In 2011 we concluded that AHS made satisfactory progress in implementing our earlier recommendation to establish outcome-based performance measures for non-hospital surgical facilities and use these standards of performance to monitor contracted facilities.

What we found

We concluded that AHS has not made further progress since 2011 and we are repeating our recommendation.

At the time of our audit, AHS’s internal audit team had completed its own audit of systems to monitor and evaluate contracted surgical service delivery. Although our audits were performed independently, the findings produced by both audits are consistent.

What remains to be done

To fully implement the recommendation, AHS needs to:

  • clarify roles and responsibilities for managing performance under non-hospital surgical facility contracts, particularly in the area of service quality and patient outcomes
  • define specific quality indicators that:
  • allow for consistent analysis and benchmarking of quality data across surgical facilities
  • are aligned with requirements of the Health Care Protection Act for the purpose of the public benefit analysis
  • establish a formal process to periodically review performance under contracts, analyze and act on results, and provide these facilities with timely and appropriate feedback

Why this is important to Albertans

Without adequate systems to monitor and manage performance of contracted surgical facilities, Albertans may not receive the quality of healthcare service they should.


We performed our current follow-up audit in early 2014 to determine whether AHS has fully implemented the recommendation.

We conducted our field work between January and April 2014. We substantially completed our audit on April 25, 2014. Our audit was conducted in accordance with the Auditor General Act and the standards for assurance engagements set by the Chartered Professional Accountants of Canada.
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