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Vol 1 • No 4 | September 2009

Contributors to this issue:

Introduction
ne of our goals at the Ontario Centre for Engineering and Public Policy is to demonstrate to decision-makers, opinion leaders and the broader public the breadth of the work of Ontario’s engineers, especially in areas where their contributions are perhaps unrecognized. One such field is the health-care system. In our own way, we are trying to redress this situation with three separate articles on the subject. As with issue #3 of The Journal of Policy Engagement, I am pleased to showcase the groundbreaking work of a bright young engineer–in this case Alex Mihailidis of the University of Toronto. I first became aware of Alex’s work about this time last year through the Toronto Star. Alex was one of five innovators profiled by the newspaper, two of whom were engineers. The goal of Alex Intelligent Assistive Technology and Systems Lab is to “develop zero-effort technologies that are adaptive, flexible and intelligent to enable users to participate fully in their daily lives.” I was particularly attracted to Alex’s work for a couple of reasons. First, Alex and his collaborator, Jennifer Boger, are working outside of a traditional faculty of engineering, in this case the department of occupational science and occupational therapy. Second, Alex makes no bones about engineering being a helping profession. His work is all about dignity and quality of life. I have particular empathy for this research since I sit on the volunteer board of directors of a Meals on Wheels organization in my community, a group also dedicated to providing individuals with the means that allow them to remain in their homes. The second article also demonstrates the important role engineering plays in the health-care sector. In their work, Michael Carter and Andriy Kolos of the Centre for Research in Healthcare Engineering at the University of Toronto focus “...on the application of industrial/systems engineering techniques in relation to demand and capacity modelling and resource allocation issues in

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Colin Andersen, CEO of the Ontario Power Authority, weighs in on the great opportunities the Green Energy Act presents to the engineering sector (page 16).

the health-care industry. Our goals include creating quantitative decision support tools to help policymakers and industry leaders make better-informed decisions.” In this particular article, they review their efforts attacking the surgery wait list problem in Ontario. While the McGuinty government is to be credited for allocating additional resources to this problem, it is equally refreshing to see that Carter’s and Kolos’s work has led to data-driven decision-making at Queen’s Park. In the past few months, the issue of medical isotopes has dominated national headlines, not least because of some unfortunate comments

In this issue:
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . How engineers are helping seniors with dementia stay at home By Alex Mihailidis and Jennifer Boger . . . Reduction of Ontario surgical wait times By Michael Carter and Andriy Kolos . . . . . . Canada’s medical isotope crisis: A way forward By Jatin Nathwani . . . . . . . . . . . . . . . . . . . . .

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Tony Dean, a fellow in residence at the School of Public Policy at the University of Toronto, explains how engineers can influence public policy-making (page 19).

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Between a rock and a hard place: An engineer’s duty to warn By Catherine Karakatsanis . . . . . . . . . . . . . . 14 The Green Energy Act and the future of sustainable electricity in Ontario By Colin Andersen . . . . . . . . . . . . . . . . . . . . .

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Matthew Mendelsohn, founding director of the Mowat Centre for Policy Innovation at the University of Toronto, details highly effective strategies engineers can use to get a foot in the door at Queen’s Park (page 21).

What can engineers do to gain better access to the corridors of power? By Tony Dean . . . . . . . . . . . . . . . . . . . . . . . . . . 19 What can engineers do to gain better access to the corridors of power? By Matthew Mendelsohn . . . . . . . . . . . . . . . 21 1

Volume 1 • No 4 | September 2009

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ON TA R IO CEN T R E FOR ENGINEERING AND PUBLIC POLICY
THE

OF POLICY ENGAGEMENT

JOURNAL

Vol 1 • No 4 | September 2009

The Journal of Policy Engagement is published six times a year by the Ontario Centre for Engineering and Public Policy. The council of Professional Engineers Ontario (PEO) established the centre in June 2008 to enhance the engagement of the engineering profession in the development of public policy to better serve and protect the public interest. The centre’s mandate also includes outreach to members of the engineering profession, the academic community, policy-makers and others interested in advancing the public interest. The views expressed here are those of the authors and do not necessarily reflect those of PEO or any other organization. Contact: Donald Wallace, Executive Director Ontario Centre for Engineering and Public Policy 1000-25 Sheppard Avenue West Toronto, Ontario M2N 6S9 416-840-1078 dwallace@ocepp.ca
SUBSCRIPTIONS (non-PEO members) Canada (6 issues): $21.00 incl. GST Other (6 issues): $25.00 Students (6 issues): $10.50 incl. GST Single copy: $3.67 incl. GST Approximately $5.00 from each PEO membership fee is allocated to The Journal of Policy Engagement and is non-deductible. Contact: Catherine Shearer-Kudel, 416-224-1100, ext. 1204, cshearerkudel@ocepp.ca.

of the federal natural resources minister that were caught on tape. If you are like me, you’ll appreciate University of Waterloo engineer Jatin Nathwani’s dispassionate and reasoned approach to this complex subject. With his work on this matter and others like Smart Grid, Jatin is the epitome of an engineering leader fully engaged with government and the pressing issues of our society. Excerpts from his recent testimony before a Commons committee are included inside. We are also most fortunate to have PEO President Catherine Karakatsanis contribute an article on an engineer’s duty to report. This piece had its genesis in a presentation Catherine made at a seminar of the Ontario Bar Association’s environmental section. That session was designed to address the tricky problem of the potential conflict between the duty to report and client/ solicitor privilege. When I attended the seminar, I instantly perceived that Catherine’s insightful overview deserved a wider audience. I’m grateful to Bruce Matthews, PEO deputy registrar, regulatory compliance, and David Smith, PEO’s manager of communications, for their help on this article. I am very pleased to include here three presentations from our recent policy conference. On May 8, the Ontario Centre for Engineering and Public Policy gathered more than 200 industry executives, engineers, Ontario government policy

advisers, university faculty and students, and association personnel to examine the interface between engineering and public policy. The day was a resounding success, in no small measure as a result of the uniformly high quality of the presentations. From his current perspective as CEO of the Ontario Power Authority and backed by a background as a long-standing Ontario deputy minister of finance, Colin Andersen offered a frank and insightful reading of how engineers can make their voices heard by policy-makers and opinion leaders, particularly in the context of the recently adopted Green Energy Act. We were exceptionally privileged to have Tony Dean, former secretary to the Ontario cabinet and head of the Ontario public service, and Matthew Mendelsohn, former associate secretary of the cabinet among other deputy minister assignments, as speakers. Many engineers have asked me how to engage effectively in the policy process, and I am glad to include the advice of these ultimate insiders. Please don’t hesitate to share your thoughts with me (dwallace@ocepp.ca). Your views matter. Donald Wallace Executive Director Ontario Centre for Engineering and Public Policy

How engineers are helping seniors with dementia stay at home
By Alex Mihailidis, PhD, P.Eng., and Jennifer Boger people manage ordinary tasks, such as hand washing or toileting, which they might not otherwise be able to perform on their own. Through verbal and/or visual cues, dementia sufferers are taken through these activities on a step-by-step basis that allows them to accomplish these basic functions without the help of a caregiver. The result: a greater number of older people with cognitive impairments can remain in the familiar surroundings of their homes, relieving pressure on family and institutions that might otherwise have to care for them. One of the most sophisticated cognitive assistive technologies is the product of the University of Toronto’s Intelligent Assistive Technology and

Executive summary
Medical breakthroughs and better overall health care have become part of a double-edged sword. While people are living longer, there has been an increase in mental conditions associated with aging, such as dementia and particularly Alzheimer’s disease. Looking ahead, people are expected to grow even older and, as a result, more people will suffer from these debilitating conditions. While there is no cure for this mental aspect of aging, engineers are at the forefront of developing innovative technology that allows sufferers to cope better with day-to-day living. Among the exciting discoveries, known as cognitive assistive technologies, are sophisticated sensors that help

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The Journal of Policy Engagement

Systems Lab in collaboration with the Toronto Rehabilitation Institute. Known as COACH, this user-friendly system employs computer vision and artificial intelligence techniques to provide oral and/or visual reminders for common-care activities. Its success demonstrates how engineers, working in tandem with professionals from other disciplines, can achieve results that dramatically make a difference in people’s quality of life.

Aging and dementia
Globally, the number of individuals aged 65 years and older is predicted to increase steadily, particularly among those aged 80 years and over, after the year 2010 (U.S. Census Bureau). This will result in an increase in the worldwide number of individuals diagnosed with dementia, particularly Alzheimer’s, to 81.1 million by 2040 from the estimated 24.3 million individuals in 2006 (Ferri et al.). Dementia is an acquired, persistent condition where significant deficits exist in memory and other cognitive functions sufficient to interfere in social and occupational function (American Psychiatric Association). Alzheimer’s is the most common form of dementia and has, in many respects, become synonymous with the broad category of dementia. The primary clinical features associated with Alzheimer’s include severe memory deficits and compromised episodic, procedural and semantic memory (memory involved in recalling personal events, remembering the sequence of actions and retaining knowledge, skill and understanding). People with Alzheimer’s have difficulty with delayed and immediate recall of information. These memory difficulties cause problems with orientation to time, place and person. Alzheimer’s is a progressive disease, with associated difficulties worsening with time. This makes it extremely difficult, and eventually impossible, for a person with Alzheimer’s to learn and retain new information (Lubinski). To date, there is no cure, although drug treatments can slow the progression in most cases. As a dementia such as Alzheimer’s progresses, a person may need assistance in various self-care activities because he/she lacks the initiation and planning abilities to carry out these tasks (Harrell et al.). In the early stages, the underlying problem may be an inability to locate a particular room, such as the washroom, as a result of spatial disorientation. As the disease progresses, a person tends to have difficulty initiating a task, such as taking medication or remembering the proper sequence of steps that must occur during the activity. For example, a person may use the toilet before removing the appropriate clothing. During early stages, occasional verbal cueing, or prompting, will suffice. However, as dementia progresses, constant supervision and assistance are required. It is often at this stage that the burden of care becomes too great, and the person is removed from his/her home.

