health human resource influenza pandemic preparedness planning in ontario … partnering for success...

Health Human ResourceInfluenza Pandemic

Preparedness Planningin Ontario …

Partnering for Success

Health Regulatory Colleges,Delivery Stakeholders and

Government

2006 Annual Conference

Alexandria, Virginia

Council on Licensure, Enforcement and Regulation

Expect the Unexpected: Are We Clearly Prepared?

Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia

2Potential Influenza Pandemic Scenario

• Won’t be like– seasonal influenza epidemics– SARS– avian influenzaBut important lessons have been learned from each

• Will likely– Start at any time during the year– Happen in waves – the first hitting “a few weeks” after the pandemic emerges– Have a wave duration of 6 – 8 weeks – with a 2nd wave occurring 3 – 9 months

after the 1st

– Experience the majority of infectious cases in the 1st wave– Thereafter, settling into a seasonal pattern

• Probable impacts– Up to 70% of Ontarians infected at some point throughout the full period– Limited (rationed) antivirals, no effective vaccine for a minimum of 4 – 6 months,

and rationed when available, rapid depletion of personal protective equipment (masks, gowns, gloves)

– Healthcare services – particularly acute and critical care – quickly beyond capacity– 20% – 25% peak workplace absenteeism – fear, added in-home care giving– Intermittent community infrastructure disruption: transportation, food, power, fuel,

protective services, etc.


3Conceptualizing Systemic Impact

Vulnerabilities Strategy Preparedness Components

Controlling the population attack rate

Limited / no “flex” capacity of formal

care system

Caring for the “worried-well” / “not-so-sick”

Public EducationPrevention

Cross-sectoralbehaviour change - how resources are

used

Diversion“Alternate” care

Self-help

Preventative / protective behaviors

Anti-viral / vaccine availability / delivery

“Remote” response capacity - multi-media

“Info” / “Assessment” Centres

“Lite” / informal care venues

Advance scenarios & “trial-run” practices

Pandemic-specific care protocols

Adapt “tools”, their use, practice standards

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“How do I avoid getting it?”

“Do I have it? How bad?”

“Access to efficient care for the most sick”


4The Approach to Planning for Deployment

• Combines a population needs-based with a provider capacity and competency-based approach to planning

• This model follows from, and builds on, earlier pieces of work in Canada on:

– Health human resource planning in Atlantic Canada; and

– A Canadian nurse practitioner initiative which focussed on primary health care delivery

• Provides local planners and care providers with information to …

– Describe their anticipated population need, their provider capacity, and anticipate their unique gaps or pressure-points most likely to occur at the time of a pandemic

– Understand how the legislative infrastructure for regulating health professionals (the Regulated Health Professions Act, 1991 – RHPA) organizes “who can do what”, under what circumstances

• And provides a series of key questions to guide them toward appropriate preparedness decision-making now – in the pre-pandemic phase – rather than later – when we get to WHO-phase 6 (“increased and sustained human-to-human transmission in general population”)

• The intent of this approach is not to “count-heads”, but to cause planners and providers to re-think traditional, usage and credential-based health system planning, in preparation for a time when the “normal” will not exist, while making as much use as possible of familiar and practised processes and infrastructure supports


5

Why This Way?

• No / limited “usage”-base of information to plan on – 1918, 1957, and 1968 were all distinct, and occurred in very different times

• It will be a public health emergency – naturally lends itself to a population-needs-based analysis

• There will be more demand than response-capacity – by a wide margin – and a need to “think-outside-the-box”

• “Normal” surge response planning will fall short

• The surge will be protracted – unlike most emergencies which tend more toward the episodic

• Ontario’s health regulatory framework is a “controlled acts” model, already featuring multi-profession access to designated controlled acts through mechanisms for sharing responsibilities

• The belief that health workers who do not normally provide influenza care still possess relevant competencies that would be of great assistance in the care of flu patients

• The approach was intended to identify and create potential to deploy these competencies, as well as the competencies of health care workers who normally provide influenza care, in the most efficient manner

• The experts recommended it


6Composition of the Advisory Group

Health Services Delivery Sectors

Acute Care – rural, urbanCommunity CareLong-Term Care

Health Regulatory Colleges

DentistsMedical Laboratory TechnologistsNursesPharmacistsPhysicians and SurgeonsRespiratory Therapists

Organized Labour

Professional Associations

MedicineRegistered NursesRegistered Practical Nurses

Government

Broad-based, Senior-Level Membership

Commitment Evident

Effective Working Relationship


7

Anticipated Benefits

• A structured way to prepare in advance – based on local evidence (analysis of need based on independent measurement of potential demand, supply)

