April 9, 2021 Via Email

In Ontario, the staff at both the central and regional public health laboratories have been called upon repeatedly in crises over the past decade to perform massive test volumes rapidly for Public Health Units and health care providers. SARS, West Nile, and tuberculosis in Toronto’s hostel system are but a few examples. The ability to rise to these challenges reflects the tremendous effort and dedication of the professional and technical staff within the public health laboratory, not withstanding the chronic and increasingly urgent need to stabilize and strengthen these facilities.

Dr. Sheela Basrur, Chief Medical Officer of Health, 20051

April 9, 2021

Via email: [email protected] Hon. Peter Bethlenfalvy President Treasury Board Secretariat Whitney Block, Room 4320, 4th Floor 99 Wellesley St. W Toronto, ON M7A 1W3

Dear Hon. Bethlenfalvy,

Re: Exemption under the Protecting a Sustainable Public Sector for Future Generations Act, 2019 for the bargaining unit at Public Health Ontario

We write today to respectfully request an exemption for Public Health Ontario (PHO) and OPSEU in accordance with s. 27 of the Protecting a Sustainable Public Sector for Future Generations Act, 2019 (the “Act” or “Bill 124”).

1 Basrur SV. Building the foundation of a strong public health system for Ontarians: 2005 annual report of the Chief Medical Officer of Health to the Ontario Legislative Assembly. Toronto, Ont.: Ministry of Health and Long-Term Care; 2005.

Without an exemption, PHO, as an agency under the Crown, is subject to the compensation limits dictated by the Act. An exemption would allow the parties to bargain above 1% total compensation in each year—something that is absolutely vital to maintaining the PHO workforce relative to other major employers of laboratory professionals in the province. Freedom to bargain outside of the Bill’s limits would facilitate the achievement of the government’s public health objectives and would allow PHO laboratory professionals to achieve recognition for their value relative to hospital workers and for their extraordinary contribution to the fight against COVID-19.

Accordingly, OPSEU submits the following three rationales to support its request for an exemption for this bargaining unit:

1. To achieve the government’s public health objectives as first expressed in 2004 after SARS and for the current pandemic.

2. To ensure that the professionals testing Ontarians for COVID-19 achieve a bargained wage rate that reflects the value paid to such work in hospitals.

3. To bestow the bare minimum recognition for the contribution of these members to the fight to overcome the spread of COVID-19.

Background

The Ontario Public Service Employees Union represents over 180,000 workers in a variety of sectors, including the Ontario Public Service, community colleges, the Liquor Control Board of Ontario, the healthcare sector (hospitals, long-term care homes, mental health facilities, children`s treatment centres, community health care agencies), social service and developmental service agencies, the publicly funded school system, ambulance services, and municipalities. Bill 124 applies to more than 165,000 OPSEU members, or over 92%.

As of January 2021, the OPSEU bargaining unit at PHO had 1137 members in the following broad classifications:

Laboratory Technologists: 312 (27%) Laboratory Technicians, Lab Attendants: 535 (47%) Data Entry Operators: 184 (16%) Clerical Staff: 43 (4%) IT/Professional Staff: 63 (6%)

Laboratory testing is the foundation of all other pandemic-fighting efforts. Our members have stepped up day after day, meeting the extreme demand for testing by working overtime, nights and sacrificing their personal and family lives. They have worked 84,060 hours of overtime since February 1, 2020. These laboratory workers conduct more tests than any other laboratory in the province

Without the testing work of these incredible employees during the current COVID-19 pandemic, our province would be faring far worse today. While our laboratory members in public hospitals are also working hard, there is no way they could have stayed on top of the testing needs of this province alone. Our PHO members were the first in the province to begin testing for the virus and are the only ones doing genomic sequencing of the COVID-19 variants for clinical use.

OPSEU members at PHO are long-serving employees whose dedication predates the creation of the Agency. Forty-five percent of our membership have more than 13 years of service. Fifty-five percent have more than 10 years’ service. These highly dedicated individuals have devoted the majority of their working lives in service to public health. OPSEU represents the majority of employees at the agency. They work in 11 locations:

PERMANENT TEMPORARY Location TOTAL FT PT FT PT Hamilton 18 41 7 66 Kingston 22 23 2 47 London 47 40 2 89 Orillia 16 1 17 Ottawa 27 1 44 7 79 Peterborough 11 3 2 16 Sault Ste. Marie 7 2 9 Sudbury 8 1 8 17 Thunder Bay 17 2 19 1 39 Timmins 10 19 29 Toronto 331 7 365 26 729 Total: 514 11 565 47 1137

Rationale #1: To achieve the government’s public health objectives as first expressed in 2004 after SARS and for the current pandemic

PHO was created as a response to the call for the renewal and revitalization of the Ontario public health system in light of the public health disasters of Walkerton in 2000 (E. coli water contamination), SARS in 2003 and food safety gaps in 2004. A series of

3 reports2 called attention to weaknesses in a system which had not adequately anticipated or responded to infectious disease outbreaks. These reports highlighted the need for, among other things, a strengthening of laboratory capacity.

In 2004, the Province launched Operation Health Protection, a three-year Action Plan to rebuild Ontario’s public health system, out of which came the creation of PHO. The stated goal of the Action Plan was to create a “state-of-the-art public health laboratory system.” The Ontario Agency for Health Protection and Promotion (OAHPP) was established by legislation in June, 2007 and began operations in July, 2008. In 2011 the OAHPP adopted the operating name of Public Health Ontario.

In 2006 the Final Report of the Agency Implementation Task Force, entitled From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion, outlined the authors’ best advice on implementing and building the new agency. With respect to the staff that make public health laboratories function, the authors noted that their invisibility relative to other health professionals in the system contributed to their inability to compete for scarce resources. The authors hoped that with the creation of the new Agency that this would change and that a renewed focus on recruitment of these essential workers would be moved to the forefront:

The OPHL today is faced with a pressing shortage in certain critical areas of expertise. This is most acutely felt in those professions in shortest supply, particularly microbiology. The challenges in attracting medical microbiologists, scientists, and medical laboratory technologists to the OPHL are acute and have been for a number of years. Competition is greater for the qualified individuals that do exist and the OPHL has struggled to keep pace with the conditions of employment in place for certain positions in academic health sciences centres and other research centres both within Ontario and nationally. This imbalance is not only shown in terms of remuneration levels for certain positions, but in terms of the culture of research and innovation that many leading scientists now actively seek out when choosing where to work. … The real challenge we see is reshaping, re-equipping and re-focusing the OPHL so that the individuals working in that system are enabled with the tools, processes and support that they require and that we require of them, not just to cope with challenges, but also to feel valued and to excel.

(Ontario, From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion (March 2006), pp. 56, 57 (Exhibit A))

2 The reports on the SARS crisis by the National Advisory Committee on SARS and Public Health chaired by Dr. David Naylor, the Expert Panel on SARS and Infectious Disease Control chaired by Dr. David Walker, and the SARS Commission Reports of the Honourable Mr. Justice Archie Campbell.

These public health objectives of the government have not been fully realized. Indeed, it is not possible to describe the PHO as a “state-of-the-art” “internationally recognized centre of expertise” as long as its workers continue to provide the highest caliber of specialized testing yet are compensated as the poor second cousins of their laboratory colleagues in public hospitals.

Rationale #2: To ensure that the professionals testing Ontarians for COVID-19 achieve a bargained wage rate that reflects the value paid to such work in hospitals

Our laboratory members at PHO have the same education and the same qualifications as their counterparts in hospitals. 71% of our members are in classifications that are identical to those in public hospitals. Their work is essential, which is why they are deemed a hospital for the purposes of the Hospital Labour Disputes Arbitration Act.3

The inequity between PHO and hospitals has existed since the inception of the agency formerly known as the Ontario Agency for Health Protection and Promotion (OAHPP). In each round of bargaining, OPSEU has managed to close the gap incrementally. Absent Bill 124, it would be possible to close the remaining wage gap, allowing PHO laboratory employees to achieve hospital parity for the 2020-2023 agreement.

OPSEU members at PHO not only do similar work as hospital employees, but they do it under increasingly difficult circumstances. Before the pandemic hit, the number of lab workers at the PHO had been declining steadily since 2013. In the fall of 2020 the government provided temporary funding to PHO to hire an additional 500 employees to assist with COVID-19 testing. This increased our membership by 43%, but the demand for tests is much higher. In 2020 the increase in tests performed relative to 2019 was 60%4. Unfortunately for all of us, the way 2021 is going so far, there is every reason to expect the demand for testing will continue to increase. The graph below shows the number of specimens logged in each public health lab since 2014:

3 The Ontario Agency for Health Protection and Promotion is deemed a hospital for the purposes of HLDAA (s.1.o(5)) as is Canadian Blood Services (s.1.1), which we should note, also pays its lab employees wages on par with hospitals. 4 In 2019 2,553,777 samples were processed. In 2020, 4,069,530 samples were processed.

PHO staff were the first to begin testing for COVID-19 beginning in January of 2020. Seeing the potential for demand to outstrip capacity, PHO and the Ministry of Health put out a call for help to private labs and hospitals in late February. Hospitals that answered the call to take on PHO testing paid their workers between 2.3 and 4.5% more than PHO.

In addition to COVID-19 testing, PHO employees conduct the tests that Hospital staff do not have the expertise or equipment to do. This work is called “reference work.” As explained on the PHO website:

PHO’s laboratory is a key component of Ontario’s health system, providing essential services to hospital and community laboratories, public health units, long-term care facilities, clinicians in private practice and private citizens. Many of the tests conducted by PHO’s laboratory, especially those for high-risk infectious diseases, and rare infections, are not available elsewhere in Ontario. PHO is a reference laboratory for the province, meaning that clinicians, institutions, hospital and community laboratories across Ontario look to PHO for specialized laboratory testing. In addition to developing and performing tests, PHO’s laboratory services are integral to the province’s ability to detect and respond to outbreaks, biological incidents

and other public health threats. Many diseases of public health significance are detected by public health laboratory testing. This testing is important not only because it informs clinical diagnosis and treatment, but because it provides critical information to public health officials in controlling the spread of disease in the population. Our services inform and enable public health policy, program and practice.

Our members are also responsible for such crucial and highly specialized work as:

 Parasitology  Susceptibility Tuberculosis testing (PHO is the only lab which can do this)  Bio-terrorism testing (PHO is the only lab which can do this)  Specialized pediatric testing  Confirmatory HIV testing (PHO is the only lab which can confirm result)  Food and water testing to support the health units  Mycology (fungus) testing  COVID-19 validation testing

Our members were the ones who first responded to outbreaks that have devastated communities in our recent past:

- Walkerton water crisis (2001) - SARS (2003) - H1N1 (2011) - Measles outbreak (2016) - Zika virus (2016) (over 26,000 samples received in 2017) - Surgical instrument infection outbreak (2018)

To sum up, our PHO members are the specialists of the laboratory world. This was recognized as early as 2006 when the Agency Implementation Task Force (the authors of From Vision to Action) suggested that tests that had become routine should no longer be performed at the Agency as they could no longer fit within the Agency’s mandate5.

Would a Dermatologist or an Epidemiologist ever accept a lower salary than a General Practitioner? The answer is obvious. Why should this same principle not apply to these highly skilled laboratory workers?

5 Ontario, From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion (March 2006), pp. 60 (Exhibit A)

Independent interest arbitrators have all agreed the gap needs to be closed

OPSEU has resorted to interest arbitration three times since 2008 in order to pursue wage parity with hospitals. In each arbitration award, special market adjustments were awarded in recognition of the need to close the gap.

Arbitrator Gerry Lee made the following observations in his October 2013 award:

…both parties noted that the job rate, that is the highest rate of pay for the respective classifications are approximately 7 - 12% lower in the Employer’s collective agreement than the Participating Hospitals and OPSEU collective agreement. The respective gaps were closed substantially in my last award, which demonstrates how far behind the “market” these respective classifications were at the time of divestment, and why “market adjusted” increases were, and continue to be appropriate for this group of employees; despite the current economic and collective bargaining environment.

Within these classifications the reasons for the differential between the “MLT 1” and the Registered Technologist classifications is exacerbated due to the fact that the Participating Hospitals and OPSEU collective agreement provides for 2 additional steps on the grid.

…

I find that the Parties would have replicated the trend of general increases established by the Participating Hospitals and OPSEU Central collective agreement. The 2.75% increase on April 1, 2013 is awarded to keep pace with the bargaining units’ closest Hospital comparator, otherwise, the gap between OAHPP laboratory classifications will widen in 2013, which would counter the impact and intent of the market adjustments awarded below.

(Re: Ontario Agency for Health Protection and Promotion and OPSEU (October 4, 2013), pp. 5-6, (emphasis added), Exhibit B)

Arbitrator Gail Misra, in the most recent award issued September 2019, summarized the parties’ history and the problem to be solved as follows:

reduced substantially through the Lee awards, there remain significant differences in the rates. As such, market adjusted increases continue to be appropriate for these groups of employees despite the current economic and bargaining environment.

…

(Re: Ontario Agency for Health Protection and Promotion operating as Public Health Ontario and OPSEU (September 16, 2019), pp. 4-5, Exhibit C)

Arbitrator Misra awarded a special increase of 1.5% to Medical Laboratory Technologists, closing their wage gap to 4.5% relative to their hospital counterparts. Senior Medical Laboratory Technologists (MLT 2) were awarded a 1% special increase, reducing their wage gap to 2.5% and the Laboratory Technicians (Lab Attendant 2) were also awarded 1%, reducing their wage gap to 2.3%.

Canadian Blood Services

There is one other another stand-alone employer in the broader public service that employs laboratory professionals represented by OPSEU: Canadian Blood Services (CBS).

Canadian Blood Services is a not-for-profit charitable organization that operates independently from government. It was created in 1997 as a result of Justice Horace Krever’s final report of the Royal Commission of Inquiry on the Blood System in Canada – a Commission created to prevent any future contamination of the blood supply. Canadian Blood Services provides blood and blood products, transfusion and step cell registry services and a transplant registry service. It employs both Technologists and Technicians (Assistants) as well as clerical and other support staff.

The Laboratory Technologists and the Laboratory Attendants at CBS have similar job duties to the corresponding classifications at PHO and public hospitals. CBS pays these

9 workers the same wage as hospitals. Canadian Blood Services understands that it must match the market rate to staff its laboratories.

Wage parity exists across Canada

Wage parity between public health lab workers and public hospital lab workers exists in most of the country. Below is a snapshot of the major public health laboratories in four other provinces. All four have near or complete wage parity between hospitals and public health labs6.

 British Columbia – the Provincial Agreement between the Health Science Professional Bargaining Association and the Health Employers Association of BC encompasses a huge number of health employers. Among these employers are hospitals as well as the B.C. Centre for Disease Control. There is a single pay grid for Medical Technologists working in all workplaces listed in Attachment A of the collective agreement.

 Alberta – the collective agreement between the Health Sciences Association of Alberta and Alberta Health Services covers the entire province of Alberta, including the two public health laboratories in Calgary and Edmonton. Medical Laboratory staff get paid the same regardless of whether they work in hospitals or public laboratories.

 Saskatchewan – the description of the Roy Romanow Provincial Laboratory is very similar to that of PHO. This facility is part of the public service and is captured in the collective agreement between the Saskatchewan Government and General Employees’ Union (SGEU) and the Government of Saskatchewan. A system of “supplemental” increases has been a feature of the collective agreement for quite some time. The Supplemental Salary range for Lab Technologist is regularly pegged to that of hospitals.

 Manitoba – in this province all diagnostic services outside of the civil service fall under the umbrella of a crown corporation called Diagnostic Services of Manitoba. A restructuring of health services is underway in Manitoba and DSM is now referred to as “Shared Health”. Cadham Provincial Laboratory, which does the same kind of testing as PHO, is found under the civil service agreement. The collective agreement between the government and the Manitoba Government and General Employees Union (MGEU) has a special clause that ensures pay equity between Medical Laboratory Technologists covered by the government employees’ Master Agreement and wages outside government in the health field.

6 The following information comes from one-on-one conversations with staff in the provincial unions that represent medical laboratory employees.

The above evidence clearly demonstrates near universal agreement that public sector laboratory professionals should be paid equally, regardless of their workplace.

Rationale #3: To bestow the bare minimum recognition for the contribution of these members to the fight to overcome the spread of COVID-19

During a pandemic is the wrong time to perpetuate laboratory wage disparity.

PHO needs to remain competitive in order to attract and retain trained laboratory professionals. While it previously was able to attract laboratory professionals that didn’t want to work a night shift, this distinction between a PHO lab and hospitals labs is no longer relevant. The five largest locations now operate 24/7, covering 89% of the OPSEU membership at PHO.

PHO is losing staff to the hospital sector where the pay and premium pay for non- standard shifts is higher, particularly in the Ottawa area. The Canadian Society of Medical Laboratory Science (CSMLS) has been sounding the alarm for decades about the coming shortage of these crucial hospital professionals. Christine Nielsen, CEO of the CSMLS, has stated that Ontario is short as many as 300 lab professionals and 50 per cent of the current workforce is eligible to retire in the next five years.7

A precarious supply of laboratory professionals is a problem that can only get worse. Our lab professionals are under immense pressure, performing their usual tasks in addition to working to meet the government’s testing quotas. As the pressure on these workers continues to rise, those who do not burn out or decide to retire will ‘vote with their feet’ and move to an employer where their skills attract more value. We cannot afford to wait another three years—for the good of the entire system, now is the time to equalize the wages between PHO and public hospitals.

The Protecting a Sustainable Public Sector for Future Generations Act, 2019 makes the achievement of parity impossible for the coming term. There is no worse time for this government to say to essential laboratory workers, “you are not as worthy as your hospital counterparts”.

In light of all of the above, OPSEU requests an exemption pursuant to s. 27 of the legislation in order that OPSEU and Public Health Ontario may be free to bargain a resolution to this difficult issue.

7 https://globalnews.ca/news/7396535/ontario-lab-worker-training-covid19-test-backlog/

We make this request without prejudice to OPSEU’s position that the Act violates the Canadian Charter of Rights and Freedoms, or to any position that OPSEU may take in other fora regarding the constitutionality of the Act.