Introduction
Imagine losing the ability to take care of yourself, not being able to remember how to complete even the most basic tasks like using the toilet or getting dressed. As your memory gets worse, your need for supervision and help from your spouse, son, daughter or a caregiver increases to the point where the burden becomes so great that you are forced to leave your own home and live in a long-term care facility. Sadly, this scenario is far too common for many older adults who live with a cognitive disability, such as dementia or Alzheimer’s disease. What can be done to help these people stay in their own homes, while easing the burden of care on their families and loved ones? Various research studies have concluded that older adults (particularly those who have Alzheimer’s) function better in familiar environments that can provide memory and task cues (Bryant, Cutchin, Intille). However, any shift from hospital to home-based care means an increasing dependence on family members and other informal caregivers to attend to the long-term health-care needs of older adults with Alzheimer’s. Continuous supervision of the care recipient is exhausting and difficult for family caregivers, especially for activities that require an invasion of privacy, such as toileting. Furthermore, increased dependence and changes in the relationship dynamic between people with Alzheimer’s and their family caregivers are often difficult to accept. The role reversal that accompanies care by a son or daughter can add to feelings of helplessness and embarrassment for both the caregiver and recipient (Dura, Stukenberg and Kiecolt-Glaser). In response to the above concerns, engineers have become instrumental in addressing the question of how to better care for our growing older-adult population. They have developed new, sophisticated technological solutions, known as cognitive assistive technologies (CAT). These CATs help Alzheimer’s and dementia sufferers perform a range of different tasks, such as getting dressed, meal preparation and self-care (Intille). These technologies come in a wide variety of forms, from hand-held devices, such as Palm Pilots, to more advanced systems that are integrated into the user’s environment, such as a smart home. Often coupled with some form of artificial intelligence, CATs strive to support cognitive disorders, thereby enhancing the user’s autonomy (Mann et al.). This paper presents an overview of CATs and how they have been used to date in the home to support older adults with dementia. The scope includes a consideration of aging and dementia, key examples of CATs, including a case study of a breakthrough technology developed at the University of Toronto. The paper concludes with a discussion of this field’s future and how engineers can continue to play a significant role, not only in the development of new CATs but also in the wider application of technology to some of the challenges of aging.
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Cognitive assistive technology
CATs have been developed to assist people with a variety of disabilities, including traumatic brain injury, stroke, learning disabilities, multiple sclerosis, autism and dementia (LoPresti, Mihailidis and Kirsch). Depending on the user’s specific needs, these technologies may be used in a number of ways. One approach is to capitalize on skills that have not been compromised, enabling a person to complete tasks using alternative strategies. For example, a person with poor visual letter recognition, but strong verbal language skills, may employ a computer that generates emails using speech recognition rather than typing. Similarly, a personal digital assistant may be used for daily planning by a person with memory impairments, but relatively intact executive skills. For more severely impaired individuals, an alternative approach has been to develop extrinsic interventions that assume greater
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responsibility for initiation, cueing, activity guidance and maintenance of daily information. For example, a technology may be designed that, in addition to providing simple alarms about when medications are to be taken, provides step-by-step guidance about how to take the medication (LoPresti, Mihailidis and Kirsch). A multitude of CAT devices have been developed in response to the broad and diverse range of needs and abilities. As it is not possible to address the full spectrum of available CATs, this paper primarily focuses on technologies intended for older adults with dementia and similar cognitive impairments. (For a more detailed discussion of other types of CATs, the reader is referred to LoPresti, Mihailidis and Kirsch.) A significant amount of recent work in CATs relies on various computing techniques, such as artificial intelligence and probabilistic modelling, to infer task and user status from sensors distributed throughout a person’s living environment (Pentney et al.). For example, software known as Autominder uses artificial intelligence planning to schedule events (e.g. medication taking) at times when they will not interfere with a person’s daily schedule, such as favourite television programs or daily walks (Pollack). Autominder also uses environmental sensors to detect the status of activities and, if required, provides the user with context-aware reminders regarding unattended activities. The Gator Tech Smart House is an example of a smart home designed with older adults in mind (Helal et al.). Sensors distributed throughout the house interact with applications running on computers to take into account context when performing actions. For example, if it is a sunny day outside and the occupant has the television on, the Gator Tech Smart House will automatically close the blinds to reduce glare. Other features include medication reminders that can appear on the bathroom mirror and automatic sensing and ordering for soap and toilet paper refills. Pigot et al. developed Archipel, a cognitive modelling system for cooking tasks that recognizes the user’s intended plan and adapts prompting to a predetermined cognitive impairment level. Sensors placed in the kitchen environment, such as radio frequency identification technology tags and readers, detect which objects have been used and provide cues (audio, video and strategic lighting) to help users through each step in the task. As with Autominder, Archipel will not give reminders for tasks the person has already accomplished. In addition to the above systems, which are primarily installed within a person’s environment, there are also several CATs designed as wearable devices. For example, memory glasses is a context-aware memory aid that is embedded in a pair of eyeglasses, which provides reminders to the wearer (Bharucha et al.). The reminders take the form of images and text. These glasses use a variety of computer vision techniques to collect data from the user’s environment to infer the user’s context and provide prompts that are relevant to the user and his/her actions, preferences, etc. This device is targeted at helping people to remember names and faces, which is a common problem for those who have a mild cognitive impairment or dementia. Microsoft’s SenseCam is a retrospective memory aid that uses a small digital camera to passively take pictures while being worn around a user’s neck. It employs a wide-angle lens to record events as they happen, without any manual input from the user. The SenseCam then
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allows a user to view image sequences to help him/her remember events that have occurred and share them with others, which in turn is thought to lead to consolidation of autobiographical memory and positive social interactions (Bharucha et al.).

The COACH prompting system
The extent to which CATs can aid an individual with dementia depends on the user’s willingness to implement them, which in turn depends on whether the individual and/or his/her caregiver can operate the devices and feels the devices are helpful, and whether they support or undermine the sense of personal identity (McCreadie and Tinker). To be useful to both a care recipient and his/her caregiver(s), a CAT must be autonomous, non-invasive and not require explicit feedback (e.g. button presses), as this cannot reasonably be expected of either people with Alzheimer’s or overworked family members and caregivers. The cognitive assistance should be able to accommodate high levels of customization, as the more it is personalized and appropriate to the deficits in question, the more likely it will be adhered to and understood by the user (Wilson et al.). In addition, assistance should be given only on an “as needed” basis to minimize confusion and to keep the user as cognitively involved in the task as possible. Finally, the CAT should be user-friendly. The majority of currently available CATs require extensive sensor deployment and maintenance and/or input from a cognitively intact individual. This means the caregiver would likely have to learn how to operate and, to some degree, maintain a potentially complex planning system. As many caregivers are overburdened as is, this additional expectation is not realistic or appropriate and leads to non-acceptance or abandonment of the device. The Intelligent Assistive Technology and Systems Lab (IATSL) at the University of Toronto and Toronto Rehabilitation Institute has been working for several years to develop more advanced CATs that keep the above design criteria in mind. IATSL, part of the university’s department of occupational science and occupational therapy, is a unique engineering laboratory in that it not only employs engineers and engineering students, but also works with professionals from other disciplines, such as occupational therapy, rehabilitation sciences, speech language pathology and computer science, as well as theatre and drama. This mix produces a highly interdisciplinary approach in the development of new technologies, which is extremely important in ensuring that a holistic approach is taken throughout the engineering design process. One of the devices that has come from this collaborative approach is an advanced CAT called COACH (Cognitive Orthosis for Assisting aCtivities in the Home). COACH employs various computer vision and artificial intelligence techniques to autonomously provide an older dementia sufferer with oral and/or visual reminders during common self-care activities, such as handwashing. Handwashing was chosen because it is a relatively safe activity that older adults with dementia have difficulty completing because of the planning and initiation skills required.
The Journal of Policy Engagement

Camera

Monitor and speakers

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Figure 1: The COACH installation shows (a) a small video camera and a flat-screen monitor, and (b) a close-up of the video prompt (for the rinse-hands step) being played in (a).

Since COACH uses very little hardware, purchasing costs are low and installation requirements are realistic for a home environment. As seen in Figure 1, the latest version of COACH consists only of an overhead camera, a flat-screen monitor with built-in speakers and a laptop computer. The computerized portion of the system is represented in Figure 2. It has four integrated components: tracking, state monitoring, policy and prompting. During the software’s development, images captured

by the video camera are processed by the tracking system. The tracking system extracts the hand and towel positions, which are used by the belief-monitoring system to compute the belief state, a probabilistic estimation of the current state of the user and environment. The belief state is passed from its monitor to the policy, which is essentially a look-up table that determines the best course of action for the system to take. The policy translates each belief state into an action.

Tracking
video

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Belief monitor convert observations check belief change

grab frame update tracker

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new, stable belief detected?
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Possible COACH actions are to provide a low-guidance oral prompt, a high-guidance oral prompt, an oral prompt with an accompanying video demonstration, a call to the caregiver to intervene, or to do nothing and continue to observe the user. Having different levels of prompts allows COACH to select the most appropriate support for each individual’s stage of Alzheimer’s and overall responsiveness. Thus, the type of prompt played for the user is based on factors such as the error committed, sensory and cognitive status of the user, and past responsiveness to the previous prompts. Tracking is accomplished using a computer-vision technique known as flocking, which was developed by IATSL collaborators at the University of Dundee (Hoey). Flocking uses models of skin and towel colour combined with a Bayesian probability sequential-estimation method. This means of tracking is able to dependably determine the location of the user’s hands and the position of the towel, even after occlusion by an object or after its leaving and returning to the camera’s field of view. The COACH system tailors itself autonomously to the individual needs of its users because it can estimate and use an individual’s traits (e.g. cognitive awareness and responsiveness levels) and can dynamically adapt to daily and long-term needs. COACH audio prompts are recorded using a male actor to emulate the cadence and tone of an expert caregiver. The user’s name is said at the beginning of each prompt to get his/her attention. Previous studies with COACH have found that some users can get confused about which activity they were asked to complete (e.g. previous participants have been known to wash the towel in the sink, wash their face instead of their hands). Therefore, to help device users remember why they are at the sink, prompts often contain a reminder of which activity they are attempting to complete (e.g. “John, you’re washing your hands”), followed by guidance for the step in the activity he/she is attempting (e.g. “Try turning on the water using the silver lever”). Since the addition of video capable of demonstrating how to correctly complete the activity step was shown to be helpful (Labelle and Mihailidis), these capabilities were added to this version of COACH. The video was shot from the perspective of the person who was washing his/her hands. They were pre-recorded in the same washroom where the device was installed to provide accurate demonstrations. An important aspect of the research and development activities at IATSL is the testing of all new technologies in real-world environments. This is especially crucial when developing new health-care and assistive technologies for people with disabilities, as designing for special or vulnerable populations could result in consequences that are far more critical than when designing for a “typical” user. With this in mind, the most recent COACH prototype was installed in a long-term care facility where it was tested with six people with dementia, five of whom had moderate-level dementia and one who had severe dementia. Efficacy testing of the system first consisted of observing each participant perform handwashing without the use of the technology (phase A) to obtain baseline measures of how much of the activity he/she could complete independently and how much assistance he/ she required from a caregiver. At the completion of this baseline phase, the COACH system was introduced and used as the primary
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form of assistance for each participant (phase B). The phases were repeated in the order A-B-A-B. As can be seen in Figure 3, when participants used COACH, they showed an overall increase in the number of handwashing steps they were able to complete without assistance from the caregiver, as well as a decrease in the number of times they required assistance during the activity. In general, COACH made the participants less dependent on a human caregiver. Looking at the results individually, the effectiveness of COACH varied considerably and seemed to be dependent on each individual’s idiosyncrasies. These findings suggest that COACH could be useful to individuals who prefer visual to tactile clues (e.g. touching a person’s arm or physically guiding his/her hand). These findings also support the importance of understanding the special, diverse and dynamic needs of this target population to ensure that appropriate, customizable assistance is available. Overall results for all participants in the COACH efficacy trials show (a) the mean number of steps completed independently, and (b) the number of times the caregiver had to provide assistance. A1 and A 2 are the baseline phases (COACH not used), B1 and B2 are the intervention phases (COACH used). Still, several areas in need of improvement have been identified. During this study, COACH had a total of 750 observed conditions. Of these, 170 (23 per cent) were errors (i.e. a false alarm or a miss), which occurred because the system misinterpreted a step in the handwashing task. For example, an ambiguous user action like touching the taps may have caused the system to incorrectly presume the water had been turned on. Wrong assumptions by COACH reduce the probability that the correct course of action will be taken. When COACH was not able to correct itself through other observations, prompts were often either missed or provided for the wrong step. Yet the overall study results are very encouraging. Further clinical trials are being planned that will include more participants and will be conducted within homes. Some COACH improvements could include the adaptation of the system to distinguish between multiple washroom activities of daily living, such as tooth brushing, and, eventually, toileting, as well as the implementation of speech recognition to allow the system to recognize other types of implicit user feedback and multiple camera input (vision/tracking systems) gained by placing cameras in various positions throughout the washroom. The latter could provide greater user observation accuracy and versatility and would enable 3-D observations.

The future
The research described in this paper is changing the face of the assistive technology field. The positive results being obtained are providing strong evidence that assistive technology can be used to support older adults with cognitive impairments remain independent. Those people– especially those who have more severe levels of impairment–have often been ignored in the development and use of assistive technologies. In addition, the sophisticated techniques that are being applied in these new CATs are providing strong evidence that areas that have not traditionally been a part of the assistive technologies field, such as artificial intelligence, can play a significant role in the development
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5 4.5 4 3.5

A1: Without COACH

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Mean (µ) number of interactions with a caregiver

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Figure 3: How COACH can help

of solutions that are more flexible, scalable and robust–all important design criteria for any technology to support older adults. This realization has resulted in a large influx of new researchers from fields like computer science, computer engineering and electrical engineering, as well as an explosion in the number of research projects that are being conducted with a focus on advanced technologies for older adults with dementia. As a result, the road is being paved for more innovative research and technologies. In addition to developing COACH, researchers at IATSL and elsewhere at the University of Toronto are working on several new projects that capitalize on the emergence of artificial intelligence and other advanced computer science concepts. Many of these projects apply concepts that were developed for the COACH system. For example, similar computer vision concepts have been used in the development of a fall detection system that can automatically determine if a person has fallen (without any markers or devices having to be worn by the user) and place a call to the appropriate respondent based on a dialogue the system has with the user via speech recognition. With respect to the overarching goal of keeping older adults safe in their own homes, many research groups are working towards the common goal of developing an “intelligent home” that integrates
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many of the CATs and concepts discussed in this paper. Such a home would be able to sense and determine the actions, needs, preferences, abilities and overall context of an occupant–and provide appropriate assistance if and when necessary. This assistance may come in many different forms, such as guidance for self-care activities, reminders for medication, semi-automation of tasks (such as automatically turning off the water when the bath is full), or just checking in with the occupant to make sure he/she is feeling okay. This type of intelligent environment would be useful to anyone, not only to older adults who wish to stay in their own homes. For example, a common scenario is an occupant who wants to leave the house but does not remember where the has left the keys. Imagine the house being able to recognize the user’s intent of wanting to leave, automatically locating the keys and telling the occupant where they are. While this scenario may seem far-fetched, the basis for many of these technologies already exists (such as the COACH and Autominder) and simply requires integration into a common platform. The development of such a common platform has started to emerge as a new research area at several universities across Canada (and, indeed, globally), with the goal of achieving an intelligent home within the next decade.
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The future of the assistive technologies field, and in particular CATs, to enable older adults to remain at home longer is looking extremely bright. This is a direct result of the involvement of highly skilled engineers from various disciplines and the close collaboration of these engineers with researchers and experts from other professions, such as computer science, rehabilitation sciences and nursing. The field continues to flourish because of the significant increase in the number of engineering students who are becoming interested and actively involved in health care. Training of highly qualified engineers and researchers, who are able to understand the needs of older adults and others with health issues or disabilities, is proving to be a crucial element in the expansion of this field.

The University of Toronto has become a renowned world leader in biomedical engineering and rehabilitation engineering. These and similar programs at other universities will provide the expertise needed to develop new and innovative technologies that will help older adults (and other people with disabilities) remain independent. Improving independence among this population will significantly and positively impact quality of life, as well as help to reduce the burden of care facing many families and caregivers. Clearly, engineering will continue to play an invaluable role in the development of CATs, as the profession strives to achieve greater success in providing older adults, and any person with a disability, the ability to remain in their own homes and communities much longer. to older people.” Ageing and Society 25 (2005): 91-110. Patterson, Christopher. “Focusing on Alzheimer’s disease.” The Canadian Journal of Diagnosis. December (1999): 62-74. Pentney, William et al. “Learning large scale common sense models of everyday life.” 27th Annual Conference of AAAI. Vancouver, 2007. Pigot, Hélène et al., eds. A Smart Home to Assist in Recipe Completion. Amsterdam: IOS Press, 2008. Pollack, M.E. “Autominder: A case study of assistive technology for elders with cognitive impairment.” Generations 30.2 (2006): 67-79. U.S. Census Bureau. Global Population Profile: 2002. International Population Reports Wp/02. Washington DC: U.S. Government Printing Office, 2004. Wilson, Rozanne et al. “Examining effective communication strategies used by formal caregivers when interacting with Alzheimer’s disease residents during an activity of daily living (ADL).” Brain and Language 103.1-2 (2007): 199-200.

References
American Psychiatric Association. DSMIV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington DC: American Psychiatric Association, 1994. Bharucha, A.J. et al. “Intelligent assistive technology applications to dementia care: Current capabilities, limitations, and future challenges.” American Journal of Geriatric Psychiatry 17.2 (2009): 88-104. Bryant, Lucinda. “In their own words: A model of healthy aging.” Social Science and Medicine 53.7 (2001): 927-41. Cutchin, Malcolm. “The process of mediated aging-in-place: A theoretically and empirically based model.” Social Science and Medicine 57 (2003): 1077-90. Dura, J.R., K.W. Stukenberg and Janice Kiecolt-Glaser. “Anxiety and depressive disorders in adult children caring for demented parents.” Pscyhology and Aging 6 (1991): 467-73. Ferri, Cleusa et al. “Global prevalence of dementia: A delphi consensus study.” The Lancet 366.9503 (2006): 2112-17. Harrell, Minnie et al., eds. Cognitive Rehabilitation of Memory: A Practical Guide. Maryland: Aspen Publishers, 1992. Helal, Sumi et al. “The Gator Tech Smart House: A programmable pervasive space.” IEEE Computer 38.3 (2005): 50-60. Hoey, Jesse. “Tracking using flocks of features, with application to assisted handwashing.” British Machine Vision Conference. Edinburgh, Scotland, 2006. Intille, Stephen. “A new research challenge: Persuasive technology to motivate healthy aging.” IEEE Transactions on Information Technology in Biomedicine 8.3 (2004): 235-37.

Kaelbling, L.P., M.L. Littman and A. R. Cassandra. “Planning and acting in partially observable stochastic domains.” Artificial Intelligence 101 (1998): 99-134. Labelle, K.L., and Alex Mihailidis. “Facilitating handwashing in persons with moderate-to-severe dementia: Comparing the efficacy of verbal and visual automated prompting.” American Journal of Occupational Therapy 60.4 (2006): 442-50. LoPresti, E.F., Alex Mihailidis and Ned Kirsch. “Assistive technology for cognitive rehabilitation: State of the art.” Neuropsychological Rehabilitation 14.1/2 (2004): 5-39. Lubinski, Rosemary. Dementia and Communication. Philadelphia: B.C. Decker, Inc., 1991. Mann, W.C. et al. “Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly.” Archives of Family Medicine 8. May/June (1999): 210-17. McCreadie, Claudine and Anthea Tinker. “The acceptability of assistive technology

Alex Mihailidis, PhD, P.Eng., is an assistant professor in the department of occupational science and occupational therapy, University of Toronto, with cross appointments in the university’s Institute of Biomaterials and Biomedical Engineering and the department of computer science. He is also a scientist at the Toronto Rehabilitation Institute. He has been conducting research in the field of pervasive computing and intelligent systems in health for the past 12 years, having published more than 80 journal papers, conference papers and abstracts. Mihailidis has specifically focused on the development of intelligent home systems for elder care and wellness, technology for children with autism, and adaptive tools for nurses and clinical applications. He holds a PhD in rehabilitation engineering from the University of Strathclyde. Jennifer Boger is research manager for the Intelligent Assistive Technology and Systems Laboratory in the department of occupational science and occupational therapy at the University of Toronto and the Toronto Rehabilitation Institute. She graduated from the University of Toronto in 2004 with a master of applied science degree in biomedical engineering. Boger also holds an undergraduate degree from the University of Guelph in biological engineering (honours).

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Reduction of Ontario surgical wait times
By Michael Carter, PhD, and Andriy Kolos

Executive summary
Engineering methods developed by the University of Toronto’s Centre for Research in Healthcare Engineering are making a major contribution to a better understanding of how best to reduce wait lists for key medical procedures. Under the direction of the centre’s director, Michael Carter, PhD, a team of researchers has developed a mathematical model that allows for a reliable forecast of how many people are going to require certain types of surgery and how long they will have to wait to receive it. From this model, predictions can be made about the additional public funding that is required to increase the number of available surgeries and, as a result, reduce wait times. The impetus for developing such a model comes from the 2003 federal-provincial agreement on health care that led to the establishment of targeted wait times for certain medical procedures. The five designated procedures were diagnostic scans, as well as four types of surgeries: cancer, cardiac, ophthalmic and orthopedic. The provinces agreed that 90 per cent of these procedures should take place within six months of a decision to operate. Developing an appropriate model to help achieve this objective has had to overcome a number of hurdles, including the lack of reliable information on how many people are waiting to have a certain type of medical procedure. Once the model was put in place, it led to the McGuinty government announcing increased funding that produced a significant reduction in wait times for a number of procedures.

Introduction
In February 2003, the country’s first ministers signed the historic Accord on Health Care Renewal that included a commitment to reduce wait times for five key services. The targeted procedures were diagnostic scans, plus cancer, cardiac, ophthalmic and orthopedic surgeries. For example, the accord led to establishing benchmarks for cataract, hip and knee replacement surgeries. It called for 90 per cent of these procedures to take place within six months of a decision to operate.
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To help achieve these standards, Ontario announced its own Wait Time Strategy in November 2004. A key element of the plan was the establishment of a Wait Times Information Office (WTIO). The WTIO is devoted to documenting, analyzing and reporting wait-time data. Initially, the WTIO focused on the five key benchmark services, although the mandate has now expanded to include all types of surgery. In March 2006, the WTIO asked the Centre for Research in Healthcare Engineering (CRHE) at the University of Toronto and the Institute for Clinical Evaluative Sciences (ICES) to help determine the number of additional surgeries that needed to be publicly funded to ensure the province would achieve the national targets by March 2007. For example, at the time only 71 per cent of hip replacement surgeries were conducted within the recommended maximum wait time of 26 weeks. The Ministry of Health and Long-Term Care’s goal was to increase the percentage to the mandated 90 per cent within that period. (Wait time is measured from the day the surgeon decides to operate, the decision-to-treat date, to the surgery.) The CRHE/ICES team focused on three types of surgeries: cataract, hip and knee replacement. (The Cardiac Care Network and Cancer Care Ontario monitor the wait times for cardiac and cancer surgeries.) By applying engineering and quantitative methods to health-care issues, the CRHE helped develop a model that could forecast both future arrivals of patients requiring surgery and the resulting wait list. By comparing the expected wait list to historical patterns for how long patients had to wait for certain operations, the model could be used to suggest solutions to lower these wait times to acceptable levels.