• A way to optimize to the fullest degree possible all available on-the-ground competencies

• A means to identify key areas of expertise – scarce and / or hard to replicate• Potential for tactical deployment of resources• A way of modeling in advance for alternative contingency management

deployment approaches before they develop into on-the-ground emergencies

• Opens potential for strategically “enhancing” available competencies– Retirees– Students– Other volunteers

And because it’s happening now …

• Hopefully time for preparing for challenges anticipated in implementation– Needs for training– What to do about liability


8

Components of the Approach

• The “analytic framework”

– Competencies needed / Competencies available

• The “tools” for planners and others

– I: Competencies to do what?

– II: Who can do what, when?

– III: What can I (as a health care professional) do?

– IV: Volunteer planner resource package

• Planning Activity Considerations for Health Regulatory Colleges


9Competencies needed / Competencies available

• Considers the spectrum of skills, knowledge and judgment (competencies) that people will need to care for those affected by the outbreak

• It is about sorting out the competencies that are required and those competencies available to deliver the services that people need to meet their health needs during an influenza pandemic

• Questions guide planners in applying the model to determine their requirements, supply and potential gaps


10The Tools for Planners and Others

To give effect to the competency-based approach, the tools to be described were designed to:

– Assist planners, health care providers, volunteer organizations and health regulatory colleges and their members to better appreciate the various roles in influenza pandemic planning

– Provide opportunities for, and assist in structuring local planning discussions leading to better preparedness

– Provide a bridge between the planning framework and the real world of influenza pandemic planning and care


11

I: Competencies to do What?• Provide / support patient care of flu victims• Identifies the Influenza Care Competencies (ICCs), under

categories:– Administrative / support (staffing, health records, pharmacy, medical

imaging, labs, nutrition …)– Transportation– Education – staff / public– Infection control / occupational health and safety / surveillance– Care for well persons (immunization, antiviral prophylaxis)– Care for ill persons

• Gives suggestions to planners on applying competency approach to pandemic preparations– Competencies in assessment / diagnosis most difficult to assess and

supply– Single technical skill capacity generally not useful– Team approach to care likely to be most effective – ideas on

structuring teams for greatest effectiveness– Will be influenced by “externalalities” such as care setting (physician

office, clinic, emergency department, “alternate” care sites)


12

II: Who Can Do What, When?

• Gives planners an overview of who can do what influenza care competencies (ICCs) in terms of controlled / authorized acts in the Regulated Health Professions Act, 1991 (RHPA)

• Identifies those ICCs that are among the 13 controlled acts scope of the Act, and those which are not – i.e.; those within the “public domain”, and

– for the former, identifies which of the regulated health professions (and paramedics), are authorized to perform those ICCs; and

– if they are authorized to perform them, whether they can self-initiate, or only perform by order or regulation

• Profiles additional factors to consider regarding an individual professional’s competence to perform ICCs, despite them being within scope of practice:

– specific education / training / experience to perform controlled, and “public domain” acts– practice restrictions established by other legislation (i.e. Public Hospitals Act, etc.)

• Many of the ICCs are in the “public domain” category. Despite this, most require some degree of education, training and judgement to be done effectively

• Just because an ICC that is also a controlled act may be in an individual professional’s scope of practice, does not necessarily mean that individual is competent to perform the ICC – their own professional judgement of self-competence must be considered


13III: What Professionals Can Do

• An approach to self-assessment to get health care providers thinking in advance of an influenza pandemic about how they might contribute within the context of influenza care competencies (ICCs)

• Two components:– A three-fold assessment of personal

abilities as they relate to the ICCs and key questions for individuals to consider regarding their professional / personal circumstances with respect to involvement in responding to a pandemic; and

– an RHPA controlled acts / ICCs decision tree (the graphic) that places the ICCs within the regulatory context for individuals and provides an accessible overview of certain key questions and consequences in assessing personal abilities to assist in an influenza pandemic

Influenza Care Competencies Self-Assessment- Part II

RHPA Controlled Act/ICC Assessment

In what practice settings am I able to assist? - Hospitals ICUs Stepdown units Wards Emergency Rehab Palliative Care Out-Patient Clinic Other Administration

- Long-Term Care Facilities - Retirement Homes - Community Clinics - Public Health - Hospice - Pharmacy - Laboratory - Private Practice - In Home - Rural/Isolated Areas

Does my profession do any of the controlled acts necessary for the Influenza Care Competencies (ICCs)?

