In the decade between 1974 and 1984, union certifications for service workers in the B.C. long term care industry increased from twenty-one to one hundred and fourteen. From 1976 to 1984 wages increased as much as two hundred percent in some facilities while the cost of living, went up by ninety percent. These substantial changes were due largely to the efforts of the Hospital Employees' Union (HEU). The HEU wanted to expand into long term care and attain for its long term care members the rates found in its acute care Master Agreement. This thesis analyzes the development of the HEU as the principal union representing service workers in long term care and the extent to which the Union was successful in achieving its goals. Previous to 1973 long term care unions had difficulty achieving first collective agreements due to employer intransigence. Invoking Section 73 of the provincial Labour Code, they could circumvent this problem through arbitrated settlements, thus removing one of the major impediments to union growth. The growth of non-profit facilities after 1978, brought about by public funding of the industry, acted as a catalyst to union growth. In non-profit facilities employer resistance to organizing was less than in proprietary facilities and bed capacities were generally larger, making organizing less costly for unions. In 1984 the HEU held more than two-thirds of all certifications in long term care. The Union was more willing to make use of Section 73 than the other long term care unions. It also had financial and organizational resources that contributed to its organizing success in the industry. There are two employers' associations in long term care, the Health Labour Relations Association (HLRA) and the Continuing Care Employee Relations Association (CCERA). CCERA will likely emerge as the dominant employers' association in the industry. CCERA's forerunner, the labour relations function of the Long Term Care Association, was set up by non-profit long term care employers with the help of the provincial government to provide an alternative to HLRA as HLRA mainly represents acute care employers. However, through arbitration the HEU has been able to establish its Master Agreement as the appropriate rate of remuneration for long term care employees. The greater consolidation of bargaining structure that has occurred and the creation of a separate long term care employers' association does not appear to have prevented this outcome. Through arbitrated and negotiated settlements, the HEU has achieved Master Agreement rates, or at least 95% of Master Agreement rates, in all of its long term care facilities except for those without first collective agreements, or those that achieved first collective agreements after the Compensation Stabilization Program was implemented. Arbitrators agreed with the HEU's position that its long term care members were entitled to the same rates of pay as its members in general hospitals, as the work performed was comparable. However, until the industry became publicly funded in 1978, they felt obliged to consider the employer's ability to pay an increase. From 1978 on arbitration awards more closely reflected Master Agreement rates. However, it was not until government officials publicly stated that the costs of arbitrated settlements would be covered by the Ministry of Health that arbitrators consistently began to award Master Agreement rates. The Compensation Stabilization Act, passed in 1982, has had the effect of preventing the attainment of Master Agreement rates in all HEU facilities. Although arbitrators have continued to award the Master Agreement, the Commissioner has rejected many of the resulting "compensation plans" stating that the proposed increases fall outside the Program's Guidelines. In April 1985 long term care workers represented approximately thirteen percent of the HEU's total membership. Expansion into this industry has increased significantly the Union's size. It is unlikely, however, that the HEU has yet benefited financially from this growth. Since there are five other unions in the industry, the HEU is unlikely to ever be the sole representative of long term care service workers. However, the HEU holds seventy-seven certifications in the industry while the union with the next largest membership holds only twelve certifications. The health care union clearly has come to dominate long term care. / Business, Sauder School of / Graduate

The purpose of this study is to provide a critical examination of the concept of hospital governance in a community hospital in British Columbia. The format of the thesis is to model the development of the Canadian health system in an extensive case analysis. The case analysis approach permits the expounding of theoretical concepts of hospital trustee roles and functions. Through the application of qualitative research, the fundamental issue addressed was the involvement of the Lions Gate Hospital trustees with policy issues during a ten year period of analysis from January 1969 through December 1978. The hypothesis was that the hospital trustees were not substantially involved in policy making but were primarily concerned with operational management issues and this suggested that the role of the trustee did not evolve in concert with the change in the Canadian health system under national health insurance. The hypothesis was tested through application of the research methods of content analysis and grounded theory in a review of the minutes of the Board of Management and the annual reports. In tracing the evolution of the Canadian health insurance program, it was shown that the enactment of the hospital insurance components which preceded medical care insurance produced an emphasis on hospital care and diagnostic services rather than ambulant care. Cost sharing provisions initially for capital funding and later for operational costs encouraged and stimulated the demand for hospital facilities across Canada. With the advent of these third party Insurance schemes, the role of the hospital trustee should have changed from one of fundraiser to one of policy maker; however, the trustees at Lions Gate Hospital were found to be predominantly concerned with operational management issues rather than policy issues. National health insurance established the legitimacy of hospital trustees as policy makers and the professionalization of hospital administration established the feasibility of the Chief Executive Officers being held accountable for operational management. The missing link is support from the provincial government of British Columbia and the lack of definitive legislation and requirements embodied in the Hospital Act (RS Chapter 176; 1979). The current legislation inhibits policy making and long range planning and reinforces the conception of a hospital board as an administrative body. The lack of policy development initiatives by the Lions Gate Hospital trustees resulted from the restrictive mandate of the Hospital Act, the inadequate funding system for hospitals, the process of trustee selection, the education process for hospital trustees, the role of the Chief Executive Officer and the interaction with the organized medical staff. Weak and ineffective boundary spanning roles allowed the hospital trustees to function as an administrative board rather than a policy making board. The outcome of the analysis of the governance process at Lions Gate Hospital was an unfulfilled expectation that the hospital trustees would perform three basic functions - mandate, maintain and monitor. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