We would be pleased to discuss this with you further at your earliest convenience.

Sincerely,

Steve Nield OPSEU/SEFPO Local Services Supervisor - BPS Negotiations Unit and Research Unit 100 Lesmill Rd. Toronto, ON M3B 3P8 Phone: (416) 443-8888 Cell: (613) 329-4307 Fax: (416) 448-7451

Exhibit A

Final Report of the Agency Implementation Task Force

From Vision toAction:

A Plan for the Ontario Agency for Health Protection and Promotion

March 2006 This report builds on the Agency Implementation Task Force’s Part One Report, Building an Innovative Foundation: A Plan for Ontario’s New Public Health Agency, Part One, October 2005.

Link: http://www.health.gov.on.ca/english/public/pub/ministry_reports/agency _05/agency_05.pdf

ISBN 1-4249-0097-2 (Print) ISBN 1-4249-0098-0 (PDF) Table of Contents

Agency Implementation Task Force Members ...... iii Acknowledgements ...... iii Letter of Transmittal ...... v Glossary of Acronyms ...... vi Executive Summary ...... 1 Recommendations ...... 9 Chapter 1. Setting the Stage...... 14 Chapter 2. Governance and Accountability ...... 28 Chapter 3. Ministry/Inter-Ministry Liaison ...... 36 Chapter 4. Organisational Design...... 41 Chapter 5. Legislative Authority ...... 53 Chapter 6. Ontario Public Health Laboratories...... 55 Chapter 7. Support in Emergency and Exigent Circumstances ...... 62 Chapter 8. Phasing In ...... 67

Appendices Appendix 1. Terms of Reference for the Agency Implementation Task Force...... 74 Appendix 2. Terms of Reference for the Reference Panel ...... 75 Appendix 3. Terms of Reference for the Research and Knowledge Transfer Sub-Committee...... 77

References ...... 79

List of Figures Figure 1. A History of Specialized Public Health Organizations around the Globe...... 17 Figure 2. Operational Approach ...... 19 Figure 3. The Agency’s Annual Report Cycle ...... 30 Figure 4. Proposed Governance Structure ...... 31 Figure 5. Roles and Responsibilities...... 37 Figure 6 The Role of the CMOH...... 38 Figure 7. Mechanisms for Developing the Agency’s Three Year Strategic Plan...... 38 Figure 8. Proposed Organisational Design ...... 42 Figure 9. Functions, Areas of Specialisation and Clients...... 44 Figure 10. Laboratory Services in Public Health Agencies ...... 58 Figure 11. Revitalisation of Ontario’s Public Health Laboratory System...... 59 Figure 12. Sequencing of Recommended Priorities for Agency Start-up: Years 1 and 2...... 68 Figure 13. Suggested Primary Initiatives for the Agency to Undertake...... 70

Final Report of the Agency Implementation Task Force i ii From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Agency Implementation Task Force Members

CO-CHAIRS MEMBERS

Geoff Dunkley Michael Christian Former Associate Medical Officer of Fellow, Infectious Disease and Critical Care Medicine, Health, Ottawa Public Health Unit McMaster University

Terry Sullivan Donald Cole President and Chief Executive Officer, Associate Professor, Department of Public Health Sciences, Cancer Care Ontario Faculty of Medicine, University of Toronto

Ken Deane President and Chief Executive Officer, St. Joseph’s Health Centre

Mae Katt Nurse Practitioner, Anishnawbe Mushkiki, Thunder Bay Aboriginal Community Health Centre

Alan Meek Professor, Ontario Veterinary College, University of Guelph

David L. Mowat Deputy Chief Public Health Officer, Public Health Practice and Regional Operations, Public Health Agency of Canada

Linda O’Brien-Pallas Acknowledgements Professor, Faculty of Nursing, University of Toronto The Agency Implementation Task Force would like to thank the Strategic Planning Ruth Sanderson and Implementation Branch of the Public Health Unit Epidemiologist, Middlesex-London Health Unit Health Division of the Ministry of Health and Long-Term Care for its support and excellent Andrew Simor work in the preparation of this report. Head, Department of Medical Microbiology, Sunnybrook and Women’s Health Sciences Centre The Task Force would also like to acknowledge the valuable input provided Penny Sutcliffe by the following: Medical Officer of Health / Chief Executive Officer, • Institut national de santé publique Sudbury and District Health Unit du Québec • British Columbia Centre for Ron Yamada Disease Control Founder and Executive Vice President (retired), MDS Incorporated • Participants in the roundtable discussions and the Agency Jennifer Zelmer Implementation Task Force Vice President of Research and Analysis, Reference Panel Canadian Institute for Health Information

Final Report of the Agency Implementation Task Force iii iv From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Letter of Transmittal

Dr. Sheela Basrur March 2006 Chief Medical Officer of Health and Assistant Deputy Minister Public Health Division, Ministry of Health and Long-Term Care Hepburn Block, 11th Floor 80 Grosvenor Street Toronto, ON M7A 1R3

Dear Dr. Basrur:

The Agency Implementation Task Force (AITF) is pleased to present its final report outlining our best advice on the implementation of a public health agency for Ontario.

The Task Force recommends that the agency adopt the name Ontario Agency for Health Protection and Promotion (referred to as ‘the Agency’); this proposed name is used throughout the report.

In October 2005, we presented Part One of our report. It provided the necessary foundation upon which the government could begin developing the Agency. This final report reiterates the need to move forward quickly, integrates an overview of Part One, and builds on this foundation to provide our final recommendations regarding the Agency’s operating structure, governance model, and phased implementation.

The Report outlines how the Agency could provide a valuable support function as part of an overall emergency framework. The report also contains our advice on approaches to modernise and align the vital role of the Ontario Public Health Laboratories within the overall structure of the Agency, proposed governance structure and suggested mechanisms to ensure effective coordination between Ministries and the Agency.

The case for a public health agency for Ontario is clear. It has been made by Dr. David Walker, Justice Archibald Campbell, Dr. David Naylor and countless others. It has also been reinforced repeatedly to the Task Force throughout our process in the submissions, presentations and opinions shared from across the spectrum of health care.

The establishment of a dedicated agency for health protection and promotion for Ontario will mark a milestone in the rebuilding of public health in Ontario.

We commend the Minister of Health and Long-Term Care and the government of Ontario for having made the historic commitment to a public health agency and we are honoured to have had the opportunity to contribute to this process. We thank those whose work has gone before us, and the many individuals and organisations who have taken the time to provide us with their advice and guidance. The dedicated staff of the Strategic Planning and Implementation Branch of the Public Health Division provided capable and energetic support to our efforts.

We look forward to the Ontario Agency for Health Protection and Promotion taking its place in Ontario’s public health landscape to strengthen our collective capacity to protect and promote the health of all Ontarians.

Sincerely, Members of the Agency Implementation Task Force

cc: Honourable George Smitherman, Minister of Health and Long-Term Care Honourable Jim Watson, Minister of Health Promotion

Geoff Dunkley (co-chair) Terry Sullivan (co-chair) Michael Christian Donald Cole Ken Deane

Mae Katt Alan Meek David L. Mowat Linda O’Brien-Pallas Ruth Sanderson

Andrew Simor Penny Sutcliffe Ron Yamada Jennifer Zelmer

Final Report of the Agency Implementation Task Force v Glossary of Acronyms

ADM Assistant Deputy Minister AITF Agency Implementation Task Force ARO Antibiotic Resistant Organism BCCDC British Columbia Centre for Disease Control CAO Chief Administrative Office CCO Cancer Care Ontario CDC Centers for Disease Control and Prevention CEO Chief Executive Officer CIHI Canada Institute for Health Information CIHR Canadian Institutes for Health Research CMOH Chief Medical Officer of Health CRC Public Health Capacity Review Committee EEMC Executive Emergency Management Committee EMO Emergency Management Ontario EMU Emergency Management Unit FIPPA Freedom of Information and Protection of Privacy Act HIU Health Intelligence Unit HPA Health Protection Agency HPPA Health Promotion and Protection Act ICES Institute for Clinical and Evaluative Sciences ICP Infection Control Practitioner IMS Incident Management System INSPQ Institut national de santé publique du Québec LHIN Local Health Integration Network LIS Laboratory Information System MCSCS Ministry of Community Safety and Correctional Services MHP Ministry of Health Promotion MHPSG Mandatory Health Programs and Services Guidelines MOH Medical Officer of Health MOHLTC Ministry of Health and Long-Term Care MOU Memorandum of Understanding MRSA Methicillin Resistant Staphylococcus Aureus NCC National Collaborating Centre NGO Non-Governmental Organisations OEMS Office of Emergency Management Support OHPRS Ontario Health Promotion Resource System OHSR Ontario Health Status Report OLIS Ontario Laboratory Information System OPHL Ontario Public Health Laboratories PHAC Public Health Agency of Canada PHERO Public Health and Epidemiology Report Ontario PHI Personal Health Information PHIPA Personal Health Information Protection Act PHRED Public Health Research, Education and Development PIDAC Provincial Infectious Diseases Advisory Committee RICN Regional Infection Control Network RRFSS Rapid Risk Factor Surveillance System VRE Vancomycin Resistant Enterococci vi From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Executive Summary

Ontario has clearly heard the well-grounded and remarkably consistent calls for the Province to strengthen public health capacity both locally and centrally. The work that has been undertaken by the Agency Implementation Task Force (AITF) has been influenced by and builds on the extensive work of others, as listed below:

• National Advisory Committee on SARS and Public Health, Learning from SARS: renewal of public health in Canada (Naylor Report)1; • SARS Commission, Interim report: SARS and public health in Ontario (First Interim Report of Justice Archie Campbell)2; • SARS Commission, Second Interim Report: SARS and public health legislation (Second Interim Report of Justice Archie Campbell)3; • Ontario Expert Panel on SARS and Infectious Disease Control, For the public’s health: Final report of the Ontario Expert Panel on SARS and Infectious Disease Control (Walker Report)4; • Meat Regulatory and Inspection Review, Farm to fork: A strategy for meat safety in Ontario (Report of Justice Roland Haines)5; • Report of the Expert Panel on the Legionnaire’s Disease Outbreak in the City of Toronto – September/October 2005, Report Card: Progress on Protecting the Public’s Health (Walker)6; and • 2005 Annual Report of the Chief Medical Officer of Health (CMOH) to the Ontario Assembly, Building the Foundation of a Strong Public Health System for Ontarians7.

In June 2004, the Ministry of Health and Long-Term Care (MOHLTC) released Operation Health Protection: An Action Plan to Prevent Threats to our Health and to Promote a Healthy Ontario.8 This Report responded to a number of key recommendations made in the Walker Report and the first interim Campbell Report on SARS. Operation Health Protection committed the government to a series of measures to strengthen Ontario’s capacity in a range of areas including developing and implementing a new public health agency.

In January 2005, the MOHLTC established the AITF to advise on developing a public health agency, to validate a mandate and structure, and provide an implementation plan to strengthen capacity in the areas of health protection and health promotion. Creating the Ontario Agency for Health Protection and Promotion (referred to in this Report as ‘the Agency’) presents a landmark opportunity to build an organisation through which we can strengthen both public health capacity and confidence going forward. The Agency is a key component of the renewal of the public health system. However, it is not an end in itself and must be seen as linked with the ongoing efforts to reform the public health system in the years ahead.

Final Report of the Agency Implementation Task Force 1 The Task Force used a range of approaches in completing to ongoing parallel efforts to reform and renew the its work, including literature reviews, cross-jurisdictional public health system. The Agency is a key part of analyses, and an examination of best practices in a range this endeavour of areas. The AITF sought ongoing advice and guidance from national and international leaders in existing public In the end, we will have genuinely made a difference health agencies, and from numerous public health and if our collective ability to access timely, credible, health care associations and groups. evidence-based knowledge, tools, support and advice from within our own jurisdiction is strengthened We acknowledge the advice and support we have through the Agency’s work in the years to come. received from both the Institut national de santé publique du Québec (INSPQ) in Quebec and the British Columbia The Part One Report Building an Innovative Foundation: Centre for Disease Control (BCCDC). We have also A Plan for Ontario’s New Public Health Agency (October benefited from having a Public Health Agency of Canada 2005)9 put forward a proposed mandate, vision, mission (PHAC) representative on the Task Force. The examples and core values for the Agency: and lessons learned from these agencies have been valuable and informative in helping shape our thinking. Mandate They have also reinforced for us how the establishment To provide scientific and technical advice for those of an Ontario agency is a critical and very welcomed step working to protect and promote the health of Ontarians. not just for Ontario, but for Canada as a whole. Vision National and international models and best practices, We will be an internationally recognised centre of however, provided us with only one part of the picture. expertise dedicated to the protection and promotion of We have balanced this by working hard to better the health of all Ontarians through the application and understand and respond to the documented needs advancement of science and knowledge. identified here in Ontario. We have examined in detail the specific gaps identified through the Public Health Mission Capacity Review Committee (CRC) at the local level and We are accountable to support health care providers, reviewed the findings generated through that process. In the public health system and partner Ministries in making particular, we have consciously examined the local needs informed decisions and taking informed action to improve associated with training, professional development, tools the health and security of all Ontarians through the and assistance. We are indebted to all those who transparent and timely provision of credible scientific informed this work as these consultations significantly advice and practical tools. influenced our deliberations. Core Values Since the SARS outbreak, much has changed in Ontario • Responsiveness; in public health, in emergency management and in the • Relevance; evolving shape and organisation of the health care • Credibility; system as whole. In undertaking this work, the Task • Collaboration; and Force has responded to these changes and tried to avoid • Innovation. simply recommending actions based upon what was, or was not, in place during the spring and summer of 2003. The Task Force’s Final Report builds on the Part One Report and provides greater detail on the proposed Changes have been made since 2003 and there have been Agency’s: some clear improvements both in structures and processes • Governance and Accountability; to enhance public health capacity, infection control and • Ministry/Inter-Ministry Liaison; emergency preparedness. However, while we recognise • Organisational Design; this progress,it is critical to the health of Ontarians that • Legislative Authority; this momentum be sustained in the years to come. • Ontario Public Health Laboratories; • Support in Emergency and Exigent Circumstances; The Agency presents an opportunity to build on the and progress to date by adding a critical component linked • Phasing-In.

2 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Operational Approach Governance and Accountability To effectively execute its mandate, the Agency will require broad connections and affiliations with partners To develop the proposed governance and accountability in key sectors. The Agency should establish formal structures for the Agency, the Task Force studied the partnerships, as appropriate, with academia, research governance models in place for a range of existing public bodies, non-governmental organisations and key health agencies in other jurisdictions, examined best health organisations. practices from recent literature and guidelines, and examined the experiences of a range of Ontario agencies. While it should fall to the Agency’s Board to determine how best to structure partnership agreements with To support the objective of building a credible, appropriate institutions, we believe there are several non-partisan provider of scientific and technical advice principles and elements worthy of consideration: and support, the Task Force recommends that the • The Task Force proposes that the principles Agency be established with an arm’s-length relationship of clarity, credibility, transparency, practicality, to government. To secure this status, the Task Force mutual benefits, a focus on results, and clearly recommends that the Agency be created through special defined exit rules guide the development of the purpose legislation and be established as a scheduled Agency’s partnerships. agency of the Crown. This form of legislated approach is • The Task Force has outlined a number of key consistent with the approach taken in Quebec, and at the elements of successful partnerships and identified national level in Finland, the UK, Ireland and an increasing several priority partnerships that need to be number of European states. established in the Agency’s early stages to help it carry out its mandate. The success of any agency of this type, however, is not primarily a question of legislative authority but, as While there is an increasing number of virtual and highly Justice Campbell has rightly observed, it will rest in large decentralised approaches that have been pursued in part upon its moral authority.10 The confidence and trust developing research institutes and consortia at the that the Agency can build over time, both with its national level, a number of the tasks that the Agency Ministry partners and the broader public health and would be asked to perform and the strong central health care communities, will be the true source of its relationships it would need, place very natural limits earned autonomy. on how decentralised it can be. A first step for Ontario on this path is ensuring the The AITF believes that the Agency needs a strong Agency is well governed and well run and that permanent physical presence in the downtown Toronto expectations and accountabilities are clear. To that end core to provide easy access to Ministry partners, the we have proposed a range of specific measures that Chief Medical Officer of Health (CMOH), the Emergency could help ensure effective governance. Management Unit (EMU) and the large concentration of research, medical and scientific resources available. Strong governance and accountability mechanisms, defined processes for communication and liaison, and In keeping with its philosophy of building upon clear emergency support roles as part of an overall existing capacity and infrastructure and the need to framework are consistent with an arms-length role. ensure that the work of the Agency meets the needs They are the necessary processes that help build trust across Ontario, the AITF recommends that the Agency between partners and ensure that scientific autonomy also foster a coordinated approach to linking with can co-exist effectively with the operational requirements and enhancing the work underway through Public of multiple Ministry and field partners. Health Units, the existing Regional Infection Control Networks (RICN) and the proposed regional networks As a scheduled agency of the MOHLTC, the Agency should for research and knowledge exchange. Ensuring these be required to submit Annual Reports and ensure that forms of connectedness are in place will help ensure these reports are made public, thereby demonstrating how the functions and mandate of the Agency remain its funding links to the outcomes and objectives set out in grounded in serving all of Ontario. these plans. The agreements detailing the roles and responsibilities of the Agency and MOHLTC should be

Final Report of the Agency Implementation Task Force 3 outlined in the form of a Memorandum of Understanding The Board should also be responsible for hiring a CEO (MOU), which is subject to regular review by both parties who would serve as the operational administrator and to ensure its ongoing relevance and accuracy. leader of the Agency, and who would be accountable to the Board. The CEO should possess critical abilities Board of Directors including scientific and public health/health sector The Task Force recommends that a skill-based Board of leadership skills, and an ability to foster academic Directors be appointed to govern the Agency. The Board partnerships and act as champion for the Agency. would be legally responsible and accountable for the overall stewardship of the activities of the Agency including: In hiring the first CEO, the Task Force strongly • Providing strategic direction to the organisation; recommends involving the CMOH in both the screening • Ensuring the execution of Strategic Plans and selection process. A condition of success for the comprised of both provincial priorities and needs smooth creation of the Agency will be the working identified in consultation with the field; relationship that develops between the CEO and the • Ensuring that financial accountability controls are in CMOH. This is an extremely important factor in the place and adhered to; experience of all the jurisdictions operating with an • Selecting, hiring and reviewing the performance of arms-length agency model, regardless of the formal legal the Chief Executive Officer (CEO) for the Agency; structure in place. • Being accountable for the operations of the Agency to the Minister of Health and Long-Term The Task Force recommends that four standing Care through the Board Chair; and committees be structured to advise the Board: Strategic • Submitting Annual Reports to the MOHLTC Planning, Scientific Advisory, Audit, and Governance. with copies made available to the Ministry of The Governance Committee should be comprised of only Health Promotion (MHP) for subsequent tabling Board members, whereas the other three committees in the Legislature. should be made up of both Board and non-Board members. This Report details our rationale for this The AITF recommends that Board members be selected approach and the potential role and function of each of through an open and transparent process. The Task Force these Committees. suggests that an open call be undertaken to develop a long list of potential candidates who would be screened The Task Force recommends that the CMOH participate against a clear set of competencies. From the resultant at Board meetings and be a member of the Strategic short list, an external selection body would recommend Planning Committee in order to formally provide a strong to the Minister of Health and Long-Term Care an initial liaison between provincial Ministries and the Board. slate of candidates for consideration for Board While we anticipate a consensus form of operation for membership and subsequent formal appointment. the Board, formally, the CMOH should not vote at Board meetings. The actual or potential role of the CMOH in To found the Agency, the AITF recommends that a small core approving funding and/or directing the activities of the group of between five and seven members be appointed, Agency in exigent circumstances suggests that it is with these initial positions being supplemented at a later appropriate that a degree of separation be retained. stage to create a full Board complement of thirteen people. Ministry/Inter-Ministry Liaison Board members should be screened to ensure that they have a set of standard Board skills including an The Task Force recognises that the proposed mandate of appropriate understanding of governance, financial and the Agency and its areas of specialisation have relevance legal issues, ability to work as members of a team, and to a range of Ministries (e.g Ministries of Health think strategically. In addition to these general skills, Promotion, Environment, Labour, Agriculture, Food and those undertaking Board selection must also ensure that Rural Affairs, Children and Youth Services, and Research specific competencies, including knowledge of public and Innovation). We anticipate that the Agency will health and health system organisation are reflected in the undertake work that frequently extends beyond overall Board makeup. The AITF also recommends that a traditional Ministry silos. This, in part, is reflective of the seat be reserved on the Board for a public representative, diversity of Ministries who have a direct reliance upon or who meets the standard skills set out above. interaction with public health in Ontario.

