Health Human Resource Influenza Pandemic Preparedness Planning in Ontario … Partnering for Success

1. Expect the Unexpected: Are We Clearly Prepared? Health Human ResourceInfluenza Pandemic Preparedness Planningin Ontario …Partnering for Success Health Regulatory Colleges,Delivery Stakeholders and Government Council on Licensure, Enforcement and Regulation 2006 Annual Conference Alexandria, Virginia

2. Potential Influenza Pandemic Scenario • Won’t be like • seasonal influenza epidemics • SARS • avian influenza But 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. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

3. Conceptualizing Systemic Impact Vulnerabilities Strategy Preparedness Components 1. Preventative / protective behaviors Controlling the population attack rate Public Education Prevention Self-help Anti-viral / vaccine availability / delivery “How do I avoid getting it?” 2. “Info” / “Assessment” Centres Caring for the “worried-well” / “not-so-sick” Diversion “Alternate” care in descending order of population health impact “Remote” response capacity - multi-media “Lite” / informal care venues “Do I have it? How bad?” 3. Pandemic-specific care protocols Cross-sectoral behaviour change - how resources are used Limited / no “flex” capacity of formal care system Advance scenarios & “trial-run” practices Adapt “tools”, their use, practice standards “Access to efficient care for the most sick” Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

4. The 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

6. Composition of the Advisory Group Health Services Delivery Sectors Acute Care – rural, urban Community Care Long-Term Care Health Regulatory Colleges Dentists Medical Laboratory Technologists Nurses Pharmacists Physicians and Surgeons Respiratory Therapists Organized Labour Professional Associations Medicine Registered Nurses Registered Practical Nurses Government Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

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

9. Competencies 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

10. The 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

13. III: 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

14. IV: 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

15. Health 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

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

18. References • The Ontario Health Plan for an Influenza Pandemic (OHPIP) 2006 www.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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

19. Speaker Contact Information Frank Schmidt Ministry of Health and Long-Term Care 80 Grosvenor St., Toronto, ON M7A 1R3 416 326-0224 phone, 416 314-2339 fax frank.schmidt@moh.gov.on.ca Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

20. Appendix Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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

22. Ontario – location Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

23. Pandemic 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 atwww.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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

24. Planning Structure(fall 2005) WHO Communicable Disease Surveillance & Response MOHLTC Operation Health Protection: Provincial Infectious Diseases Advisory Committee Emergency Management Unit Ontario Health Protection & Promotion Agency Chief Medical Officer of Health Ministry of Community Safety and Correctional Services Emergency Management Ontario Canadian Pandemic Influenza Plan (CPIP) Ontario Health Plan for an Influenza Pandemic (OHPIP) Steering Committee Public Health Sub-Committee Operations Sub-Committee Communications Sub-Committee I & IT Sub-Committee Surveillance Working Group Laboratories Working Group Health Human Resources Advisory Working Group Vaccines & Antivirals Working Group Supply & Equipment Advisory Group Public Health Measures Working Group Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

25. New! New! Planning Structure(2006) Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

26. Highlights: 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

27. Planning 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 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia