated to meet the CHIMA requirements for entry-level practitioners. Upon graduation, students will be eligible to write the CHIMA certification examination. In keeping with CHIMA’s desire to move toward a more professional profile in this field, diploma graduates will be able to make a smooth transition to baccalaureate preparation if desired.
Employment opportunities exist within acute care hospitals, ambulatory care facilities, Community Care Access Centres, provincial and federal ministries, insurance companies, veterinary hospitals, research centres, computer companies and health record consulting companies.
74 In the section for “Mapping of Vocational Program Outcomes and Curriculum,” under “Provincial Standard Vocational Learning Outcome,” it is noted:
Provincial program standards do not exist. The published entry functions of the Canadian Health Information Management Association (CHIMA) will be used for comparison purposes.
75 After some initial revisions concerning the general education requirements and proposed learning outcomes, the Credentials Validation Service gave its approval to the new program on February 28, 2005. However, aside from confirming that a diploma would be the appropriate credential according to the program scope and ensuring that the title was consistent with other similar programs offered in the province, the Service did not concern itself with the quality of the curriculum or the issue of CHIMA recognition. Consistent with its mandate, the Service saw these as the responsibility of the College.
76 After validation, the Service sent the form back to the Ministry, Program Quality Unit, at the Colleges Branch for funding approval.
77 Ministry staff reviewed Cambrian College’s program request and prepared a “Summary and Recommendation Form – New Program.” On the Ministry form, it was noted that four similar programs were being offered at that time with a graduate placement rate of 78.6% full-time, based on the 2001-2002 fiscal year. The form also contained the following comment in support of the program:
The level and scope of the curriculum is guided by national standards of practice as defined by the Canadian Health Information Management Association (CHIMA). Cambrian has indicated that the program will be evaluated to meet CHIMA requirements for entry-level practitioners…. It is known that CHIMA is actively soliciting and endorsing the development of new programs at the college level that reflect standards of practice and designated learning outcomes defined by that association.
A two-year diploma from a CHIMA-recognized program is required for eligibility for graduates to certify with the Canadian College of Health Record Administrators (CCHRA), through an annual national certification exam. Graduates of this program will be able to write the CHIMA certification exam. The supply of graduates from CHIMA-recognized health record diploma programs has recently been deemed as insufficient to meet the demands of the health industry.
78 Ministry staff recommended that Cambrian’s program be approved and the College was notified on June 8, 2005 that funding approval had been granted. According to the Ministry, the College received $39,000 in provincial funds for the Health Information Management program for the portion of the 2005/2006 fiscal year it was in operation, $131,000 for the 2006/2007 fiscal year and $153,000 for the 2007/2008 fiscal year.
79 Although, based on Ministry documentation, it appears that initially Ministry officials placed some emphasis on the proposed program seeking CHIMA recognition, we were advised during our investigation that this was not really significant from the Ministry’s perspective. We were told that funding approval for Cambrian’s new program was not conditional on obtaining CHIMA recognition, since it was not a regulatory requirement. In addition, Ministry officials were not concerned with whether the College actually applied for recognition. Ministry staff suggested that it was common practice for programs to operate for a few years before being sanctioned by a professional body. They did not appear to be familiar with CHIMA’s position that recognition should be obtained six months before a program begins admitting students. As the Ministry has no program standards for the Health Information Management program and it is not a regulated area of practice, it did not concern itself with ensuring that any particular standards were met with respect to the curriculum.
80 Despite Cambrian College’s stated intent to attempt to obtain CHIMA recognition, and the fact that the advisory committee and board of governors had approved the program based on materials calling for this, no concrete steps were taken to apply to CHIMA for well over a year after students began to be admitted to the new Health Information Management program.
81 In order to receive recognition through CHIMA, colleges must pay an application fee, and present material satisfying 13 standards and a matrix of learning outcomes, which have been developed by CHIMA to ensure consistency and quality in the field of health information management. A Program Recognition Committee, typically composed of eight volunteers from the profession, then reviews the applications. CHIMA’s recognition process is quite rigorous, and it is not unusual for a college to have to make two or three attempts at recognition before it successfully meets CHIMA’s criteria. CHIMA officials have advised that it is quite unusual for Health Information Management programs to begin operation before they are recognized by CHIMA or are well into the process of becoming recognized.
82 One of the key requirements for recognition is that a program must have a co-ordinator who is a certified Health Information Management professional, preferably with a university degree in the field. On occasion, CHIMA will grant temporary recognition if the curriculum meets its standards and if CHIMA can assist in locating and hiring a qualified program co-ordinator.
83 In June 2005, Cambrian’s Program Co-ordinator contacted CHIMA to request recognition application materials. On June 29, 2005, CHIMA provided the College with a draft CHIMA recognition manual, including the credential requirements for program co-ordinators. CHIMA noted that a surcharge of 50% of the application fee would be levied if the program submission was not received six months prior to the intake of students. CHIMA followed up on July 15, 2005, by email, to see if Cambrian had any questions regarding the materials. On August 12, 2005, CHIMA forwarded a copy of its Application Manual to the College and noted that a non-refundable deposit of $500 and a letter of intent to apply for recognition were required, as well as a fee of $2,500 with the submission of a completed application.
84 The College did not take any further steps to apply to CHIMA before it began to promote its Health Information Management program, which was scheduled to commence September 2005. The College had missed the annual recruiting cycle, but nevertheless it did manage to attract 15 students to the program. As to why the College did not initially seek recognition from CHIMA, it does not appear that a formal decision was made by the board of governors or even the President with respect to the timing of the recognition application. The President of the College explained to us that there was no set timeline for seeking recognition and said:
… we were launching a brand-new program and whenever we launch brand-new programs, you don’t go through accreditation until you’ve launched the program and the program’s operational and so, that was what was determined that we would do.
85 Apparently, she was unfamiliar with CHIMA’s advice that recognition be obtained before students are admitted.
86 According to the Co-ordinator, the real reason that the College delayed seeking recognition from CHIMA during the 2005-2006 school year was a financial one. She explained that after she began to receive calls from other colleges and potential students asking about CHIMA recognition, she sought guidance from the Dean of the School of Computer Studies and Engineering Technology, where the program was situated. According to her, it was his decision not to pursue recognition because he was not prepared to pay $2,500 to CHIMA on the “chance” that the program might get recognized. The College disputes this, claiming that the former dean maintained he did not say he would not pay the application fee, only that it would be paid once the process was underway, which is the typical process for applying for certification within the technology sciences. Unfortunately, this individual refused to co-operate with our investigation, and we were unable to independently verify this version of events.
87 During our investigation, the President of the College stated that the Co-ordinator had gone on sabbatical to enhance her knowledge of the health information management area and to develop the program curriculum. However, this was not in fact the case. Not only was the Co-ordinator not a CHIMA-certified health information management professional, she did not receive any time off or assistance to upgrade her skills, as the Executive Committee had originally envisioned, prior to the program commencing.
88 CHIMA continued to follow up with Cambrian College in the fall of 2005 and winter of 2006 to check on the progress of its application. CHIMA officials have indicated that at that time they were unaware that Cambrian’s program had already begun.[4]
89 After some lobbying on her part, the Co-ordinator was successful in June 2006 in having the program transferred to the School of Health Sciences and Emergency Services.
90 In July 2006, the Co-ordinator again contacted CHIMA indicating that the College would like to pursue CHIMA program recognition. That same month, she also requested a letter from CHIMA confirming that the College was in the process of obtaining program recognition, in order to facilitate obtaining software from the Canadian Institute for Health Information, which generally only provides its products to CHIMA-recognized schools. The College was successful in obtaining the software, but very little progress was made towards CHIMA recognition.
91 The Dean of the School of Health Sciences and Emergency Services did eventually submit a letter of intent to apply for recognition to CHIMA together with a $500 fee. On September 18, 2006, CHIMA provided the College with an application manual, which had been revised in May 2006 to incorporate some changes to the matrix of learning outcomes.
92 CHIMA followed up with the College on November 7, 2006, asking if there was a timeline for its submission. However, the application continued in limbo. Later that month, a teacher from Cambrian’s Health Information Management program contacted CHIMA, concerned about the limited exposure students gained to medical information coding, which was only taught in the third semester. As this is a key area for health information management professionals, CHIMA shared the concern about this aspect of the College’s program. However, it still had not received the College’s formal program submission to review.
93 According to the Co-ordinator, the CHIMA application process stalled for about six months while the School of Health Sciences and Emergency Services waited for a new dean to be appointed in January 2007.
94 In February 2007, CHIMA and the College once again communicated concerning Cambrian’s outstanding submission. At that point, the Co-ordinator explained that the program had been operational since 2005, and noted that the College had eight students due to graduate from the program in June 2007, and that an additional 22 students were in their second semester of the program. The College anticipated that it would be making its submission by March 18, 2007.
95 In early March 2007, the College inquired about how recognition might affect its current graduating class. CHIMA indicated that eligibility for CHIMA membership would depend on the number of issues it found with Cambrian’s program, and noted there was a possibility that graduates might be ineligible to write the certification examination because they had not completed a full program of approved study. Despite having received this information, according to meeting minutes, the Dean advised the Health Information Management Program Advisory Committee on November 1, 2007 that based on his experience, “certification will be grandfathered back to when the document was originally submitted, including the graduating students.” However, he apparently also indicated that if additional courses needed to be obtained to qualify to sit the certification exam, the College would offer these at a distance at no charge to the graduates.
96 Some 18 months after the start of the Health Information Management program, and just months before the first class was about to graduate, the College finally sent CHIMA its application for recognition on March 15, 2007. Unfortunately, the submission fell far short of CHIMA’s standards.
97 Even before CHIMA had finished its review of the College’s program, it was alerted to concerns about the quality of the program by a third party. A hospital official contacted CHIMA in May 2007 about a Cambrian student there on a work placement. The official questioned whether Cambrian’s Health Information Management program was recognized by CHIMA and observed that there were deficiencies in the student’s course outline. CHIMA confirmed that the program was not recognized and that the student would be ineligible to write the certification examination.
98 CHIMA did not complete an extensive review of Cambrian’s submission, as it was evident that there were too many gaps in the program to qualify it for recognition. A key omission was the absence of a certified program co-ordinator. CHIMA wrote to the College on July 5, 2007 concerning Cambrian’s submission. It noted:
… due to the number of non-compliant items within the learning outcomes document itself, we request you resubmit your documentation to show that you are/will be teaching all learning outcomes and that they will be taught at the appropriate level.
99 CHIMA gave the example of a learning outcome that had been left blank, noted that core courses must be taught by a certified health information management professional and that the program co-ordinator must also be a certified professional. Despite its assessment, CHIMA encouraged the College to work with it to realize recognition. In a September 2007 teleconference with the College, CHIMA was told that the Program Co-ordinator had begun taking Health Information Management courses to upgrade her skills. Unfortunately, while the Co-ordinator did enroll and attempt to take courses online through the Canadian Healthcare Association, without time off work or any additional support, she was unable to complete them.
100 While the College grappled with the rejection of its recognition application, the program’s Class of 2007 graduates were already out in the workforce looking for employment opportunities, and facing the reality that their options were limited due to the program’s unrecognized status.
101 By the fall of 2007, CHIMA began to field calls from prospective employers and graduates about the possibility of students from Cambrian’s program challenging the certification examination for entrance into the health information management profession. On September 20, 2007, a CHIMA official sent an email to the Co-ordinator, noting:
I am concerned about the 2007 graduating class as we had/have calls coming from grads/employers wanting them to be able to challenge the exam. It should have been made clear to all students that the program was not CHIMA-recognized, so they would not be eligible to challenge the exam. I don’t know what information was relayed to your students, so would be interested to hear how CHIMA recognition and the ability to challenge the exam is being handled from your end.
102 In November 2007, a hospital contacted CHIMA explaining it had a Cambrian graduate in a clerical position and it wished to support her in obtaining a position requiring CHIMA certification. CHIMA advised the hospital that based on its initial review there were areas where the program’s graduates would need to increase their knowledge and skill level. A Cambrian graduate working at another hospital contacted CHIMA in January 2008, explaining that she was working on condition that she acquire CHIMA certification. She requested information about how to go about this. She was referred to other programs for information, and told:
As for the Cambrian College program, until the program is an officially recognized CHIMA program, we cannot begin the process of working with them to decide on a route for past graduates. There will be additional learning required, however, I cannot say what it will be at this time.
103 The College eventually decided to retain a former dean, who was generally familiar with accreditation processes in the health field, to assist it in revamping its recognition submission. It also took steps towards hiring an individual, who was CHIMA-certified and had taught in the program, to act as the program co-ordinator on a part-time basis. Unfortunately, this later arrangement never materialized. Finally, in February 2008, the College resubmitted its recognition application to CHIMA.
104 While the College had hired an experienced individual to prepare the second submission, unfortunately, she had no specific experience with the field of health information management. In the end, she was unable to complete the matrix outlining how the program met CHIMA’s learning outcomes. In a November 5, 2007 email she sent to the Dean, she noted:
… There are lots of gaps (we have to show that all the outcomes are achieved, so cannot leave gaps).
In many instances, it looks like the students learn something in one year and are never exposed to it again. It is important that the areas outlined for the matrices show that the content is interspersed throughout the program and that students are introduced to something early but learn to assimilate and develop more complex/advanced knowledge and skills as they move through the program.