In 1960, the Home for the Aged, an institution of the Province of British Columbia, underwent an official name change to Valleyview Hospital. The change in name indicated a change in the philosophy toward the treatment of the aged mentally ill person. This change can be equated with new knowledge about the physical, psychological and social aspects of aging. Formerly the program and the goal were related to custodial care; now, the program and the goal are related to treatment which will result in the aged mentally ill patient returning to a living arrangement in the community that is most appropriate to his needs. This study, cites the problems of aged people in this province, with particular reference to problems of mental illness. The process of admission to hospital, treatment programs and discharge procedures, particularly as they relate to the work of the Social Service Department, are described. Against this background of procedures, the particular criteria for discharge and rehabilitation planning, as related to the hospital and to the resources available in the community are examined. Particular patient groups are noted in relationship to the particular resource required to receive them back into community. The study reveals that, although, using hospital criteria for discharge, a large number of patients could be appropriately rehabilitated, but sufficient community resources, including family care, boarding and nursing homes, are lacking for such patients. Furthermore, community attitudes towards the aged mentally ill person have not changed to meet the new philosophy about their treatment in Valleyview Hospital. Since correspondence revealed that Valleyview Hospital is unique amongst mental hospitals for the aged on this continent, the study was of necessity a pilot one, and is primarily descriptive. However, the questionnaire method was used to gather data about existing living accommodation available to discharged patients. Finally, the study offers some suggestions for improvement and expansion of community resources, and of legislation concerning them which, if carried out, would ensure, to a greater extent, that the philosophy of treatment and rehabilitation, rather than custodial care, could be translated into practice. / Arts, Faculty of / Social Work, School of / Moorhouse, Clayton Herbert Todd; Starak, Igor / Graduate

Plant location as a centralized planning objective in which some agency has control over most of the system elements can be reduced, in many circumstances, to the problem of finding the medians of a weighted graph. This concept is feasible if it can be assumed that each location sought is constrained to a subset of p nodes on an n node network. This combinatorial programming problem can be formally stated as follows: if G is a weighted graph, [formula omitted] the weighted distance of node [symbol omitted] to node [symbol omitted], and Xp is any set of p nodes on G (x₁, x₂, •••,Xp), then the required set of p nodes Xp∗ on G is the p median of the graph if it satisfies the expression [formula omitted]. Although this objective can be explicitly optimized by branch bound algorithms, those developed to date can become computationally infeasible for some large scale problems. A fast method for estimating the medians of a weighted graph is given which will provide optimal or near optimal solutions on any type of network. The heuristic procedures adopted in this study can be generalized in terms of three basic steps; 1) partition the graph to obtain an initial feasible solution, 2) re-iterate over; step 1 to achieve a local minimum, and 3) perturb this convergence to test for a lower bound. The design of steps 1 and 3 are crucial to the success of the algorithmic method. Two procedures are given for the basic partitioning of the graph, one of which is a modification of a criterion originally developed by Singer (1968) . The other method introduces a node elimination recursion which appears, experimentally, to be the more efficient procedure for certain types of weighted networks. Efficient perturbation methods are developed for testing the lower bounds obtained. The basic model structure is modified by the introduction of heuristics for the constrained plant location problem under a wide variety of restrictions. Numerical procedures are suggested for restricting the search to a subset of m potential plant sites among all n nodes on the network. Heuristics are developed for forcing certain locations into solution, for placing upper bound constraints on plant sizes, and for restricting the maximum link distance over which a particular allocation might be made. Attention is given to the problem of estimating the joint minimization of plant and transportation cost functions over a network surface. For dynamic location-allocation systems an explicit dynamic programming formulation is developed for the optimal sequencing of plant locations over time subject, if necessary, to periodic variations in all cost functions and node weights. An application of the basic median algorithm to the problem of rural hospital locations in Southeast British Columbia is demonstrated, and computer codes are listed for all the specified models. / Arts, Faculty of / Geography, Department of / Graduate