4 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion As such, there is a need to develop structures and • Policy development; supports that will ensure effective cross-Ministry input • Enforcing compliance of the Mandatory Health and communication. To this end, the Task Force Programs and Services Guidelines (MHPSG)11; recommends that a series of coordinating mechanisms • Human resource planning; be put in place through the position of the CMOH to • Emergency management; ensure Ministries’ input into the priority setting and • General communications; strategic planning process of the Agency. • Funding of Public Health Units and other health care facilities; While it is important that the Agency be linked to multiple • Formal federal/provincial liaison with Health Canada Ministry partners, it is also essential that a clear single line and PHAC; of accountability exist to one designated Minister. For this • Setting standards; and reason, we recommend that the Agency be accountable • Legislation and regulatory issues. through the Chair of the Board directly to the Minister of Health and Long-Term Care, who would be accountable The Task Force envisions the Agency having six functions to the Legislature for the activities of the Agency. in three areas of specialisation with one cross-cutting theme in order to serve its primary client base of health We acknowledge the important role of the MHP, which care providers, Public Health Units, and partner Ministries. shares extensive common interests in health promotion, chronic disease and injury prevention. As such, the Functions: CMOH, who currently serves as an Assistant Deputy • Surveillance and Epidemiology; Minister (ADM) in MOHLTC and MHP, is the logical • Research; connection between the two Ministries and the Agency. • Knowledge Exchange; • Laboratory Services; The CMOH should also be designated to ensure • Professional Development; and processes are in place to coordinate the input and advice • Communication. from other Ministries through a broader Inter-Ministry Committee. This committee would coordinate requests Areas of specialisation: to undertake initiatives and projects consistent with the • Infectious Diseases (including infection prevention Agency’s mandate and prioritise them for submission to and control); the Agency for inclusion in the Strategic Plan. • Health Promotion, Chronic Disease and Injury Prevention; and Priority Setting (Field Input) • Environmental Health.

Balancing the priority initiatives identified at the provincial Cross-cutting theme: level, the AITF is recommending that a series of • Support in Emergency and Exigent Circumstances. mechanisms be put in place to ensure that there is input into the Agency’s Strategic Plan from the field In each function and area of specialisation, the Agency (Public Health Units and health care providers). These should be focussed on: mechanisms could also include formal links to the newly • Providing a single window of access to expertise developing RICN and the creation of a coordinated (common science); network in the field of public health knowledge exchange • Translating science and research into practical tools and training. Supplementing these approaches would be and useable information (common language); and topic and issue specific fora allowing for direct input into • Supporting collaboration, information exchange and priority setting. sharing of best practices among existing and new communities of practice. Organisational Design The Agency should have a role in risk communication, with The Task Force recommends that the Agency have a clearly a distinct focus upon refining approaches to effectively defined role focussed upon a range of defined activities communicate scientific and medical information in a and that appropriate Ministries continue to be responsible manner tailored to the practical needs of the user to assist for key stewardship and oversight functions including: decision making at both the local and Provincial levels.

Final Report of the Agency Implementation Task Force 5 Legislative Authority current reporting requirements set out in the HPPA should remain in place with the Agency providing The Health Promotion and Protection Act (HPPA)12 complementary analytical, technical and field support, specifies the responsibilities of local Boards of Health, as required. and local Medical Officers of Health (MOHs) for managing public health programs and services required under the The Task Force also recommends that through HPPA. This Act also provides for a series of powers for contractual and legal means, the CMOH be vested MOHs to take actions to mitigate or control risks to with the authority to mobilise the Agency’s resources human health and sets out the obligations requiring the to assist in addressing urgent and emergent issues, reporting of specified diseases to the Public Health Unit when these are consistent with the Agency’s mandate and the subsequent obligation of the Unit to report these and in the opinion of the CMOH, the skills of Agency to the MOHLTC. personnel are required.

The AITF reaffirms the role played by local MOHs and To that end, we are recommending that the Agency strongly supports the philosophy of continuing to be staffed with both the capacity and requirement to vest responsibility for public health management and provide direct field support in emergency or exigent response to outbreaks and threats to health, first and health-related circumstances. The CMOH will activate foremost at the local level. The role of the Agency should the involvement of the Agency. Once deployed, the not be, in any way, to weaken existing structures, but Agency will operate under the chain of command rather support reinforce and enhance local responses established by the Incident Management System (IMS) when required. in place, either in the field in an exigent circumstance or through the Executive Emergency Management Collectively, our primary focus should also be on Committee (EEMC) in an emergency. To formalise improving our ability to anticipate and prevent threats the power of the CMOH to activate the Agency’s to our health before they occur, and to contain them involvement in emergency and exigent circumstances, locally when they do occur. Key to this is ensuring that we recommend that, through the MOU and appropriate existing legislation is clear and up to date. contractual and legislative means, this be enshrined in the founding documents of the Agency. In this regard, we are aware of Justice Campbell’s extensive work documenting some of the shortcomings Ontario Public Health Laboratories and gaps in the current powers of MOHs to uphold the (OPHL) HPPA and fulfill their mandate.13 We do not, however, believe that creating specific overriding legislative powers Dr. Sheela Basrur, the CMOH, observed in her 2005 for the Agency is appropriate to address these gaps. Report to the Legislature that “the best and possibly only hope for public health laboratory renewal lies in Justice Campbell in the Second Interim Report of the Ontario’s commitment to create a provincial Public SARS Commission has called for significant review of Health Agency.”15 the powers and duties of both MOHs and the CMOH under HPPA.14 This work is necessary and needs to be The AITF supports Dr. Basrur’s statement and believes undertaken. It is through this type of comprehensive that placing operational responsibility for the OPHL with review of the legislative framework for public health that the Agency will be critical in helping to overcome a the overall question of the balance of appropriate powers number of long-standing and well-documented held locally and provincially should be resolved. challenges faced by the OPHL in recent years.

Before the completion of this review, we do not First, the proposed incorporation of public health recommend a piecemeal approach to dividing powers laboratory functions under the Agency would address the among the CMOH, the local MOHs and the Agency. organisational need for a stronger formalised intersection Rather, the Task Force believes that the focus should be of the OPHL with the broader surveillance and on ensuring that the requirements placed upon Boards epidemiology functions of public health and infectious of Health and the powers held by the MOH, the disease control. CMOH and Minister are appropriate. To that end, the

6 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Second, the relocation of select core Central Public Emergency Management Ontario (EMO), which has Health Laboratory services from the existing facilities to a a designated provincial role associated with general central Agency site would address, at least in part, the emergency preparedness, has been supplemented current facility constraints faced by an aging Central by specific health sector and MOHLTC organisational Public Health Laboratory. As proposed in the Part One and planning capacity through the EMU. This unit was Report, co-location provides an opportunity to modernise created after SARS and reports to the CMOH. We see the laboratory’s physical plant and simultaneously help tremendous value in the work that has been undertaken to bring its functions into more organised contact with by this unit and the contribution it is making to improving the broader research community and related functions readiness through augmenting Ontario’s health sector of the Agency. planning capacity.

Third, we believe that the ability of the OPHL to attract In undertaking its work, the AITF has ensured that its and retain the skilled staff it requires in microbiology, recommended approach fits into the existing emergency genetics, and other disciplines in short supply, is management framework. We have all learned through SARS contingent on enhancing and supporting the promotion that clarity regarding who is in charge is critical. To that of research excellence. It is also contingent on providing end, we are recommending that in any formal emergency both the setting and the mandate to attract personnel circumstance, the Agency function under the existing with these skill sets. The move to an agency with a emergency framework, acting as a central scientific and clear role in research and innovation can only assist in technical resource to be drawn upon as required. this effort. In circumstances which, in the opinion of the CMOH, The Task Force recommends a phased transfer of the present an urgent or exigent threat to human health, but OPHL in its entirety to the Agency by the end of 2008. It are still below the level of a formal declared emergency, is clear that the need to focus and modernise the we recommend that the CMOH be authorised to call on capacity of the OPHL cannot be achieved by partial the resources of the Agency to provide support as required. measures aimed at the Central Laboratory’s functions alone. We believe that improving the functioning of, and We do not see the Agency duplicating the valuable support to, regional laboratories as part of a linked work being undertaken by the EMU. We see great system is the right approach and will avoid the danger of importance in this planning work continuing within the a fragmented laboratory system. MOHLTC. Rather, we see the Agency being a vehicle to supplement these activities by providing ready access to Work on the transition needs to begin immediately to a pool of scientific and technical areas of specialisation ensure that the laboratory services and staff are on a permanent and ongoing basis. We would see a integrated in an organised way that minimises service working partnership developing between EMU and the disruptions and is undertaken in manageable stages Agency jointly improving the capacity for risk analysis respecting the need for continuity. We would underscore and the development of approaches to specialised the need for a transitional plan that is agreeable to all communication. We also see extensive opportunities for parties. To this end, we recommend establishing a formal the Agency to undertake enhanced outbreak modelling transition group to expedite this work, with external capacity to provide better guidance to planners on support as required to assist in the transition. The Task health-related emergency scenarios. Force has also prepared a pre-transition list of requirements to begin the suggested three-phase In an emergency situation, we recommend that the CEO transition be initiated as quickly as possible. be a member of the Executive Emergency Management Committee (EEMC) of the MOHLTC, and, as such, Support in Emergency and Exigent function under its direction as part of a centrally led Circumstances coordinated response mechanism.

In the area of emergency management support, the Task Phasing In Force has spent considerable time mapping out the specific place of the Agency within the overall In the final component of our report, we have attempted to emergency management framework. provide a series of steps that could be undertaken to

Final Report of the Agency Implementation Task Force 7 establish the Agency and identify areas of early activity for funding for Ontario’s National Collaborating the first three years. Centre (NCC) in Public Health Tools and Methodologies should be re-assigned to the We would caution, however, that the final task of Agency by 2007/08. determining the priorities and precise timing of the areas • The Agency should be permitted and indeed of activity to be addressed will need to made through the encouraged to seek access to third-party funds, strategic planning processes we have outlined. This particularly in the area of research, to supplement Strategic Plan, under the model we are proposing, will its base allocation without these funds affecting ultimately be determined by a process of input from both core Provincial funding. the field and Ministries into the new Agency. As such, dictating what will be the first five initiatives launched by Conclusion the Agency is not something that this Task Force has the authority to determine. This will fall to others. The plan In concluding, we would like to acknowledge and thank outlined in this Report broadly illustrates certain critical all those who have provided us with their advice, support supports and informational needs that we believe the and guidance throughout this process. We have Agency would be well positioned to address. benefited greatly from this input.

Funding Creating a new Agency is an enormous undertaking and will take time to get right. We will need to learn as we Dr. David Walker had, in the final report of the Expert go, as those who have gone before us have had to do. Panel on SARS and Infectious Disease Control, We cannot possibly know all of the answers today, nor recommended an operational budget of $45M16 excluding can all of them be prescribed in advance by this Task existing base expenditures associated with laboratory Force. Looking back to SARS and forward to the risks operations. Dr. Walker had further recommended a that may face us in the coming years, we are in no doubt capital allocation of $35M and $3.5M in design and whatsoever that creating the Ontario Agency for Health development costs. Protection and Promotion is the right thing to do.

A range of variables which are outside the responsibility We need to forge a new partnership between the way of this Task Force complicate final approaches to funding. that Ministries, health care providers and researchers Firstly, and most significantly, any decisions and costs interact around the shared objectives of equipping associated with the formal OPHL review which we ourselves with the best available knowledge, tools and understand is almost finalised will have to be taken into supports to protect and promote the health of all consideration. Secondly, the decision and timing of Ontarians. To do this, we need to harness and draw on laboratory services transition will adjust the overall the skill and knowledge buried in structures that too budget totals significantly. In addition, project reviews, often are isolated and disconnected from each other. such as the review called for in our Part One Report of the Ontario Health Promotion Resource System We are honoured to have had the opportunity to (OHPRS), are required to determine what, if any, roles contribute to this historic undertaking and hope that our of existing entities funded by the Province in the area of work can provide some assistance in meeting some of health promotion might be assumed by the Agency. the challenges ahead. It is our earnest hope that a few years from now Ontario and Ontarians will be justly Acknowledging these significant variables, we would proud of their Agency and truly see a Province that recommend an allocation consistent with the range indeed fully learned from SARS, remembered and acted. offered by Dr. Walker but with the following considerations. • Laboratory transition and modernisation costs should be considered as additional costs over and above any base allocation for the Agency. • Areas with specific project funding which align with the Agency mandate should be examined for consideration for transfer to the new organisation at a later date. In particular, existing PHAC

8 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Recommendations

Maintaining the Momentum

1. The MOHLTC should ensure that a dedicated transition support group, with continued access to appropriate internal and external expertise, is in place by spring 2006. This team should assist with the phased implementation of the recommendations of the AITF and, in particular, with planning and support required for the effective transition of laboratory services to the Agency.

Creating the Agency

2. The Agency should be established through special purpose legislation.

a. The Agency should be a scheduled agency of the Crown.

b. The Agency should be granted the necessary powers to access and hold third party funds to enhance its research capacity.

c. The Agency should be granted the legal authority to collect, use and disclose data in a privacy-sensitive manner.

d. Existing legal reporting requirements to Public Health Units and to MOHLTC as stipulated in the HPPA should remain in place subject to the overall results of a full HPPA review.

Governance

3. The Agency should be functionally arm’s length from the MOHLTC and be governed by a Board of Directors.

a. A Board of Directors for the Agency should be in place by late 2006, starting with a core of five to seven members and moving gradually to a full Board of thirteen members.

b. Members of the Board should be selected through a transparent, non-partisan process involving appropriate external expert advice. Board members should be appointed by Order in Council with staggered terms.

c. Membership of the Board should represent a suitable breadth of skills and competencies reflective of the Agency’s mandate and include a public health presence and a public representative.

Final Report of the Agency Implementation Task Force 9 d. Clear reporting relationships should be 9. Support in emergency and exigent circumstances established whereby the Chair of the should be a theme that cuts across the Agency’s Agency’s Board is directly accountable to the areas of specialisation and functions and be Minister of Health and Long-Term Care. The structured to allow for response and support Minister would be, in turn, accountable to within the overall provincial emergency the Legislature for the Agency’s activities. management framework.

e. A series of standing committees should 10. The Agency should adopt and promote the practice report to the Board, including Governance, of using multi-disciplinary teams, which work Strategic Planning, Scientific Advisory and together across the various areas of specialisation Audit. Membership on the Governance and functions to ensure the efficient, flexible and Committee should be Board members only. rapid flow of information and expertise. As appropriate, The remaining committees should also these teams would include people outside the include non-Board members. Agency from the field and various Ministries.

f. The Strategic Planning Committee should be 11. The Agency should work with MOHLTC in order to given the task of recommending a multi-year put into place appropriate library and information Strategic Plan that aligns with both technology infrastructure that allows for optimal Provincially identified and field priorities to alignment and connectivity to existing systems be approved by the Board. established by the Province.

4. The Board should be required to establish by-laws Strengthen and Align Ontario Public and appropriate policies including those related to Health Laboratories ethical governance practice and conflict of interest to guide the effective management and operations 12. A reformed and strengthened OPHL should be of the Agency. a core component of the Agency’s activities. The implementation of AITF recommendations The Agency’s Activities contained in its Report should be closely aligned with any final recommendations emanating from 5. The Agency’s primary clients should be health care an operational review of the OPHL. providers, Public Health Units, and partner Ministries. 13. The AITF recommends a phased implementation 6. In undertaking its activities the Agency should be of transition of the OPHL into the operational guided by relevance to all of Ontario, and as such structure of the Agency by the end of 2008. we recommend that the Agency has in place mechanisms to ensure that issues pertinent to 14. The transition team should assess the following First Nations/Aboriginal communities are critical areas: appropriately included. • Workforce strategy and planning; • Logistics associated with the acquisition 7. The Agency’s initial areas of technical specialisation and move to new laboratory space for core should be: infectious diseases (including infection Central Laboratory functions; and prevention and control); health promotion, chronic • Implementing the a single integrated disease and injury prevention; and environmental Laboratory Information System (LIS). health. These areas should be understood to include family health as appropriate to each area 15. The Agency should ensure that regional laboratory of specialisation. renewal is addressed.