Most of the learning outcomes show only one course as addressing each outcome: should show all that apply (I know that in most cases, many courses address each outcome).
I have no problem doing the ones re Generic Skills and Biomedical Sciences, but when it gets to the technological courses and the specific HIM courses, I’m more than a bit lost. Can you get the appropriate faculty to look at the matrices and indicate which of the courses would address all or part of the outcomes. Thanks.
105 In the end, the Program Co-ordinator was the one who ended up completing the application.
106 It took CHIMA just over two months to complete its review of the College’s second submission. On May 9, 2008, CHIMA wrote to the Dean, noting:
The Program Recognition Team has had the opportunity to conduct a thorough review of your submission and they have identified a substantial number of areas where the current curriculum is non-compliant with the CHIMA LOHIM [Learning Outcomes for Health Information Management] and/or with the level at which the learning outcomes should be delivered.
107 CHIMA again identified that the program’s co-ordinator was not a certified Health Information Management professional, and that core courses must be taught by a certified professional. A number of specific additional concerns were also identified. A detailed 23-page evaluation was provided, setting out program deficiencies.
108 According to the evaluation, more than half of the CHIMA learning outcomes were not being met by Cambrian’s program, often because they were targeted at too basic a level. The evaluation also emphasized that the lack of a certified professional to act as program co-ordinator had been an outstanding issue since Cambrian had first approached CHIMA, and stated: “Upon review of the program content, it is imperative that an experienced certified HIM professional with experience with a broad range of experience be hired.”
109 CHIMA found Cambrian’s program to be non-compliant with respect to all three CHIMA standards for program faculty. The program was also non-compliant with respect to outcomes for theoretical knowledge, practical experience, and standards regarding the advisory committee. Numerous recommendations were made by CHIMA to address these issues. In the “Program Recognition Summary,” it was noted that other than submitting all the required documentation, Cambrian was non-compliant with respect to all four key criteria for recognition.
110 CHIMA continued to offer support to Cambrian in its attempt to obtain recognition. A teleconference was held to review CHIMA’s evaluation. At that time, Cambrian was again told that it would need to have a certified health information management professional to co-ordinate the program to qualify for recognition. It also expressed concern around student expectations, and stressed that Cambrian would have to make it clear to its students that they could not write the CHIMA examination and that there was no guarantee that they would be able to do so by graduation. CHIMA also warned the College that even if it did eventually recognize the program, those who had graduated based on its present curriculum could not write the examination because they were missing key learning outcomes.
111 On May 30, 2008, CHIMA provided the College with the name of a consultant who could assist with the recognition process.
112 The College did retain a consultant to conduct a “gap analysis,” which compared its Health Information Management program with Sir Sandford Fleming College’s CHIMA-recognized program. The analysis it received in September 2008 noted:
The major differences in the two programs occurred in the core courses that are specifically related to the role and functions of a Health Information Management Professional. The discrepancies between the two programs were significant and it was difficult to equate courses here on a course-by-course basis. For example, at Cambrian College, coding …. was spread out over many courses but it was not apparent that there was significant depth…. Since coding is an integral function of the HIMP, this was regarded as a major deficit in the Cambrian program. The same was true of abstracting and it was not evident that students were given hands-on experience in a particular abstracting system. The courses that related to health information seemed to be suited to students in a medical office program and not to students who would be health information professionals. There were some similarities in content but the depth of the Cambrian courses did not compare in this area to the learning outcomes and content in the Fleming program.
Major modifications would need to be made to the Cambrian program core health information learning experiences and content if these students were to become eligible to challenge the national certification examination. This would not be impossible but would require significant adjustments.
113 The analysis also suggested that it would be difficult for students to apply for advanced standing at Sir Sandford Fleming, since:
It would be necessary … for them to successfully complete all the courses that prepare students in the professional core competencies of the health information management professional. This would be difficult since these courses are delivered over four semesters and build on the knowledge gained in previous courses and successful completion of intensive practicum assignments.
The current graduates from Cambrian College might be suited to positions in agencies such as public health where their research and computer skills could be used. They would not be suited to situations where the knowledge and skills of a health information management professional are required.
114 The gap analysis also highlighted areas of Cambrian’s program that seemed out of place with health information management curriculum. For example, in terms of the Health Records Management course at Cambrian, it was observed:
Much of the content of this course refers to communications, safety and appointment scheduling and it was not apparent if coding was actually included. Since patient scheduling is not part of the role of a health information management professional, it was unclear as to why this content was included since this would be appropriate for a medical secretarial course. The text used also was suited to a medical secretarial course and is not suitable in the HIM program. This could give students a mistaken impression of what the role of a health information professional actually is. This was a concern especially since role identification and modeling is important in a professional program. … There were virtually no similarities between the core HIM course content in semester 1 for the two programs.
115 On November 6, 2008, CHIMA contacted the Dean, repeating an earlier offer to help with the recruitment of a HIM professional through placing an advertisement on its website as well as sending a communication to its members. Sir Sandford Fleming College was apparently successful in finding a program co-ordinator after taking up a similar offer from CHIMA. However, the College did not pursue this option.
116 To date, Cambrian is the only college that has been unsuccessful in meeting CHIMA’s standards. At present, the College continues to contemplate the future of the Health Information Management program. No further attempts have been made to secure CHIMA recognition.
117 From the vantage point of many of the graduates of the Classes of 2007 and 2008, the failure of the College to obtain CHIMA recognition has severely affected their ability to compete for desirable jobs in health information management in the hospital sector – something they claim they were led to believe would be open to them as Cambrian graduates. At this point, it is useful to examine what the College actually told students about CHIMA recognition and their employment prospects as graduates of its Health Information Management program.
118 Enrolment numbers are key to the success of any college program, and it is understandable that Cambrian would endeavour to showcase its new Health Information Management program in a positive light. One of the factors that is clearly important to students is the potential for future employment. In the case of Cambrian’s Health Information Management program, “employment opportunities” were first formally described this way in the 2006-2007 Academic Calendar:
Successful graduates will be prepared for careers across Canada in the health and community-based facilities such as acute and chronic care hospitals, health care private practitioners, offices and clinics, ambulatory care facilities, insurance companies, research centres, veterinary care facilities, government agencies, pharmaceutical companies and medical diagnostic laboratories.
119 The calendar also contained an inspiring quote from the Co-ordinator:
Health information management professionals have identified that there is a national health information skills shortage and that there is a need to train health information professionals. If you are interested in a career in health care information technology, why not look to Cambrian’s New Health Information 2-year diploma program.
120 What the calendar neglected to mention was that professional positions in health information management in the hospital sector are generally only available to individuals who have graduated from a CHIMA-recognized program and that Cambrian’s program was not CHIMA-recognized. It also failed to note that CHIMA’s observation about a shortage of health information management professionals was in reference to individuals with the appropriate CHIMA credentials.
121 The College also produced a brochure on the Health Information Management program, which was posted on its website. Once again, employment opportunities were listed, including in the hospital sector:
Successful graduates will be prepared for careers across Canada in a number of health and community-based settings, including hospitals, acute and long-term care facilities, private practitioners’ offices and clinics, ambulatory care facilities, community care facilities, government agencies, pharmaceutical companies, and medical diagnostic laboratories. …
122 While the College did not state that its program was CHIMA-recognized, it did refer to the association and mistakenly characterize it as a regulatory body under the heading “Follows National Guidelines,” stating:
It’s a program based on requirements established by the Canadian Health Information Management Association (CHIMA), a national health educational regulatory body….
123 In its July 5, 2007 letter to the Co-ordinator regarding the College’s application for recognition, CHIMA drew attention to this reference, noting it had been included without CHIMA’s permission and was inaccurate. It requested that the reference be removed. However, the offending statement appears to have remained until it was finally deleted over a year later, in August 2008.
124 During our investigation, we interviewed 14 former students who attended Cambrian’s Health Information Management program between 2005 and 2008 about their understanding of their employment prospects based on the information the College had provided. Not surprisingly, most of them were enticed to enroll in the program by the lure of the demand for health information management professionals in the hospital sector, where certified health records professionals can earn $25-plus an hour. Students claimed that the Program Co-ordinator in various information sessions had personally discussed the potential wages and job opportunities that awaited program graduates.
125 Sara Wright’s response was typical of those who reviewed the College’s promotional material. She was a former waitress and homemaker in her early 30s with three young children when she decided to enter the program in 2006, after completing some upgrading courses at Cambrian. When she looked at the College’s website, she was excited by what “looked like a high-demand field” that would allow her to work anywhere in Canada upon completion. She did some research and was attracted by the possibility of working in a hospital with a good starting salary.
126 Other students were persuaded by the Co-ordinator’s enthusiastic comments regarding the program. For instance, Jennifer Renaud and Kristine Landry, both 21, enrolled in the program in 2006 after listening to the Co-ordinator speaking of the “high demand” for health information management professionals. Ms. Renaud explained to us:
I thought, that’s a course that’s going to get me a good job, a high-demand job and in the health field, it was perfect. So I registered for the course.
127 She expected to graduate as a coder and work in a hospital setting. Ms. Landry echoed this sentiment, noting that the Co-ordinator “really sold us on the program and also the job opportunities.” She too envisioned a future with a coding and abstracting job in a hospital, where she could make “good money” and have job security.
128 What none of the students we spoke to were aware of when they enrolled in the program, and what the College neglected to tell them, was that it was highly unlikely that Cambrian’s unrecognized program would lead to access to the lucrative jobs they anticipated in the hospital sector.
129 Graduates of the program explained to us that the College had instructed them about CHIMA and the fact that in order to qualify for certification as a health information management professional, they had to pass a national examination. However, they were not told that the College’s program would not actually qualify them to write the national certification examination. Like other students we spoke to, Jennifer Renaud assumed that after graduation she would be able to write the national examination. For many months, as she applied herself to her studies she was oblivious to the significance of CHIMA recognition. She observed:
We weren’t aware that we even had to be accredited. We’d never heard that word before in our course so we really didn’t know what it meant to be accredited. We just thought that we did our course, we wrote our exam and we got our job. We weren’t aware that we needed accreditation to write an exam.
130 It was only after students learned on their own about the implications of CHIMA affiliation that the College confirmed that it was not operating a recognized program. During our investigation, the Co-ordinator acknowledged that students expected they would be able to write the certification examination based on the information they had received. While she granted that their concerns when they discovered otherwise were legitimate, she and other Cambrian officials explained that no promises had ever been made.
131 Julie Carriere, 22, enrolled in the program in 2005. Based on her previous experience with a medical laboratory program, she was one of the few students familiar with the concept of “accreditation”. During her first year in the program, she started asking instructors whether it was recognized by CHIMA. She says she and other students were reassured by the Co-ordinator that as it was only the first year of the new program, recognition “would happen” and the students just had to “be patient.” During her second year, with no evidence that recognition would be forthcoming, Ms. Carriere contemplated dropping out of the program. However, she claims that the Co-ordinator repeatedly reassured her that the program was going to be recognized. She told us that the Co-ordinator’s constant refrain in response to student concerns was “don’t worry.” However, after two years of being patient and staying positive, there was still no word concerning CHIMA recognition when she graduated in June 2007.
132 Twenty-two-year-old Melissa Monahan joined the program in 2006. During her first year, she took a co-operative work placement at a hospital where she learned from medical records staff that Cambrian’s program wasn’t recognized by CHIMA and that accordingly she would not be eligible for the hospital coding jobs she had been working towards. She says hospital officials advised her to leave the program. She explained:
Their opinion was that it was a bad program, and they told me that if I stay there, I would not get a job anywhere, and the only job that I would maybe be able to get is a secretary job at a doctor’s office, but they said anyone can get that. You can get it without education and it will be a $12-15-an-hour job. Whereas if I got out and I took it, say at George Brown.. or Sir Sandford Fleming… I start at $30 an hour…”
133 When Ms. Monahan returned from her co-op placement, she confronted the Co-ordinator about what she had found out about the program’s status. She says the Co-ordinator assured her that the College was “working on” CHIMA recognition. She also claims that the Co-ordinator and Dean asked her to refrain from sharing what she had discovered with the rest of the class. However, she refused to hide the information from her classmates, and disclosed the implications of being in an unrecognized program in class one day. She acknowledges that this “caused an uproar,” and the incident apparently led to a summons to the Dean’s office. In the end, Ms. Monahan opted to leave Cambrian and pursue her studies in the CHIMA-recognized program at Sir Sandford Fleming College.
134 The Cambrian Health Information Management graduates we spoke to consistently recalled that the Co-ordinator repeatedly assured them the College was “working on” program recognition, that they should “stay positive”, and “not worry.” Some students told us that the College went further and that they were actually assured that the program would be “accredited.” The Co-ordinator acknowledged that she tried to reassure students, telling them: “We’re working to have this program accredited, let’s stay positive. Whatever recommendations they make, we can change them.” However, again she denied making any promises about CHIMA recognition. The Dean indicated that while he occasionally visited program classes to share information about the College’s attempts for CHIMA recognition, he never offered any guarantees regarding the program’s prospects of obtaining CHIMA recognition.