Can I be trained and/or educated to perform any of the controlled acts necessary for ICCs?

What training and/or education is available to me to acquire ICCs? - Self-Instruction? - Clinical? - Theoretical? - Supervision/Mentor?

Can I do Public Domain activities of ICCs?

Are there any terms and conditions on my Certificate of Registration which prevent me from performing these controlled acts?

Do I have the necessary competency (skill knowledge and judgment) to perform these controlled acts?

Can the terms and conditions be removed?

Do I regularly perform these acts and ICCs?

In practicing the ICCs, do I feel competent to perform these activities: - By myself?

- In a Team Setting? - With Supervision?

What training and/or education is available to me to acquire ICCs? - Self-Instruction? - Clinical? - Theoretical? - Supervision/Mentor?

YES YES

NO

YES

NO

YES

NO

NO

YES

YES

NO

NO

NO

YES

YES


14IV: Volunteer Planner Resource Package

• For health planners, leaders and managers within health care facilities and senior leaders of volunteer agencies and organizations on helping to support a volunteer response in an influenza pandemic

– Volunteers are defined as those who have not completed formal health professional training, who receive no direct monetary compensation, and who are available to provide assistance during a pandemic in a formal or informal health care setting

• Content:– A synthesis of and rationale for the needs- competency-based approach– Advice on determining which ICCs will be required / supplied by each voluntary

group; developing job descriptions and recruiting; screening; orienting; training and retaining volunteers

• Uses a “key questions” format, similar to the analytic framework– Draws heavily on the rich international voluntary sector library, incorporating

lessons learned from diverse previous emergency management experiences (e.g.: previous influenza pandemics, SARS, the Sumatran tsunami, hurricanes Katrina, Rita and Wilma)

– Appendices containing resource information, such as:• Sample volunteer position descriptions, request for volunteers form, volunteer

application form, volunteer screening procedures• List of Ontario volunteer centres• Canadian Code for Volunteer Involvement


15Health Regulatory College Planning Considerations

• Planning Activity Considerations to support health regulatory colleges, individually and collectively, in their creating action plans to support a consistent, co-ordinated provincial response

• Three themes:

– Communications• e.g.: consideration of appropriate communications strategies with college

staff, councils and members with accompanying infrastructure(s)

– Regulatory• e.g.: consideration of the establishment of complementary guidelines and /

or policies for influenza care during a pandemic as between regulatory colleges

• e.g.: consideration of the development of coordinated policies on the delegation of controlled acts during an influenza pandemic

– Corporate• e.g.: consideration of ability to provide and maintain critical college

operations during a pandemic


16

Lessons to This Point

• Partnership has been essential– To “ground” planning in realities of care delivery– To provide support for “order and leadership” in what needs doing

to get ready– To champion conceptual approach

• The “normal” can guide planning for the unusual– It is the accepted standard for quality and safe practice– Qualities that still need to be uppermost despite extreme pressures– It is (somewhat) familiar to all concerned

• Not a slam-dunk– Real – purposeful – differences in perspective– Potential of the scenario unifies– Listening … accommodating have been Important– It’s (been) worth the effort


17

Challenges for the Future• Assumptions will change with new information

– “supply” will be the problem (< 2004)– “absenteeism” will be the problem (2006 >)

• Ethical choices– Finding the “right” balance – quality and safety in extreme practice conditions

• Additional supports needed to “land” it– Recognize that this approach is new – and not the way people think now in a day-to-

day practice context

– The “best approach” may be to identify roles where capacity will be drained first, and plan first-level replacement providers who could move into those roles with supports, then identify who could replace the roles of the first-level replacement providers, etc.

• Advance preparation– Training, supervision, care plans– “just-in-time” – but how much time?

• Acceptance – the “reality” will be different from the scenarios, the modelling, the imaginings and the press

• Health Human Resources will be stretched beyond capacity across all sectors and jurisdictions – mutual aid across jurisdictions will be minimal if any

• WE STILL NEED TO PREPARE


18

References

• The Ontario Health Plan for an Influenza Pandemic (OHPIP) 2006www.health.gov.on.ca/pandemic

• The Canadian Pandemic Influenza Plan (the Public Health Agency of Canada)http://www.phac-aspc.gc.ca/cpip-pclcpi/index.html

http://www.phac-aspc.gc.ca/cpip-pclcpi/index.html


19Speaker Contact Information

Frank SchmidtMinistry of Health and Long-Term Care 80 Grosvenor St., Toronto, ON M7A 1R3416 326-0224 phone, 416 314-2339 [email protected]