8. The Agency should provide the following functions: 16. Select Central Laboratory testing should be surveillance and epidemiology; research; physically co-located with the Agency and a knowledge exchange; laboratory services; detailed review of the current testing menu should professional development; and communication. be undertaken by 2008.

10 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Funding a. Periodic external reviews of the Agency should be carried out to assess and evaluate 17. The Agency should be funded by the MOHLTC its performance. on a multi-year basis, subject to an annual review based upon its approved Strategic Plan. b. The Agency should submit a formal Annual Projects outside the Strategic Plan would need Report to the Minister of Health and to be considered for supplementary resources Long-Term Care, for subsequent tabling in where required. the Legislature, on activities of the Agency after its second year of operations. This a. The Agency should receive initial annual would provide time for the Agency to recruit funding of at least $45M as recommended staff and initiate Agency functions. The in the Walker Report excluding existing Annual Report would monitor progress base expenditures and costs associated against the proposed plan from the previous with recommendations from the OPHL year, report the funding received and spent, review. Thereafter, funding should be on a and highlight issues for the coming year. multi-year basis. 20. The Chair of the Agency Board should be formally b. Existing funding for the OPHL including accountable for the operations of the Agency to overhead and centralised support costs the Minister of Health and Long-Term Care. should be transferred in whole to the Agency upon completion of the required a. The accountability and reporting relationship transition planning. should be outlined in an MOU.

c. The Agency should be granted the right to b. The MOU should be reviewed on an annual hold third-party funds e.g. project-based basis and updated at least every five years. funding and national research grants consistent with the Agency’s objects, Working with Partners without these amounts affecting core provincial funding. 21. The MOHLTC should develop a mechanism based on models outlined in this Report to coordinate the d. Existing PHAC funding for the NCC in Public process by which other Ministries submit their Health Tools and Methodologies should be requests or proposals for specific projects or re-assigned to the Agency by 2007/8. initiatives involving the Agency that fall outside the Agency’s approved Strategic Plan. 18. The Agency should be granted the authority to access supplementary funds in an emergency or 22. The Agency should encourage project-based exigent circumstance, equivalent to three months teamwork and cross-sector participation, through of the operating budget of the Agency. appropriate agreements with the Ministries and the Agency’s partners, including non-governmental Accountability and Reporting organisations (NGOs), academia, health care providers, and public health practitioners. 19. The Agency should submit performance plans to the MOHLTC well in advance of the new fiscal 23. The Agency should have an internal intellectual year. The results of the activities contained in property policy consistent with its mandate as a these plans should then be documented in means to ensure clarity in any anticipated Annual Reports submitted to MOHLTC and made academic affiliation or other agreements. publicly available. The Reports should forecast financial projections over a three-year period and Research and Knowledge Exchange be aligned with the overall Strategic Plan once the Agency is mature. 24. The Agency with the MOHLTC should support the development of a province-wide network for public

Final Report of the Agency Implementation Task Force 11 health research, training and knowledge exchange. required to provide provincial priorities for The network should build upon existing capacity undertaking by the Agency. and be structured to support access to training and knowledge exchange resources on an equitable 29. The CMOH should have membership on the basis. Where appropriate, the network should standing Strategic Planning Committee of the begin by linking with other networks (e.g. RICNs, Board of Directors, thereby ensuring a direct Tobacco Control Area Networks and Public Health transmission of priorities identified at the Research, Education and Development (PHRED) provincial level. programs). The network will evolve over time, but should be established by early 2007. Selection of 30. The Agency should be required through appropriate potential partners in the network should be legislative and contractual means to ensure the transparent and based upon: availability of core scientific and technical capacity for deployment in emergency or exigent • Demonstrated contribution to the field of circumstances when required. public health; • Broad-based collaboration and academic Ministry Roles partnerships; • Demonstrated regional partnership; and 31. The MOHLTC and MHP, as appropriate, should • Alignment with the Agency’s Strategic Plan maintain the lead role and responsibility in the and objectives. following areas:

25. The Agency should take a lead role in developing a. Development and review of legislation and a three-year rolling province-wide agenda for regulations; public health research and knowledge exchange relevant to Ontario public health practice and b. Policy development; policy, including an implementation plan and timeline for activities. c. Adoption of program standards;

26. The Agency should, at minimum, draw upon d. Ensuring compliance and accountability with the available provincial financial resources in the standards and guidelines; PHRED program. Furthermore, we recommend that the Agency assume direct oversight for the e. Formal public health human resource provincial budget component of the PHRED planning, assessment and training; program by April 1, 2007. f. Emergency management activities (with Chief Medical Officer of Health Roles EMO and other relevant Ministries);

27. The CMOH should attend all of the Agency’s g. General health communication to Board meetings. To support this, advance practitioners, professionals, the public and notice and materials should be provided to the media; the CMOH. On issues where the Board may be required to vote, the CMOH should be h. Funding of Public Health Units and health considered non-voting. It is not recommended care facilities, and ensuring accountability for that the CMOH be permitted to send designates the use of these funds; and to the Board. i. Maintaining direct relationships with 28. The CMOH should be designated as the formal Federal departments such as Health liaison between the MOHLTC, the MHP and Canada and PHAC through established the Agency. Consistent with this role, the Federal/Provincial/Territorial processes, CMOH should be responsible for establishing except where such responsibility is the Intra-Ministry and Inter-Ministry Committees delegated to the Agency.

12 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Support in Emergency and Exigent Circumstances

32. In emergency situations that have health impacts, the CMOH, acting within the Provincial framework and under the EEMC, activates the Agency's involvement. Once deployed, the Agency operates within the established IMS structure and chain of command in place.

33. The CEO should be a formal member of the EEMC and related structures as required in an emergency.

34. The Agency should be available to provide technical and scientific advice and support to the MOHLTC, including where required field support capacity before, during and after an emergency with health impacts or in exigent circumstances.

Leadership

35. The Board of Directors should select and hire the CEO of the Agency through a transparent recruitment and selection process.

a. The CEO should possess critical abilities including scientific and public health leadership skills, and an ability to foster academic partnerships and act as champion for the Agency.

b. The Board should be responsible for assessing the performance of the CEO.

36. The CEO should not be a member of the Board, but should attend and participate in Board meetings as required except on matters pertaining to the evaluation of the CEO’s performance.

37. Board meetings should be open to the public, with the Board reserving the right to go into executive session as required.

38. The Board should function to the extent possible on a consensus basis.

Final Report of the Agency Implementation Task Force 13 Chapter 1 Setting the Stage

Context

Operation Health Protection In response to the recommendations contained in the Walker Report on SARS1 and the first Interim Report of Justice Archie Campbell, SARS and Public Health2, the Ministry of Health and Long-Term Care (MOHLTC) released Operation Health Protection — An Action Plan to Prevent Threats to Our Health and to Promote a Healthy Ontario on June 22, 2004.3

A key strategic priority of this three-year action plan to strengthen public health was a landmark commitment to create a new arm’s-length public health agency for Ontario (now recommended to be called the Ontario Agency for Health Protection and Promotion or ‘the Agency’ in this Report), dedicated to preventing and controlling disease and promoting health with the following core functions: • Enhanced and specialised public health laboratory services; • Infectious diseases (including infection control and communicable disease capacity); • Emergency preparedness assistance and support; • Health promotion, chronic disease and injury prevention; • Risk communications; and • Research and knowledge exchange.

The goal of the Agency, as stated in Operation Health Protection, would be to “strengthen Ontario’s capacity to provide scientific and technical advice for and within the health sector in the areas of health protection and promotion.” 4 The present government has made a commitment to establish this Agency with a formal Board structure in place by 2006/7.

Agency Implementation Task Force Operation Health Protection also made a commitment to establish an Agency Implementation Task Force (AITF) to act as an advisory body to the MOHLTC to provide guidance on the potential design and functioning of the new Agency. The AITF was formally struck in January 2005 with a mandate to: • Validate the Agency’s proposed mandate, key functional areas, structure and governance; • Recommend operational public health responsibilities for the Agency and delineate its roles and responsibilities in relation to those of the MOHLTC, academia, the broader health system, and the Public Health Agency of Canada (PHAC) and its National Collaborating Centres (NCC); and

14 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion • Recommend a comprehensive three-year • Facilitating stronger connections between implementation plan for the Agency, including these communities of practice and the field; infrastructure, financial requirements, human • Developing online resource tools, training resources and transition planning. opportunities and continuing education initiatives; and The AITF has met regularly since early 2005 and in • Increasing ease of access to a range October 2005 issued a Part One Report. This final Report ofspecific areas of technical expertise by builds on the earlier work and provides additional detail in liaising formally and informally with local, a number of areas with particular emphasis on national and international experts; emergency support roles and relationships, laboratory • Developing links and communication channels transition and specific governance and coordination to improve and coordinate the sharing of best issues related to the establishment of the Agency. (See practice information, data and analytical findings; Appendix 1 for the full terms of reference for the AITF.) • Developing practical tools based on evidence and science; for example, developing specific tools Validating Our Work and supports to assist Public Health Units in The Task Force used numerous strategies to validate the implementing the Mandatory Health Programs and proposed areas of specialisation and functions of the Services Guidelines (MHPSG)5; Agency, including: • Shaping research agendas in both the province and • Searching the literature to determine best practices; nationally such that public health research, • Learning extensively from the direct experiences of including applied and intervention-based research, other jurisdictions; is not only undertaken but more effectively • Consulting various existing public health agencies translated and disseminated; and about their programs and functions; • Providing leadership in partnership development • Consulting experts on governance in the public and networking, as well as collaborating sector; provincially, nationally and internationally to: • Conducting roundtable discussions with • Build technical capacity; participants representing a wide variety of • Provide improved access to leading-edge expertise, knowledge and experience, including scientific and technical support; and those from Public Health Units, hospitals, • Encourage and leverage research in community health settings, the voluntary sector identified areas of need. and academia; and • Reviewing the key findings of extensive survey and This validation was overwhelmingly consistent in terms interview data generated from all 36 Public Health of pointing out a definite need for the Agency to engage Units and from over 1,300 public health professionals. in the areas of specialisation and fulfill the functions that the AITF is recommending. Roundtables were convened on: • Health promotion, chronic disease and injury In addition to the roundtables, the AITF has consulted prevention; with a range of health system stakeholders. A Reference • Infectious diseases; and Panel was established and has met several times to • Environmental health. provide a forum for the AITF to update stakeholders on its activities and to hear a variety of perspectives The outcomes of the three roundtables were consistent on a wide range of issues related to the creation of the and validated the role of the Agency. Roundtable Agency. (See Appendix 2 for the Terms of Reference participants envisioned the Agency as playing a central for the Reference Panel.) supportive role in their respective fields by: • Building core technical capacity of relevance The feedback and input we have received throughout this to practitioners and professionals in a range process has underscored the need for the Agency as of disciplines by; recommended in the Walker Report. At the core of the • Identifying gaps in capacity and supporting comments received has been the consistently identified networks of expertise or communities of need for a trusted source of scientific and technical practice (for example, in epidemiology); guidance that is relevant and focussed on translating

Final Report of the Agency Implementation Task Force 15 research and evidence into tools, training and supports, The AITF has also benefited from ongoing advice and geared to health care providers and public health lessons learned from discussions with the British Columbia practitioners. Centre for Disease Control (BCCDC)10 and the Institut national de santé publique du Québec (INSPQ),11 as well While there are clear areas of excellence, public health as from examining the structure and experiences of practitioners and health care providers often face a series the CDC12 and the U.K. Health Protection Agency (HPA) of systemic barriers in accessing support for research a recently established legislated agency with the and knowledge exchange, namely: specific mandate to “protect health and reduce the • Weak coordination between multiple producers impact of various hazards”13. The Ontario model being of work of variable quality in different domains recommended most closely resembles Quebec’s model. of activity; Figure 1 provides is a representative selection of some • Limited direct relevance for front-line application; specialised public health organisations. At the same time, and as we examined other agency models, we were also • Insufficient focus on mechanisms to support very aware of the evolving roles of ministries. the use of evidence through the translation of knowledge into practical tools. Ministry Stewardship Just as there is an increased focus internationally Research and knowledge exchange should be key on specialisation evidenced by the establishment of pillars of the Agency. The AITF established a Research dedicated centres of health protection and promotion and Knowledge Transfer Sub-Committee, including in many jurisdictions, so too, the emphasis on defining nationally recognised experts, that has developed an organisation’s core business is gradually altering recommendations related to the Agency’s work in the way many governments are defining their role in these areas. The Sub-Committee also reports to and health care. supports the work of the CRC. (See Appendix 3 for the Terms of Reference of the Research and Knowledge Recently across Canada, greater emphasis is being Transfer Sub-Committee.) placed upon defining the role of government in health care in terms of stewardship. This has permeated Building on the Successes of the language of reform for several years now and Other Jurisdictions is witnessed in the recent reforms proposed for Much can be learned from the successes of other the MOHLTC. national and international jurisdictions. Many either have in place, or are currently taking steps to establish, Behind the concept of stewardship is the belief that more focussed and specialised bodies dedicated to core government responsibilities include: policy providing technical and scientific public health support. development and analysis, legislation, long-term Most recently, the European Union6 and Hong Kong7 planning, setting strategic directions, enforcement and have moved to create specialised bodies. Countries accountability for funding and outcomes, and monitoring, as diverse as Finland8 and Brazil9 have in place reporting and overseeing performance. In addition to specialised public health bodies distinct from their devolving aspects of program management to the local principal health care planning bodies. These bodies planning level, another reform has been to reduce range in size from approximately 8,000 employees at government involvement in direct health care delivery. the U.S. Centers for Disease Control and Prevention Much of the Province’s work in public health falls clearly (CDC) through to as few as 70 or 80 employees at into the domain of stewardship and therefore is not the smaller organisations. Despite their diversity, what role of an agency. tends to be common among these organisations is a dedicated focus to promoting of research and scientific Effective health protection and promotion efforts, engagement to enhance the ability of planners and however, rely on a range of activities and supports which providers to the access to advice, evidence and support fall far less easily into the core definition of stewardship, for their work. and, as such, into how Ministries structure and prioritise their functions. Some of the activities and supports that Two Canadian provinces, Quebec and British Columbia, the Agency could provide: currently have specialised public health bodies in place. • Generation of research evidence;

16 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion A History of Specialized Public Health Organizations Around the Globe

Quebec BC US UK Hong Kong EU Institut national de Centre for Disease Centers for Disease Health Protection Centre for Health European Centre for santé publique du Control (BCCDC) Control and Prevention Agency Protection Disease Prevention Québec (INSPQ) (CDC and Control Date of 1998 1997 1946 2003 2004 May 2005 creation Type of Entity Fully arm’s-length Arm’s-length (degree) Part of government Fully arm’s-length Part of government Fully arm’s-length

Authority derived from Established as a Society Part of the Department of Authority derived from Part of Hong Kong’s Authority derived from special legislation (An Act (corporate body) and Health and Human special legislation (Health Department of Health (the special legislation Respecting Institut accountable to the Services Protection Agency Act Controller for the CHP (Regulation of the National de Santé Provincial Health Services 2004) reports to the Director of European Parliament and Publique du Québec, Authority – somewhat Health) of the Council, 2004) 1998) arm’s length Mandate To improve the To support a To promote health and To protect health and To achieve effective To identify, assess and coordination, comprehensive program quality of life by reduce the impact of prevention and control of communicate current and development and use of of communicable disease preventing and controlling infectious diseases, diseases in Hong Kong in emerging threats to expertise in public health, and environmental health disease, injury and chemical hazards, poisons collaboration with major human health from and to develop knowledge prevention. disability. and radiation hazards. local and international infectious diseases (may and share information in stakeholders. be broadened to non- public health. infectious diseases after a scheduled review in 2007). Focus • Surveillance and • Hepatitis services • Health promotion and • Infectious diseases • Surveillance and • Networking public population health • Epidemiology services prevention of disease, • Chemicals and poisons epidemiology health authorities to assessment • Laboratory services injury and disability • Radiation • Emergency response foster coordination and • Health promotion • Sexually transmitted • Preparedness, • Emergency response and information collaboration. • Disease and injury disease/AIDS control including protection • Local and regional • Infection control • Linkages with prevention • Tuberculosis control from infectious, services • Program management international partners • Health protection • Drug and Food occupational, • Research and professional (e.g. World Health • Administration of Information Centre environmental and • Risk communications development Organization, CDC) public health • Food protection terrorist threats • Public health laboratories, • Radiation protection laboratory toxicology centre, • Public health services provincial audiological and radiological screening service

Figure 1. A History of Specialised Public Health Organisations around the Globe.