The rapid and accelerating growth of hospital Emergency Department utilization over the past twenty years has transformed a once well-defined and well bounded care setting into a highly complex and integral component of a total health care system. This increasing role complexity has created a demand by hospital decision-makers for an information system to describe, measure and evaluate Emergency Department activity within the context of broader health care issues and activities. This study is an attempt to identify and integrate the information needs of the hospital decision-makers into a meaningful whole. The evolution of emergency care in British Columbia is described in order that needs for information will not be developed in isolation from the activities of major planning, funding and professional groups in the health services. Two major issues are identified in the literature - the utilization of Emergency Departments and thrusts towards classification or categorization of Emergency Department capabilities. From this, three major policy/planning foci are selected - day to day emergency care, disaster planning, and the "mopping-up" role of Emergency Departments. Ideas about these are developed in light of six classifications of information users' needs - patient care, management, quality of care, strategic planning, research and development and policy-formulation. "Needs" were validated by two panels of major decision-makers from a representative sample of Greater Vancouver Regional Hospital District Hospitals. The results of the investigation are analyzed in light of the issues of professional power and control and political influences and recommendations made as to the appropriate components of a hospital emergency department information system. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The quality of health and hospital care is usually measured by one of three basic approaches. Structure measures assess the inputs used or available for use in the treatment of patients. Assessments of process look at "how" patients were treated. Outcomes measures are concerned with the end-results of care. Outcomes have considerable intuitive appeal to consumers and it is assumed in this thesis that quality is defined in terms of outcomes; providers (e.g. physicians) however may have preferences for hospital structure for its own sake. Structure and process measures are generally regarded as proxies for outcomes measures. They are used because they are easier to measure than outcomes, but the relations between the proxies and outcomes have not been completely tested. This thesis is concerned with the empirical verification of the relationship between two types of measures, structure and outcomes of hospital care at the aggregate level, and a possible link between provider preferences for structure and observed "excess" structure. The outcomes measures are based on adjusted hospital death rates. The adjustment factors draw on detailed diagnostic and demographic information available in the British Columbia hospital reporting system. Several possible adjustment factors (proxies for severity) are considered. The structure measures include measures of inputs per case, and measures of the facilities and services offered by a hospital. The discussion centres on three hypotheses. The first two concern the empirical relation between structure and outcomes. The first hypothesis that the two types of assessment are equivalent was tested using correlation analysis of alternative outcomes measures and structure measures. The results indicate that structure cannot be substituted for outcomes measures in the evaluation of quality. The second hypothesis is that there is ineffective or "excess" structure. This is demonstrated if the impact of incremental structure on outcomes is not positive. The results generally support the existence of excess structure. Extensive regression analysis and exploration of possible weakness did not result in the modification of the basic conclusion. The third hypothesis is that such "excess" structure arises and persists because providers value structure for its own sake, and are able to impose their preferences on hospitals. The discussion is essentially theoretical and considerable evidence supporting the hypothesis is provided, although no formal proof is offered. Physicians value structure because it enables them to increase their income and/or leisure, and also to satisfy their professional desires with respect to their working environment. Arguments are presented to support the claim that physicians get some of the structure they want because of imperfections in real-world agency relations and the institutional features of the health care system. Given the basic premise of the thesis (that consumers would define quality in terms of outcomes), the results of both the empirical and theoretical investigations have implications for policy. Policy changes suggested in the discussion that concludes the thesis are concerned with resource allocation within the hospital system, quality measurement, monitoring of policy changes, and incentives and programs to modify provider preferences. / Arts, Faculty of / Vancouver School of Economics / Graduate

This study examined hospital governance in British Columbia. Considered to be one of the most important issues facing the health care industry today, hospital governance is nevertheless an ill-defined and poorly understood concept. Foundational and exploratory in nature, the study’s primary objectives were: a) to define hospital governance within the context of British Columbia; b) to examine the structural and functional relationships among key participants; c) to investigate decision-making responsibilities; d) to investigate what, if any, variations exist in the governance of acute care, long term care, and specialized care hospitals; and e) to explore the critical issues which face hospital governance today and in the future under New Directions policy initiatives. All hospitals (N=107) in the province were studied, with the exception of diagnostic treatment centers, private for-profit facilities, military, and federal institutions. Utilizing documentary examination, survey administration, and interview techniques, the study included hospital chief executive officers (N=106), hospital board members (N=735), hospital board chairs (N=106), and selected high ranking senior officials from the Ministry of Health who had direct responsibility for hospital activities (N=15). Results of the study provide for in-depth demographic board profiles, and show that hospital governance is similarly defined across all hospital categories as “a complex relationship of overlapping structures and activities which has the responsibility and the authority to oversee the organization’s operation and to ensure its commitment of providing optimum health care to its residents.” The study identifies the key participants of hospital governance and delineates sixteen activities considered to be under the hospital board’s domain. Seven issues are identified as being critical for hospital governance in the future. Although there was general agreement as to the individuals most often responsible for recommending and implementing activities brought before the board, there were considerable perceptual differences between participants as to who possesses final decision-making responsibility. Data results consistently demonstrated important differences in responses between the hospital and Ministry populations. The study shows that overall, the participants of hospital governance are generally satisfied with the traditional roles and structures of hospital boards and are overwhelmingly dissatisfied with New Directions policy initiatives. This study further suggests that due to the discrepancies in priorities, perceptions, and ideologies of the hospital and Ministry populations, hospital governance is in a highly volatile and transitive state.