135 Unfortunately, as the first graduates of the program emerged into the workplace, they began to face the reality of diminished job prospects as a result of the program’s unrecognized status. While the College was aware in July 2007 that its first recognition attempt had failed, it was not until the graduates themselves pressed for answers that the College acknowledged CHIMA’s rejection. The College has excused this oversight by suggesting that since school was not in session at the time, there was no one on campus to inform.
136 Matthew Barney is married with two children. He graduated from Cambrian’s program in 2007. When he first learned that the program was not CHIMA-recognized, he considered transferring to another college, but was convinced to stay by the Co-ordinator’s reassurances. During his co-operative placement at a hospital, he was told that the only reason he was not offered a position was because of Cambrian’s program status. On August 22, 2007, Mr. Barney emailed the Program Co-ordinator in frustration, noting:
I would like to know the status of accreditation. I have recently applied to the Queensway Carleton Hospital in Ottawa and was declined the job in my interview because they looked up Cambrian’s Health Information Management Program eligibility for accreditation with CHIMA. They notified me that Cambrian hasn’t received privileges. This was very upsetting due to the fact that my family was excited for the move to Ottawa.….
I would like to know what is being done. The deadline for signing up to write the CHIMA test is in September. If we are not accredited by September, I will be forced to ask for my educational funding (books/placement expenses) in return [for] unsuccessful program promises. This is unacceptable and extremely embarrassing to have to tell family and coworkers of my 2 years wasted on education….
137 The next day, Mr. Barney’s classmate Julie Carriere sent a similar missive to the Co-ordinator:
I’ve heard that accreditation did not follow through. I am now wondering what Cambrian College is going to do for the students who have spent 2 years of their lives studying at Cambrian College. I expect to have returned to me: my tuition for 4 semesters, the money for my books, living expenses for 2 months I moved out of town for my field placement. This is the least of my concern, because unfortunately you cannot return the time I wasted in this Program. I was going to drop out of this program for this reason, and I was reassured by you that it was in the process and that we would be accredited. I am now in a position where I am waiting to write an exam so I am able to work in Ontario as a Health Information Management Professional and I cannot write it because the faculty I attended does not meet the criteria. I think this is highly unacceptable, and would like to know how an institution can offer training, and mislead students in such a way!
138 The College continued to placate graduates, assuring them that it was continuing to work towards CHIMA recognition. For instance, in an October 19, 2007 communication to students and graduates, after apologizing for not formally notifying students of CHIMA’s rejection, the Dean commented:
It is my feeling that the issues encountered with the first submission are with the representation of the course standards within the document itself and not an issue with the program. To that end, I am optimistic of a successful outcome. If it should turn out that there are specific deficiencies, then we will address them as they become known to us. ….what is important is our resolve to have the HIMP program accredited such that graduates of the program can challenge the CHIMA certification exams. I can sympathize with your frustrations. While I cannot guarantee that this submission will be successful, I can assure you that we are working actively to achieve just that….
If there are deficiencies identified in our next submission the college is prepared to offer remedial courses, at a distance (or online) to the 2007 graduates, at no cost to the graduates. If we are successful in our next attempt (and we hope we will be) the college is prepared to cover the cost of the first attempt at the certification exam for all nine 2007 graduates. Finally, the college will be hiring a new program co-ordinator who is CHIMA-certified to ensure we meet compliance…
139 The College continued to attempt to appease program graduates and students while its second CHIMA recognition submission was under consideration. On March 8, 2008, the Vice President Academic sent an email to Jennifer Renaud, following a meeting with her and her mother. The Vice President expressed optimism, and set out the commitment the College was prepared to make:
Should the need for preparatory courses be required, in particular for last year’s graduating class, the college has made the commitment to cover any and all associated costs with the course. While we don’t anticipate the current graduating class necessitating any further preparation, should any student from this graduating class wish to take the course, the college would be prepared to cover course costs. …
I do apologize for any inconvenience caused to you, Jennifer, and hope that with the program receiving accreditation, you will be able to seek successful employment in your chosen career field.
140 As complaints from graduates and their families continued to mount, and as it was once again denied recognition by CHIMA, the College sent out a communication to students and graduates of the program on May 12, 2008. The Dean wrote:
… It is with deep regret that I must inform you that we were once again unsuccessful in obtaining recognition. …
I am currently unable to assess what our failed attempt means both from the perspective of our current graduates of the program and of the future work that needs to be done to be successful in our attempts for LOHIM recognition. …
I remain committed to achieve LOHIM recognition however, as you are well aware, it is a slow process. I am also committed to the offers made in the first correspondence with you …
This process has been a long and consuming one for everyone. While I don’t wish to sound disheartened, I would suggest that if you were considering taking any self-directed learning opportunities to expedite your attempts to self qualify to challenge the national certification examination, I would recommend consideration of that opportunity. I am not, at least at present, able to predict when we will be successful.
141 By the spring of 2008, it was clear that Cambrian’s program had significant challenges to meet before it would ever qualify for CHIMA recognition. At that point, its communications with students and graduates took on a noticeably less enthusiastic tone. Instead of emphasizing the College’s efforts to gain recognition, the College downplayed the significance of CHIMA recognition, claiming that it had not been part of the College’s original plan. On July 14, 2008, the Dean sent another letter to graduates and second year students of the program, noting:
The College undertook LOHIM recognition to expand employment options for our graduates. While this recognition was not part of our original program offering, we felt that increasing employment opportunities for our students was a valid priority and remain committed to that goal. The key issue is that we cannot guarantee, within any reasonable timeframe, that we will be successful in obtaining LOHIM recognition. There are a number of issues that must be resolved and the final decision on recognition status rests with the Canadian Health Information Management Association (CHIMA).
Cambrian has been actively reviewing our program, talking with CHIMA, program consultants and other colleges. We have circulated our curricula to two other program providers (and have a third in mind) to determine where similarities and differences exist. We are in the final stages of an approval process to consider the recruitment of a HIM-certified professional to act as program co-ordinator in line with CHIMA requirements. While all of this activity has occurred over the last month, the actual work to revise our existing curriculum will take a significant amount of time. Once the revisions are complete, we still must attain CHIMA recognition before we could provide any remedial programming to you …
142 The Dean also advised that the College had shared its curriculum with the Canadian Healthcare Association, which would be accepting students into the second year of its online program in health information management. The course cost, exclusive of books, was estimated at $1,625, which the College was willing to pay in full upon proof of successful completion of the program. A similar offer was made for individuals who registered for a health information management program at another college. Cambrian also committed to cover the cost of challenging the CHIMA examination for those who successfully completed upgrading. The offer was open for acceptance until July 31, 2009.
143 After receiving the Dean’s communication, a number of students raised concerns regarding the tight deadline and the fact that they had to come up with the money for the CHA course up front. To compound the time pressure, as a result of an oversight, the letter was not initially sent to the Class of 2007 graduates until July 30, a day before the registration deadline for the 2008 CHA program.
144 While the College assured students they had until 2009 to take up its offer, many students expressed apprehension about delaying their education further, as one student noted in July 2008 in a communication with the College:
I am aware that we can enroll into the program for next September, however many of us would like to complete this as soon as possible as we are not able to find jobs in our field and would like to start our working lives. That is why we are put on such a tight deadline, if we wait a year the information will not be fresh in our minds and it is difficult for us to take a break, find jobs, then go back to school afterwards.
145 A number of graduates complained to the College, to their local Member of Provincial Parliament, and to my Office concerning their treatment. The President went so far as to label one student’s efforts to pursue her concerns to be “harassment.” However, the College was not prepared to modify its offer except to the extent that in August 2008, it made two sets of textbooks for the CHA course available through its library.
146 In support of the reasonableness of its offer, the College has indicated that 12 graduates from the program took up the offer to pursue upgrading through CHA. However, many of the graduates we spoke to, who had registered for the CHA course, found the content extremely challenging and unfamiliar, and some eventually withdrew. Even the Co-ordinator acknowledged that the CHA course is geared to individuals working in a hospital environment, to which many graduates had no exposure. One of the fundamental problems with the option of upgrading through CHA appears to be that Cambrian’s program may not have adequately prepared students for the CHA course content.
147 Graduates told us that Cambrian’s Health Information Management program courses were random and disorganized and that the Co-ordinator, who taught many of the courses, was obviously not trained or experienced in the area. The inferior quality of Cambrian’s program became apparent to Melissa Monahan once she dropped out of the program after first year. Ms. Monahan worked for a year to earn money to pay off the $6,000 debt she had incurred attending Cambrian then registered with Sir Sandford Fleming College’s Health Information Management program. Unfortunately, she was told that her credits from her first year at Cambrian would not be recognized because they were not equivalent. The program co-ordinator at that college explained to our Office that Cambrian’s program was organized in too different a manner to credit Ms. Monahan with a semester or to provide her with advanced standing in their program. Essentially, the courses were different, and taught at different times, making it virtually impossible to match up the courses between the two programs. Ms. Monahan herself observed that her new program is much more comprehensive and in depth compared to what she took at Cambrian. This is also consistent with CHIMA’s evaluation of Cambrian’s curriculum, the independent gap analysis obtained by the College, as well as the observations of hospital officials we interviewed, who have had occasion to interact with Cambrian graduates.
148 Internal College communications indicate that the decision to assist students who chose to upgrade their skills was considered a gesture of “goodwill” on the College’s part, and an attempt to limit its risk of exposure to litigation and loss of reputation. It is clear from College records – and indeed from interviews with senior administrators conducted during this investigation – that the College accepts no responsibility for student expectations with respect to CHIMA recognition. In addition to denying making any representations to students about CHIMA recognition, Cambrian officials provided three justifications to support its position:
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the decision to seek CHIMA recognition was essentially an “add-on” not originally contemplated when the program began;
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problems with recognition stemmed from CHIMA changing its recognition requirements; and
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contrary to the allegations of the graduates, the College had upheld its end of the bargain and provided students with fair value for their money.
149 However, these arguments do not hold up under closer examination.
150 College administrators informed students, parents and our Office that recognition by CHIMA was really a gratuitous afterthought on the College’s part, undertaken for the benefit of students. For instance, in replying to one mother of a graduate on April 24, 2008, the Dean commented:
As you know, the program was launched without the requirement for certification. It has become evident that CHIMA certification was a valued addition to the program, specifically for those students seeking employment in the hospital sector.
151 In a July 17, 2008 email to another student, the Dean remarked:
… We have done the best that we can and have come up with what we consider is a fair offer to assist you and your fellow students and graduates. You cannot lose sight of the fact that we undertook accreditation to enhance opportunities for our students. That was our sole motivation.
152 On August 13, 2008, the Dean wrote to our Office and made the following statements about CHIMA recognition:
… We were hoping to have given them this added value beyond the Diploma that was bargained for….
We feel that current graduates are attractive employees with good job prospects. In this era of credentialism, they join legions of people who, after graduating from an academic program, must undergo further professional development in order to rise within their chosen profession.
… I truly hope that the office of the Ombudsman will recognize that the College has not abused, misled or disadvantaged its students in any way. To the contrary, by subsidizing CHA courses for them, Cambrian is going beyond its obligations to support graduates to achieve the next career goal, for those who seek it.
153 An internal College proposal prepared by the Dean after the second recognition attempt failed indicates that he was under the impression that there was “no consideration of accreditation at the time of launch” of the College’s Health Information Management program and that the “recognition of value of HIM certification came later.” However, the Dean was not present at the College when the program was being planned and approved. Despite the College’s current assertions that seeking recognition from CHIMA was not really contemplated at the outset of the program and was not integral to the original program planning, the College’s documentary record clearly demonstrates the contrary.
154 College and Ministry officials have emphasized that market research must always be conducted as part of program planning to ensure that there are employment opportunities for students associated with a proposed program. However, in the case of Cambrian’s Health Information Management program, the market research focused primarily on job prospects for health information management professionals certified by CHIMA. In fact, the College’s documentary record confirms that both the advisory committee and board of governors approved the program proposal on the understanding that CHIMA recognition would be sought. The fact also remains that the College conducted virtually no market research on the job prospects of students taking health information management courses that were not recognized by CHIMA.
155 In the proposal document, the Dean also suggested that the decision to become CHIMA-recognized in 2007 was “timed with substantive revisions to CHIMA standards that increased the rigor/requirements for certifications.” The President of the College made a similar suggestion in responding to an MPP inquiry on July 24, 2008, when she referred to “changes at CHIMA” affecting the College’s “accreditation” attempts.
156 As to the suggestion that the College’s attempt at recognition was impacted by increasingly rigorous CHIMA requirements, there is no evidence that this was the case. CHIMA officials have indicated that the rejection of Cambrian’s recognition applications was not based on changes in its requirements, and the College has been unable to substantiate this claim. While there were some changes to CHIMA’s matrix of learning outcomes in May 2006, the College was aware of these months before it made its first submission to CHIMA.
157 The College’s failure to achieve CHIMA recognition was not attributable to shifting and stringent CHIMA requirements, but to the quality of its programming, which fell significantly below the standards set by CHIMA.