Methodology
Conceptually, the measurement of wait times should be straightforward. If one knows the number of people waiting for a particular surgery, and the arrival rate of new patients seeking the same surgery, one can create a model to compute the number of additional

surgeries required. Prior to the creation of the WTIO, wait-list information was typically kept in individual surgeons’ offi ces. The hospitals learned who required surgery only a week or so before the procedure was scheduled to take place. The CRHE/ICES research team began its work by reconstructing past wait lists from historical data between April 2001 and October 2006. Since most surgeons are paid on a fee-for-service basis, the research team relied on Ontario Health Insurance Plan (OHIP) billing records to determine the number of operations for previous years. The researchers performed an analysis to determine a patient’s last consult date and used it as the decision-to-treat date. The ensuing time to the surgery provided a waittime estimate. The number of surgeries performed between each patient’s decision-to-treat date and their actual surgery could therefore be calculated. The time in between was considered as the wait list for each patient. CRHE researchers plotted the mean, median and 90th percentile of the wait-list length among the patient population scheduled for surgery. (The critical 90th percentile in this analysis is that point on the wait list where 90 per cent had a shorter wait time for an operation than the remaining 10 per cent.) Figure 1 shows the number of patients waiting for cataract surgery by month. It illustrates the mean, median and the 90th percentile for patient wait-list time. In 2004, there were approximately 110,000 cataract surgeries in Ontario. Since the 90th percentile wait time was over one year, some 11,000 people were waiting for more than a year for their surgery. Since the wait time for surgical patients could be identified only after the surgery took place, the completeness of the wait list decreased as the measurements approached the present. Therefore, as the 90th percentile of the wait-list duration began to drop sharply, the researchers assumed there were still a significant number of people on the wait list who had not yet had their surgery.
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450 400 350 300
Mean 90th percentile Median

Days

250 200 150 100 50 0

Figure 1: Patient wait times for cataract surgery over time

3.0 2.5 2.0 1.5 1.0 0.5 0.0
Apr-01 Apr-02 Apr-03 Apr-04 Oct-01 Oct-02 Oct-03 Apr-05 Oct-04 Oct-05

Figure 2: 90th percentile-to-mean ratio as an approximation for the curve of the wait time distribution

Arrivals 14,000 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000

Corrected arrivals

Total surgeries

Figure 3: Arrivals to wait list (observed and forecast) and surgeries (observed)

One of the challenges that faced the team involved the estimate of the 90th percentile. It is difficult to relate the wait-list length to the 90th percentile without an estimate of the underlying wait-time distribution. Since wait times vary by surgeon, there is a wide range of wait times. Figure 2 depicts the ratio of the 90th percentile of the cataract wait list to that list’s mean over time. The researchers

observed that even as wait times improved, the ratio remained approximately constant around 2.3. This constant ratio provides important information about the shape of wait lists. In particular, to achieve the 90th percentile (target wait time of 26 weeks), the mean should be 11 weeks (assuming the distribution stays relatively unchanged). Since average wait time

is simply the number of people waiting divided by the number of surgeries performed, the constant ratio averages are easier to quantify than the 90th percentile. A similar pattern was observed for hips and knees. Based on the three years of OHIP data from Figure 1, the researchers computed the number of monthly arrivals (new additions to the wait lists). This summary information provided sufficient data to model trends and seasonality patterns. Forecasting with exponential smoothing created an estimate for future patients’ decision-to-treat dates (arrival) and provided a predictive model for the length of the surgical wait list. Figure 3 illustrates the forecast for cataract surgeries. Note that monthly surgeries tend to decline in summer and around Christmas and March break, when surgeons often take vacation. By spring 2006, WTIO had collected four months of hospital estimates for the length of the wait lists. For hip and knee surgeries, the researchers were able to construct a single model that nicely imitated the characteristics of these four monthly wait lists. Given the nature of the cataract data, the researchers found it necessary to construct an “aggressive” model to match the first two months of the hospital wait-list estimates and a “conservative” model to capture the last two months. The researchers assumed the data quality was improving month by month, so they were more confident in the results of the conservative approach. Finally, the Ministry of Health and Long-Term Care provided estimates of future base rates for surgical procedures. All these estimates (i.e. current wait list, forecasted arrivals and number of funded surgeries) were combined to predict the wait list as of March 31, 2007. The target wait list was obtained by multiplying the average weekly surgical volumes by 11 weeks, the target for the mean. The difference between these two estimates provides the additional number of surgeries required to reduce the wait list to the target. To validate the methodology, we used the Cardiac Care Network’s data set that includes a central provincial wait list. The researchers found that by using only three years of observations, they were able to forecast future arrivals to within one standard

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deviation of actual observations, nine times out of 12, and to within two standard deviations, 12 times out of 12. Clearly, the model worked.

Results
The aggressive cataract model produced a recommendation that an additional 5400 cataract procedures needed to be funded by March 2007, while the conservative model identified that the observed current surgical rate would adequately reduce the wait list. (The actual model recommended a reduction of 4141 surgeries below the current level.) The hip and knee surgery models identified a need for 5500 more knee replacements and 1000 more hip replacements before March 31, 2007. Armed with these results (along with other sources of information), the McGuinty government on September 12, 2006 announced additional funding to improve access to five key health-care services as part of its wait times strategy. Specifically, the province provided funding for 6100 more cataract surgeries and a combined total of 3008 more hip and knee joint replacements. One can only speculate on the rationale behind funding so many cataract surgeries. However, such surgery is relatively inexpensive, and resources were readily available. So it is not perhaps surprising that the ministry was keen to ensure that the 90th percentile was exceeded. The funding for hips and knees was likely tempered by capacity, and human resource and time constraints. Hospitals were awarded additional funding for surgeries if they were on target to meet base surgical volumes for the year and had available capacity. Hospitals were required to maintain current volumes of other surgeries. By March 31, 2007, wait times had markedly improved from the previous six months. Ninety per cent of cataract surgeries took place within 156 days, inside the six-month target, while hips were operated on within 244 days and knees within 326 days. Not all hospitals were able to take advantage of the additional funding. Many found they could not meet the target volumes due to resource or personnel constraints. Of the 6100 additionally funded cataract surgeries,

it was estimated that only 5217 were performed. Similarly, only 1032 hip and 1340 knee replacement surgeries were completed. However, a review of the number of actual arrivals and wait-list observations as of March 31, 2007 reveals the research model recommendations were accurate. The 90th percentile wait time for cataracts would have been 185 days with the conservative model and, had the normal surgical rates for hips and knees not changed, 169 days for hips and 183 days for knees.

Situation today
In the past two years, there have been further marked improvements in lowering wait times, although the 182-day standard has not been met in all cases. As of March 2009, the observed 90th percentile provincial wait time was 111 days for cataract surgery, 153 days for hip replacement surgery and 176 days for knee replacement surgery.

Conclusions
WTIO has significantly improved its datacapture capabilities and accuracy over the years. Wait-list information is now collected for all types of surgery. However, the wait times are still calculated on the basis of patients who have already had their surgery. In the model described here, the wait list is constructed based on arrivals and the wait times are estimated using planned service

rates. Moreover, the wait list can be predicted for any time in the future. (It is much better to know you may have a problem in the future so you can take remedial action today.) The current reporting system is retrospective and leaves little time to correct resource issues. The models would be particularly useful for monitoring future wait lists in provinces such as Ontario that have adopted a guaranteed wait time for some services (i.e. if wait times fall below the target, the province is required to pay for people to have their surgery out of province if necessary.) Maximum recommended wait times are a function of ensuring the majority of patients do not wait for surgery longer than some reasonable clinical standard based on quality of life and medical recommendations. Engineering modelling techniques allow governments and institutions to act proactively, knowing a problem is approaching, instead of reacting to observations of inappropriately long wait times for key surgical procedures. The modelling work was effectively used to provide quantitative decision support to help the ministry make informed decisions to reduce wait times. Improved data on service rates and arrival rates offer health-care managers a higher level of wait-list control and allow them to make modifications to service volumes for key services. The result: a healthcare system that runs more effectively for the benefit of the patient.

Michael Carter, PhD, is director of the Universit y of Toronto’s Centre for Research in Healthcare En g ineerin g and a professor in its depar tment of mechanical and i ndustr ia l en g i neeri n g. Car t er received h is doctorate i n mathematics f rom the Un iversit y of Waterloo in 1980. Since 1989, h is research focus has been healthca re resou rce model l i n g w it h a v a r iet y of project s i n hospit a l s, home ca re, rehabi l itat ion, lon g-t er m ca re, med ica l labs a nd menta l hea lt h i n st it ut ion s. Ca r ter is a th ree -ti me w i n ner of the A n nual P ractice P r i ze f rom the Ca nad ian Operational Resea rch Societ y (1988, 1992 and 1996) and, i n 2 0 0 0, received the societ y ’s Awa rd of Mer it for l i feti me contr ibutions. He ser ves on the ed itor ia l boa rd of t he Jour n a l of S ch edulin g an d Hea lth Ca re Man a ge m e nt S c i e n ce, is a member of the adv isor y boa rd for the R egenstrei f Centre for Hea lthca re En g ineerin g at P urdue Universit y and is an adjunct scientist w ith the Institute for Cl i n ica l Eva luative Sciences i n Toronto. Andriy Kolos has been a research associate with the Centre for Research in Healthcare Engineering since 2006, focusing his efforts on forecasting, wait lists, patient travel and mapping models. Prev iously, the Universit y of Toronto engineering graduate worked on a collaborative radiology system improvement project with three Ontario hospitals : Ross Memorial in Lindsay, Northumberland Hills in Cobourg, and the Peterborough Regional Health Centre.

Volume 1 • No 4 | September 2009

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Canada’s medical isotope crisis: A way forward
By Jatin Nathwani, PhD, P.Eng. Editor’s note: The headlines over the recent closure of the Chalk River reactor that produced isotopes for hospital patients around the world were naturally dominated by the medical fallout. The political name-calling between the government and the opposition over the handling of the issue also competed for public attention. Lost amid the scare stories and mud-slinging was the reasoned voice of one of the province’s leading engineers. This paper is based on Jatin Nathwani’s testimony before the House of Commons Committee on Natural Resources in June.

Executive summary
Jatin Nathwani, executive director of the University of Waterloo Institute for Sustainable Energy, appeared before a Commons committee on June 18, 2009 to urge the government to remain in the isotope production business. Nathwani argued that too much is at stake to abandon an industry in which Canada, until recently, was a world leader. He called for the resurrection of the troubled MAPLE reactors, saying their technical concerns can and need to be resolved in the national interest. Nathwani also called for a more reasoned debate about nuclear technology. He urged the politicians to judge nuclear technology on the basis of its “net benefit” and not to succumb to popular anti-nuclear sentiment.

Introduction
The shutdown of the National Research Universal (NRU) reactor at Chalk River, Ontario, has again brought into sharp focus the critical need for a reliable supply of isotopes to our hospitals. The most compelling and difficult issue, however, is the reliability and safe operation of a single aging reactor on which depends the well-being of so many–both in Canada and globally. The realization of such extreme dependency and vulnerability on a single source is a matter of profound shock and incredulity. How did we get into this corner? And what steps do we take next? The current medical isotope crisis that has dominated newspaper headlines is but the simplest and clearest example of how we effectively ignore the benefits of nuclear technology because the political “comfort zone” is too narrow to allow for a more balanced and nuanced response. I will confine my comments to three aspects: 1. the need for a reliable supply of isotopes;

An interior view of the Chalk River reactor. It was the world’s largest source of medical isotopes until its closure earlier this year.

2. technology choices and future options; and 3. some suggestions on governance and public dialogue for acceptance.

The need for a reliable isotope supply
The government’s recent indication to exit from the supply side of isotopes production by 2016 would make us dependent on sources outside of Canada. For a resource this critical to the

overall health and well-being of Canadians, the exit strategy does not appear to be prudent. The provision of a reliable supply of medical isotopes is far too important to have the terms and conditions of supply and prices determined by others. If frustration with current costs is the primary driver for determining exit, what of the higher costs later when we have conceded all control of any assurance of our own supply? Upon exit, we simply become a minor player with no influence. Having enjoyed a

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reasonable degree of success in the global markets, what is the compelling case for jeopardizing our own security of supply? And if we take the long view, could the exit strategy not compromise our ability to control health-care costs if, over time, the use of isotopes continues to become more widespread in medical practice? The fact that Canada has played a leadership role in the development and application of the innovations in nuclear medicine and nuclear technology over the last 50 years is worth noting. Why would we simply walk away? Is there not a case for nurturing our own strengths and putting in place the solutions for realizing the benefits of this technology into the future?