Appendix



21

Ontario – some facts• Canada’s 2nd largest and most populous province (12¼ million) *(see note 1 below)

• Larger in area than France and Spain combined *(see note 2 below)

• 90% of the population live on < 15% of the land – within 100 miles of the St. Lawrence River, and along the north and north west shores of Lake Ontario

• Ontario is Canada’s industrial heartland, contributing > 40% of GDP

• Major industries are auto manufacturing, mining, and forestry

• The St. Lawrence Seaway gives direct continental access to the Atlantic, and is one of the world’s busiest shipping lanes

• Capital city is Toronto (pop 2.5 million)

• Toronto is the country’s main entry-point for immigration, and its communications, commercial and financial centre

http://plasma.nationalgeographic.com/places/provinces/province_ontario.html?source=G1223

• Toronto was also the continent’s epicenter for the 2003 SARS outbreak

* Note: 1. slightly less than the population of Pennsylvania

2. In more familiar terms, 55% larger than Texas; or a bit more than ⅝ the size of Alaska




22

Ontario – location


23Pandemic Preparedness Planning in Ontario

• Occurring at federal, provincial and local levels of government: linked to the WHO influenza pandemic planning effort through Health Canada

• Ontario’s provincial plan is modelled on the Canadian plan

• It has been renewed annually since 2004 – the 2006 version viewable at www.health.gov.on.ca/pandemic

• Its objectives:– Minimize serious illness and overall deaths through appropriate management

of Ontario’s health care system– Minimize societal disruption in Ontario as a result of influenza pandemic

• Uses a strategic approach – Be ready: establish comprehensive contingency plans at provincial and local

levels– Be watchful: practice active screening and monitor emerging epidemiological

and clinical information– Be decisive: act quickly and effectively to manage the pandemic– Be transparent: communicate with health care providers and Ontarians


24

Planning Structure (fall 2005)

Canadian Pandemic Influenza Plan(CPIP)

Ontario Health Plan for an Influenza Pandemic (OHPIP)Steering Committee

Operations Sub-Committee

Public Health Sub-Committee

Laboratories WorkingGroup

Health Human ResourcesAdvisory Working Group

Public Health Measures Working Group

Vaccines & AntiviralsWorking Group

SurveillanceWorking Group

Communications Sub-Committee

Supply & Equipment Advisory Group

MOHLTCOperation Health Protection:

Provincial Infectious Diseases Advisory CommitteeEmergency Management Unit

Ontario Health Protection & Promotion AgencyChief Medical Officer of Health

Ministry of Community Safety andCorrectional Services

Emergency Management Ontario

WHO Communicable DiseaseSurveillance & Response

I & ITSub-Committee


25

Planning Structure (2006)


26Highlights: 2006 Version of the OHPIP*

• Organized into 3 parts with stand-alone chapters on– Planning context: background, roles, assumptions, “phase” activities, references– Systemic issues/activities/tools: surveillance, PH measures, the workforce,

antivirals/vaccines, procurement, communications– Context-specific issues/activities/tools: PH, labs, communities, hospitals, paediatric, LTC

• Chapters– Sector-specific: Pandemic Lab Manual (tests available; recommended tests); Pandemic

Plan for Long-Term Care Homes; Paediatric chapter; Acute Services (triage and critical care); Community strategy; Public Health (public health measures, surveillance, infection control)

– System-wide: Surveillance, Public Health Measures, Infection Control and Occupational Health and Safety, Communications, Equipment and Supplies, Antivirals and Vaccines

– Identification of work to be done– Tools– Highlighting of significant changes for 2005 version

• Heath human resource-related sections of interest in the overall plan– Ethical framework– Occupational health and safety– Approach to planning for deployment

* OHPIP: Ontario Health Plan for an Influenza Pandemic


27Planning Process / Milestones

• Process– An engagement of experts and community-based stakeholders– Led and supported by government– Over an 18 month development cycle– Invaluable, “fundamentals”-based – seen by most as an opportunity to

significantly influence and guide operational policy development

• Milestones– Advisory Group concept development – November 2004 to April 2005– Steering Committee / stakeholder acceptance – April 2005– Identifying / developing “deliverables” – April 2005 to September 2005– Steering Committee acceptance – September / October 2005– Request for proposal development – October / November 2005– Consultant acquisition / engagement – December 2005 / January 2006– “Product” drafting / clinical verification – February / March 2006– Stakeholder consultations / verification – March to May 2006– Steering Committee acceptance – May / June 2006

health human resource influenza pandemic preparedness planning in ontario … partnering for success...

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