158 College officials insist that the Health Information Management program has led to graduates obtaining employment in the field that they trained for. They stress that it is only with respect to the hospital sector that certain jobs are not available, and minimize the significance of this. In fact, the President went further. During our investigation, she explained that it was not unusual for a student who had just graduated to be unable to secure the top position in the field, and that additional education might be necessary. The President pointed to herself as an example of this and suggested that few two-year college programs offer students the ability to earn $30 or $40 an hour. She advised that it was only the “top level” jobs in the hospital sector that were outside Cambrian graduates’ reach:
From what we understand, the only job that you can’t do in the area of Health Information Management without the designation is to be the top person that oversees Health Information Management in the hospital.
159 She also noted:
So, what they can’t get is the high-paying $30-or-40-an-hour job as the manager of the whole department….
160 Regarding obtaining CHIMA recognition, as noted earlier, the President was apparently unaware of CHIMA’s position on the matter. She maintained that a program had to be ongoing to be “accredited” and that “accreditation” would be attempted but could not be guaranteed, as it was not within the control of the College. She repeatedly explained that some programs require “accreditation,” such as civil engineering and nursing, and others such as the Health Information Management Program do not. She also told us:
There was never an intention, never anything that we communicated that said we are absolutely going for accreditation immediately.
… there was no timeline attached to when we would do that or how we would do it…. It hasn’t stopped the students from getting employment.
161 As far as the President was concerned, the College had fulfilled its end of the bargain. She was particularly critical of the efforts of one student’s family in seeking a remedy. In referring to some students who felt the College’s “goodwill” offer to assist them was not good enough and that it should reimburse their tuition, she observed:
They took the program that was a legitimate program. We fulfilled all of our obligations on that program. They received a diploma and they had their work placement…. They all had opportunities for employment.
162 Hospital officials we interviewed concerning opportunities for professional positions in health records management confirmed that this continues to be a growth area with great demand in the hospital sector. But they also noted that they would not hire individuals for work in professional positions unless they were CHIMA-certified. They suggested that in the past, some hospitals in the far north have hired uncertified individuals, but the field is “tightening up.” They explained that the salary for a certified health records professional at their hospital starts at $24.57 an hour and ends at $27.46, and that while individuals can work as records “clerks” without certification, clerical positions only require a high school diploma. With respect to Cambrian’s program, one official commented that she was “floored” when she found out that Cambrian’s program was not recognized. These hospital officials also expressed concern about the quality of education received through the College, noting that Cambrian students placed with them in the past were “not up to par,” and that program graduates had sometimes even failed the test for clerical positions. While students might be accepted in other areas of the hospital in clerical capacities, hospital officials we spoke with noted that their hospital was no longer accepting students for co-operative placements from Cambrian in the area of health information management.
163 While College administrators suggested that Health Information Management program graduates have been successful in many areas relating to this area of study, they initially provided only anecdotal information and were unable to provide us with any particulars of positions actually obtained by graduates. For instance, we were given a December 23, 2008 email from the Co-ordinator that indicated:
With reference to the information about graduates of HIMP employment status, I have no confirmation of such. However some of the graduates have called me and informed that one of their classmates is working at the hospital or at a local clinic or at the CBS (Canadian Blood Services). I have no written and or confirmed documentation from students or the college’s student employment services….
164 During the course of our investigation, we spoke with a number of program graduates concerning their employment history since leaving Cambrian. While their job experiences differ, they share a common belief that Cambrian failed to deliver the quality of education they expected given the promotional materials and assurances they received from program administrators.
165 Based on our interviews with program graduates, it appears that although some have found employment – most commonly after job placements – this appears to have been a rather random result. The majority of graduates are not working in the field they trained for, and those who are, are working in clerical positions not requiring any formal education or on the condition that they upgrade their skills. Some graduates have been less fortunate, and continue to struggle to make ends meet without any immediate prospects of secure employment.
166 The President of the College held out Jennifer Renaud, 21, as an example of a successful Cambrian graduate. She emphasized that Ms. Renaud “has a very well-paying job in her field.” However, Ms. Renaud has a somewhat different take on the facts. After graduation, she obtained a position as an administrative statistician at Vale Inco. While she fully acknowledges that she is lucky to have a job, she explained that the work she is doing has nothing to do with health information management. In addition, the College had very little to do with her luck. When it came time to find placements for students in her year, the Co-ordinator was away on an extended leave, while the Dean was busy with other matters and had not started looking for student placements. So Ms. Renaud took the initiative to find her own placement. Although she would like to pursue her original goal of working as a health information management professional, her initial attempt at the CHA course was unsuccessful. She told us that she had difficulty balancing the high demands of this course while working full-time, even though the College had promoted this option to her as something she could easily do while working. She eventually withdrew, losing her deposit.
167 Twenty-two-year-old Julie Carriere accepted an out-of-town placement in London, Ont. after finishing the program at Cambrian. She is one of the few working in a field related to health information management. She actually started out in a hospital doing coding, until she was removed from the position when the hospital discovered she had not attended a CHIMA-recognized program. She continued to work at the hospital in other areas, and is currently working with health information on condition that she completes the CHA course, which she enrolled in even prior to the College’s offer, and obtains her CHIMA certification. Despite having incurred $17,000 in debt to attend two years at Cambrian, Ms. Carriere finds herself in the daunting situation of incurring additional costs to redo her second year of health information management, while continuing to work full time.
168 According to the Co-ordinator, Diana Peltier is another success story who found work in the field of health records. Ms. Peltier is working at a Health Centre on Manitoulin Island on condition that she becomes CHIMA-certified. She also arranged on her own to take the CHA online program prior to Cambrian’s offer. While she is closer to meeting her goal of being a health information management professional, she is frustrated by the additional time and money involved. Looking back, she remembers that she initially considered taking the Health Information Management program at Sir Sandford Fleming College. However, as with many students in the North, she chose Cambrian because it was closer to home. She had to leave her young daughter to attend the program during her first year. By now, she had hoped to be reaping the rewards of her sacrifices and hard work, but instead she finds herself once more under stress, trying to balance being a mother, working, and taking courses to upgrade her skills.
169 Sara Wright acknowledges that she did get a job out of her placement at a hospital. She is a data entry clerk, making $19 an hour. However, the position requires a high school diploma, and she could have applied for it without having incurred a $17,000 student loan to take Cambrian’s Health Information Management program. As for the College’s offer to reimburse a CHA online course, she says she simply cannot come up with the required fees on her own. She also expressed concern about the prospect of finding her own field placements, a requirement of the CHA program.
170 While Mathew Barney is now working in a hospital, he has repeatedly been rejected for positions in health information management. He incurred $5,000 in student loans and $2,500 in placement expenses while attending Cambrian’s program. He is currently taking the CHA course online and hopes to be able to one day finally fulfill his hopes of working as a health information management professional. However, he is resentful of the additional time and money he must expend to do so.
171 Twenty-two-year-old Danielle Smith is an acting supervisor in a records office at Health Canada. While her placement after Cambrian’s Health Information Management program led to her indirectly obtaining a job through a federal student-hiring program, she is working with corporate records and not in a capacity directly related to her training in health information management. Like others we spoke with, she contemplated quitting the Cambrian program halfway through, but says she was assured that the College’s second submission to CHIMA should be successful. Having stuck it out for two years at Cambrian, Ms. Smith is now saddled with a bank student loan debt of $30,000, which leaves her with no funds to invest in further education.
172 Kristine Landry did a placement at Sudbury Regional Hospital as part of her program at Cambrian. However, her placement didn’t involve health records or coding. She worked under a medical secretary. She is now a temporary clerk at a credit union, where again, she doesn’t have any responsibilities relating to health information. She initially took up the College’s offer to take the online course with CHA, after borrowing the tuition from her grandmother. However, she found it too difficult to balance her work and studies and she eventually dropped out, obtaining only a partial refund. After incurring $1,200 in student loans and $24,000 in debt on a line of credit, Ms. Landry feels that her time at Cambrian was a complete waste.
173 Nicole Solomon, 20, had pinned her hopes on working in a hospital medical records department. After graduation, she was unsuccessful in finding a hospital position because of her lack of certification. She is weighed down by a $20,000 student loan debt left over from two years at Cambrian. Now earning $10 an hour working part-time at a general store, she figures she will spend the rest of her life paying it off. Ms. Solomon told us she had considered dropping out when she heard about the CHIMA recognition issue, but the Co-ordinator urged her to stay on and not to be discouraged. At present, instead of looking forward to an interesting career in a “high demand” field, her dreams of being a health information management professional have been shattered.
174 After spending almost $9,000 in student loans to attend Cambrian’s Health Information Management program, Sheena Xavier, 22, graduated in 2008. Rather than working with health records, she is working part-time in a clothing store. She tried the CHA online course but found it too difficult and withdrew. For her, the diploma she received from Cambrian is virtually worthless.[5]
175 Christie Charette is a 29-year-old single mother of two young children. She owes $25,000 from her experience at Cambrian. After graduation she remained unemployed and had to borrow money from family to take the CHA course, her only hope of getting a decent job. Unfortunately, she too is finding the course difficult after her experience at Cambrian.
176 The graduates we spoke with indicated that they would have made different choices had they realized the significance of Cambrian’s program not being CHIMA-recognized when they were registering. While College officials claimed they were under no obligation to tell students that the Health Information Management program was not CHIMA-recognized, in order to ward off future claims, the College has now taken the step of explaining the program’s status to new students in advance.
177 In July 2008, the Dean sent a letter out to the students set to begin the program in September 2008, welcoming them to the program and noting:
… Our graduates are well received and have found employment in a number of industries including; health records, physician offices, industry (occupational health), medical clinics, and Health Canada. Within the hospital sector however, it is a requirement that you obtain a HIM professional certification prior to working as a health information management (HIM) professional. This designation is granted by CHIMA upon successful completion of their comprehensive exam.
Graduation from our program will not, on its own, qualify you to challenge CHIMA’s examination. To qualify for the opportunity to challenge the CHIMA exam, some of our graduates are accessing additional online courses from the Canadian Healthcare Association (CHA). As graduates of Cambrian College’s Health Information Management program, students have received advanced standing relative to the courses they have taken with us. In addition, they are required to successfully complete some of the CHA online courses prior to challenging the CHIMA examination. ……
178 In addition, Cambrian’s program overview on its website no longer refers to the program leading to employment opportunities in the hospital sector, and also cautions that Cambrian’s program will not “on its own” qualify graduates to challenge CHIMA’s certification examination.[6] However, the program brochure, dated August 2008, which is also available on the College’s website, continues to reference that successful graduates will be prepared for careers across Canada in a number of health and community-based settings, including hospitals. It also includes the rather ambiguous statement that the program “Follows National Guidelines.”[7]
179 At least in the case of new students to Cambrian’s Health Information Management program, they have received some warning before commencing their studies. However, even then the College appears unable to resist putting an overly positive gloss on the facts. In the Dean’s letter to the students, he lists a series of areas where graduates from the program have been successful in obtaining employment. It is not clear where the Dean obtained this information at the time, as it was not until very recently that the College was able to supply our Office with any details confirming whether and where its Health Information Management program graduates were employed.
180 Unfortunately for the graduates who complained to us, when they considered applying to the program, and even after they had registered, they were missing key information that might well have affected their decisions regarding program options. To illustrate this, it is useful to compare Cambrian’s Health Information Management program with the programs available elsewhere in Ontario.
181 While Cambrian College’s Health Information Management program is not up to the CHIMA-recognized standards of other similarly titled programs offered by colleges in Ontario, surprisingly, it is the longest and one of the most expensive programs of its kind available.
182 Cambrian College offers a four-semester program with an additional two-month placement, while St. Lawrence offers a three-semester course, including practical placement, and George Brown and Sir Sandford Fleming both offer four-semester programs including placement.
183 Based on current rates, the total fees required to complete the program are approximately $3,000 at St. Lawrence College, $5,500 at George Brown, and $6,000 at Sir Sandford Fleming. Cambrian’s program costs approximately $5,600 in total fees.
184 The big difference is what students get for their money. At the three other colleges offering Health Information Management programs, graduates not only receive a diploma, but also qualify to challenge the CHIMA national certification examination. In addition, they eventually may have the option of applying to Ryerson University to complete a degree program in Health Information Management. According to the Director of the Health Information Management program at Ryerson, in order to apply for this degree program, students must have a two-year diploma in health information management, be certified by CHIMA and have worked in the field for at least two years. In the case of Sir Sandford Fleming, students may also apply to the University of Ontario Institute of Technology for upgrading to a degree. In contrast, students graduating from Cambrian College – even if they were somehow fortunate enough to work in the field for two years – would be ineligible for Ryerson University’s degree program unless they upgraded their skills on their own in order to successfully challenge the CHIMA examination. While Cambrian’s Health Information Management program brochure refers generally to agreements with universities that enhance student mobility and recognize and facilitate the transfer of credits, there is no agreement with Cambrian that governs the Health Information Management program. While Cambrian’s students might be left with the impression that Cambrian’s program might eventually assist them with a degree program in health information management, this is not the case.
185 In terms of value for money, Cambrian College’s program is clearly dead last. The Ministry, which has general oversight of colleges in Ontario, remains unconcerned about the quality of programming provided by individual colleges. In fact, it has not drawn any distinction between the Health Information Management programs available in the province, despite the fact that Cambrian’s program does not meet the same standards as the three programs recognized by CHIMA.