• Development of best practices and decision aids; These are functions that often fit uneasily into a • Provision of professional development supports traditional Ministry structure. However, it is precisely and training; these forms of support that are increasingly needed. • Assessment of scientific findings in a wide range Health care provider organisations and public health of areas; professionals have consistently reiterated that these • Development of effective support tools for types of activities and supports are only partially and program delivery; inadequately being provided through existing structures. • Delivery of distance training and education; and The Task Force believes that by focussing on these • Enhancement of outbreak modelling capacity and types of activities the Agency would both improve risk analysis. the informational supports provided to public health

Final Report of the Agency Implementation Task Force 17 practitioners and health care providers and increase the health of all Ontarians through the application and availability of public health research to Ministries. This advancement of science and knowledge. would, in turn, support the core roles of government. Mission Much of this type of work would involve drawing upon We are accountable to support health care providers, the and linking together the knowledge and skills of those public health system and partner Ministries in making working in a range of areas, in Ministries, in the field and informed decisions and taking informed action to improve in research centres through a structured organisational the health and security of all Ontarians through the hub, a role which we see the Agency performing. transparent and timely provision of credible scientific advice and practical tools. By establishing the Agency, the AITF envisions building a more collaborative and consistent approach to Values enhancing the public health system provincially, and locally To guide the Agency’s mandate, vision and mission, the or regionally through the generation of tools, advice, AITF recommends a set of core values. training and support across the system. Establishing a dedicated and focussed central resource for public health Responsiveness will also allow for the Agency’s partner Ministries to draw The Agency will meet the needs of its clients across upon a more unified and structured scientific base. In the continuum of the health system by providing timely addition to the MOHLTC, the new Ministry of Health analysis and practical support by developing and Promotion (MHP), the Ministry of the Environment (with translating applied research, training and advice. jurisdiction over water and air safety) and the Ministry of Agriculture, Food and Rural Affairs (with jurisdiction over The Agency will have a field response capacity, both food safety and elements of animal health) are all logical in-house and through partnerships, to support, assist and clients of the Agency. There is a need to further develop augment local and provincial health system capacity. our shared understanding and evidence base on human health risks. This would only help leverage more Relevance coordinated approaches to anticipating and addressing The Agency will translate research into action-oriented risks which routinely cross a range of mandates. advice and tools for evidence-based public health programs, policies and practices. The threat of an influenza pandemic from an avian source amply demonstrates just how linked the science and The Agency will base its priorities on close consultation knowledge of human health need to be to our research with health care providers, Public Health Units and and understanding of animal health. The proposed approach partner Ministries to ensure its services continue to meet places great importance on strengthening this link. current and emerging needs.

Strategic Framework Credibility The Agency will be guided by the best available evidence Defining the Agency’s mandate, vision, mission, values and science to consistently provide quality information and philosophy is key in setting the direction and and services in an independent and unbiased manner. foundations upon which the Agency will operate. Environmental scans, experience from other jurisdictions, Collaboration stakeholder consultations, and both formal and informal The Agency will build partnerships and will draw upon discussions have contributed to the development of the best available expertise provincially, nationally these basic principles, providing the AITF with a strong and internationally. The multidisciplinary staff of the foundation on which to make recommendations for Agency will respect, support and promote one the Agency. A strategic framework starts with an another’s creativity, expertise and well-being. organisation’s vision, mission and values. Innovation Vision The Agency will be at the forefront of knowledge We will be an internationally recognised centre of generation and knowledge exchange in Ontario and expertise dedicated to protecting and promoting the beyond. The Agency will provide leadership by being

18 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion anticipatory and proactive to threats to, and opportunities We are all collectively aware of the many experts in for, the health of Ontarians. Ontario who currently contribute to scientific or technical panels of international organisations such as the CDC, Guiding Principles that many of us in Ontario subsequently seek out as The AITF spent considerable time looking at guiding definitive sources of information. In addition, Ontario has principles that should direct and sustain the Agency in seen a number of key leaders in public health leave the carrying out its mandate. The work of the Agency should system during the period of downloading and instability, be guided by a population health approach that supports to provide valuable guidance and leadership elsewhere. improving the health of all Ontarians throughout their lives and commits to reducing inequities in health status Clearly, we would envision the Agency changing this between population groups. dynamic over time, by building an organised cadre of scientific expertise here in Ontario based around the The AITF recognises that multiple factors, including Agency’s identified areas of specialisation. By striving to material and social inequities, contribute to a disparity in make the Agency a flagship, we would not only increase health status among populations. Ontario has a diversity Ontario’s public health profile, but would take clear steps of populations including First Nations/Aboriginal forward in helping to draw expertise to the province, a communities and francophones. Recognising this benefit to both the Agency and the system. diversity in the work and approaches of the Agency would only increase its relevance. Scientific and technical skills however are not enough. If the Agency only becomes a source of published scientific Operational Approach papers, but is unable to translate this knowledge and evidence into tools and supports that are usable for a The AITF has recommended that the Agency adopt a public health practitioner, in public health, a nurse in a framework to guide its operational approach. Three long-term care facility or a Ministry facing emergent success factors have been delineated: oustanding issues and requiring timely and reliable advice, then it will people, effective processes, and relevant outcomes. not have achieved its goal. This addresses the need to It is against these success factors that the Agency combine scientific and technical skills with skills in could develop goals, objectives and outcomes. knowledge translation and communication.

The Agency also needs to be grounded and remain relevant to the issues faced at the point of public health Outstanding VISION Effective and health care delivery. This requirement points to the We will be an People internationally Processes need for a staffing approach which, for some portion of recognized centre of its staffing, would allow for individuals to maintain their expertise dedicated to the protection and current clinical practice or public health role, while promotion of the health serving on a shared time, rotational or affiliate basis at of all Ontarians through the application and the Agency. advancement of science and knowledge We believe this approach has merit as it could: • Partially mitigate against the new Agency Relevant permanently drawing scarce resources out of the Outcomes system by allowing engagements that promote a sharing of capacity between various bodies and Figure 2. Operational Approach organisations; • Allow for a broader pool of experience to be drawn Outstanding People: Staffing Philosophy into the Agency’s activities; No matter how well-crafted the organisational design and • Prevent the Agency from becoming overly well-thought out its policies and procedures are, the AITF academic or otherwise disengaged from front-line believes that the Agency will only achieve its goals if it work; and attracts the right people. This will rest in large part on the • Reduce the distance between the Agency and the staffing philosophy adopted by the new organisation. front-line by acting as a two-way conduit between

Final Report of the Agency Implementation Task Force 19 public health practitioners and health care providers For example, in the area of infection control, an Infection in the field and the Agency itself. Control Practitioner (ICP) employed part-time at a hospital and part-time in the Agency would enable the ICP to We would also strongly recommend the Agency adopt a bring to the Agency the realities and issues of day-to-day progressive approach regarding graduate placements and practice. At the same time, the Agency could provide training positions. Creating new opportunities for people that individual with access to a multi-disciplinary team to enter the field is critical for a public health system engaged in cutting-edge research. facing staffing challenges which are at risk of worsening in the years ahead. Affiliate Scientists/Researchers Having scientists or researchers affiliated with the Agency Students considering public health as a career often is an effective mechanism used by organisations such as face significant challenges in obtaining public health the Institute for Clinical and Evaluative Sciences (ICES) to placements. This limits the pool of those who might promote innovative research. This approach would allow choose public health as a career and slows attempts to an individual to be formally affiliated with the Agency, rebuild the public health workforce. The Task Force work on certain core projects on an as needed basis, and believes that the Agency has a responsibility to lead by at the same time retain their field or academic affiliation example and act as a magnet location for placements, and employment. Affiliation should be based on thereby influencing and assisting to improve the supply demonstrated expertise or contribution to a specific field. of public health professionals available to the system as a whole. Cross-Appointments Researchers and specialists in public health, chronic For the reasons set out above, it is our belief that the disease, infection prevention and control and environmental Agency should consciously adopt a staffing philosophy health are first and foremost knowledge workers. People that allows and encourages flexible staffing arrangements. who work in senior levels in these fields often spend much of their lives bridging research practices and Staffing Mix field or clinical practices. This reality of current work Full-Time Staff expectations needs to be reflected in the way in which To achieve organisational permanence and relevance, and the Agency designs its staffing framework. to develop effective working relationships across a range of partners, the Agency needs to create a workplace Recruiting high calibre individuals in the future will not history and culture. This requires a degree of permanence, simply be about how much they are paid. It will be about continuity and stability at the core of its organisation. As how their expectations can be met for a work well, a number of core day-to-day operational functions environment which not only allows, but also supports need a sufficient complement of permanent full-time staff and fosters, research and practice. in place to succeed. We therefore strongly support the promotion of The AITF recommends that the senior and lead staff in all cross-appointment arrangements through academic technical areas be engaged on a full-time basis. In affiliation agreements. This approach is used effectively addition, the functioning of the Ontario Public Health in public health agencies in British Columbia and Quebec, Laboratories (OPHL) requires an adequate pool of at the CDC, and at the state level in the United States. permanent, full-time support. It also resembles the approach adopted in the UK agency and the Public Health Observatories, as well as Part-Time Staff approaches pursued by a number of Public Health Units To maintain relevance and ensure that the expertise in and research centres in Ontario. the Agency remains current, a spectrum of flexible work arrangements should be in place. This concept of a more The Task Force envisions that, over time, cross- permeable structure, than in the bureaucratic norm, that appointments could be used as a mutually beneficial would allow those working in the field to maintain their approach to recruiting and retaining skilled staff. For expertise and bring it into the Agency. At the same time, example, a staff member of the Agency could have a such staff would have access to the Agency’s resources, cross-appointment for teaching at the University of research and cross-disciplinary expertise. Toronto and a faculty member of the University of

20 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Waterloo could have a cross-appointment to the Effective Processes Agency to engage in research. This has the added Priority Setting benefit of beginning to break down the silos between In the Part One Report, the Task Force recommended academic, policy and practice. that the Agency develop a three-year rolling Strategic Plan with input generated through priorities identified Secondments and Transition through two streams. Effective links and knowledge of organisations and institutions will be required in many areas of the First, a coordinated mechanism for MOHLTC, MHP and Agency’s work. It is important to ensure that the Agency partner Ministries to engage in priority setting is is a functional partner and understands the processes set out in some detail in Chapter 3. Recognising the and structures of other organisations, with which it will breadth of public health and the value of cross-Ministry require effective working relationships, such as partner awareness and input into work undertaken by the Agency, Ministries and Public Health Units. We envision that the the Task Force recommends that the Chief Medical Agency’s structure will allow for two-way secondments Officer of Health (CMOH) lead the establishment of intra- between staff in appropriate areas. This would enable and inter-Ministry coordinating process. This type of staff from both the Agency and other organisations to mechanism has been effectively used in Quebec to bring into the Agency direct experience and take back ensure that the strategic directions of the INSPQ are experience and knowledge gained to their Public Health aligned with the appropriate Ministries in Quebec, in a Unit or faculty. For example, staff from the MHP could clear and coordinated manner. take a secondment at the Agency to work on assessing evidence of behavioural interventions to combat obesity Second, the AITF proposes that a range of mechanisms together with researchers and field experts. be built into the planning cycle to ensure clear and planned opportunities for public health practitioners and Training Placements and Professional Development health care providers to identify areas of need consistent The Agency should, as we have recommended, act as a with the mandate of the Agency. Such mechanisms training ground for new public health professionals by might include: providing placements for students and others entering • Establishing a table of representatives from public the field through an organised placement program. health and provider organisations (e.g. Regional Infection Control Networks (RICNs), and the Project Specific Engagement proposed network for research and knowledge We would envision these as time-limited engagements exchange) that would come together at appropriate associated with specific projects or initiatives focussed intervals in the Agency’s planning cycle in order to on addressing a short-term or localised need. This would convey strategic priorities. The organisations would allow staff from a variety of disciplines to work with be responsible for canvassing their members and the Agency while enhancing both the Agency’s expertise bringing forward priorities or identified gaps. and depth and level of engagement. Such an approach • Representatives from each Public Health Unit might be a time-limited project associated in a highly could come together for roundtables, reference specialised area of expertise, for example, developing groups and regional feedback sessions to best practices in tuberculosis control measures among establish the priorities and directions most new immigrant populations. important for them.

Standing Advisers on a Retainer Although it is the ultimate responsibility of the Board A standing adviser arrangement could be effectively to decide on the Agency’s Strategic Plan, this Plan employed to access certain highly specialised skill set will need to have appropriately incorporated into it a that the Agency would require from time to time. The balance of priorities identified through the Agency. The expert would work for the Agency on a retainer and process for ensuring adequate input from the field is an could be called upon as required. The Agency would, for important component that can assist the Agency in example, likely not require a full-time specialist in the fulfilling its mandate in a manner that is relevant and impact of silica exposure. However, on as needed basis, practical to those carrying out health protection and it would need to have the mechanisms in place to access promotion in Ontario. such services to supplement its capacity.

Final Report of the Agency Implementation Task Force 21 Relevance and Access both the means to disseminate and deliver work, but also The AITF recommends that the Agency not be structured a mechanism by which specific needs and priorities can as a virtual organisation, but rather function as a viable, be directly relayed to the Agency. comprehensive infrastructure with a tangible physical presence. The AITF further recommends that the Agency In the area of Health Promotion, the AITF in our Part One be located in Toronto to provide easy access to the Report had indicated the need for a comprehensive CMOH, and key Ministries. review of Ontario Health Promotion Resource System (OHPRS) to be undertaken as a necessary pre-condition At the same time, we have consistently adopted the to better delineate where and how the activities of philosophy that the overall approach of the Agency to the Agency could best link with this existing capacity developing academic partnerships should not be in a manner that was non-duplicative and promoted determined by physical proximity to Toronto, but to greater cohesion and access to the types of products and where centres of expertise and experience relevant to supports currently provided by the OHPRS. the functions and mandate of the Agency are currently housed. To that end, we would strongly recommend that Once this review is completed, we would anticipate that the Agency retain this philosophy and over time establish work between the new Agency and the Ministry of Health the appropriate affiliation and partnership agreements Promotion would need to be undertaken to determine with such centres across the province as the need and how best to structure future relationships in this key area. opportunity warrants. In the broader area of local or regional approaches to We have also spent considerable time trying to work public health research, education and training, we through the best way in which research, knowledge have learned much from the wealth of experience exchange and training could be effectively conducted of both the Health Intelligence Unit (HIU) and the across a vast geography of diverse needs. Public Health, Research, Education and Development (PHRED) program. The HIU program no longer On a very basic level, the AITF acknowledges that the formally exists and the PHRED program, while work of the Agency can only benefit from strong capacity nationally recognised for the work it has undertaken, at the local level. From a local perspective there is clearly has gone through the challenge of a disconnect a need to ensure that there is sufficient critical mass with between expectations of meeting provincial and the know-how and skills required to apply research and regional objectives while being partially dependent evidence to policy and practice of local public health on funding from individual municipalities. delivery. In this regard the outcomes of the Public Health Capacity Review Committee (CRC) and the ensuing Coordinated Networks for Research and actions which may follow to strengthen Public Health Knowledge Exchange Units will be of clear importance to the Agency. Well coordinated regional efforts are increasingly required to better support the delivery of knowledge translation In addition, the AITF is conscious that a number of and training activities in public health, as are currently activities of the Agency would require that it have in being developed in infectious disease control. place clear coordinated links for the purpose of the delivery of training supports and research and for Clearly, we would see the need for a more cohesive and ensuring that needs and risks are identified early. equitable approach to the knowledge exchange, training and research supports at a regional level. In undertaking In the area of Infectious Diseases (including infection this work, we suggest that a process be put in place prevention and control), there are clearly emergent drawing on experiences of the RICNs, for example, with opportunities for the Agency to develop effective lead organisations selected against clear criteria which coordinated linkages that cross the province. The might include: recently established RICNs, organised along Local Health • Regional representation, involvement and access; Integration Networks (LHINs) boundaries, draw together • Multi-disciplinary steering committee; public health, acute care, long-term care and community • Strategic Plan which aligns in key areas with that providers around a focussed set of objectives. These are of the Agency; one obvious vehicle that can provide the Agency with • Established academic affiliation agreement; and

22 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion • Demonstrated track record in the fields of to develop and implement RICNs. These networks grew knowledge exchange, training and research. out of the recognition for the need to ensure greater coordination and consistency in infection prevention and Making this sort of transition from the existing approach control within and between sectors. The networks bring is not going to be easy or quick. However, change to together acute care, public health, long term care and the status quo is required in order both to harness the community based providers in a formal coordinated available expertise and experience while ensuring that manner, organised along LHINs boundaries to identify this is made available across the province in a and improve approaches to awareness, resources, coordinated and equitable manner. training and support for infection prevention and control.

Promoting the establishment of coordinated regional We would see the Agency, upon its establishment, approaches to increasing both the availability and building upon and linking to the capacity of the networks relevance of research on a more equitable basis should by providing materials, training and support, and by be an early area of focus for the Agency working in receiving from the networks both information and concert with partners Ministries to achieve this objective. identified priority areas for assistance in infectious diseases and infection prevention and control. Collaborative Work Team-based work and cross-participation should permeate Dissemination and Delivery of Knowledge Products the culture and philosophy of the Agency in its relationship Producing tools, supports and training requires that the with Ministries and the field. The Task Force supports the Agency use a range of accessible and cost-effective Agency promoting team-based work through agreements, approaches to delivery. The Task Force sees an while respecting appropriate areas of responsibility. opportunity to leverage the considerable investments that have already been made by both the provincial and For example, a physician employed by the Ministry of federal governments in information technology and Labour and a public health physician from the MOHLTC delivery systems, and to the extent possible all efforts working with others from the field, could, under the should be based on utilising existing systems. approach we are proposing, engage with Agency staff and affiliates in examining the latest research evidence The opportunities are many and include: on measures to improve protection of health care • Telemedicine Services: Utilising the provincial personnel in specific circumstances. We would see this telemedicine services such as Network North for form of approach as spanning a range of levels from the delivery of distance training and supports. This participation to time-limited secondments. approach is increasingly used in a number of disciplines as an effective way of delivering The roles of the Ministries would be to bring to the specialised training and technical support to large team their particular expertise and knowledge in the area, numbers of health care providers on a cost as well as comprehensive knowledge of the legislative effective and accessible basis. and regulatory frameworks that may apply. The legislated • Public Health Portal14: The Agency should build responsibilities of Ministries would obviously remain upon work already undertaken to develop a public in place. The Agency, in this respect, would act as a health portal for Ontario. In this regard, the scientific bridge and work to provide both Ministries, provision of webcasts and web-based training and and ultimately the field, with the best available evidence. support tools could be a practical early step, one This approach is also an important way to develop the which builds upon investments already made. effective working relationships that may be required. It is Webcast training is increasingly used by the CDC also an effective approach to ensure that the professional as a means to allow practitioners and providers to development opportunities opened up by having an access international expertise. A good example Agency structure in place are broadly available to the of the type of value that the Agency could bring is field, Ministries and Agency staff. to support the equivalent of ‘video-rounds’, making available and disseminating through webcasts the Research, Knowledge Exchange and Training latest conferences on topic specific updates. This Regional Infection Control Networks effective means to increase broad access to top In regions across Ontario, extensive work is underway level expertise is currently underused in Ontario.