Technology choices and options
One option is a combination of best-effort, short-term fi xes for the NRU reactor. That would allow us to muddle along until 2016 or so. Given the age of the reactor, this is the best that can be done in the short term. But this is not a credible or a sustainable solution for the long term. If we accept that the need for medical isotopes is not about to disappear, a more robust solution is necessary. In light of our current difficulties, it makes sense to revisit the decision to cancel the MAPLE reactors. There are technical issues that need to be resolved to be sure, but a strong recommendation by the House of Commons Committee on Natural Resources to reconsider the decision would pave the way for the resolution of the technical issues. Whatever the business model, whether it is a public-private partnership, government ownership or some other, the goal is to ensure the national interest is taken into account. Atomic Energy Canada Limited halted work on the reactors last year after 15 years and $300 million had failed to yield a replacement for the NRU. Bringing the already built MAPLE reactors to an operating state over the next six to 18 months offers the best prospect for an assured supply of isotopes for Canadian needs.

to the Nuclear Safety and Control Act (NSCA) that would have included a test of “net benefit” to Canada. Such a legislative test would provide a stronger framework and guidance to the regulatory function, clarity of direction to industry and broad public support for a coherent decision-making rationale in the public interest. We cannot allow ourselves to be stymied by “perceived risk of reactor operation,” which places undue weight on hypothetical imaginings and ends up denying patients the healing benefits of the reactor technology. The costs are real, but not astronomical; the risk is not zero, but low–while benefits are large and positive. The trade-off to serve the public interest is clear and simple. There is a small but strong anti-nuclear sentiment that dominates public discourse on matters nuclear. Even though the safety risks are generally very low, the social amplification of risk through the media gives rise to a political and cultural climate that makes it difficult for policy-makers to take a strictly rational approach. It reduces their comfort zone of operation and forces the easier way out–witness the exit strategy proposed by the government. The time has come to shift the terms of debates around nuclear issues and help reduce the social friction so all parties will begin to articulate clearly the benefits of nuclear technologies. Over time, this would create sufficient space in the public sphere for a more informed dialogue.

The current crisis is but the simplest and clearest example of how we effectively ignore the benefits of nuclear technology, because the political comfort-space is too narrow for a more balanced and nuanced response. We create a cultural straightjacket that leads directly to an exit strategy–an easier and quicker response to a problem. However, such a rash decision does not take into account the full consequences in the long term. For Canada, it would be truly unfortunate to walk away from having built and led a successful enterprise around the production of isotopes without a determined effort to fix the shortterm problems. In conclusion, I have four simple recommendations: 1. Confirm the need for a robust and dependable supply of medical isotopes for use in medical practice and whether the trend for increased use is expected to continue; 2. Revisit the decision to cancel the MAPLE reactors. This is a credible path to a robust base for supply assurance long into the future; 3. Amend legislation to include a test of net benefit to Canada in the NSCA. This would provide a strong foundation for balancing difficult trade-offs in regulatory decision making; and 4. Commit to a useful public dialogue on matters nuclear to help create a positive environment for policy-makers to make rational decisions.

Jatin Nathwani, PhD, P.Eng., is a professor and the Ontario research chair in public policy and sustainable energy management in the faculties of engineering and environment at the University of Waterloo. Nathwani has extensive experience in the energy sector at the corporate level, focusing on strategy and policy development, business planning for long-term initiatives, contributions to the evolution of industry structure, management of regulatory affairs and environmental issues and timely integration of strategic R&D into business practice. Recently, he contributed to the development of the Ontario Power Authority’s integrated power system plan focusing on the environmental and sustainability issues relevant to the planning process. He holds a PhD in chemical engineering and applied chemistry from the University of Toronto.

Governance and public acceptance
When I appeared before the House of Commons Committee on Natural Resources on February 7, 2008, I advocated an amendment

Looking for an earlier paper?
Past issues of this publication are available at www.ocepp.ca, while articles are posted individually on the Research page of our site.

Volume 1 • No 4 | September 2009

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Between a rock and a hard place: An engineer’s duty to warn
By Catherine Karakatsanis, P.Eng. Editor’s note: This paper is based on a presentation to the Ontario Bar Association’s environmental law section in June. discipline, and that they are taking responsibility for the outcomes of their work. And that licence holders, themselves, understand their professional obligations–both to their clients or employers and to the general public. Once in a while, however, these obligations will be in conflict. For example, on the one hand, a practitioner is obligated to keep confidential information relating to the business affairs, technical methods or processes of his or her client or employer and must avoid the use of such information to the disadvantage of the client or employer. On the other hand, PEO’s definition of professional misconduct provides that failure to report a situation that a practitioner believes may endanger the safety or welfare of the public constitutes professional misconduct that could result in disciplinary action.

Executive summary
Engineers are unique among regulated professionals in that they have an obligation to take action to prevent any situation involving engineering that might cause harm to the public. This responsibility to the public good is often cited, but poorly understood, even among practising engineers. A large part of the problem is a lack of legal or other clarity as to how this responsibility should be exercised in the real world. Sometimes the practitioner is trapped in an impossible position, with no clear path out. Professional Engineers Ontario (PEO), as the provincial regulator for the profession, must assure the public that licensed engineers are qualified. It must also ensure that engineers are appropriately exercising their obligations to both their clients and the public at large. It is when these two obligations come into conflict that the water muddies, despite the paramountcy of an engineer’s duty to public welfare. An engineer’s challenges in dealing with this thorny issue are discussed by PEO President Catherine Karakatsanis, P.Eng., in her aptly titled paper “Between a rock and a hard place.” Karakatsanis suggests some paths engineers might take when facing potential dangers to society, such as first raising the matter with the client. If that fails to produce a satisfactory solution, the next step is reporting a potential danger to the appropriate authority. But at the end of the day, Karakatsanis acknowledges that public authorities have the final say when dealing with an engineer’s concerns.

Engineers obliged to act
There should be no doubt, however, about how PEO licence holders must act. They must regard their duty to public welfare as paramount. So, regardless of the scenario, the obligation of a licensed engineering practitioner is always the same: if he or she believes that a situation represents a danger to the safety or welfare of the public, he or she must act to correct or report the situation. In reporting the situation to an appropriate authority, the practitioner is not, however, obliged to disclose all the details about his or her client or the tasking. That is, he or she does not have to reveal the client’s identity, or provide details about the work he or she was undertaking when the danger to the public became apparent. Similarly, he or she would not have to disclose any report produced for the client. However, whatever evidence led the practitioner to the conclusion that there is a potential danger should be provided. As noted, it would be professional misconduct, specifically under section 72(2)(c) of Regulation 941, for a licence holder to fail to report such a situation. Of course, in a disciplinary hearing arising from any such alleged misconduct, the burden is on PEO to prove the practitioner actually believed a danger existed and failed to act–clearly, not an easy thing to do. It has been very rare for this particular scenario to form the basis of a disciplinary hearing. This is largely due to the fact that professional engineers take their “duty to report” obligations very seriously.

Introduction
The ancient Roman engineers had a wonderful tradition for assuming accountability for their work. Whenever an engineer constructed an arch, he assumed responsibility in the most profound way possible. As the keystone was hoisted into place, he stood under the arch. Now, unlike in Roman times, licensed practitioners, which include professional engineers and holders of temporary, provisional and limited licences, aren’t asked to stand behind–or under–their work in such a literal way. They are, however, held professionally accountable in as strong a fashion. How, exactly, does PEO, as the provincial regulator, hold its licence holders responsible for their actions and handle issues of reporting situations that represent a danger to the public? For 87 years, the Professional Engineers Act has set the bar for practice in a profession in which the public welfare and safety–in its broadest sense–is paramount. Public safety and the public good are the key focus of the years of education, training and supervised experience that go into making the now more than 71,000 professionals who practise within 41 engineering disciplines. As the regulator of engineering in Ontario, PEO’s role is to assure the public that licensed practitioners are competent to practise in their chosen
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A recent example
A relatively recent case, however, demonstrates the extent to which licence holders can be held accountable. In 2002, a consulting engineer, John Yat-Man Kwan of Markham, Ontario, was selected as an independent party to investigate alleged construction deficiencies in a home under construction in Ajax. The homeowner had concerns that certain construction items appeared not to comply with his understanding of the Ontario Building Code and CSA standards. Kwan, hired by the builder at the urging of the town to settle the dispute between the homeowner and the builder, was responsible for reporting on the alleged deficiencies.
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In his report, Kwan noted some, but not all, of the actual deficiencies. Later, in sealed documents, he incorrectly stated that all remedial work had been identified and subsequently rectified by the builder. The homeowner, however, observed that certain deficiencies were left uncorrected by Kwan. The homeowner consequently engaged another consultant to check the work allegedly inspected by Kwan. In his final report, the second consultant noted several instances where the original inspection reports issued by Kwan stated that the finished work complied with the applicable CSA standards and the Ontario Building Code when, in fact, it did not. Based on these facts and a plea agreement entered into by Kwan, PEO’s Discipline Committee found him guilty of professional misconduct for: • negligence; • failing to report construction deficiencies that he knew, or ought to have known, were in violation of the Ontario Building Code; • providing information in an inspection report that he knew, or ought to have known, was incorrect with respect to completion of the remedies stipulated in an earlier report; and • acting in an unprofessional manner. As a result, Kwan received a penalty of a reprimand, a requirement to write and pass PEO’s professional practice examination within a fixed time frame or else face suspension or revocation, and an order to pay costs.

a clearly defined responsibility to regard their duty to public welfare as paramount, above their obligations to clients or employers. The Code of Ethics is a basic guide to professional conduct and imposes duties on practitioners with respect to: • society; • employers; • clients; • colleagues (including employees and subordinates); • the engineering profession; and • himself or herself (a duty to oneself is a reflection of the integrity that PEO expects of practitioners). This code has no legal weight at present. Section 72 of Regulation 941 excludes from the definition of professional misconduct “an action that is solely a breach of the Code of Ethics.” The PEO Code of Ethics is essentially “unenforceable” to the extent that no disciplinary action can arise from a breach of only the Code of Ethics. But section 77 of Regulation 941 states that: “A practitioner shall regard the practitioner’s duty to the public welfare as paramount” and that, “A practitioner shall maintain the honour and integrity of the practitioner’s profession and without fear or favour expose before the proper tribunals unprofessional, dishonest or unethical conduct by any other practitioner.”

Professional obligations, ethical principles
Although a licensed practitioner’s ultimate responsibility to public safety is clear, there is no set procedure for discharging this responsibility. Our licence holders’ duty to report is founded on certain professional obligations and ethical principles found in the same Regulation 941, which defines professional misconduct as “failure to act, to correct or report a situation that the practitioner believes may endanger the safety or the welfare of the public.” In most cases where professional conflict occurs, it is resolved simply by informing the client or employer of the situation and working with them to determine an alternative, acceptable course of action. In some cases, the approach to the client or employer may have to be reinforced by citing the requirements of applicable legislation, including the Professional Engineers Act or the Ontario Building Code. In the rare case where there’s a stand-off with the client or employer, the practitioner must consider taking more drastic action with highly increased personal jeopardy. PEO does not have provisions to protect whistleblowers and it is possible that reporting a dangerous situation to a responsible authority could result in punitive action against the engineer.