The D'Arcy Island leprosarium, located in Haro Strait off the east coast of southern Vancouver Island, B.C., was first established in 1891. During its thirty-four years of operation it was administered by three governments: the Victoria municipal government from 1891 to 1904, the B.C. provincial government during the year 1905, while the federal government was in charge until closure of the institution in 1924. The colony now comprises three archaeological sites, the earliest phase DdRt 29 on Little D'Arcy Island, where predominantly Chinese males were incarcerated, DdRt 28 the remains of the caretakers' facilities built in 1907 on D'Arcy Island, and the latest phase of the colony DdRt 31, located to the south of the caretakers. The purpose of this research is to examine why and how social inequality is created and how it is maintained. Specifically, it will evaluate the historical sociopolitical circumstances surrounding the establishment of the colony, explain why it was created, and why and how the form of the institution changed over its thirty-four years of existence. Archaeological investigations are employed to illuminate the ongoing material and social conditions of the unfortunate lepers, in contrast to those of the colony caretakers. Historical research is used to provide a meaningful context to understand colony developments. Historical data are also used to complement the gaps in the archaeological record. In my research, I combine aspects of two theoretical approaches employed in contemporary archaeological theory. Processual archaeology is used to provide a framework for evaluating the relationship between racist ideology and the material manifestations of the D'Arcy Island leper colony. Changes in both the location and the architectural form and function are linked to changes in government policy and legislation to exclude Chinese immigrants. Apparently deliberate actions of the medical community to ignore available knowledge about leprosy are also associated with changes in the colony. Symbolic archaeology is employed to illustrate how portable material culture, cultural landscape and architectural form are utilized to symbolically reinforce the ideology of White dominant society. Inferior status based on perceived racial and social difference are reinforced by the cultural manifestations of the facilities. It is my contention that racist ideology is the prime mover in the creation and evolution of the D'Arcy Island leprosarium. It was fueled by stereotypical views of the Chinese immigrants held by White dominant society of the late 19th and early 20th century. The unwarranted fear of leprosy was seized upon by those in power to further incite racism in the general public. It was also used to support the belief that Chinese should further be excluded from mainstream Canadian society. The timing of the establishment of the colony followed a decade of strong anti-Oriental agitation. Other developments in the colony may be directly linked to federal and provincial actions or changes in immigration legislation. Further proof that racism was involved is that there were alternate means available to deal with the issue of the Chinese lepers: care in the Victoria Chinese Hospital, deportation, or transfer to the leprosarium at Tracadie, New Brunswick. Differential care of non-Chinese lepers also indicates that the provision of appropriate medical care was not a consideration in the maintenance of the colony. The D'Arcy Island leper colony was part of an historic process which contributed to racist ideology. The location, landscape, and architectural design all reflected the perceived inferior and outcast status of the Chinese lepers. They also reinforced the power and dominance of Euro-Canadians, maintaining social distance and creating social inequality.