Final Report of the Agency Implementation Task Force 23 • DVD and CD-ROM-based Televisual tools: An • Cross-appointments for teaching and professional opportunity exists for improving access to training development. supports in a range of formats. Increasingly DVD and CD-ROM technology is cost effective and The demonstrated benefits of formal partnership or affiliation allows for providers to obtain high quality training models seem clear for the purposes of recruitment, pursuit materials and presentations according to their of shared areas of research interest, and for: own schedules. • Promoting better links between research, policy and practice; Partnerships • Leveraging research funding; We have no interest in proposing that the Agency unduly • Attracting human resource excellence to the duplicate expertise and capacity that currently exists Agency and its partners; and elsewhere, nor do we envision the Agency as functioning • Allowing the Agency to provide more effective in a vacuum. To be most effective, it will need to access to expertise, support and guidance to meet leverage the capacity, skills and opportunities that exist its mandate. in a number of networks and organisations both within Ontario and outside. To effectively meet its mandate, Partnerships are not, however, without potential the Agency will therefore need to establish formal and problems – problems of differing cultures, expectations, informal working partnerships with academia, research and incentive structures. Closing the gap between the bodies, non-governmental organisations and key health needs of health care providers and public health organisations (such as Public Health Units). practitioners, Ministries planning programs and the research community is not always a simple task. The In its Part One Report, the AITF developed a set of best advice we have received is that the Agency should guiding principles upon which partnerships should be have clear principles of engagement in place before it based. The principles were developed very much proceeds with formal academic affiliation agreements, based on advice from others who have grappled with and approach this area, starting gradually based on clearly the challenges of creating and living with academic identified functional requirements. partnerships at centres with comparable mandates in Canada and internationally. Starting with first principles, any partnership considered should: The INSPQ has affiliations and partnerships with a • Align with the Agency’s values, mission, vision and number of academic centres including McGill University critical objectives to enhance its ability to meet its and the Universities of Montreal and Laval, as well as mandate; with research bodies and non-governmental associations. • Be governed by an intellectual property policy that The BCCDC has a close partnership with the University will delineate, at the outset, the appropriate sharing of British Columbia. The CDC and the UK Public Health and ownership of information and innovation; and Observatories all employ multiple forms of affiliate • Meet a set of key principles set out below. arrangements with academic centres across their respective institutions. Guiding Principles for the Agency’s Partnerships Clarity While the specific types and forms of academic affiliation The objective(s) of the partnership will be clear, well- agreements vary from place to place, typically they often defined and directly aligned with the objectives and cover the following range of activities. strategic priorities of the Agency. Rules governing the • Interdisciplinary research agenda or focus of partnership should similarly be clear and well-defined. interest and need to both parties; • Access to established ethics review; Credibility • Database access; Partner organisations will have a demonstrated track • Academic affiliations for individual Agency record in contributing to a key area of knowledge and staff members; expertise relevant to the Agency’s mandate. • Cross appointments for academic researchers into the Agency; Transparency • Placement program or programs for students; and The purposes of, approaches to, and mechanisms of

24 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion entering into partnerships will be transparent and open to approaches the data that might be collected nationally the parties concerned. and Provincially.

Focus on Results Surveillance and Epidemiology Partnership arrangements will include clear and The Animal Health Laboratory at the University of Guelph measurable performance expectations with results that collects surveillance data on animal and zoonotic diseases. are of value to both parties and that are monitored and This data, as has been identified by others, needs to be evaluated accordingly. coordinated among public health, food safety and animal health organisations. With most emerging infectious Governed by Exit Rules diseases originating in animal populations, surveillance of Partnership arrangements will exist for a clear and this kind is crucial to increasing both our understanding defined period of time, be renewable, be based on of and ability to anticipate emergent risks. In addition, achieving stipulated objectives and/or results, and early in the Agency’s operation, partnerships on data have clearly stated terms for both engagement agreements will be required with the Ministry of the and disengagement. Environment with regard to data pertinent to environmental and health analysis. Practicality Partnership arrangements will incorporate mechanisms for Training and Education practical, cost-effective and timely resolution of disputes. To develop and carry out its professional development mandate, the Agency should consider early partnerships Mutually Beneficial with various organisations and academia. For example, a Partnerships will be structured to ensure they are partnership with the Public Health Units for placement of sustainable with benefits to both parties. its public health professionals in the Agency or with medical and public health schools for students interested Priorities for Partnerships in the field of public health. Early partnerships to support The Agency will need to put into place mechanisms in capacity building in Ontario could include PHAC’s its early phases to determine priorities for partnerships. Canadian Field Epidemiology Program and the initiatives The AITF recommends that these priority partnerships underway through the PHRED program. be driven by the functions that the Agency will require to meet its commitments and deliverables. The AITF Access to tailored training in specialised areas, for suggests the Agency consider the following partnerships example, zoonoses in public health, might be provided in its early stages to better perform and carry out its through an Agency partnership with the Ontario Veterinary mandate. While it will ultimately be for the Board College to deliver this. In addition, we would see potential to determine the following examples illustrate areas for alliance between the Agency and the Ontario Public of opportunity. Health Association to provide training tools on core compentencies. At the same time, the Agency should Data and Information invest in professional development for its own staff. The Institute for Clinical and Evaluative Studies (ICES)15, the Canada Institute for Health Information (CIHI)16 and Communication Statistics Canada17, Canadian Institutes for Health To quickly build its communication capacity, the Agency Research’s (CIHR) Institute for Population and Public should examine the opportunities with the Health Health18, and Cancer Care Ontario (CCO)19 are just a Communication Unit at the University of Toronto. few examples of critical organisations housing data This partnership could also potentially enhance the that the Agency will need access to carry out a range Agency’s ability to provide knowledge exchange in its of the analytical functions required to fulfill its mandate. start-up phases. Establishing data access agreements, either centrally through MOHLTC or directly, is a clear early task for the As the Agency builds a partnership structure, it will need Agency. Over time, however, we would envision the to consider how to foster collaboration, build strong Agency playing a role not simply in using data that is networks and adopt an integrated approach that ensures currently available to create a richer capacity for public effective communication and response among the health analysis – but also in shaping through partnership various partners, as well as within the Agency.

Final Report of the Agency Implementation Task Force 25 Types of Partnerships and the way in which research and evidence is often All of the Agency partnerships need to be governed made available. Some innovative ways in which the initial either by a legally binding contract or mutually agreeable results of research can be disseminated quickly to the terms of reference. Partnerships will also include field include: institutional level agreements governing such areas as • Produce one-page summaries of key findings cross-appointments, secondments, employee sharing, to-date and their application; and affiliate positions. • Develop and refine simple decision algorithms for public health and infection control practitioners; By building on existing capacity, the Agency would be • Pilot test approaches to conveying scientific in a position earlier in its mandate to offer professional information to providers and policymakers; and development, training and placement opportunities. • Issue electronic bulletins on research and program This is especially important because of the Agency’s developments in other jurisdictions. desire to deliver tangible results early for public health practitioners and to increase recognition of the public The AITF strongly suggests that the Agency put into health profession. place outcome measures that track their ability to deliver relevance in the work they produce. It should not be Relevant Outcomes enough simply to list the products produced; critically The Agency should be required to have in place important will be a focus on knowing that the work is performance indicators and outcome measures against making a difference and that uptake in use is measured. which it can be measured and by which it publicly demonstrates accountability to its clients and funders. Reliability In developing performance measures for the Agency, Ontario has the scientific expertise necessary to have we would suggest that both the approaches of the an Agency that is respected beyond the boundaries BCCDC and the INSPQ be reviewed. Both set multi-year of the Province. To achieve credibility over time, high performance measures with detailed public reports on quality peer-reviewed articles, abstracts and reports progress. In addition, we would suggest that four key will be a required output. To maintain high standards, domains of measurement be examined. it will be important for the Agency to have in place an expert review process which draws on leaders in the Timeliness specific fields of inquiry both inside and outside the A consistent challenge faced by policy-makers and Province. One important set of markers and outcomes decision-makers in many levels of health care is needing measures related to this goal is the extent of the use high-quality material, good evidence or best practice of the Agency’s materials, including citations in peer information upon which to ground a decision very quickly, reviewed journals. at a pace that is often at odds with the way that academic research is structured and undertaken by many Applicability researchers. The Agency will only begin to add value Equally important is presenting scientific and technical when it starts to close this gap, increasing the timeliness materials and evidence in a form that is usable to and responsiveness of research to field and Ministry providers and policy-makers. To achieve this will require needs. Achieving this goal, however, will be challenging certain specialised skill sets in order to synthesise and will bring to the fore the tension between the need and analyse scientific findings, data and evidence so for immediacy and the importance of quality. That said, that the impact on policy and practice is clear, evident timeliness must be built into the overall performance and understandable. framework for the organisation. A question for the first Board and CEO is how to structure the Agency to ensure Understanding how scientific or technical guidance can that it can give reliable information quickly and in a be applied in different settings is also critical if the useable form. Agency is to be able to be relevant to providers working in diverse settings. Usability There is a need to narrow the gap between the needs This means special attention needs to be paid to ensure identified by Public Health Units and health care the form of information presented is sensitive to the providers for practical evidence-based tools and supports differing realities of the various components of the

26 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion health care system. This also means that there is a need to structure outputs appropriately, to test and retest the most effective ways to provide information to different audiences.

For example, best practice information on the control of a disease cannot simply be developed for acute care. It will need to be tailored for homecare or long-term care settings and would also need to be written in a manner that is usable for registered practical nurses or personal assistants. The Agency, should have outcome measures that demonstrate its ability to produce accessible and applicable tools and information which are then field tested and evaluated directly with providers in a range of settings.

Final Report of the Agency Implementation Task Force 27 Chapter 2 Governance and Accountability

Overview

To determine the Agency’s proposed governance structure, the AITF consulted with experts in the field, researched principles of good governance for non-profit corporations in a number of jurisdictions and had discussions with a number of key leads for both research and health sector agencies in Ontario and across Canada.

Certain key principles underlie good governance; accountability, transparency, appropriate delineations of roles and responsibilities and not least, a conscious attention and focus on the practice of governance.

The recommended governance model we propose is consistent and aligned with best practice principles set out in the following documents:

• Meeting the Expectations of Canadians: Review of the Governance Framework for Canada’s Crown Corporations;1 • Public Appointments Processing Guide;2 • Agency Establishment and Accountability Directive;3 • Corporate Governance Guidelines for Building High Performance Boards;4 • Principles for Good Governance in the 21st Century;5 • Appointment Guidelines Governing Boards and Other Public Sector Organisations.6

Independence For the Agency to be credible as a non-partisan, non-political provider of scientific and technical advice, the AITF recommends that it be functionally and operationally arms-length from the MOHLTC, in accordance with recommendations in the Walker, Campbell and Naylor Reports7–9, and as echoed in the commitments made in Operation Health Protection10. This approach is complementary to the legislative changes undertaken in Ontario post-SARS to clearly provide the CMOH the right to speak independently on matters of public health.

While a greater arms-length role has been widely cited as providing both greater flexibility and allowing for a more focussed approach to the core elements of the Agency’s mandate, it does not in itself guarantee good governance. Stressing autonomy is the easier part of the equation; balancing this with effective coordination and strong governance is hard.

The INSPQ, established in 1998 by special purpose legislation that ensconces the mission, governance and functions of the organisation in detail in a statutory expression, provides a good model of walking the fine line between autonomy and coordination.

28 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion In addition to the legislative framework, a detailed Agency to collect, use, and disclose personal health memorandum of understanding between the INSPQ information, as well as enable other entities to and the Quebec’s Ministry of Health and Social disclose and share information with the Agency. Services exists that clearly delineates a number of roles and responsibilities. Memorandum of Understanding To enhance accountability and clarity of role definition, This arrangement has served the INSPQ well in the the AITF recommends developing a Memorandum of seven years of its operation, and is the foundation for the Understanding (MOU) between the Agency and the respect INSPQ maintains despite major political changes MOHLTC. The MOU should: in government and ongoing reform and transitions at the • Clarify in detail the roles, responsibilities, Ministry level in Quebec. relationships and mutual expectations of the parties; Ontario has learned from other jurisdictions in proposing • Clearly delineate the role of the Agency in support the structure for the Agency. Unlike experiences in in emergency and exigent circumstances within British Columbia and Quebec or indeed the U.S., where the Provincial framework; these agencies evolved incrementally over many years, • Set out in detail the accountability mechanisms, as Ontario has made a conscious decision to create a health well as the framework for reporting requirements protection and promotion agency with a clear and defined including the Business Plan, performance mandate within a specific timeframe. This carries the measurement and Annual Reports; greater challenge of attempting to introduce a new • Define the communication mechanisms, protocols organisation into a well developed and complex field. It and issues management procedures between the does, however, allow for greater conscious choice to be MOHLTC and the Agency; made at the outset in shaping the new agency. • Lay out the mechanisms and structures for inter-Ministry input (e.g. from the MHP) into the Special Purpose Legislation Agency’s Strategic Plans; The AITF deliberated on how best to establish the • Require processes be in place to ensure that the Agency and considered several options, including: Agency can meet its fiscal responsibilities and • Special purpose legislation; mandate; • Regulation under the Development Corporations • Specify the principles and administrative Act11; and procedures the Agency and all parties should • An affiliation agreement with an existing agency follow; and or centre. • Include the requirement for the Agency to have undertaken periodic third party external reviews of The AITF strongly recommends that the Agency be its operations to ensure it is fulfilling its mandate. created through special purpose legislation as soon as possible. The Agency should be a scheduled operational Multi-Year Funding service agency of the Crown, with formal accountability The AITF recommends that the Agency be funded to the Minister of Health and Long-Term Care who in turn on a multi-year basis. This would provide the Agency would be accountable to the Legislature for the activities with a longer-term approach to planning and resource of the Agency. management. A multi-year funding plan will better allow the Agency to incorporate long term activities that are The AITF recommends that the legislation contain relevant to the field and the province. Multi-year funding provisions to: provides predictability, both to the Agency and to the • Allow the Agency to have access to and hold third government funder. It also allows for the better alignment party funds; of strategic planning and accountability, since the longer • Put in place a Board that is competency based and timeframe allows funds to be better tied to outcomes and independent from government; deliverables that take more than one year to realise. • Include a public representative on the Board; • Allow for the re-deployment of staff in times of Accountability emergency and exigent circumstances; and As well as enhancing accountability through the • Obtain the legal authority required to allow the instruments mentioned above (legislation, MOU,

Final Report of the Agency Implementation Task Force 29 multi-year funding), the recommended governance model and an Annual Report. These documents will clearly lay sets out clear lines of responsibility and clear reporting out the goals of the Agency, as well as document the relationships, building in both audit and governance Agency’s progress and results and set out time frames functions into the structure of the organisation. Every for achieving goals. The Minister will be responsible for report on public health since SARS has identified tabling the Annual Report in the Legislature. organisational autonomy as essential. This is clearly one necessary condition of success. While autonomy Third-Party Review carries with it a series of potential benefits in terms of The AITF recommends that there be regular third organisational flexibility, responsiveness, and scientific party reviews of the Agency’s operations. Given the recruitment and retention, it also carries with it risks. Not weaknesses highlighted in reports following the SARS least of these is the risk of the Agency not discharging its outbreak, the AITF is aware of the need to ensure that obligations in an accountable and transparent manner. For the Agency undergo third party reviews on a regular these reasons, we have focussed on strong governance. basis. The AITF proposes that these reviews draw upon expertise and be undertaken by expert individuals The Chair of the Board is accountable for the functioning from comparable agencies and Ministries from within of the Agency to the Minister of Health and Long-Term and outside of Ontario, and that the key findings of Care, who in turn is accountable to the Legislature for these reviews should be publicly available. the activities of the Agency. Although the Agency should serve both the field and several Ministries, a single Transparency accountable Minister should be in place to answer for the The Agency must have systems and structures in activities of the Agency, thereby providing clarity. place to ensure there is transparency in applying and complying with internal policies. Stakeholders, In keeping with good governance principles, an accountability government and the public should have the means, framework with performance indicators should be via regular reports, of ensuring that the Agency is developed and the Agency be required to report annually accountable for delivery of its mandate and activities on progress against these performance measures. and is using its resources effectively.

Agency – Annual Report Cycle The Strategic Plan of the Agency should bring together the common priorities of the clients and be available Minister must table the Annual Report with the Legislative Assmbly within 60 days of receiving it. to the public. The Strategic Plan should be developed by the Strategic Planning Standing Committee of the Board and take into consideration the gaps, opportunities and priorities of its clients including the Ministries in the Annual Report, Annual Report Business government, as well as key priority areas idenstified including the including Plan Business Audited the Audited Plan must through engagement with health care providers and Financial submitted be Report, Financial Report, January 1 submitted Public Health Units. must be submitted on or before submitted July 31 January 1st within 120 or another days of fiscal day The Agency’s annual Business Plan should lay out year-end i.e. specifies by on or before the Minister. the Agency’s plan of action, the specific goals that July 31st or another day are to be achieved, strategies for achieving the goals, specifies by Business the Minister. Plan as well as the objectives and performance measures adopted April 1 for each goal.

The Board must adopt the Business Plan on or before For example, in the area of detecting and responding April 1st or another date specified by the Minister. to new disease threats, strategies or goals may include: strengthening surveillance capacity regarding Figure 3. The Agency’s Annual Report Cycle emergent facility-acquired infections, and building the human resources and expertise required in the Accountability Agreement field of infectious disease and infection prevention Accountability mechanisms for the Agency should and control. Performance measures for these goals include: a Business Plan including a performance plan may include:

30 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion • Module for continuing education on infectious the outset a cluster of blurred affiliations that could diseases for public health professionals developed impede the focus required to get a new organisation and delivered to a specific number of sites; and up and running. • Educational seminars held in a specific number of locations specifically for family physicians and The AITF recommended in the Part One Report that emergency room personnel on infectious diseases the Board be relatively small (seven to thirteen and infection prevention and control. members including the Chair) and members must represent a suitable breadth of skills and competencies; The governance model recommended by the AITF for the for example, legal, financial, business, scientific and Agency, including reporting relationships, is set out below. technical, communication and knowledge exchange. The Board should include individuals with public health Proposed Governance Structure and broader health sector leadership skills.