186 In the 2007 Employment Profile posted on the Ministry’s website, the employment experience of 2005-2006 college graduates six months after graduation was set out. Under “Health Records Administration,” the Ministry noted that of 90 graduates, 71 of 75 graduates surveyed were in the labour force, 53.3% of those employed full-time in a field related to health information management. The average salary listed for these positions was $36,540, with a median of $37,413. In connection with this data, the Ministry identified all colleges at that time providing health information management programs, including Cambrian College. A Ministry official explained that the purpose of making the profile information available is to assist students in making their decisions as to program selection. However, the information in this profile was clearly misleading. Not only was Cambrian’s Health Information Management program significantly different in content and potential outcome from the CHIMA-recognized programs offered at other colleges, but no data concerning Cambrian’s graduates had even been collected because the program had no graduates at the end of the 2005-2006 school year. We were advised that in preparing the most recent Employment Profile for the 2006-2007 school year, which can now be found on the Ministry’s website, only schools that the Ministry actually has data for have been listed. Cambrian is not referenced in this profile, since it had not yet provided any statistical information regarding its graduates from the Health Information Management program. Unfortunately, the previous profile contained significant misinformation as it related to Cambrian, which might well have influenced students in their program choices.
187 During our investigation, Ministry officials emphasized that colleges have been provided with more independence since 2002, and that the Ministry’s role is now restricted to matters related to funding. We were told that the Ministry’s approach is “pretty much… hands off” when it comes to program quality.
188 While the Minister has established broad policy as set out in the Framework for Programs and Instruction and Funding Approval of Programs of Instruction, under the current system, the Ministry’s review of a college’s efforts at course creation is perfunctory at best. As long as the Credentials Validation Service has approved the program proposal and the college’s president has certificated that the specified criteria have been met, Ministry approval is virtually guaranteed. Unless an area is actually regulated, the Ministry does not concern itself with the requirements of relevant professional organizations. We were told that the Ministry does not have “a strong interest if it’s not a mandatory regulated field” and that colleges are “mature” organizations that should not be interfered with at the Ministry level. The flaws in this approach are all too evident when one considers what occurred with Cambrian’s Health Information Management program, which is not a regulated area. Recognition by CHIMA is optional, although as my investigation demonstrates, it has significant practical consequences for student job prospects.
189 In accordance with the Ministry’s Directives, Cambrian’s program was initially developed based on a clearly identified economic and societal need, specifically for trained health information management professionals. Labour market research was conducted by the Co-ordinator in developing the program proposal, which indicated that there was a growing demand in the hospital sector for health information management professionals certified by CHIMA. The appropriate approvals were obtained from Cambrian’s advisory committee and the board of governors, based on this information. However, the ability of Cambrian’s program to meet the economic and societal need identified by the College’s research largely hinged on its ability to provide a program that actually met CHIMA standards. There was no clear demonstrated economic or societal need to produce graduates of a program, which would not qualify for certification. The College’s funding request also referred to its intent to seek CHIMA recognition.
190 Unfortunately, the whole premise of Cambrian’s program – that it was to fill an identified economic and societal need related to the profession of health information management – was undermined when the College proceeded to offer and operate a program for three years without obtaining CHIMA recognition. What the College ended up marketing and creating was essentially a poorly constructed knock-off of CHIMA-recognized programs with the same title offered by other colleges in Ontario. As a consequence, Cambrian’s program has fallen far short of meeting the economic and societal need that the program was primarily created to respond to, and the Ministry has ended up paying taxpayers dollars to fund a program that has not only generally failed to meet an economic and societal need, but left vulnerable students in substantial debt – many with very little to show for their time and effort.
191 Students should be entitled to look to the Ministry to ensure that their interests as education consumers are protected. However, if what occurred with Cambrian is typical, it is clear that the Ministry’s oversight offers little comfort.
192 One official described the Ministry’s approach to college program development as follows:
One of the things we ask them to have done is a labour market survey in the area that there’s need for it. We assume they have had a Program Advisory Committee of professionals and employers in the area who have looked at the program. We assume through this directive that they have quality control processes. … we assume that the colleges have quality control and that they’re doing audits of them….
193 In connection with Cambrian’s Health Information Management program, the Ministry actually praised the College’s proposal. We were told, “… from the Ministry’s perspective, it was a well-thought-out program and they did their homework.”
194 However, it is apparent that the Ministry also made a number of assumptions in relation to the significance of CHIMA recognition. Officials downplayed the importance of meeting CHIMA standards and suggested, without any substantiating evidence, that Cambrian’s graduates had fared well in the workplace despite the program’s questionable professional status. One Ministry official told us:
… I did some research myself looking at job opportunities and it appears to me that it’s the large urban hospitals that would require this designation. So, I would imagine that most of the students did get employed – even in the hospitals because there’s such a shortage of these trained professionals that even the hospitals snapped them up. I believe Cambrian has now arranged for them to take these two online courses so that they could sit for the exam. But I suspect that most of the students were snapped up and got employment…
195 During our investigation, Ministry officials also repeated the claims made by College officials that Cambrian Health Information Management graduates were getting jobs in the field. One Ministry official confidently told us that according to the College, most program graduates had obtained jobs.
196 It is apparent that under the current scheme for program development and review, the Ministry has abdicated any responsibility to ensure that a college actually delivers the program as proposed in a funding request, and placed too much trust on colleges overseeing themselves. The current approval process is essentially an exercise in rubber-stamping without any independent analysis or follow-up. The Ministry assumes that the colleges have the best interest of students at heart, and assumes that it has delivered the promise of meeting a stated economic and societal need. However, it has not established sufficient checks and balance to ensure that this is the case. College self-audits and key performance indicator information provided at some point down the line are inadequate safeguards against the type of conduct displayed by Cambrian College in this case.
197 Cambrian clearly did not meet its mandated objects of providing education and training to assist individuals in finding and keeping employment, meeting the needs of employers and the changing work environment and supporting the economic and social development of local and diverse communities. Instead, Cambrian put its own efforts to replace a program with declining enrolment – and, later, to deflect blame for an inadequately conceived and executed program – ahead of the interests of its health information management students. While Cambrian officials may vociferously deny this suggestion, I believe the evidence clearly supports it.
198 From the College’s perspective, its health information management students were the authors of their own misfortune. They made false assumptions concerning their future and developed unrealistic expectations concerning the College’s program. The College sees itself as doing students and graduates a favour by attempting to obtain CHIMA recognition, and later by offering assistance with CHA course funding, contingent on successful completion.
199 However, the evidence relating to the program’s development shows that CHIMA recognition was fundamental to the Health Information Management program. The College’s promotional materials were reflective of a program that met CHIMA standards, and when the program began and continued without recognition, students were kept in the dark. Cambrian left unsuspecting students to their own resources to discover the restrictions that would apply to their careers in health information management as a result of attending its program. As awareness dawned, students were continually provided with vacant assurances.
200 In terms of the College’s recognition efforts, the President of the College at one point suggested that it had “diligently pursued accreditation.” However, the facts do not bear this out. No attempt was made to seek CHIMA recognition until 18 months after the program commenced in September 2005. Even then, both recognition attempts were virtually doomed to failure because the submissions were not prepared by individuals sufficiently knowledgeable in the field and the program lacked key features, such as a CHIMA-certified program co-ordinator.
201 If Cambrian had been open and honest with students at the outset, it is possible that different decisions would have been made and different paths pursued. However, that choice was taken away from students by Cambrian’s failure to disclose important information at the outset.
202 College officials have denied any responsibility for explaining to students entering the Health Information Management program that the College was not recognized by CHIMA or the implications of this ambiguous status. They have essentially suggested it was up to the students to research the different programs available and make an informed choice.
203 However, Cambrian College cannot have it both ways. It cannot produce a promotional brochure identifying itself with CHIMA and at the same time maintain that no representations were made to students regarding CHIMA affiliation that might be misleading. Cambrian cannot market a program with a list of potential employment opportunities leading off with the hospital sector and then suggest that the fact that its graduates cannot qualify for health information management positions in hospitals is of little consequence. It is the hospital sector that has generated a demand for health information management professionals and is the primary employer of these professionals.
204 The courts have recently suggested that educational institutions must be careful not only with respect to the information that they include in their promotional materials, but also with respect to the information that they neglect to include. In Olar v. Laurentian University[8], the Ontario Superior Court of Justice considered the case of a student who had been induced to attend Laurentian University in Sudbury, in part because of information provided in marketing materials concerning the possibility of transferring elsewhere to complete the third and fourth years of an engineering program. The university failed to disclose critical information concerning the risks and difficulties facing transferring students. The court found that the university had negligently misrepresented information. Its promotional materials were considered equivocal, inaccurate and misleading, and the student was found to have reasonably relied on its representations to his detriment. The court concluded that the university’s failure to provide timely and meaningful disclosure concerning the transfer issue deprived the student of the opportunity to make an informed choice regarding which program to attend, and ultimately cost him an extra year to obtain his degree.
205 In this case, Cambrian College held out the carrot of potential future employment in the hospital sector, and suggested that its program was based on CHIMA standards, which it fell woefully short of meeting. Course administrators were aware that students would only have access to the professional designation granted by CHIMA if they attended a recognized program qualifying them to write the national examination. The College was aware of its unrecognized status and its implications, yet, year after year, it relied on promotional materials from which it could be reasonably inferred that students would gain access into the profession of Health Information Management and potentially obtain attractive coding positions in the hospital sector. Even when the truth began to emerge, students were constantly urged to be patient and stick with the program, despite the distinct uncertainty that it would ever be recognized by CHIMA unless major structural and operational changes were made.
206 Whether the actions of Cambrian College reached the level of negligent misrepresentation or not, clearly its conduct fell far below the standard that should be accepted from a provincial institution mandated to serve the public of Ontario. The College’s indifferent attitude towards the Health Information Management program students and its attempts to deflect all accountability for its actions are in direct contrast to the motto of “responsibility with excellence” that it purports to uphold.
207 Cambrian’s failure to put students first, and the Ministry’s misplaced reliance on the College to guard itself, have left many graduates of the program frustrated, disillusioned and in debt, without any reasonable prospect of employment in the field where they believed they were training to work. While not all students have suffered equally, they share a common sense of outrage. Cambrian’s offer to assist to reimburse a portion of the costs of the CHA online program upon successful completion does not adequately compensate graduates for its maladministration of the Health Information Management program. While a few individuals may find their way into the health information management profession through this route, it means an extra year of study that they had not bargained for when they enrolled in Cambrian’s program. Given the array of deficiencies in the quality of Cambrian’s program, it is not surprising that many students have found that they are not up to the challenge of completing the CHA course. Others have already expended considerable funds on attending Cambrian’s program, and are understandably unable to finance further education. Under the circumstances, Cambrian should be striving to provide broader relief to these graduates, which recognizes the substantial investment of time, and money that students have incurred in attending its substandard Health Information Management program.
208 Cambrian’s Health Information Management program graduates should also be adequately compensated for the extra time and effort they must now expend to secure academic upgrading because of the deficiencies in Cambrian’s program. In addition, those who are not in a position to upgrade their skills by reason of financial debt incurred in attending Cambrian’s Health Information Management program and/or their previous sub-par education through Cambrian should be provided with compensation to reflect what they found to be a waste of time and money spent on a program that proved virtually worthless to them.
209 While it is clearly Cambrian College that had a direct relationship with the students of the Health Information Management program and primary responsibility for the quality of their education, the Ministry must also shoulder some blame for its role with respect to this situation. From a systemic perspective, the Ministry failed to establish adequate measures to ensure colleges such as Cambrian deliver the programming they promise in their program funding approval requests. In this specific instance, the Ministry failed to ensure that Cambrian complied with its undertaking to seek CHIMA recognition. The Ministry’s inertia has rendered the funding approval process essentially meaningless. The Ministry not only failed in its fiduciary role as steward of “limited” public funds, but also neglected to adequately safeguard the interests of vulnerable student consumers. The Ministry’s passive approach to college program development and approval enabled Cambrian to operate without supervision or censure to the detriment of the College’s Health Information Management program graduates.
210 It is my opinion that Cambrian College’s failure to properly administer its Health Information Management program, including effectively pursuing CHIMA recognition as originally contemplated in its program approval documents, and providing timely, accurate and sufficient information to students concerning the consequences of the program’s failure to be recognized by CHIMA, was unreasonable, unjust and wrong in accordance with s. 21(1)(b) and (d) of the Ombudsman Act.
211 I also find that the Ministry of Training, Colleges and Universities’ failure to effectively oversee Cambrian’s Health Information Management program was unreasonable and wrong in accordance with s. 21(1)(b) and (d) of the Ombudsman Act.
To address the concerns that I have identified in my investigation, I am making the following recommendations:
Cambrian College
Recommendation 1
Cambrian College should reasonably compensate graduates of Cambrian’s Health Information Management program for the losses they have suffered as a result of program deficiencies.
Subsection 21(3)(g) Ombudsman Act
Recommendation 2
Cambrian College should report back to my Office at quarterly intervals on its progress towards providing relief to Cambrian’s Health Information Management program graduates, until such time as I am satisfied that appropriate redress has been provided.
Subsection 21(3)(g) Ombudsman Act
Ministry of Training, Colleges and Universities
Recommendation 3
The Ministry of Training, Colleges and Universities should implement adequate safeguards, including engaging in active monitoring, where appropriate, to ensure that colleges fulfill the representations made in program funding approval requests to deliver programming that meets identified economic and social needs.