Exercising the duty to report
The obligation to correct or report a situation that a practitioner believes is a danger is absolute. In fact, there are few serious breaches of the Code of Ethics that are not captured in some way in the legal definition of professional misconduct, as there is considerable overlap of subject matter between the two sets of obligations. Nevertheless, some of the regulation’s wording raises questions and issues, such as: • To whom must a situation be reported? • What form should the reporting take? • What’s the difference between a danger to public safety and a danger to public welfare? • What if whomever the practitioner reports the situation to doesn’t take any action? and • What if someone else believes a danger may exist, but the practitioner doesn’t agree?

Taking action
Beginning with the first question: PEO’s advice to practitioners is that the situation must be reported to an individual or organization in a position to take corrective action. This may be as simple as reporting to someone more senior in the licence holder’s organization. However, the individual or organization to whom a practitioner is considering reporting a situation must be free from bias in the circumstances– meaning the individual or organization should not have an interest in not taking action. Ideally, a situation should be reported to the regulatory authority having legislated responsibility and jurisdiction, such as a municipal building official, a government agency or ministry. There is no particular

Sense of duty
Nevertheless, we expect our licence holders to act out of a sense of duty, with full knowledge of the effect of their actions, and to accept responsibility for their judgment. They are encouraged to raise their concerns first with their employers or clients in an open and forthright manner before reporting the situation to a responsible authority or, ultimately, to PEO. In addition, PEO’s Code of Ethics supplements the legal obligation to public safety and welfare. According to the code, practitioners have

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format for a report of this nature, except that it should be in writing and the practitioner making the report should keep a copy. The reason for believing a danger exists should be clearly explained as should the potential consequences of failure to take action. Sufficient information, such as field data or photographs, should be provided to the authority to properly convey the concerns of the professional engineer and enable the authority to take corrective action. The professional obligation to report relates only to matters that a practitioner believes may endanger public safety or welfare. Generally, a situation endangering public safety will have the potential for acute harm or injury and present an imminent risk. A situation endangering public welfare, on the other hand, is one that has the potential to have negative consequences for society’s well-being in a range of areas, such as health, the economy or public order, and may also include safety, but that risk will be over the long term. If the regulatory authority chooses to take no action, the decision to further escalate a report to an even higher authority is at the discretion of the practitioner and is not required as part of fulfilling his or her professional obligation under Regulation 941. PEO acknowledges that our licence holders do not have the final say in all matters relating to public safety and welfare. Also, PEO recognizes that their judgment may be overruled by a responsible

authority for reasons of public policy, economy or other considerations. Indeed, even PEO’s registrar has no powers to compel a responsible authority to heed the concerns expressed by a practitioner. Engineering practitioners are the only regulated professionals with a positive duty to act to correct or report a dangerous situation. It is this selfless regard for the public welfare that sets professional engineers apart and keeps them in high regard in the eyes of the public and government.
Catherine Karakatsanis, P.Eng., is president of Professional Engineers Ontario for 2009-2010. She is also a senior vice president and board member at Morrison Hershfield Limited, where she heads up the building and facilities division that provides multidisciplinary engineering expertise to the commercial, institutional, residential, industrial and public sectors. After graduating with bachelor’s and master’s degrees in engineering science from the University of Western Ontario, Karakatsanis became a research assistant at Western’s Boundary Layer Wind Tunnel Laboratory. She has been an active volunteer in the engineering community for more than a decade, having served on the board of the Ontario Society of Professional Engineers (OSPE) for five years and as OSPE president and chair. In addition to her role as president of PEO, she is a member of the boards of the Ontario Professional Engineers Foundation for Education and Western’s faculty of engineering advisory committee.

The Green Energy Act and the future of sustainable electricity in Ontario
By Colin Andersen Editor’s note: This paper was presented at the OCEPP policy conference in Toronto on May 8, 2009 prior to the passage of the Green Energy Act on May 14. Thank you, Kim Allen, registrar and CEO of Professional Engineers Ontario, and Donald Wallace, OCEPP executive director, for the opportunity to join you today. Unlike [then] Research and Innovation Minister John Wilkinson earlier, who had only had a half cup of coffee before delivering his address, I have managed to have two cups of coffee today. However, I can’t promise that my speech will be four times better! I would like to begin by commending the Ontario Centre for Engineering and Public Policy and Professional Engineers Ontario for your efforts to foster the connection between engineering and public policy. Professional engineers have a lot to contribute to policy development, and it’s great to see your organizations working to provide a strong voice for the profession in this area. For those unfamiliar with the Ontario Power Authority (OPA), our mandate is to secure a reliable and sustainable electricity supply for the province. To that end, we focus on three key areas of activity: promoting electricity conservation and efficiency; planning the province’s electricity system for the long term; and procuring new supply resources. The [then] proposed Green Energy and Green Economy Act has two tracks: increasing the roles of conservation and renewable energy in meeting Ontario’s electricity needs. So our mandate and the goals of the [then] proposed act are closely connected. The act is truly leading edge in North America and is providing an opportunity that doesn’t come along very often. It’s bringing together as partners governments, electricity producers, distributors, transmitters, academics, industry, businesses, communities and concerned citizens in developing solutions to our energy challenges. The challenge for all of us is to collaborate, to be ready and to not miss this unique opportunity. But, arguably, the Green Energy Act presents its greatest opportunities, in fact, to the engineering sector. The [then] proposed act’s focus on renewable energy sources and environmental sustainability coincides with the need for a fundamental renewal of Ontario’s energy infrastructure. It will stimulate new industry and bring new opportunity. Engineers will play a critical role in the design, construction and operation of both projects and systems associated with this new infrastructure. For the engineering sector, the act undeniably brings challenges. Renewable generation is quite different from coal-fired electricity and other power sources. Unlike a large coalfired plant, for example, renewable energy is by nature decentralized and geographically distributed. It will require new approaches and

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innovative solutions to integrate these new technologies into an existing system. But, fundamentally, the engineering role will not change. Problem solving and the drive to maintain project integrity will remain at the core of what you do. And many of the changes in the Green Energy Act have been implemented–successfully–in other jurisdictions. Western Denmark, for example, currently meets 50 per cent of its electricity needs through wind power. I have full confidence that Ontario’s engineers will be able to make renewables work here in an Ontario context. A major component of the [then] proposed Green Energy Act is the creation of a Feedin Tariff Program (also known as FIT). The

OPA has been hard at work getting ready to launch North America’s most comprehensive FIT program next month. Some of you may have participated in our weekly workshops helping to design the program. The FIT program is aimed at encouraging investment in renewable energy projects through the creation of a simplified contracting process and standardized prices. These prices are intended to cover all capital, operating and maintenance costs, while offering a reasonable rate of return over a 20-year contract period. The act also [puts in place] a streamlined environmental approvals process that will make it easier to bring valuable renewable energy projects to life–another area where engineers come in.

A second track in the act, but always first on the list for the OPA, is conservation. You may be aware that the province has set a conservation target that is the most aggressive and ambitious in North America–and arguably the world. Our target reduction of 6300 megawatts in peak demand by 2025 will take care of three-quarters of our projected growth in demand over the period. To put it another way, it is equivalent to removing one in five electricity users from the grid. Assuming its passage, the Green Energy Act will initiate concrete action that will help us to meet–if not exceed–this target. Improved energy-efficiency codes for buildings and standards for equipment and appliances have the potential to contribute as much as 50 per cent

Hold that date!
Information session Interested in running for public office?
October 14, 2009, Toronto Engineers who are interested in seeking election as an MPP , or assisting engineering colleagues to do so, are invited to attend the 2009 Engineers Candidate College co-hosted by Professional Engineers Ontario and Engineers Canada. Elected politicians and campaign specialists will offer valuable insight as well as practical information gleaned from their many years of experience.The session will be held at PEO’s Toronto office (25 Sheppard Avenue West, Suite 1000) from 5:30 to 9:30 p.m. To register, please contact kendra@brown-cohen.com. Space is limited. No charge.

A photo from a previous candidate college. The October 14, 2009 event presents another opportunity for engineers to learn the tools and knowledge needed to get more politically active.

Symposium Ground source heating and cooling
October 20-21, 2009, Woodbridge This two-day event will explore a range of information and issues such as the history of ground source heating and cooling systems, an update on provincial regulations and approvals, and environmental benefits. Guest speakers include Grant Ferguson, PhD, (St. Francis Xavier University), Aart Snijders (IFtech, Netherlands) and Bill Wong (SAIC). The event is sponsored by the hydrogeologists of the Conservation Authorities of Ontario and it will be held at the Kortright Centre for Conservation (9550 Pine Valley Drive, Woodbridge). Symposium fees are $300 ($250 by September 20) and $50 for students. Online registration and conference details are available at events.Signp4.com/geoscientists.

Presentation The Arctic: Challenges and opportunities in Canada’s backyard
October 28, 2009, Ottawa Peter Harrison, PhD, director of the School of Policy Studies at Queen’s University and a former federal deputy minister, will deliver a dynamic and highly informative presentation on some of the issues and opportunities Canada faces regarding the Arctic. The event will be held at the Canada Science and Technology Museum (1867 St. Laurent Blvd., Ottawa) from 6 to 8:45 p.m. Wine and cheese and a discussion of fascinating Arctic artifacts with museum curators will precede the presentation. Space is limited and early registration is encouraged. For registration information and other details, please see the flyer on the Events page of www.ocepp.ca. No charge.

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of the target reduction in peak demand. The act will make energy efficiency a central tenet in Ontario’s building code, and it will introduce North American-leading Energy Star efficiency standards for household appliances. It also proposes steps to green our public sector buildings, positioning these facilities as positive examples for the rest of the province. The act will also assign new responsibilities for local distribution companies in meeting conservation targets and planning their systems. My father was an engineer; all my life I seem to have been surrounded by them. As OPA CEO, I work with a lot of engineers. And when I was deputy minister of policy and finance–it’s nice to see [PEO councillor] Thomas Chong here, who’s representing your largest region–I dealt with a lot of big infrastructure projects like the Toronto subway extension and hospital planning. In the lead-up to today, I talked to a few engineers at the OPA and at other electricity agencies–JoAnne Butler, our VP of procurement, and Paul Murphy of Independent Energy System Operator, in particular–about the evolving role of the engineer in what we do. There once was a time when engineers talked almost exclusively with engineers–benefiting from a common language, background, expertise and technical understanding. Now, when working on a project, the disciplines interact more throughout the stages of a project, meaning engineers may end up dealing with: • business development–lawyers and financiers–on the contracting; • economists–on the planning; • communicators–on the stakeholder engagement; and • accountants–you certainly can’t forget them. You can imagine the fun that ensues when we’re all in one room at one time. All of these professions each have their own language, perspectives, objectives, ways of planning and consulting–even their approach to solving a problem. What does this mean for engineers (and all the professions really)? It means you have to be careful listeners. It means you have to confirm understanding–don’t presume even basic understanding. Realize that there are many, many different ways of decision-making. And the fact that it isn’t necessarily logically
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and orderly laid out, the way an engineer may approach it, isn’t necessarily a bad thing, but is a reality. I’ll give you two examples. The first is governments. It’s an easy and regularly made mistake to pass off decision-making uncertainty or slowness as “governments are stupid; let’s throw rocks at them.” What people don’t often realize is that so many planets have to align before any government decision gets made. A decision doesn’t just rest on the intrinsic value of the proposal alone. It’s a real balancing act of many competing objectives. The second example ties in to [Waterloo Provost Amit Chakma’s] comments earlier on the need to be culturally sensitive. First Nations and Métis are playing an increasingly important role in all types of infrastructure. They have a very different way of coming to consensus and approving projects to go ahead. What else does working more closely with other professions mean? Well, training should include as much multi-disciplinary interaction as possible–I would certainly agree with the provost there, too. To tie this back to real life examples from the Green Energy Act, we are experiencing a paradigm shift in planning that will result in a build-out of our system never seen before–an open-ended FIT program, a smart grid with two-way flows of electricity and information, and electric vehicles. We are looking to double intermittent renewable resources. First, there is the physical reality–where the engineers come in, operating the system and planning it. Also, designing and building individual projects, both big and small. Then, there is the intersection with contract design. How do we integrate or marry the physical operation with the economic models or incentives to achieve the best outcomes for the consumer and the ratepayer (who are the same person)? These both interact with social objectives. Green resources may not be the cheapest or the easiest to integrate, but other concerns may take precedence (like jobs). There is also interaction with the political. If engineers can’t figure out how to integrate significant amounts of intermittent resources into our system, the lights may not stay on and companies won’t get paid. Ontario consumers could end up subsidizing the US consumer through cheap exports. All issues with political implications.