Agency Government The Task Force also suggests that the Board formally invite key PHAC representatives and other provincial Chair Standing Board Minister of Minister of public health agencies to Board meetings to foster Committees Health and Health Long-Term Promotion better linkages between the new organisation and key Care Governance resources and supports across the country. CEO

Strategic Planning The AITF strongly recommends that the founding CMOH / ADM Board for the Agency of five to seven members be in Scientific Advisory CMOH Functional Relationships place by in 2006 to support the timely start-up of the - Working Relationship with CEO - Sits on Strategic Planning Committee Agency and meet the government’s commitment as - Activates Agency participation in times of Audit emergency or exigent circumstances Public Health stated in Operation Health Protection. The Board can - Non-voting Board member Division subsequently be expanded in an incremental fashion, to a full complement of thirteen. Figure 4. Proposed Governance Structure The Agency as an independent non-profit corporation Board of Directors should have the power to establish committees of the Board. In the Part One Report, the AITF Board Structure and Competencies recommended that the Standing Committees of the Directors of a Board are legally charged with providing Board include a majority of non–Board members. the informed strategic stewardship of an organisation. However, in subsequently reviewing best practices, We have learned much from examining the pitfalls and the AITF noted that it is recommended that Standing risks that arise from poor or ill-defined governance. It Committees of Boards have a majority of Board is because of the fact that poor governance so often members on them to ensure that accountability and translates into poor performance that we have spent so responsibility of the Committees rests with Board much time on this area. members. The AITF recommends that the composition of the Standing Committees be carefully considered so Based on best practices, the AITF recommends that the as to ensure that Board accountability is maintained. Board of the Agency be competency-based rather than representational or health-discipline or sector based. The AITF recommends that the Board establish, at a minimum, the following standing committees: Consistent with affirming support for an appropriately arms-length nature, we also recognise that elected Audit Committee officials and officials sitting as representatives of a This Committee should be charged with: specific part of the health sector, a specific health • Ensuring the fiscal accountability of the Agency is discipline or public health organisation have a distinct appropriately monitored; duty to their constituencies. Constructing a formal • Reviewing, and recommending for adoption by Board on a representational basis is therefore not the Board, the appropriate financial policies and supported by the AITF as it risks building in from controls for the Agency;

Final Report of the Agency Implementation Task Force 31 • Functioning as the liaison point for both internal plan and bringing them forward expeditiously and external auditors; for resolution; • Ensuring that the Agency conducts itself according • Bringing forward to the Board approaches to refine to the principles of ethical financial behaviour and and improve the strategic planning process as a is efficient and responsible in its use of public whole; and funds; and • Identifying risks to the organisation in achieving its • Identifying and reporting to the Board potential strategic objectives and recommending to the financial risks to the Agency. Board approaches for mitigation.

Members of this Committee should be transparently As a member of this committee, the CMOH would act as independent of management and will need to have a key participant to ensure that the Agency’s Strategic financial literacy and suitable skills, abilities and Plan is informed by provincially identified priorities and experience in financial risk management. Ministry partners.

Governance Committee This Committee should also provide guidance to In the AITF’s Part One Report, the AITF did not include the Board on mechanisms to ensure that broad a Governance Committee in its recommendations stakeholder input is sought out and taken into for Standing Committees of the Board. The Task Force consideration. The Committee should be charged now recognises that supporting effective governance with recommending approaches to strengthen and needs to be built into the Agency at the time of its develop regional and local input into the priority setting incorporation, not after possible failures occur. The AITF functions of the Board. recommends that the Agency establish a Governance Committee to put in place the processes and protocols Scientific Advisory Committee to ensure maximum Board effectiveness. This Committee should be comprised of clinical, academic and public health science experts drawn Governance involves a distinct skill set that has been both from the Board and external to the Board. It identified as a competency for Board members. The will provide scientific and technical advice and be Agency’s Governance Committee should be exclusively closely linked to the Strategic Planning Committee. made up of Board members who will be responsible for This committee should be charged with bringing to activities such as: the Board: • Developing and reviewing the Agency’s policies • Guidance on ensuring scientific consistency and creating by-laws; and rigour; • Establishing processes for Board, and Board • Protocols regarding ethical research practices; and member, evaluations; • Assistance in securing national and international • Setting criteria, benchmarks, goals and performance expertise to support peer review of practices, measures for the CEO and senior management; protocols and materials generated by the Agency. • Establishing processes and programs for Board orientation and ongoing education; Selection and Appointment of • Succession planning for Board members, including Board Members maintaining profiles of current and required skills Founding Board and expertise; and In its Part One Report, the AITF recommended a staged • Establishing and implementing processes for approach to developing the Board, in order to have in identifying possible new Board members place some directors with start-up expertise to facilitate for consideration. the process of launching the organisation.

Strategic Planning Committee These founding members are then expected to form The purpose of this committee should be to advise the the core of the Board by continuing to serve as full Board on the strategic direction of the Agency, including: Board members. This staged approach, moving • Bringing forward a three-year Strategic Plan to from a start-up Board of between five and seven the Board; members and expanding to thirteen may minimise • Identifying modifications or adjustments to the delays in getting the Agency up and running while

32 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion providing for continuity and stability in Board Demonstrated specific competencies and skills for Board membership and leadership. members at the Board aggregate would include: • Knowledge of organisation, financing, structuring This staged approach would also give the Founding Chair and delivery of public health services/health services; a better opportunity to assess the balance of skill-sets • Senior level management experience in a complex required after a brief period of operation for the Agency environment; and to bring forward suitable candidates to address • Financial expertise – including financial analysis, potential areas of weakness in the Board. forecasting, and budgeting; • Strategic planning; Full Board • Quality assurance, risk management and As is usual with agents of the Crown, the appointment performance management; of Board members should be through Order in Council. • Legal skills including an understanding of The AITF recommends that potential candidates for the intellectual property rights and health law; Founding Board and the Board Chair be identified through • Human resource management; a transparent and non-partisan process led by the AITF • Expertise with start-up organisations; co-chairs, appropriate external experts in the field, and • Information systems management; a representative from the INSPQ. A long list should be • Communications and marketing in a government developed from which a short list would be submitted to and media/public relations context; the Minister of Health and Long-Term Care for review. • Academic expertise in scientific, research or The clearly defined criteria, including job description and education fields; and qualifications on which candidates will be assessed, • Other specialised technical skills such as should be publicly available. expertise in a technical field, environmental health, zoonotic diseases, laboratory medicine or other To ensure that Board members have the skill sets to relevant fields. meet the changing and evolving needs of the Agency as it grows, the AITF recommends that staggered terms of Chief Executive Officer service for Board members be used. Appointments for The Chief Executive Officer (CEO) is the operational some Board members would be for three years while administrator and leader of the Agency and is for others it would be two years. All Board members accountable to the Board of Directors. The Board would have the opportunity for one subsequent should be responsible for selecting and hiring the three-year re-appointment. This plan allows for orderly CEO through a clear and transparent recruitment and succession planning, as well as giving Board members selection process, and subsequently for evaluating the the opportunity to develop and move into leadership performance of the CEO. positions, such as Chair of the Board or of a committee. The Task Force strongly recommends that the CMOH Criteria and Competencies of Board Members have a direct role in the selection of the CEO. While The AITF has set out generic competencies that all reporting to the Board as a whole, the working relationship Board members must demonstrate, as well as specific developed between the CMOH and the CEO will be a competencies and skills that should be present on significant factor in helping ensure the Agency is able to the Board. The AITF has also recommended that a function smoothly. representative of the public be a part of the Board. The CEO will be responsible for the management and Demonstrated generic competencies and skills for Board performance of the Agency, as well as for implementing members include: the Strategic Plan and ensuring that performance plans • Understanding the principles of good governance; are achieved. • Ability to commit time to participate effectively in the governance process; The CEO will provide scientific guidance to the • Ability to work effectively as a member of a team; Agency’s work. The AITF recommends that an • Effective communication skills; and international search be undertaken for candidates • Absence of any conflict of interest that would for the CEO position. interfere with participation on the Board.

Final Report of the Agency Implementation Task Force 33 The AITF also recommends several non-negotiable Committee will ensure that the Agency’s Strategic Plan is competencies that must be demonstrated in the CEO: aligned with the priorities of the partner Ministries. • Proven track record as a health sector/public health leader; While the AITF recommends that the model for • Knowledge of broad Ontario health system issues decision-making for the Board be consensus based, and trends including a knowledge of public health there will be times when items will need to be voted priorities and needs; on by the members of the Board. The AITF feels that • Ability to recruit and retain skilled individuals; the CMOH should not be a formal voting Board member • Organisational leadership; for the following reasons: • Demonstrated ability to effectively function within • If the Agency is accountable and funded through government and/or with various levels of the MOHLTC, it is likely, directly or indirectly, government; that the CMOH will be the Assistant Deputy • Outstanding verbal and written communication Minister (ADM) responsible for decisions skills, as well as motivational and public relation potentially affecting the funding of the Agency skills; and by the MOHLTC. • Demonstrated operational experience with • The CMOH would, under the approach proposed evidence of outstanding team development and in this Report, have the authority to activate sensitivity to front-line workers. redeployment of personnel or resources of the Agency to address emergency and exigent The AITF also recommends that the CEO should circumstances where required. This is an demonstrate the following competencies: important and necessary provision, which provides • Ability to develop, foster and maintain strategic the CMOH with significant authority over the relationships and partnerships with a number of Board in certain circumstances. diverse stakeholders including academia, various levels of government, Public Health Units, health In adopting this approach, we have attempted to meet service providers and health care organisations, as three objectives: well as national and international agencies; 1) Ensuring a defined role for the CMOH in • Extensive management experience and knowledge developing the Agency’s direction and Strategic of innovative management methods, approaches Plans; and strategies; • Ability to demonstrate that he/she is not unduly 2) Protecting the integrity of the CMOH’s role as an risk-averse; ADM with direct or indirect authority regarding • Skill as an integrator and mediator of complex Agency’s budget; and issues among diverse stakeholders; • Demonstrated success in creating a healthy 3) Retaining the primary role of the CMOH vis-à-vis workplace; the Agency in emergency or exigent circumstances. • Experience with managing the start-up implementation of an organisation or business; The CMOH should also have direct involvement in • Demonstrated integrity and high ethical standards; reviewing a performance plan or agreement between the • Demonstrated leadership in research; and MOHLTC and the Agency that would align with the • Demonstrated flexibility and ability to adapt to a Agency’s Strategic Plan. growing and changing environment. The CMOH could also have the authority, delegated from Role of CMOH in Relationship to the Board the Minister, to “contract” with the Agency for specific The CMOH must have a role that ensures alignment projects or research through this performance plan or between Provincially identified objectives and agreement as part of the annual budget process. expectations, and Agency priorities. The AITF recommends that the CMOH, by virtue of office, attend Finally,a good day-to-day working relationship among and participate at all Board meetings and be a member of senior management of the Agency (including the CEO), the Strategic Planning Committee of the Board. The the CMOH and the Public Health Division is essential. CMOH membership on the Strategic Planning Standing The Agency must also work well with other parts of the

34 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion MOHLTC and other Ministries on an ongoing and collaborative basis. The need for regular communication and dialogue between governments and public health agencies has been identified as a key success factor by both the BCCDC and the INSPQ.

Final Report of the Agency Implementation Task Force 35 Chapter 3 Ministry/Inter-Ministry Liaison

The Part One Report articulated the Task Force’s recommendations on proposed roles and responsibilities for the Agency and Ministries as lindicated in Figure 5.

We recommend, for the purposes of clear accountability, the Agency has a single formal window coordinated through the MOHLTC for the purpose of receiving Provincially identified strategic priorities. To support this, mechanisms will need to be put in place to ensure that priority setting incorporates input from a range of Ministries with interest and/or relationship to the areas within the Agency’s mandate.

The MHP will share a number of important areas of common interest with the Agency. In particular, the Health Promotion, Chronic Disease and Injury Prevention area of the Agency will need to be responsive to those priorities, needs and strategies identified through MHP.

Intra-Ministry Committee

Since, under this model, the MOHLTC would be responsible for communicating the priority areas of work to the Agency, the AITF recommends that the MOHLTC establish an Intra-Ministry Committee to coordinate project identification. This internal Committee could also ensure that the priority areas of work identified for the Agency’s Strategic Plan from a Provincial perspective appropriately cross the spectrum of the health care system (e.g. long-term care, community health, primary care, acute care, home care, etc.). This Committee could also work to ensure that projects initiated are suitably consistent with the mandate of the Agency.

The AITF recommends that the Intra-Ministry Committee be established by the CMOH or delegate, thereby ensuring a direct link to MHP. The Committee should meet four times a year and more often when needed and include representatives from the appropriate Divisions of the Ministry.

Inter-Ministry Committee

To effectively coordinate the input and advice of other Ministries that the Agency needs to consider in developing a Three-Year Strategic Plan, the AITF recommends that the MOHLTC establish an Inter-Ministry Committee.

The Inter-Ministry Committee should pool and identify initiatives, projects or programs that are consistent with the Agency’s mandate. These would be recommended and prioritised for either Year 1, 2, or 3 of the Agency’s Three-Year Strategic Plan.

36 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Roles/Responsibilities MOHLTC/MHP* Agency

Policy, Legislative and Regulatory Maintain lead Inform and contribute by providing scientific and technical advice and Development identifying emergent risks Compliance and Accountability Enforce compliance with Support MOHLTC/MHP with the provision of research and evidence the MHPSG1 relevant to maintaining the standards and developing best practices, templates, tools and support to assist with field delivery of MHPSG Public Health Human Resource Planning, Hold overall responsibility Survey and report on public health training gaps Assessment and Training for formal public health Identify and deliver issue specific training and specialised support tools human resource strategies Act as a provider of continuing professional development for public health practitioners, scientists and researchers Emergency Management Lead remains with Available to provide technical and scientific assistance and support to relevant ministries government before, during and after an emergency

Provide rapid on-site field support as required and directed Communications Lead for general health Provide specialised communication to health care providers and Public communication to Health Units. practitioners, the public and the media Support on risk communication Relationship to Public Health Units, Lead for funding Public Provide specialised scientific and technical support including field Hospitals, Long-Term Care Homes, and Health Units and other and training support Community Health Centres health care facilities Synthesize best practices, guidelines and practical tools

Provide expert advice Reportable Diseases Formal reporting remains Support trend analysis on available data, developing and updating to Public Health Unit and epidemiological tools to MOHLTC Provide, as required, additional epidemiological analysis and interpretation support Standard Setting Ministries retain role in Provide evidence and analysis to assist in the setting of standards standard setting for program delivery

*Note: for MHP some roles currently may not apply (e.g. emergency management). Figure 5. Roles and Responsibilities

The AITF proposes that the CMOH would chair the The activities of these Ministries intersect with those of Inter-Ministry Committee and that it should meet four the Agency’s. These core Ministries might be expanded times a year and more often when needed. The Task as the Agency’s role is established and evolves. In order Force recommends that the Inter-Ministry Committee to ensure that priorities that may emerge from the 14 include the core Ministries of: Local Health Integration Networks (LHINs) are • Health and Long-Term Care; considered, it is recommended that established channels • Health Promotion; in MOHLTC be used to funnel emerging strategic • Agriculture, Food and Rural Affairs; priorities to the Intra-Ministry Committee. • Labour; • Environment; and The CMOH also has a role inside the MOHLTC and the • Child and Youth Services. MHP as an ADM. The AITF suggests that with the dual role the CMOH is the logical person to bring forward the priorities identified through the processes set out above.

Final Report of the Agency Implementation Task Force 37 The CMOH would therefore be well positioned to bring be a provider of technical and scientific advice and issues back and forth between the MOHLTC and other support/response capacity where such assistance is Ministries and the Agency. However, the AITF recognises called upon. that this proposed model introduces additional responsibilities for the CMOH. As such, the AITF Mutual notification requirements recommends that the CMOH should have the capacity to The AITF recommends that there be a framework delegate these responsibilities, as appropriate and noted and process in place for mutual and early notification by the asterisks in the following diagram. of emerging issues. For example, if an unusual trend is identified by the MOHLTC, that has relevance Proposed Role for CMOH with Agency to the activities and mandate of the Agency, the obligation would be for early notification to the

CMOH Agency. A reverse obligation would also be required of the Agency.

Member Chair* Chair* Agency Strategic Performance and accountability processes Inter-Ministry Committee Intra-Ministry Committee Planning Committee Performance and accountability processes should be established in an MOU, or in formal agreements for Figure 6. The Role of the CMOH projects and initiatives that fall outside the MOU.