Subsection 21(3)(g) Ombudsman Act
Recommendation 4
The Ministry of Training, Colleges and Universities should report back to my Office at quarterly intervals on its progress towards implementing Recommendation 3 until such time as I am satisfied that appropriate safeguards have been put in place.
Subsection 21(3)(g) Ombudsman Act
212 At the conclusion of my investigation, a preliminary report and recommendations were provided to both the College and the Ministry for their response.
213 On April 22, 2009, the Deputy Minister responded to my preliminary report and recommendations on behalf of the Ministry. Rather than address the specifics of Cambrian College’s creation and administration of the Health Information Management program, the Ministry focused on the broader issue of the accountability relationships in post-secondary education. The Ministry began by summarizing the history leading up to the government’s adoption of a modern accountability model, as reflected in the Ontario Colleges of Applied Arts and Technology Act, 2002. It explained that this model was further reinforced in the Report and Recommendations of the Post-secondary Review that was delivered to the Minister in February 2005, and which stated, regarding governance and accountability, that:
... enthusiasm for “greater accountability” should not become a synonym for more government control. Academic freedom is also an important value. So are self-government and institutional flexibility… the federal and provincial governments have a clear responsibility to ensure that their demand for review and accountability does not become too heavy-handed…
214 The Ministry expressed the belief that establishing the ideal balance of responsibilities between institutions such as the colleges and government is critical, and submitted that:
In Ontario, the balance is achieved by allowing the experts – the college faculty, administration and boards, who know their broader community, and who work with employers to understand their needs – to make decisions on the delivery of programs and to develop curriculum. At the same time, the appropriate role for government is to support program quality by establishing guidelines on governance and by requiring system, institutional and program quality measures.
215 The Ministry went on to describe the various quality assurance measures that currently exist in the system, referenced earlier in this report. It said:
Quality assurance mechanisms and accountability expectations are internationally recognized as the most effective means for government to ensure that higher education institutions are meeting their obligations to provide excellent and relevant programming.
216 It then reiterated information that had been provided during the investigation concerning its approach to certification and licensing. It noted that where legislation requires licensing or certification for a person to practice a profession or trade, it requires colleges to ensure that their program standards meet the standards required by the regulatory body. However, in the case of voluntary standards maintained by private associations, it noted:
In the majority of occupations, professions and trades, … there is no statutory regulatory body. One or more private associations may exist, which generally function as advocates for their members and sometimes develop voluntary standards of practice. In some cases, there is more than one member-driven association which purports to be the official voice of the occupation, profession or trade. These associations may lobby government or market their role so as to be seen as the “official” voice of the occupation, profession or trade and reinforce the credibility of the association to its members.
Government generally, however, limits the granting of legislative authority to private bodies in occupations and professions where it has identified that there is a public interest in having oversight over the standards of the profession or trade. Where no public interest has been identified, the Ministry has a responsibility to ensure that it does not give the appearance that the government endorses the standards imposed by private associations or implies that it supports membership in the association as a necessary condition of employment. This is even more so, taking into account that the Ontario government has recently affirmed its commitment to the labour mobility principles reflected in the federal/provincial Agreement on Internal Trade. This agreement imposes obligations on Ontario to reduce interprovincial barriers to the certification/licensing of workers moving from one jurisdiction to another in regulated professions and trades. In this context, it would be inconsistent for the Ministry to require colleges to obtain the certification of private associations for their new programs as a necessary condition of government funding.
217 The Ministry did not respond to the concerns I had identified regarding the fact that the College’s market research and its board of governors and program advisory approvals appeared to have been premised on the program becoming CHIMA-recognized. Nor did it comment on the fact that the College delayed seeking recognition, and ultimately failed in its recognition attempts because of inherent inadequacies in the program. Instead, the Ministry made some general remarks about program development and Cambrian College’s attempt to seek CHIMA recognition. The Ministry stated:
The Ministry has confidence that colleges and college professors who are knowledgeable in their fields, in collaboration with Program Advisory Committees, which include experienced practitioners, make informed choices about their reliance on information from member-driven advocacy groups when planning curriculum.
Recognition by the Canadian Health Information Management Association (CHIMA), as in the case of Cambrian’s Health Information Management program, is voluntary. It is evident that Cambrian College made several attempts to obtain voluntary recognition from CHIMA, as it stated it would do in its program-funding request. The Ministry supports the initiative of Cambrian College in identifying and seeking this voluntary recognition but, for the reasons set out above, does not consider that failure to obtain the voluntary recognition should be a basis for denying program funding. Indeed, at no time was CHIMA certification a condition for receiving funding approval from the Ministry.
218 Consistent with the tenor of its response, the Ministry did not believe that the complaints to my Office revealed any systemic problem that required the level of additional government intervention that I had recommended. (Recommendation 3) However, it said that in the interest of ensuring consistency in communications between colleges and their students with regard to the promotion of new programs, it would develop advertising and marketing guidelines that would clarify the responsibilities of colleges in the promotion of new programs, and it would report back to me at a future date with the details. (Recommendation 4)
219 The Ministry concluded by again generally referencing the accountability relationship that has been adopted in Ontario, noting:
The Ministry’s role in college accountability is deliberate and thoughtful and is based on modern research and practice. The Ministry is confident that quality assurance processes balance college autonomy, the interests of students and the public’s interest in ensuring colleges offer high quality relevant programs.
220 I was disappointed by the Ministry’s response, which was couched in generalities and dismissed and disregarded my findings that the circumstances surrounding Cambrian College’s administration of the Health Information Management program underscored a significant gap in the current oversight system for college program development. While the Ministry emphasized the various quality control measures that are in place around program development generally, clearly these measures were inadequate and failed to protect the students in Cambrian College’s Health Information Management program. After reviewing the Ministry’s response, I encouraged officials to take time to reconsider their views. Subsequently, on June 19, 2009, I received a further response from the Deputy Minister.
221 Unfortunately, in its second response, the Ministry once again placed considerable reliance on the “modern principles of accountability in the postsecondary sector”, noting:
In this modern accountability framework, the education experts are responsible for decisions about program development and delivery. Indeed, the issue in this complaint is directly related to the delivery of an educational program and is a matter between the College and these students relating to certification by a voluntary, not regulatory, association. These kinds of disputes about programming, while regrettable, arise from time to time in any educational institution.
222 The Ministry also again rejected the suggestion that there was any systemic problem requiring that it move to an accountability framework that would involve more direct government control over college programming, explaining that it had established a range of quality assurance expectations and accountability expectations for the colleges. The Ministry emphasized that the expertise in matters of program selection, quality, delivery and review rests primarily with the colleges, working closely with their broader communities.
223 The Ministry did, however, revise its undertaking to develop advertising and marketing guidelines for the promotion of college programs, strengthening its commitment by indicating that it was now prepared to issue a binding policy directive to all colleges under the Act. The Ministry advised that the issuance of a binding policy directive with respect to this matter would add a layer of accountability for colleges to help ensure accurate advertising and promotion of their programs.
224 I am encouraged by the Ministry’s implicit recognition that Cambrian College’s promotion of its Health Information Management program was problematic, and by its pledge to issue a directive that should help ensure that students are provided with transparent and accurate information about college programming in the future. It is regrettable, however, that the Ministry has not agreed to take any further steps to address the systemic concerns that I raised about quality assurance in program development and administration. While I recognize the principles underlying the government’s decision to provide increased autonomy to colleges of applied arts and technology, my investigation into Cambrian College’s administration of the Health Information Management program has shown that independence in the community college sector should be better balanced with effective safeguards. I continue to believe that in order to protect Ontario’s students, and at the same time, ensure value for money for Ontario’s taxpayers, greater Ministry oversight is necessary in this area.
225 Cambrian College provided a lengthy response to my preliminary report and recommendations through its counsel on April 21, 2009. At the outset, counsel reiterated the College’s concern regarding the lack of procedural fairness involved in my investigation, declared that my preliminary report bore “significant factual inaccuracies and omissions” and indicated that the College had “significant cause to be concerned” that I had “drawn unfounded conclusions” and that my recommendations were “based on an incomplete and misleading finding of facts.”
226 The College’s response discussed my preliminary report in considerable detail, much of it duplicative and quite defensive in tone. Some of the College’s comments have been incorporated into the body of my report. My Office also followed up with the College, seeking further clarification and support for a number of the statements contained in its response, and took steps to obtain additional evidence from other sources in an attempt to verify information provided by the College.
227 The College’s response summarizes the facts from its perspective. There is considerable overlap between the College’s recitation of the facts and the information as it appears in this report. The primary difference lies in the interpretation placed on events. Not surprisingly, the College takes a much more positive view of its own actions.
228 The College has a much more optimistic outlook on the prospects of graduates from the Health Information Management program. It denied that it failed to live up to its obligations to students and stated that it had offered a program where job opportunities existed, asserting that the “majority of graduates have found well-paying employment in this HIM field, including the vast majority of the student witnesses cited in this Report.”
229 The College noted that as of April 2009, 19 students had graduated from two classes in the Health Information Management Program. It referred to an April 2009 Graduate Survey Outcomes report prepared by CCI Research Inc., which covers 2007 graduates, and shows that of the eight 2007 graduates, five had found full-time employment related to their program and two had found unrelated part-time employment.
230 The College also advised that it had reason to believe that eight of the 11 individuals from the 2008 graduating class had obtained good jobs in their chosen field. When pressed for particulars of the employment of graduates, the College provided us with some charts on May 19, 2009. With respect to 2007 graduates, the chart indicates that six graduates are working in hospitals, three as clerks. Of the individuals working in hospitals, three are complainants to my Office; Matthew Barney, Julie Carriere and Diana Peltier. Two other complainants, Danielle Smith, who works with Health Canada and Nicole Solomon, who works as a sales clerk part-time, were also referenced.
231 Thirteen names appear on the chart prepared in connection with 2008 graduates, 11 of which appear to be those of 2008 graduates. Of the 2008 graduates, only two are employed in a hospital environment; Sara Wright, one of our complainants, is a records clerk, and the other individual is a clerk in an x-ray department. The chart references three other complainants to our Office: Jennifer Renaud, who works at Vale Inco; Kristine Landry, a temporary clerk for a credit union; and Christie Charette, who, after we interviewed her, returned on a contract basis to the Canada Revenue Agency, where she had worked before going to Cambrian. The remaining two 2008 graduates mentioned in the chart hold clerical positions – one as a clerk in a print shop and the other as an administrative assistant at a blood donor clinic. The chart contains reference to two other former students who appear to have graduated after the rest of the class of 2008 and obtained work where they had completed their program placements. One graduate was apparently working at a clinic and the other was working on contract at a local hospital. One of these individuals recently filed her own complaint with my Office about deficiencies in the College’s Health Information Management program.
232 More than half of the 2007 and 2008 graduates from the Health Information Management program have complained to my Office. It is true that some of them are working in positions that relate to their studies at Cambrian. However, of those graduates, some have had to undertake further study and upgrading to secure positions in health information management, and others are working in clerical positions that require no more than a high school education. Graduates also told us they had lost opportunities for coding positions in hospitals because of their inability to qualify to obtain CHIMA certification. Many who have been successful in finding employment attribute this to their own efforts, as opposed to their Cambrian training. Finally, some say they have little hope of finding positions related to their studies, while others remain unemployed.
233 Counsel on behalf of the College also pointed to the fact that the College’s Employer Satisfaction statistics are higher than the provincial average. While this might reflect on the quality of graduates of the College overall, given the time they were collected, the statistics would not appear to include information concerning 2007 or 2008 Health Information Management program graduates.
234 In addition, the College maintained that its Health Information Management program graduates obtained a quality education and suggested it is up to them to make the most of it. Counsel on behalf of the College observed:
Not every student that goes to college or university is guaranteed a job or a salary of his or her choice. In a world of lifelong learners, it is understood that one must continually upgrade his or her skills and knowledge. Teachers realize that to become principals, they must achieve further degrees and qualifications. Apprentices are on a cycle of learning, returning to college several times before completing the requirements that qualify them to write the certification exam. The graduates of Cambrian’s Health Information Management program received a quality education and as a result of that education, many students have gained employment. There are pathways available to them should they decide to upgrade their skills and knowledge to qualify for promotions into higher-level jobs.
235 The College asserted that 75% of the complainants to my Office as well as many other graduates are employed “in the field doing exactly what they were trained to do,” some even working in hospitals. It dismissed the evidence of these individuals concerning their struggles, and with respect to those who have been unsuccessful in finding secure employment, it said:
As in any program, there are students who are less successful in finding employment in their field immediately upon graduation. Sometimes it is difficult for students to move or to give up a lower-paying job in order to undertake a search for one in their field. This may be the case for graduates such as Nicole Solomon, who is currently not working in the field.
236 With respect to the evidence from CHIMA and hospital sector professionals, which indicated that there were concerns about the quality of Cambrian’s Health Information Management program, the College simply blew these off – remarking that it doubted their credibility since no one from any hospital addressed any concern with the College directly. It suggested that:
The College finds it surprising and unlikely that CHIMA would be notified and not the College if its placement hospitals truly had an issue.
