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

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Health Human ResourceInfluenza Pandemic
Preparedness Planningin Ontario Partnering for
Success
Expect the Unexpected Are We Clearly Prepared?

• Health Regulatory Colleges,Delivery Stakeholders
  and Government

Council on Licensure, Enforcement and Regulation
2006 Annual Conference
Alexandria, Virginia
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Potential Influenza Pandemic Scenario

• Wont 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.

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Conceptualizing Systemic Impact
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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

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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
• Ontarios 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

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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

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

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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

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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

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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

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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)

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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 professionals 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 professionals 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

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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

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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

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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

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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
• Its (been) worth the effort

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Challenges for the Future

• Assumptions will change with new information
• supply will be the problem (lt 2004)
• absenteeism will be the problem (2006 gt)
• 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

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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

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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_at_moh.gov.on.ca

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Appendix
Presented at the 2006 CLEAR Annual
Conference September 14-16 Alexandria,
Virginia
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Ontario some facts

• Canadas 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 lt 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 Canadas industrial heartland,
  contributing gt 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 worlds
  busiest shipping lanes
• Capital city is Toronto (pop 2.5 million)
• Toronto is the countrys main entry-point for
  immigration, and its communications, commercial
  and financial centre
• http//plasma.nationalgeographic.com/places/provin
  ces/province_ontario.html?sourceG1223
• Toronto was also the continents 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 ? the size of Alaska

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Ontario location
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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
• Ontarios 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/pand
  emic
• Its objectives
• Minimize serious illness and overall deaths
  through appropriate management of Ontarios
  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

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Planning Structure (fall 2005)
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Planning Structure (2006)
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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

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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