If I was going to be frank to this audience– and Donald said I should be–I would say this: you have lots of “natural” advantages–you’re innovative; you’re involved in problem solving; you like to figure out how to do things better; you take the long-term view. But it’s not enough. Sometimes, the input you provide, however well intentioned, can come across as “This is why you can’t do what you’re trying to do.” This isn’t just engineers. It’s lawyers and other professions, too, sometimes. I’ve seen it in all sectors–hospitals, transit and electricity. The engineers who come across as the most relevant are those who change that to “here’s how.” They don’t just answer strictly the question asked (that means people have to know enough to ask just the right questions). They really try to think about what’s behind the question, what the goal is. Don’t expect to operate in a world of clarity and logic. We’re operating in a world of unpredictability and ambiguity. I encourage you to be as collaborative–and patient–as you can. So, these are exciting times for the electricity sector in Ontario and for engineers in Ontario. I believe we have great reason for optimism. In introducing the [then] proposed Green Energy Act, the Honourable George Smitherman, minister of energy and infrastructure, shared his vision of Ontario becoming the world’s leading energy jurisdiction. Through the dedication of professional engineers, and the collaboration of individuals and organizations across the province, it’s a vision that I believe will achieve reality.
Colin Andersen was appointed chief executive officer of the Ontario Power Authority (OPA) in September 2008. Prior to joining OPA, Andersen held a variety of senior financial and policy positions in the Ontario Public Service. Among his most recent jobs: deputy minister, ministry of fi nance; secretary of treasury board; deputy minister, ministry of revenue; chair of the Ontario Financing Authority; and chair of the Ontario Electricity Financial Corporation. He has also served as deputy minister of policy, cabinet office, and acting deputy minister in the Ministry of Health and Long-Term Care. Andersen has an MA in economics from the University of Toronto and a BA (hons) from the University of Calgary.

The Journal of Policy Engagement

What can engineers do to gain better access to the corridors of power?
By Tony Dean Editor’s note: This paper is based on a presentation made by Tony Dean at the OCEPP policy conference in Toronto on May 8, 2009. I’m going to address the way that the process of making policy is changing and has changed very dramatically over the last decade, and how the environment for crafting policy has changed. The more you know about how policy decisions are made, the better placed you are to influence the process. To start, policy is getting more complex. When we think about safe water, when we think about energy policy, when we think about climate change, we’re talking about intensely complicated policy that requires relatively unique skills. The other important thing is that policy is becoming more responsive to citizen expectations and the interests of stakeholders. Certainly during the 20 years that I was in government, I saw a big transition from stakeholders being viewed as people one is forced to deal with to thinking about them as very, very important partners. Governments are increasingly realizing that they can’t do anything really well in the policy or implementation area on their own. There are many more opportunities for influencing and collaborating now than there would have been a decade or two ago… these are opportunities, but they are also necessities. We used to think of policy as relatively local or even provincial. It isn’t anymore. It is local, provincial, national, international and global. When you think about things like climate change and energy and economic development, you see very good examples of that phenomenon. In order to come to grips with these increasingly crosscutting or “wicked” policy challenges and opportunities, governments have been forced to

Executive summary
Once the top civil servant in Ontario, Tony Dean knows first-hand what it takes for an engineer to make an impression on a government policy-maker, whether elected or a government official. Speaking at the inaugural Ontario Centre for Engineering and Public Policy conference, Dean told his audience they are well placed to have influence on government policy-makers. Governments today are concerned about policy implementation and “you are terrific system thinkers, terrific project managers.” He added: “You build delivery chains for a business. We don’t have as much of those skills inside government as we used to. And offering that expertise about implementation and execution is going to carry an awful lot of weight.” But engineers need to first market their skills to the appropriate people. Relationship building is key. “Find the assistant deputy minister,” said Dean. “Find the director. Find the policy adviser who is the key person on the file. Call them up and say, ‘Let’s get together,’ or ‘Let’s chat on the phone about our idea, or your idea, and how we can help you.’”

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Introduction
I love talking about public policy. I worked in it for about 20 years. It’s about how you get things done in government, or how you try to get things done through government. For the last year or so, I have been out of the country working in a number of developing countries in the areas of public policy and public administration. When you come back to Canada, certainly Ontario, you realize very quickly how well endowed we are with government and public administration and with democratic processes, but also with terrific capacity for both developing policy and implementing it.

HERE’S MY INFORMATION:
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SEND TO: info@ocepp.ca or The Ontario Centre for Engineering and Public Policy, 25 Sheppard Avenue West, Suite 1000, Toronto, ON M2N 6S9
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operate much more as a corporation rather than 25 or 26 individual ministries. As a result, developing policy is becoming much more horizontal. That’s important to you because you can’t think any more about just one ministry or one department. Increasingly, we have to work collaboratively across government, with municipalities, with the federal government. When you think about energy policy, when you think about climate change, when you think about safe drinking water or major health issues, this requires collaboration across many levels of government. Such policy-making also involves the professions. It’s not just an afterthought, asking before launch: “What do the engineers think? What do physicians think?” This work has to be done upfront now involving the expertise of, say, the professional engineering community at the design and development stage. Policy-making also includes the nonprofit sector, the voluntary sector, the private sector and, yes, social enterprises as well. In other words, we’re moving much more towards a network or a collaborative approach to policy-making. Another thing: policy-making is becoming more integrative. Ten or 15, maybe 20 years ago, a minister, a premier or a policy adviser would have a good idea, and it would work its way through the system over weeks and months, go to cabinet and, at some last stage in the process, somebody would ask “Well, how much is this going to cost?” And then the financial analysis would be done. And then someone would ask “How are we going to market it?” And then the communications work would be done. Over the last decade, policy-makers at the front end of the process have to think not just about how we implement an idea, but how are we going to explain it? How are we going to market it? How are we going to sell it, and have we got the money to pay for it? So that’s requiring more and more networking and integration inside government and that includes thinking about implementation as well.

I want to return very briefl y to this notion of a porous approach to policy-making. Policy is being made now on a just-in-time basis, reacting very, very quickly to emerging events. Where we used to have months, we’re sometimes given weeks and, in some cases, days to turn around very complex policy products. We can’t do that without help, and we need to increasingly reach out to you and others to get that help. The important point here is that we need to be consulting and working collaboratively at the front end of processes in order to ensure that we’re getting the very best product. That means partnerships. It reflects the fact that government can’t do it on its own anymore. Twenty or 30 years ago, governments were, for the most part, hegemonic–they were the only game in town. There wasn’t a 24/7 media, they didn’t have any powerful stakeholders and powerful opposition. It actually would have been much easier in those days to be really inclusive as government because the risk of being inclusive was low. The forces of the last couple of decades have turned events on their head. You now have massive transparency, instantaneous news coverage, very emboldened, signifi cant and powerful interest groups. Those are driving governments to be more open and inclusive, but they actually make it more difficult for governments to be open and inclusive because the playing field isn’t level. So every time the government goes out with an open, blank canvas and says “Tell us what you think,” it is trying to be open and democratic, but the stakes are high. It cannot be sure about what it will hear (possibly from small but very well-funded interest groups) and how much control it will have over the agenda. While governments are trying really hard to be more inclusive, they’re also doing that in a field in which they’re in very tight competition for ideas and the dominance of ideas. The discourse has entirely changed from where it was some time ago. And, for that reason, it actually makes the notion of democratic government a much more

complicated business than it would have been two or three decades ago. You’re not trying to break into a fortress government of Ontario or a fortress federal government. The doors are far more open than they used to be. Bearing in mind two or three things will probably be helpful in figuring out how to successfully navigate your way through those doors. You’ll be far more successful, and the road will be easier, if you think about the financial implications and where the money might come from as you develop your ideas and your proposals. You should also think about the marketing side. Why it’s a good idea for government. Where’s the political win in this for government? Supplying those ideas to government makes a pretty big difference. Your demonstration of an understanding of the complexity of an issue and your offer to provide hard data and information on what can help the decision-making process is a very helpful and useful way to develop and cement relationships with your colleagues inside government. Your honesty about the weaknesses of ideas and proposals demonstrates integrity on your part. Stepping forward and helping government shore up the weaknesses of a particular policy proposal as opposed to pretending they aren’t there will be appreciated. Every government now is focused on implementation. If there’s one thing that’s really changed in just about every government, in every jurisdiction I’ve worked with, is that the key decision-makers–premiers, prime ministers, deputy ministers and cabinet secretaries–are all gripped with how we can more effectively get policies off a page and into municipalities, into schools, into hospitals, into institutions. It’s all about execution. I know from having worked for the predecessor organization of the Society of Energy Professionals many years ago that you are terrific system thinkers, terrific project managers. You are trained to think about how you get effectively from A to Z in a project management process. You build delivery chains for a business. We

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don’t have as much of those skills inside government as we used to. And offering that expertise about implementation and execution is going to carry an awful lot of weight. Let me leave you with these thoughts: 1. Influencing public policy-making is all about developing relationships, just as is every other area of your life. Find the assistant deputy minister. Find the director. Find the policy adviser who is the key person on the file. Call them up and say “Let’s get together,” or “Let’s chat on the phone about our idea, or your idea, and how we can help you.” 2. Talk about the data. Talk about your expertise. Talk about what you can bring to the project and start an honest dialogue. Just build relationships. It’s critically important because that builds trust. Demonstrate a feel and sensitivity for how tough it is inside government. It’s a crazy place to work. It’s a fantastic place to work, but it’s very busy, it’s very hectic, and people are trying to tackle complex just-in-time policy conundrums in increasingly short times. 3. Look for opportunities to chat, just for the purpose of sharing information. If you’ve done a study, an analysis through your research department, ask those ministries if you can come in and present it directly to key policy-makers. And I would think that eight or nine times out

of 10, the answer is going to be “yes.” They’re going to be pleased to have you there. You’ve got lots to offer. Put your best foot forward and offer it. 4. Offer your support, and don’t forget to offer your willingness to be advocates for a government initiative if indeed it’s brought to implementation. Governments are always looking for third parties to stand up and say, “You know what, that’s a hell of a good idea. We applaud it, premier or prime minister.” Show up on the day the legislation is introduced or the regulations are passed. You can’t estimate how much that is worth to just about any government. 5. Another idea would be for PEO to target the ministries with whom you do the most business and offer to come in at a policy advisor level and talk about the role of the organization, what it does, how it connects with government and how it can help. I think there would be a lot of interest and willingness to do that. When you do write in, copy the minister’s chief of staff. That might help to bring a little bit of pressure, albeit tangentially. 6. When you’ve got a good idea, it doesn’t have a time stamp on it. If you don’t get the government to listen to you the first time, it may just be that there’s not room on the agenda for it. Keep that idea fresh. Wait for the next round of budget consultations

or governments consulting on whatever. Get your idea back on the table. Time and time again I’ve seen that whether in the later stages of developing a budget or a throne speech or a potentially new platform, governments are always looking for good ideas. If you’ve got a good idea, keep going back and you’re going to have a pretty good opportunity to have that idea accepted and implemented.
Tony Dean is a fellow in residence at the University of Toronto’s School of Public Policy and Governance and an advisor on public administration and building capacity for policy and delivery. From 2002 to 2008, Dean was secretary of the cabinet and head of the Ontario public service, a position that was preceded by appointments as deputy minister of labour and deputy minister and associate secretary of the cabinet responsible for policy. Dean has extensive experience in public sector leadership, public policy development, negotiations and mediation, and has written on public administration and leadership for the Public Policy Forum Canadian Government Executive magazine, and for The Guardian newspaper’s magazine Public. Dean was a recipient of the Order of Ontario in 2008. He earned a BA in sociology and social anthropology from the University of Hull, UK, and an MA in sociology from McMaster University.