237 Contrary to the College’s suggestion, it is my experience that professionals tend to be naturally hesitant to criticize the quality of others’ work directly. One of the reasons that my investigations are conducted in private is to encourage openness and candour. I have no reason to doubt the credibility of the professionals we spoke to, who were quite consistent in their criticism of Cambrian’s program.
238 Regarding the development of its Health Information Management program, the College explained: “Cambrian’s renewal process had identified that the College’s Records Information Management Program had run its course. The same process led the College to explore other potential areas of growth.” This was certainly a different take on events than we obtained from interviewing the Program Co-ordinator, whose evidence was that she was under the impression that she needed to create a new program to secure her continued employment. The College indicated that the Dean at the time would also have been involved in program development and that there was a team approach relying on others as well. It was suggested that the Dean had envisioned a program to be more in line with technology management than health management, and that he and the Program Co-ordinator had no specific knowledge of CHIMA when first discussing the program. However, as noted earlier, we were unable to verify this version of events, as the former Dean of the School of Computer Studies and Engineering Technology refused to co-operate with our investigation.
239 The College went on to suggest that it had come to realize, through feedback from employers, that there was a need for graduates with the ability to manage health information. It characterized the program development process as “rigorous,” and justified the creation of a broader health information management program through reference to the economic realities of the North. The College advised that it develops programs that provide graduates with a greater breadth of skill and knowledge so that they can meet the needs of a broader spectrum of employers. It explained that in developing its Health Information Management program, it consulted with northern hospitals, which it said tend to promote their own employees to coding positions after completing the online CHA program, as opposed to hiring outsiders or recent graduates for senior positions. It also said it heard from other health care practitioners that there was a need for workers skilled in health information management, but not necessarily CHIMA-certified graduates. The College also consulted with other colleges offering similar programs.
240 The College’s version of its history of program development differed from the information that we obtained through review of the documents it had produced and our interviews. Accordingly, we requested that the College provide us with the evidence it relied upon to support its submissions. The College responded through its counsel on May 19, 2009. The College indicated that one of the members of its Program Advisory Committee – who was from a local hospital – had mentioned that hospitals in the North tend to promote their own employees rather than hire recent graduates. We tried unsuccessfully to reach this person, who is currently on leave. However, we had previously received information from officials at her hospital indicating that they actually planned to hire a recent external graduate from a CHIMA-recognized health information management program. The College’s evidence also reinforces the fact that hospitals, even in the North, require CHIMA certification for those working in health information management positions. The College also disclosed, for the first time, meeting minutes from a round table discussion held on October 14, 2004, which included a number of officials from northern hospitals. It suggested that these minutes supported its position that its market research indicated a need for a more general program, not necessarily a CHIMA-recognized one. Contrary to the College’s assertion that CHIMA recognition was not integral to the program, the minutes actually state that the curriculum would meet “the standards for accreditation to allow students to become certified Health Information Practitioners.” In fact, one of the follow-ups specifically listed in the Minutes was an application to CHIMA. There are a few comments in the discussion section about creating a broader program, including:
-
Create a generalist as opposed to a specialist
-
Need some generalizing in the North so individuals can also work in doctor’s offices, etc.
241 There was also a reference to the fact that the program could “set a bar” for other hospital areas, which only required staff to have a Grade 12 education. However, an overwhelming number of the recorded comments focus on the coding and abstracting component required for health information management professionals, including suggestions that the curriculum required more coding and abstracting instruction to meet certification requirements. The minutes also include information from CHIMA, emphasizing opportunities for certified health information management professionals.
242 The College also claimed that the fact that placements in hospital settings continue to be offered to Cambrian students indicated that hospital officials must believe that it is a valuable program. While students may find placements in hospitals, officials from a health records department of a local hospital were quite emphatic when they told us they would no longer accept the College’s Health Information Management program students because of concerns about the inadequacies of the program. There are other clerical positions in hospitals that may relate to record-keeping which do not involve the field of health information management. These are the positions that graduates and hospital officials have confirmed tend to require a Grade 12 diploma.
243 Finally, the College submitted information prepared years after the program was introduced. It referred to minutes from a November 1, 2007 Program Advisory Committee meeting, in which the Program Co-ordinator is quoted as stating that there is a high demand within the federal government for information management for those students who do not necessarily want to become coders. This comment came two years after the program had commenced. It was apparently in relation to Danielle Smith’s success in obtaining a placement with the federal government, in a position that did not directly involve health information management. Ms. Smith, who is currently employed with Health Canada, advised our Office that her Cambrian training had no bearing on her current position, working with corporate records.
244 The College also provided four job postings for positions that do not appear to require CHIMA certification, although one from Southern Ontario indicated that certification was preferred. Two other postings are for positions in Saskatchewan and Alberta. The last posting requires a degree in health service management, health information management or a related field, as well as five years related experience in health care or a related field. The Program Co-ordinator has confirmed that these postings were gathered during the research and development stage of Cambrian’s Health Information Management program. In addition, the College submitted a recently prepared document that purported to identify job opportunities for non-certified graduates. It is difficult to see how this information assists the College’s position, since it refers mainly to information provided by CHIMA concerning opportunities for certified health information management professionals.
245 In support of its decision to provide a program in the absence of CHIMA recognition, the College referred to other “health information management” programs offered by George Brown, Conestoga, Centennial and Seneca Colleges, suggesting none of these programs were recognized by CHIMA. We obtained further information about these courses, none of which bear the title Health Information Management, and learned that these non-CHIMA-recognized programs are actually in the field of informatics. Informatics is considered a separate area of study by CHIMA, which is not subject to recognition or certification through CHIMA. One of these programs is actually a post-graduate co-op program for individuals coming out of a computer technology program.
246 The College emphasized that it was never told by CHIMA that it should pursue certification before admitting students. It also pointed to two colleges that had admitted students to their health information management programs before they were recognized by CHIMA. However, our research confirmed that both of these schools had begun the process for applying for CHIMA recognition six months prior to admitting students and the application process had been well underway at the time their programs started. These colleges had already received responses from CHIMA and only required a few items to satisfy CHIMA requirements. In addition, both programs had full-time CHIMA-certified program co-ordinators.
247 With regard to promotion of the Health Information Management program, the College denied that it had ever indicated that the program was certified by CHIMA. It maintained that its marketing had accurately said the program was based on CHIMA requirements. As noted earlier, even CHIMA found this reference misleading, and asked in July 2007 that the College remove it, as it suggested an affiliation with the certifying body that did not exist. CHIMA told the College that the reference was made without permission and was inaccurate. In fact, the College did not remove the reference from its website until our Office began to make inquiries as to why it was still there. It was finally removed in August 2008.
248 The College continued to maintain that its Health Information Management program was never developed to solely meet CHIMA recognition requirements, and that it only applied for recognition as an “added value” to students. It emphasized that CHIMA recognition is voluntary, and that it had made two attempts to obtain it.
249 In the College’s revisionist version of the application process, it claimed that it was unsuccessful with respect to its first application, made in March 2007, because it was judged against CHIMA’s new learning outcomes, while the program had been designed based on George Brown College’s curriculum, which had been approved based on an earlier set of standards. The College stated that it wasn’t until late 2006 that it became aware that the certification standards had been revised. However, based on the documentary record we obtained directly from CHIMA, the College was aware of the revisions to the matrix of learning outcomes by at least September 2006, months before it made its first submission. CHIMA officials have advised that learning outcomes are regularly updated, and that these revisions do not represent a significant overhaul of requirements. During our investigation, program co-ordinators from two Ontario colleges offering health information management programs confirmed that they had no issues with adjusting programs to reflect CHIMA’s 2006 changes in learning outcomes.
250 In its response, the College stated that it had successfully hired a part-time program co-ordinator who was CHIMA-certified. It described this as “a considerable accomplishment given the small number of CHIMA-certified people available in the North.” It stated that unfortunately, the position’s effectiveness was hampered by the demands of the program, the limitations imposed by a part-time position and the demands of the person’s full-time work. The College was dismissive of CHIMA’s offer of assistance in hiring a program co-ordinator. It asserted that CHIMA’s offer to help in the hiring process was limited to offering to post an advertisement on its website. It stated that this occurred after the College’s plan for developing the existing full-time Co-ordinator towards certification through CHA online courses had become frustrated. During our investigation, College officials admitted that they never actively posted or searched for a certified full-time program co-ordinator and that the part-time co-ordinator they hired never actually took on the role once she learned the true scope of the duties she was to assume. As to the College’s plan to have the original Program Co-ordinator upgrade her skills, it failed primarily because she was given no time off in which to pursue this goal.
251 With respect to the College’s second application for CHIMA recognition, it suggested that it was unsuccessful largely because it did not have a full-time CHIMA-certified co-ordinator on staff “and because there were shortfalls in some parts of our curricula when compared to CHIMA standards.” It maintained that it had recognized that there might be curriculum gaps since the program was not developed solely to achieve CHIMA certification. Again, it suggested that its failure could also be attributed to the program using a model that pre-dated changes to CHIMA standards in 2006. The College also focused blame on CHIMA’s failure to provide it with a detailed report on its first submission. Finally, the College asserted that it had not continued to pursue CHIMA recognition because it was awaiting the outcome of complaints to my Office. As noted earlier in this report, CHIMA advised us that it had not completed an extensive review of the first application since it was deficient in so many respects. However, CHIMA advised College officials shortly after sending its July 2007 response that it wished to meet to discuss the application and offered dates later in July and in August 2007. The College’s Program Co-ordinator did not respond until August 22, 2007, apparently because she was away for most of the summer. On September 24, 2007, CHIMA and College officials took part in a telephone conference to discuss the first application. Another teleconference was held on November 20, 2007. Given CHIMA’s contact with the College and the information it had been providing since the summer of 2005 regarding recognition requirements, the College should not have been surprised by what was needed to ensure a successful application. Without a suitably trained health information management professional assisting in preparing the curriculum, the College’s failure to obtain recognition was virtually inevitable. As noted earlier in this report, its second application was also fraught with deficiencies. Finally, at no time has my Office ever indicated to the College that it should hold off on attempting to obtain CHIMA recognition for its Health Information Management program. I find the College’s attempt to attribute its current inertia to my investigation an abandonment of its own responsibility towards current and future students of the program.
252 The College stated that students in the Health Information Management program did not seem to be aware of the CHIMA recognition issue until the College informed them about it. It suggested that students selected the program solely based on the opportunities and curriculum shared in College materials. It claimed that it communicated with students throughout its recognition attempts, but continued to emphasize to the students that it could not guarantee recognition, and that, whether certified or not, they would continue to be eligible for the jobs in their field upon graduation. We heard a very different story from students, who claimed that they were enticed into the program by the prospect of high demand jobs in the hospital sector, often as a result of discussions with the Program Co-ordinator. The students we interviewed claimed that they were repeatedly assured that CHIMA recognition was in the offing. This is supported by a July 30, 2007 email from the Program Co-ordinator to one student, in which she assured, “I am positive by October that we will be accredited.” Graduates also consistently stated that while they learned about the significance of CHIMA in their studies, they first found out that the program was not CHIMA-recognized from other students, not College officials. They also complained about the limited communication from College officials regarding its recognition applications.
253 The College explained that several students became adamant that certification was their goal and engaged various officers of the College, claiming the College had misled them. It noted that officials met with students upon request despite the “inappropriate behaviours some students exhibited in this regard.” The College indicated that when it learned that its second application for recognition had failed, it “developed a pathway for those students who wanted to pursue the certification option in the immediate future.” Students can enter the final year of the online CHA program or attend Sir Sandford Fleming College’s CHIMA recognized program. The College reported that 12 students had taken up its offer and enrolled in the CHA program, and that three were performing above average, three within the average range, and that three had dropped out. It stated that one individual had dropped out shortly after enrolling because she had determined that coding was not for her, and that none of the students had failed the program. The College suggested that there was nothing unusual about the distribution of academic success in this course.
254 As noted earlier in this report, two of Cambrian’s graduates had already enrolled in the CHA course on their own before the College had made its offer of future reimbursement of the course upon successful completion. Some graduates simply could not afford to pay the necessary fees upfront on their own. Two individuals told us that they initially attempted the course but had found it too difficult. All of the former students we interviewed believed that they should not have had to invest further time and money in obtaining upgrading to qualify to write the CHIMA certification examinations after two years in the College’s Health Information Management program. As for the option of attending the Sir Sandford Fleming course, this is not much of an option, as Sir Sandford Fleming does not provide Cambrian Health Information Management graduates with any advance standing in its program. Essentially, to pursue this course, students must go back to square one.
255 As for its current students, the College indicated that it “continues to ensure that they fully understand the opportunities the program offers and the fact that the program is not certified with CHIMA.” In July 2008, the Dean wrote to students about to begin the program and explained that it was not recognized by CHIMA, and the reference to opportunities being available in the hospital sector has been removed from some of its promotional material. All of which suggests that, while it strongly denies it, at some level the College recognizes that its previous representations were misleading.
256 The College seeks to turn the tables and suggest that my Office is the one that is doing students of the Health Information Management program a disservice. It commented that current students were less interested in the program’s recognition status and referred to a media article noting that some students who had recently signed a petition regarding the program’s status no longer wished to push for CHIMA recognition. It explained:
Their concern about negative publicity, ultimately generated by a few disenchanted individuals, having an impact on their job prospects cannot be lightly discounted. Certainly, the College has been sensitive about trying to avoid such consequences. The Ombudsman’s Preliminary Report appears to miss this point entirely.