This study examined hospital governance in British Columbia. Considered to be one of the most important issues facing the health care industry today, hospital governance is nevertheless an ill-defined and poorly understood concept. Foundational and exploratory in nature, the study’s primary objectives were: a) to define hospital governance within the context of British Columbia; b) to examine the structural and functional relationships among key participants; c) to investigate decision-making responsibilities; d) to investigate what, if any, variations exist in the governance of acute care, long term care, and specialized care hospitals; and e) to explore the critical issues which face hospital governance today and in the future under New Directions policy initiatives. All hospitals (N=107) in the province were studied, with the exception of diagnostic treatment centers, private for-profit facilities, military, and federal institutions. Utilizing documentary examination, survey administration, and interview techniques, the study included hospital chief executive officers (N=106), hospital board members (N=735), hospital board chairs (N=106), and selected high ranking senior officials from the Ministry of Health who had direct responsibility for hospital activities (N=15). Results of the study provide for in-depth demographic board profiles, and show that hospital governance is similarly defined across all hospital categories as “a complex relationship of overlapping structures and activities which has the responsibility and the authority to oversee the organization’s operation and to ensure its commitment of providing optimum health care to its residents.” The study identifies the key participants of hospital governance and delineates sixteen activities considered to be under the hospital board’s domain. Seven issues are identified as being critical for hospital governance in the future. Although there was general agreement as to the individuals most often responsible for recommending and implementing activities brought before the board, there were considerable perceptual differences between participants as to who possesses final decision-making responsibility. Data results consistently demonstrated important differences in responses between the hospital and Ministry populations. The study shows that overall, the participants of hospital governance are generally satisfied with the traditional roles and structures of hospital boards and are overwhelmingly dissatisfied with New Directions policy initiatives. This study further suggests that due to the discrepancies in priorities, perceptions, and ideologies of the hospital and Ministry populations, hospital governance is in a highly volatile and transitive state. / Graduate and Postdoctoral Studies / Graduate

The D'Arcy Island leprosarium, located in Haro Strait off the east coast of southern Vancouver Island, B.C., was first established in 1891. During its thirty-four years of operation it was administered by three governments: the Victoria municipal government from 1891 to 1904, the B.C. provincial government during the year 1905, while the federal government was in charge until closure of the institution in 1924. The colony now comprises three archaeological sites, the earliest phase DdRt 29 on Little D'Arcy Island, where predominantly Chinese males were incarcerated, DdRt 28 the remains of the caretakers' facilities built in 1907 on D'Arcy Island, and the latest phase of the colony DdRt 31, located to the south of the caretakers. The purpose of this research is to examine why and how social inequality is created and how it is maintained. Specifically, it will evaluate the historical sociopolitical circumstances surrounding the establishment of the colony, explain why it was created, and why and how the form of the institution changed over its thirty-four years of existence. Archaeological investigations are employed to illuminate the ongoing material and social conditions of the unfortunate lepers, in contrast to those of the colony caretakers. Historical research is used to provide a meaningful context to understand colony developments. Historical data are also used to complement the gaps in the archaeological record. In my research, I combine aspects of two theoretical approaches employed in contemporary archaeological theory. Processual archaeology is used to provide a framework for evaluating the relationship between racist ideology and the material manifestations of the D'Arcy Island leper colony. Changes in both the location and the architectural form and function are linked to changes in government policy and legislation to exclude Chinese immigrants. Apparently deliberate actions of the medical community to ignore available knowledge about leprosy are also associated with changes in the colony. Symbolic archaeology is employed to illustrate how portable material culture, cultural landscape and architectural form are utilized to symbolically reinforce the ideology of White dominant society. Inferior status based on perceived racial and social difference are reinforced by the cultural manifestations of the facilities. It is my contention that racist ideology is the prime mover in the creation and evolution of the D'Arcy Island leprosarium. It was fueled by stereotypical views of the Chinese immigrants held by White dominant society of the late 19th and early 20th century. The unwarranted fear of leprosy was seized upon by those in power to further incite racism in the general public. It was also used to support the belief that Chinese should further be excluded from mainstream Canadian society. The timing of the establishment of the colony followed a decade of strong anti-Oriental agitation. Other developments in the colony may be directly linked to federal and provincial actions or changes in immigration legislation. Further proof that racism was involved is that there were alternate means available to deal with the issue of the Chinese lepers: care in the Victoria Chinese Hospital, deportation, or transfer to the leprosarium at Tracadie, New Brunswick. Differential care of non-Chinese lepers also indicates that the provision of appropriate medical care was not a consideration in the maintenance of the colony. The D'Arcy Island leper colony was part of an historic process which contributed to racist ideology. The location, landscape, and architectural design all reflected the perceived inferior and outcast status of the Chinese lepers. They also reinforced the power and dominance of Euro-Canadians, maintaining social distance and creating social inequality. / Arts, Faculty of / Anthropology, Department of / Graduate