What can engineers do to gain better access to the corridors of power?
By Matthew Mendelsohn, PhD Editor’s note: This paper is based on a presentation Matthew Mendelsohn made at the OCEPP policy conference in Toronto on May 8, 2009. Deputies, senior civil servants, cabinet ministers and their advisers are constantly asked to do something or listen to a particular piece of advice. The trick is to have your foot in the door beforehand. “If you build relationships to provide information, to provide knowledge, to provide expertise, to build dialogue, to provide access to stakeholder communities,” Mendelsohn said, “then when the time comes for an ‘ask,’ when you do have a particular issue that you would like to raise, you have already established that relationship of trust.”

Executive summary
Another prominent speaker at the Ontario Centre for Engineering and Public Policy’s first annual policy conference was former provincial deputy minister Matthew Mendelsohn. He told the group governments are receptive to fresh ideas from outsiders, such as engineers, despite conventional wisdom to the contrary. “People with specialized expertise, people who can mobilize communities, people who have policy ideas, really can have an influence,” Mendelsohn said.

Introduction
To outsiders, governments often look like a big black box, and it’s not clear how you penetrate them. There is an easy cynicism within the

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public about how government makes decisions and, speaking as someone who’s been outside and inside government, I think it’s too easy to fall into that easy cynicism. While we may be sometimes disappointed in our governments, we should recognize the great benefi ts and luxuries we have to be able to influence public policy, influence government decision-making, and to be living in liberal democracies. Indeed, our governments are remarkably open. It is easy to say governments are closed and I don’t know who to talk to, and that government just listens to a bunch of special interest groups. It’s easy to fall into that patter, but it’s not true. Just about every public servant and elected official, and everyone who works for them, is looking for good ideas. You may disagree with their ideology or their way of doing things, but they are genuinely interested in serving the public interest. Governments are enormously responsive to public opinion. Some people say, “That’s not very good, governments are just listening to polls,” but the flip side is that people with specialized expertise, people who can mobilize communities, people who have policy ideas, really can have an influence. I’d like to review where some of those influence points are. If you visit government websites, you will be amazed at how much information you can find out about what government actually does. They have posted results-based plans or strategic plans–and their budgets. You can see what various units are doing and what policies and programs may be relevant to your work. You can see who’s running them and how you can connect with them and perhaps talk to them and influence them. I recognize there’s lots that goes on within government that you can’t figure out when you look online, but if you want to find out where legislation is in the legislative cycle, if you want to see an org chart of a ministry, if you want to see what the various divisions are in, say, the Ontario Ministry of Training, Colleges and Universities, and who the directors are and what their strategic goals are, and what their accessibility plan looks like and what their major programs are, some of

Engineers who build relationships and trust at Queen’s Park are more likely to be able to influence public policy and government decision-making.

it is delivered in boring language, but a lot of it is there online. If you also speak to people, they will be remarkably willing to tell you what’s going on with programs and delivery. I would encourage people to go into the issue of public policy with an open mind and an open spirit. There’s actually a lot of information out there and a lot of levers that people can push. The main issues I want to talk about are the roles of relationships and trust, perseverance, windows of opportunity and the importance of knowledge.

Relationships and trust
Think about relationships and trust from the perspective of a mid-level public servant or a political staffer or even a cabinet minister. People are always asking them for things. They are often under enormous pressure to deliver. Try to identify issues and frame them

in ways that show what’s in it for them, how it is helpful for them. Every day, all kinds of people ask ministers for things. Every day, all kinds of people ask ministerial staffers for things. People usually do not frame their “asks” clearly enough in the context of what is in it for the person to whom they are speaking. If you build relationships to provide information, to provide knowledge, to provide expertise, to build dialogue, to provide access to stakeholder communities, then when the time comes for an ask, when you do have a particular issue that you would like to raise, you have already established that relationship of trust. Talking to mid-level public servants, executives and managers is important, as is making contacts with the political side. Ministerial staffers and junior-level staff in the premier’s office are enormously accessible

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The Journal of Policy Engagement

at all kinds of public meetings, at all kinds of party meetings, even if you’re not a partisan. They are out there in the public talking to people, understanding public opinion, understanding stakeholders. Every citizen has an enormous opportunity to have conversations with these people, build relations with them and call upon those relationships when necessary. Governments do consultations all the time. Some of those are public, some of those are private, and some of those are worth thinking about. If there’s a new plan, a new piece of legislation, and the minister or a senior official or aide says, “I’m going to call up 12 or 15 people I trust and who have some expertise,” it’s great if you’re one of those 12 or 15 people. If they say, “We should talk to some engineers on this particular policy issue, and I remember these people, they’ve given me good advice in the past and they’ll be giving me good advice in the future,” that is a way to have an impact. Clearly, longterm, enduring relationships, and being a trusted partner rather than just a critic, are very important.

Windows of opportunity
Let me also emphasize the importance of opposition parties and changes of government. Changes of government are enormous opportunities for new ideas, but so is the lead-up to an election campaign when political parties set their party platforms. While it’s tough for a random person to get a meeting with, say, the premier’s chief of staff, it’s probably easier to make contact with political staffers in opposition parties. And it is those political staffers, or the platform committees of opposition parties, who are thinking about ideas, about the initiatives they want to introduce in public policy terms, but also in communication terms in preparation for a next election. So, as you think about relationship building, think not only about the bureaucracy and the party in power. People usually have more time and are not as inundated with demands when in opposition. If you can establish relationships of trust at that time, the foundation is set even more so for you to have influence if political power changes hands.

Knowledge is power Perseverance
As a senior public servant, I worked for years on the issue of employment insurance. Bob Rae, as an NDP premier, worked on it, and Mike Harris, as a Conservative premier, worked on it, and we didn’t make much progress. Now, all of a sudden, there’s a window of opportunity given the dramatic change in economic circumstances. All of a sudden, the federal government is paying attention, or opposition parties are paying attention and, just because you don’t succeed the first time, that doesn’t mean you won’t succeed in the future. I can’t understate the importance of perseverance. And that speaks to people outside and speaks to people inside as well. If you stick with your ideas, eventually public opinion turns, the overall environment changes, and all of a sudden there is opportunity. If you’re prepared to seize those and take advantage of them, those are good opportunities. When we teach people about intergovernmental negotiations, the one thing that is most important is that the person who knows more usually wins. Likewise, it’s enormously important when lobbying on an issue or when trying to persuade people to change policy platforms to know your stuff as well as you can. You need to know the whole range: the policy, the fiscal impact, the communications, the operational, but also who the players are. Who has power? Who doesn’t have power? Are you talking to the person who can make a decision or are you talking to someone who supports someone who can make a decision? If not, you’re talking to the wrong people. You also need to understand the machinery of government, how decisions get made and where things are in the process. If something’s already gone through cabinet, the big decisions have been made. If something has already gone through first reading in the legislature, the big decisions have already been made. You may be able to influence details at a legislative committee, but you’re not going to influence the overall policy direction. Still,

you probably could influence some operational issues at second reading during a legislative committee hearing. Understanding the machinery of government, the decision-making process, who has power, who doesn’t have power and understanding the cycles of government is critical. Learn when there will be pre-budget consultations. Those are enormously good opportunities to have an influence. Engineers have an enormous advantage because you have technical expertise; you have specific knowledge. But decision-makers are going to also want to know that you have thought your idea through. There is nothing worse than saying this would be a great idea and they say, “Well, will it work in practice?” or “Have you thought these things through?” If you haven’t, that’s a problem. Before you seek out changes, make sure you understand all of the various aspects of the option you are advocating and understand whose interest it’s in–and whose interest it is not in. There is nothing worse than lobbying a minister on something and finding out later that they have a well-founded personal position in opposition to your idea.
Matthew Mendelsohn is the founding director of the Mowat Centre for Policy Innovation in the School of Public Policy and Governance at the University of Toronto. Prior to assuming this role, Mendelson served for five years as a deputy minister in the Ontario government where he held responsibilities variously for intergovernmental affairs, the democratic renewal secretariat, and the Office of International Relations and Protocol. He also served as associate secretary of the cabinet in the cabinet office. Prior to joining the Ontario government, he was a member of the political studies department at Queen’s University for more than a decade. While at Queen’s he published widely on Canadian politics and also served as director of the Canadian Opinion Research Archive. Mendelsohn received his BA from McGill University and his PhD from l’Université de Montréal, and he held a postdoctoral fellowship at the University of British Columbia. He is actively engaged in many non-profit organizations and serves as a board member and advisor to several groups.

Volume 1 • No 4 | September 2009

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Shaping Ontario’s energy future:

Charting a path to sustainable prosperity

A presentation by Jatin Nathwani, PhD, P.Eng. Executive Director, Waterloo Institute for Sustainable Energy October 29, 2009, at Hart House, University of Toronto
hat cross-currents shape the issues and policies related to energy, the environment and the economy? How do governments and the energy sector ensure a reliable energy supply that is accessible and affordable to all, while forging policies that promote long-term sustainability, prudent management of environmental impacts, and improved quality of life? These are a few of the key themes that Nathwani will explore, while demonstrating that long-term success requires the right mix of policies that build on innovation, human capital development, and reduced social and political friction between business and industry, levels of government and the community. During his presentation, Nathwani will investigate the key issues and challenges in understanding the current global and North American energy sector trends, and how universities can foster innovation to address the complex energy challenges. In addition, Nathwani will discuss specific nearterm technological innovations in Ontario to transform the energy industry. Nathwani is a professor and the Ontario research chair in public policy and sustainable energy management in the faculties of engineering and environment at the University of Waterloo. He has extensive experience in the energy sector at the corporate level, and recently contributed to the development of the Ontario Power Authority’s integrated power system plan. He holds a PhD in chemical engineering and applied chemistry from the University of Toronto. The event is presented by the Ontario Centre for Engineering and Public Policy, in conjunction with its Policy Engagement Series. Please register early (registration deadline: October 15) as seating is limited. More information can be found on the Events page and Events Calendar at www.ocepp.ca. The fourth and final Policy Engagement Series presentation for this year will be held in late November.

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