257 While I am sensitive to the fact that there are students currently enrolled in the Health Information Management program and other graduates who have not complained to my Office, I am also aware that more than half of the 2007 and 2008 graduates from the College’s Health Information Program have complained to my Office about the College’s conduct. That is a significant number, which I cannot ignore. In any event, my investigation has confirmed that there are critical flaws in the College’s administration of the Health Information Management program. It would be inconsistent with the mandate of my Office, and indeed the public interest, if I were to attempt to gloss over what I believe are legitimate, serious and well-founded concerns. It is unfortunate if some students might be negatively affected by the airing of the truth, but it is ultimately the College that must bear responsibility for its own failures in administering the Health Information Management program, not my Office for bringing them to light.
258 The College attempted to bolster its case by referring to a recent Program Quality Assurance Process Audit in which it received exemplary recognition of its quality assurance processes for new program development, curriculum development and ongoing quality management. It also referred to a recent survey finding a high degree of employer satisfaction with Cambrian graduates and a 2008 graduate satisfaction rate that was the highest in the province. However, it is unclear how any of this information assists the College, or is at all relevant to my investigation, which did not focus on the College’s programming generally, but on its administration of the Health Information Management program.
259 The College also supplied written testimonials from two recent Cambrian Health Information Management Program graduates. One stated that she enjoyed the program “while knowing that it was not recognized by the accredited organization.” She indicated that she had found employment after her eight weeks of placement and that the two-year program had “enhanced” her knowledge and skills, preparing her for a career in health information management. She went on to say:
In the absence of accreditation, the program still prepares one effeciently (sic) and effectively in the methodology of health information and how to utilize it. The courses attain their goals and outcomes as intended by the course outlines and the criculum (sic) provides sufficient background knowledge to develop ones skills to be able to be successful in the work force.
260 The other student indicated that she knew that the program was not recognized, but that she obtained a job in her field right after her placement and was enjoying it.
261 Given the information we had obtained from Cambrian students throughout the course of our investigation, my investigators were somewhat skeptical of these testimonials, which seemed to appear at the last minute in support of the College’s response to my preliminary report. We asked the College to provide us with information concerning the context in which they were supplied. Not surprisingly, we learned that a fair amount of coaching was involved. We obtained an April 14, 2009 email from the Program Co-ordinator to one of the students, in which she noted:
I have a favour to ask you. My Dean has asked me to ask past students from the HIMP program to send a quote from your academic experience in the program. Hopefully, it will be a positive quote. You can quote something like:
I enjoyed the HIMP program, while knowing that it was not recognized by the accredited organization. I found employment after my 8 weeks of placement ….etc.
262 The Program Co-ordinator advised us that in response to the Dean’s request, she had contacted six graduates to provide testimonials. Only three individuals had responded. Two provided testimonials, while the third, a complainant to our Office, had apparently indicated that she did not wish to comment. Aside from the fact that little weight can be placed on the testimonials, which were clearly solicited and virtually dictated by the Program Co-ordinator, when my investigators spoke to one of these individuals, a very different story emerged. This graduate explained that the Program Co-ordinator had called to request that she write a testimonial email. She had asked her to say that she knew the program was “unaccredited,” but that she liked it anyway. The student agreed to provide the testimonial. When we interviewed her, she told us that the program was a good experience aside from the “disaster” resulting from the program’s failure to be CHIMA recognized. Like other students we interviewed, she explained that during the program students were told they were being trained to be coders, not medical secretaries. She said students were advised that the school was working on the recognition issue and that it should be resolved before graduation. When she learned of the failure of the second application, she was upset, as she would have preferred to have had more options, but her personal plans had been to get into the medical secretarial field – so she was not as affected as those who had pinned their hopes on being coders. Once she graduated, however, she was disappointed when she was only able to obtain employment making $12 an hour at a walk-in clinic. She is a mature student with two children and cannot afford to upgrade her skills through taking up the College’s offer to refund CHA course fees. By the end of the interview, she had made a complaint to our Office about the manner in which the College treated the issue of CHIMA recognition.
263 We were unable to verify the circumstances relating to the other student’s providing a testimonial, despite numerous attempts to reach her.
264 The College was very critical of my reference to other health information management programs available in Ontario. It suggested that this “comparative analysis” was outside of my authority, and lacked “any of the elements of a true comparative analysis,” as it did not consider course offerings, student evaluations, success rates of students or the usual indicators undertaken in such a study. The College indignantly asked “that the Ombudsman leave to those who have the mandate and expertise the task of comparing college program curricula and quality control.”
265 As to the College’s disparaging comments concerning my reference to other college offerings in Ontario, it is a standard investigative practice to conduct comparative research to identify similarities and contrasts, which may assist in factual analysis. The complaints we received about Cambrian’s Health Information Management program focused on the fact that the program was not CHIMA-recognized, resulting in students being denied the option of writing the qualifying examination for entry into the health information management profession. Accordingly, it was important for us to research other health information management courses being offered by colleges in the province to determine whether they were CHIMA-recognized, and if so, what options were available to their graduates that were denied to students completing Cambrian’s program. There are likely many factors that influence students’ choice of programs. But in health information management, the potential of writing the CHIMA certification examination is clearly significant, and as we discovered, Cambrian’s Health Information Management program is the only program offered in that field in Ontario that is not recognized by CHIMA. Cambrian graduates who desire CHIMA certification must invest additional time and money to upgrade their skills in order to qualify to write the CHIMA examination, in contrast to their contemporaries at other such programs in Ontario.
266 The College also suggested that we review the January 2009 Program Quality Assurance Process Audit of the College, undertaken by the Ontario College Quality Assurance Service, which was recently made available online. After reviewing this information, I can only conclude that the College wished me to consider it as general evidence of “good character” to offset my specific investigative findings concerning the poor quality of its Health Information Management program. The Program Quality Assurance Process Audit indicates that, overall, Cambrian met four of the audit criteria and partially met a fifth. The audit team issued three commendations and applauded the honesty and candour of the self-study team at the College. The audit team was impressed “by the enthusiasm, pride and sense of collegiality that the employees expressed about their College” and noted “the students who were interviewed expressed satisfaction with their programs of study and the perceived quality of teaching, services, and future prospects … they indicated that they would recommend Cambrian College to friends and relatives.” Overall, the audit team assessed the College’s quality assurance and improvement processes and policies as fitting the “organized effort” category – indicating that quality initiatives are being planned and tracked, work methods are systematically rooted in the quality criteria, and the College has begun to develop performance metrics and norms. Unfortunately, none of these findings by the audit team apply directly to the College’s administration of the Health Information Management Program, and are not of any particular relevance to my investigation.
267 The College also submitted a number of student evaluations of some of the teachers in its Health Information Management program. Again, while some of these appear to be positive, they do not counterbalance the weight of evidence we have obtained regarding the quality of the program and student prospects as a result of attending it.
268 In its response, the College was extremely critical of my investigation in a number of respects. One of the purposes served by providing an organization with a copy of a preliminary report is to give it an opportunity to correct any factual errors and respond to the evidence obtained during our investigation. Counsel on behalf of the College pointed to a number of alleged errors and suggested that they undermined the credibility of my report. For instance, she claimed that my report stated that the Health Information Management program required “certification,” and that the College had held out that the program was to be “certified.” I have always acknowledged that recognition by CHIMA is voluntary and is not a legislated requirement. Nowhere in this report do I state otherwise. As to the promises of CHIMA recognition, my report sets out the evidence of witnesses in this regard. The College also notes that although I expressed concerns about the Health Information Management program, I did not recommend that it be suspended or discontinued. It is difficult to see how it would have assisted the College for me to have done so – as Ombudsman, it is not my role to usurp the authority of the College with respect to program development and administration. I have identified concerns with the College’s conduct, but it is up to the College to exercise its statutory authority and independent judgment to remedy the situation.
269 Rather than accepting that its conduct was in any way problematic, the College chose to follow the low road, attacking the integrity of my investigation. In summing up, it had this to say:
Were this investigation carried out in a truly fair, impartial and thorough manner, the College respectfully submits that it would find facts that do not lead to the conclusions and recommendations found in the Ombudsman’s Preliminary Report. Instead, an impartial evaluation of the evidence, even as found in the Ombudsman’s Report, should have led to the following:
a. Cambrian College acted properly at all times with regard to Health Information Management program.
b. Cambrian College acted responsibly in developing this program.
c. The program reflects the needs of most employers for most positions especially as reflected in the North.
d. Most graduates of the subject program have obtained good jobs in their field of study.
e. The College never misled its prospective students, current students, graduate employers, the Ministry or anyone else regarding the certification status or intentions regarding certification for the Health Information Management program.
f. There is no cause for making any recommendation with regard to the complaint. The complaint should be dismissed against the College and the Ministry.
270 The College also expressed the belief that my investigative approach would cause “significant harm to past, present and potentially future students of Cambrian’s Health Information Management program in their ability to progress in their careers.” It suggested that my report would substantially harm the employment prospects of Cambrian graduates by unfairly portraying the program’s high quality as “worthless.” It warned that the strength of the diploma would “indeed be greatly eroded upon release of this report.” It has also charged that my Office had failed to fully flesh out the facts, leading to inaccurate conclusions.
271 The College’s palpable derision of my investigative process, and indeed for the oversight of my Office generally, was evident throughout my investigation and was again mirrored by its visceral response to my preliminary report. The College, through its counsel, was dedicated and pugnacious in its efforts to infuse my investigation with the adversarial trappings of a judicial inquiry. It persisted in holding my legitimate investigative practices, founded in long-standing Ombudsman traditions, in contempt.
272 Instead of engaging in objective self-analysis and introspection and seeking to learn from its apparent mistakes, the College went on the offensive at every turn – challenging the integrity of my process while stridently defending its own conduct at all costs. In doing so, the College projected the same arrogance and profound lack of insight which was evident in its dealings with the students of its Health Information Management program.
273 Rather than acknowledging any responsibility for failures in the administration of the program, the College resorted to the tactic of trying to deflect blame towards my Office for the potential employment difficulties of its graduates. It offhandedly ignored the evidence of the majority of the 2007 and 2008 graduates, who characterized their own education as “worthless,” and summarily rejected and disparaged the observations of disinterested professionals who were critical of the quality of the program.
274 The end result is that there is a cavernous gap between my assessments of the evidence in this case and the College’s conclusions, which have led it to discard, wholesale, my findings, analysis, opinions and recommendations.
275 Cambrian College has been entrusted with responsibility for administering multiple millions of taxpayers’ dollars each year in the interests of the community that it serves. If Cambrian truly deserved credit as a “mature” institution, it would readily acknowledge its failings and make amends for the errors of the past before investing further in the future. Faced with the findings of my investigation, the College should be directing its energy at establishing its integrity and earning public confidence, by fulfilling its moral obligation to the graduates of the Health Information Management program.
276 Regrettably, the superior “too cool for school” attitude evidenced by the College is a discredit to its statutory objectives. I believe that the facts in this instance speak for themselves. Ultimately, the College will be judged in the court of public opinion by the community it was established to serve.
_____________________
André Marin
Ombudsman of Ontario
Final Response Letters from Ministry and Cambrian College (PDF)
[1] Ontario, Legislative Assembly, Official Report of Debates (Hansard), (04 December 2001) at 1400 (Hon. Dianne Cunningham).
[2] It would appear from the minutes that this is the name of the committee that approved the program. Once the program was established, it appears that the committee name changed to the Health Information Management Program Advisory Committee.
[3] In an April 21, 2009 response to my Preliminary Report, counsel on behalf of the College made much of the fact that my preliminary report had referred to CHIMA “accreditation”. She suggested that it was “difficult to rely on a report that misstates one of the most elemental aspects of the investigation.” College officials and students orally and in writing repeatedly referred to CHIMA “accreditation”, “recognition,” and sometimes to “certification,” interchangeably. We clarified with CHIMA officials that it does not “accredit” health information management programs, but that it will “recognize” college and university programs that teach the Health Information Management curriculum. Students who pass the CHIMA examination are referred to as being “certified.” Accordingly, in this final report we have changed the terminology to reflect CHIMA’s lexicon, except when specifically quoting from documents or the remarks of College officials or other witnesses.
[4] The College sought to dispute this. Counsel on behalf of the College suggested that CHIMA had been aware for some time that the program was operational. She referred us to an email from the Program Co-ordinator to CHIMA on February 26, 2007, in which the Program Co-ordinator stated, “you may remember, we first started the HIMP (Health Information Management Program) in 2005.” However, there is no contemporaneous documentary evidence suggesting this was the case, and CHIMA officials maintained that they only learned that Cambrian’s program was functioning in the summer of 2006.
[5] The College recently advised that Ms. Xavier is now employed at a medical clinic, but we were unable to verify this information.
[6] Online: This link opens in a new tabCambrian College of Applied Arts and Technology (date accessed: 04 August 2009).
[7] Online: This link opens in a new tabCambrian College of Applied Arts and Technology (date accessed: 04 August 2009).
[8] [2007] O.J. No. 2211 (Ont. Sup. Ct.), [2008] ONCA 699.