Ultimately, the Board will approve the Strategic Plan Mechanisms for Developing based on the provincial stream of input and field the Agency's Three Year Strategic Plan identified priority areas. The Agency should be required Intra-Ministry Committee to report on its implementation to the MOHLTC. - identifies MOHLTC priorities for Agency consideration

The AITF recommends that the Agency and the Inter-Ministry Committee MOHLTC develop formal protocols that clearly delineate - identifies ministries priorities for Agency Consideration how communication takes place between the partner Field Input through surveys, regular fora Ministries and the Agency. In particular, the AITF and needs analysis Agency Strategic Planning Committee with: recommends the following kinds of protocols. See Figure - reviews input from ministry committees - Public Health - recommends Strategic Plan for Board Approval Units 7 to illustrate recommended mechanisms for developing - Public Health Organisations the Agency’s Strategic Plan. - RICNs - Etc. Agency Board of Directors Protocols and Coordination - approves Strategic Plan

Communication protocols Agency Strategic Plan Approved - provided to MOHLTC through an annual business plan Communications protocols should be developed - implemented by Agency between the Agency and the MOHLTC to ensure that both parties are informed and aware of activities, projects and communications in all areas of mutual Figure 7. Mechanisms for Developing the Agency's Three Year interest. While this would be agreed to between the Strategic Plan first Board Chair and MOHLTC through the MOU process, the principles would apply more broadly than Ministries Sharing Information with the MOHLTC and could serve as a template for a range the Agency of Ministries. While formal priority setting should be structured and Emergency management support coordinated, this should not preclude direct working Much work has been done to outline the role and relationships evolving on projects and tasks undertaken responsibilities of Ministries in an emergency and the between the Agency and the partner Ministry once that Agency would occupy a clearly defined role within this priority has been identified. Furthermore, where a chain of command. The Agency’s role is outlined in specific project arises outside of the agreed to Strategic Chapter 7. The Task Force recommends that the Agency Plan, the relationship between the Agency and Ministries

38 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion should also be structured to allow such projects to be THE AGENCY’S ROLE IN considered with supplemental resources depending upon ENVIRONMENTAL HEALTH (AN EXAMPLE) the nature and scope of the project. Research on the health impacts of air quality is poorly It will also be important that the Ministries and the coordinated and understood. Agency ensure engagement and information sharing is appropriate, timely and effective. It is anticipated that • Through a partnership with the Ministry of the these processes will need to be reviewed and refined Environment, the Agency could facilitate ongoing over time. To effectively undertake the analysis and research on air quality by systematically reviewing research within its mandate, the Agency will need the and assessing existing findings and undertaking authority to enter into a number of agreements with scientifically sound and physician-led research on Ministries to allow access to relevant data, for example, environmental health issues, and use data that the Ministry of the Environment Air Quality Valuation links air quality and health to inform surveillance Model that is used to estimate current levels of PM2.5, and research approaches provincially and locally. ozone and precursors. • The Agency could add value by cross-linking The Ministry of Agriculture, Food and Rural Affairs this data with analysis, where feasible, of undertakes aspects of animal health surveillance variations in emergency room use or, over-time including diagnostic surveillance conducted by the identification of either temporal or geographic pathologists and other staff at the Animal Health trends related to health impact. Based on these Laboratory in Guelph. Information from the Animal Health results the Agency might then provide advice on Laboratory could be provided to the Agency for mapping refining or updating the form of information that and comparing against information collected from Public might be considered in smog warnings. Health Units and laboratories for co-relational analysis. This may require modification to the existing procedures • The Agency could develop consistent evidence- regarding release of location information for animal based messages for Public Health Units and outbreaks, however, the linking of analysis of related health care providers on the interpretation and human case information would add value and allow for a relevance of Air Quality Index measurements, richer picture to evolve of the relationships between and recommend to Public Health Units key animal and human health. Such enhanced coordination of messages and strategies for getting these surveillance strategies was part of a number of messages out effectively. recommendations made by Justice Roland Haines in his Report, Farm to Fork – A Strategy for Meat Safety in • The Agency could show leadership and innovation Ontario2. Over time, links with the federal databases by bringing together and coordinating diverse would be a natural extension of provincial integration of stakeholders who may not have been involved in such surveillance data. environmental issues due to lack of resources or unclear lines of responsibility; for example, in the The coordination of surveillance databases among case of indoor air quality. The Agency would public health, food safety and animal health organisations throughout link with specific Ministries whose should be encouraged. The Office of the Chief Veterinarian mandates include environmental health issues. for Ontario was recently created to coordinate animal and food safety incidents or emergencies and link with other key partners, such as the CMOH, who would be valuable partners in assisting in this endeavour.

Final Report of the Agency Implementation Task Force 39 THE AGENCY’S ROLE IN A WIDESPREAD • Access the Agency’s networks of academics, NON-EMERGENCY OUTBREAK OF INVOLVING researchers and scientists at various institutions to HUMANS AND ANIMALS (AN EXAMPLE) facilitate data analysis and the development of advice on recommendations for practice during the An outbreak of a previously unknown agent event. The Agency in this scenario would work spreads through several communities in Ontario. jointly with MOHLTC and expertise in the Ontario An animal-borne (zoonotic) disease is suspected. Ministry of Agriculture, Food and Rural Affairs, the Ontario Veterinary College and others at the Before the Outbreak University of Guelph, and the federal Laboratory for • Connect surveillance initiatives by public health, Food-Borne Zoonoses. The Agency should also food safety, and Animal Health Laboratory (Guelph) ensure that it has in place several veterinarians and federal surveillance databases to enhance with public health experience on staff to provide overall surveillance capacity for zoonotic diseases. immediate technical support and expertise, and to coordinate these partnerships. During the Outbreak • Provide ongoing support as required to local • Liaise and work collaboratively throughout within outbreak management teams for surveillance, the overall response framework in place in epidemiological analysis, case management and conjunction with both CMOH, EMU, and contact tracing, where such support is deemed appropriate Ministries and Agencies. necessary by the CMOH. After the Outbreak • Facilitate the rapid analysis of specimens to help • Support collaboration among researchers on further determine the agent involved in the outbreak through research related to this zoonotic agent, an enhanced and expanded OPHL operating within coordinating access to data and targeted research. the Agency. • Provide the technical expertise to support, enhanced ongoing surveillance and monitoring from afar of the identified agent.

40 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Chapter 4 Organisational Design

The AITF envisions that the Agency’s operations will consist of a series of specific functions to be carried out within a number of areas of specialisation for the Agency’s clients. Support in Emergency and Exigent Circumstances falls across both the functions and areas of specialisation and is described in a separate section.

Organisational Structure and Rationale

In examining ways to potentially structure the Agency, the AITF considered the need for the Agency’s organisation to be flexible and multi-disciplinary with a strong emphasis on the creation of training, professional supports, and knowledge products that could support both the field and relevant Ministries. The Task Force then identified a series of design principles to guide them in proposing an organisational structure for the Agency.

Organisational Principles for the Agency • The design of the organisational structure should not follow the “silo” approach that is traditional in some organisations. Instead, it should support multi-disciplinary teams (e.g. epidemiologists, toxicologists and health promotion specialists) working across various areas of specialisation. • The Agency’s key functions and areas of specialisation should be immediately identifiable in the organisational structure. • The Senior Management Team should include both operational and technical skill sets to reflect the spectrum of competencies required to carry out the Agency’s mandate.

Organisational Structure The AITF described the organisational structure only to the levels shown below in the knowledge that the CEO and Senior Management Team that will need to shape the subsequent levels of the organisation based on their history and experience. The proposed structure shows the appropriate expertise and skills required in positions to meet the Agency’s priorities, its operational plan for start-up and subsequent phases of development.

Final Report of the Agency Implementation Task Force 41 Proposed Organisational Design

Government Affairs CEO - Chief Executive Officer CEO } Partnership Development CAO - Chief Administrative Officer IO - Information Officer Office of Emergency FO - Financial Officer CAO Management Support }

HR, FO, IO Director Infectious Director Director Diseases and Health Promotion, Director Medical Director Laboratory Infection Chronic Disease & Environmental Laboratory Operations Prevention and Injury Prevention Health Control

Director Surveillance & Epi Epi Epi Epi Epidemiology

Director Research Researcher Researcher Researcher Researcher

Director Knowledge Knowledge Knowledge Knowledge Knowledge Exchange & exchange exchange exchange exchange Communications expert expert expert expert

Solid lines represent direct reporting relationship. Dashed lines represent work allocation.

Figure 8. Organisational Design

Key Areas of Responsibilities Directors Chief Executive Officer (CEO) All directors should be expected to provide professional In addition to the traditional areas of responsibility, development, evaluation and peer support to staff who the AITF recommends that the office of the CEO be work in the various areas of specialisation and operate structured to carry out the functions of partnership both as part of a discipline specific team (e.g. epidemiology development and governmental affairs. team) within specific areas of specialisation (e.g. Infectious Diseases or Environmental Health). These directors Chief Administrative Office (CAO) should also be accountable for maintaining and developing The AITF recommends that the CAO office be responsible effective working relationships with counterparts within for central services including human resources, legal, partner Ministries. financial controllership, internal risk management, information management, and information privacy requirements. Directors of Infectious Disease and Infection Prevention and Control; Health Promotion, Chronic Disease and Office of Emergency Management Support (OEMS) Injury Prevention; and Environmental Health While the number of staff required for this office will be These directors should be responsible for delivering small, this will be an important area of activity for the results related to each area of specialisation, as outlined Agency. The OEMS should be responsible for putting in in the first agreed to Strategic Plan for the Agency. place processes for emergency management support across the Agency. This office would be responsible for Directors of Surveillance and Epidemiology; Research; developing the Agency’s contingency planning, internal and Knowledge Exchange and Communications adoption of an Incident Management System (IMS) and These directors would be responsible for delivering the project liaison with the EMU at MOHLTC. The Agency’s functions in each field of activity and ensuring that the role within the established chain of emergency command functions are integrated and effectively allocated across is expanded on in Chapter 7 of this Report. all areas of specialisation.

42 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Medical Director of Laboratory Services epidemiological studies and surveillance. He/she would This director would be responsible for providing medical also be part of a peer group of epidemiologists and have and scientific leadership to the laboratories and their a direct reporting relationship to the Director of Surveillance staff and for overseeing all medical aspects of and Epidemiology for professional support and laboratory functions. development. This model lets staff interact with other epidemiologists working in other areas of specialisation Director of Laboratory Operations and allows for cross-fertilisation and information sharing. This director would be responsible for overseeing all operational aspects of the laboratories and for ensuring The AITF also recognises that the Agency would that operational policies and procedures associated with require an organisational structure that would promote laboratory functioning are up-to-date, consistent and interaction between the more service-oriented functions adhered to and that supplies, equipment and supports (e.g. knowledge exchange) with the technical and are in place. scientific expertise (e.g. infectious diseases or environmental health). Rationale for Organisational Design In designing the recommended structure, the AITF This approach, we believe, would foster a balance wanted to ensure that the scientists and specialty staff between an individual with specialised content skills would be supported by peers and that opportunities for (e.g. in emergent infectious diseases or environmental professional development and learning were built into health) and another with skills in knowledge exchange the structure. and the translation of technical information to a broader audience. Operationally, if the goal is to be able to take The Task Force also recognised that staff would need science and render it relevant to the user group, this to be integrated into a multi-disciplinary team working model of staffing would clearly assist in doing so. within an area of specialisation. This way of working is sometimes referred to as matrix management. Common Science The Agency would be able to provide a single window of expertise from which various Matrix management can have negative connotations stakeholders and Ministries can obtain evidence-based as it represents a dual reporting relationship and the information and science. This would effectively establish sense that one has to follow ‘two masters’. Matrix a scientific bridge and horizontal links at a scientific and structures, however, are chosen when an organisation technical level between existing “silos”. For example, needs staff or areas to integrate effectively across an the Ministries of Health and Long-Term Care, organisation and provide two or more perspectives at Environment, Agriculture Food and Rural Affairs, and the same time. These perspectives can be related to Natural Resources could all access a common scientific particular client groups, services, functions, scientific base that they could use for their specialised purposes. expertise or other considerations. Common Language The Agency would translate science Having employees with particular skill sets work actively into practical tools and information. This would allow in two different areas within an organisation can also different parts of the health care sector, such as Public provide flexibility by allowing for greater ability to redeploy Health Units, hospitals, long-term care homes and resources when specific needs emerge. For example, community-based health care providers, to access this form of design for epidemiology services would trusted scientific information using common definitions. allow for more effective transfer of additional support across areas, as needs emerged. Communities of Practice The Agency would enhance existing communities of practice and nurture additional This structure also allows for learning opportunities from ones by supporting collaboration, information exchange both the cross-disciplinary team within each area of and sharing of best practices. specialisation, as well as from peers with information and knowledge specific to their particular area of specialisation. For example, an epidemiologist working in environmental health would be part of a cross-disciplinary environmental health team and responsible within that team for doing

Final Report of the Agency Implementation Task Force 43 Functions The Agency should also provide a mechanism to supplement surveillance activities already underway The functions are the ‘how’ of Agency operations, the through Public Health Units or other agencies. types of services it will provide to its clients in relation to any of the areas of specialisation outlined above. The All existing legal reporting requirements for Public Health AITF recommends that the following functions be Units to the Ministry should remain in place through the phased-in and carried out by the Agency. MOHLTC. The Agency is envisioned as playing a valuable role in undertaking supplemental data analysis and in Functions, Areas of Specialisation addition, the Agency should take a lead role in: and Clients • Developing surveillance capacity for facility-acquired infections and non-reportable Antibiotic Resistant AGENCY Organisms (AROs);

Pa H Infe e Publ C • Enhancing laboratory based surveillance; rtne a infe c lt i L tious disease andr h c Heal IE • Developing and bridging new and existing and Min Ca NTS c re P tion p ist th r r U surveillance networks dealing with both human ie ov n cont revention s id its er and animal health; Health p rol s disease and inju • Coordinating cross-sectoral and database links to r omoti Surveillance and epidemiology promote improved information-sharing and AREAS OF AREAS on,

Envi c Research retrospective investigation; and hr

SPECIALISATION r onmental healthry p oni c Knowledge exchange • Working with others to enhance chronic disease rev ention Laboratory services surveillance [e.g. Rapid Risk Factor Surveillance Professional development System (RRFSS)]. Suppo rt in Eme Communication The Agency’s capacity to undertake advanced planning rgen would be greatly enhanced by the above surveillance cy and Exigent Circumstances activities. In addition, these activities would support FUNCTIONS outbreak and scenario modelling, focussed population risk analysis and the development of tools for Figure 9. Functions, Areas of Specialisation and Clients knowledge exchange.

Surveillance and Epidemiology The Agency could assume a leadership role in identifying “Good surveillance is both the conscience and the and assessing emergent non-traditional surveillance compass of an epidemic” 1 approaches such as syndromic surveillancea. Dr. James Curran Dean, Professor of Epidemiology, Rollins School of Public Health, Emory University. Epidemiology is the study of the distribution and determinants of health-related-states and events in Coordinated epidemiologic capacity is essential to populations and the application of this study to the provide quality data and epidemiologic research control of health problems.2 methodology to support each of the proposed areas of specialisation of the Agency. The Agency must also have, Health surveillance entails the tracking and forecasting at maturity, the capacity to carry out specific provincial of any health event or health determinant through the ongoing or targeted surveillance activities in a technically continuous collection of high-quality data, the integration, proficient manner. analysis and interpretation of this data into surveillance products (e.g. reports, advisories, warnings) and the Collecting, analysing and disseminating comprehensive, dissemination of the surveillance products to those who readily comparable data can better inform actions and need to know.3 interventions required in the field, identify emerging trends and threats, allow for richer retrospective analysis and, if undertaken rigorously, would over time better inform the process of setting goals for Ontario’s a The term ‘syndromic surveillance’ applies to surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health system. public health response (CDC, Division of Public Health Surveillance and Informatics).

44 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion The Agency is not envisioned as replacing current • By playing a primary role in defining and promoting epidemiologic and surveillance capacity in place locally or an agreed upon research agenda for public health centrally but providing a vehicle for addressing areas of in the Province; epidemiology and surveillance activities which are • By adopting an effective review and assessment currently under-addressed, such as: process with the goal of greater consistency in the • Surveillance in areas in which there is a need quality of research that is disseminated; and for greater coverage (e.g. chronic disease risk • By drawing upon its knowledge translation and factor surveillance); exchange functions to make research products • Attention on areas of emerging risk for which more relevant to users. This would mean current data capture is inconsistent, such as consciously focussing on providing research antibiotic resistant organisms and nosocomial findings that are accessible, understandable and infection surveillance; and practical for the field and policy makers. • Specific attention to improving the linkages between animal health surveillance and human health. The AITF endorses the view of the Research and Knowledge Transfer Sub-Committee that the Agency’s We would also see value in the Agency promoting greater research needs to be tied to knowledge exchange cohesion by undertaking standardised indicator development endeavours. This is consistent with the roundtable thereby improving consistency of data collection. findings where participants indicated that the key research roles for the Agency should include: The Agency would also be well positioned to provide • Promoting a system-wide and cross-sectoral quality data products to assist in determining the burden integration of research, policy and practice; and of certain diseases in Ontario. This could specifically • Maximising applied public health research capacity. include undertaking population health and geographic risk profiles with appropriate trend analysis. The Agency Through partnerships with academia, Public Health could be well placed to draw on multiple data sets to Units, academic health sciences centres, veterinary better assess the impact of selected risk factors on medicine centres and others, the Agency should disease, and generate and support research associated serve as the organisational hub for a provincial public with these factors. In undertaking this, we would see health research infrastructure and bring greater clear need to establish effective linkages with existing leadership, coherence, consistency and relevance initiatives both nationally and here in Ontario. to the research agenda.

In addition to the skills and human resource capacity Given the mandate of the five current PHREDs with required to provide a surveillance and epidemiology respect to public health research, knowledge synthesis, function within the Agency, the technological infrastructure education, dissemination and diffusion, the Agency would need to be in place to allow the Agency, the field should partner with the PHREDs as currently structured and partner Ministries, laboratories and others in the and subsequently work with MOHLTC to enhance field to share information and have access to common province-wide access to knowledge exchange, training databases in a privacy sensitive manner. Later in the and public health research through the network model report, we provide a range of suggested approaches to outlined earlier in this Report. achieving this goal. In addition, the Agency would be well placed to facilitate Research a process for identifying and focussing research Ontario has a history of research strength and expertise priorities, as well as assist in filling research gaps, both in public health. However, the AITF believes that the provincially and nationally based on identified needs. Agency could, over time, act as a vehicle for better aligning research undertaken in various centres, and The Agency should also conduct and facilitate augmenting and fostering research excellence in a outcome-directed public health research by: number of ways: • Focussing on applied research that will inform • By playing a facilitative role in providing health policy and front-line practice including: coordinated access centrally to relevant research • High quality evaluations of public underway both at the Agency and beyond; health interventions;

Final Report of the Agency Implementation Task Force 45 • Research on effective strategies to support Library and Information Technology Supports knowledge exchange; and An effective knowledge exchange function requires an • Building capacity and strengthening links with equally strong information technology infrastructure and health care providers, public health practitioners communications capacity to support it. Research and and policy-makers by providing research knowledge exchange will not be efficient or successful mentorship and learning opportunities for both without quick access to current scientific information and graduate students and field staff. resources for all staff and affiliates.

While the Agency should have strong relationships with The AITF therefore feels that having effective library and research funding bodies, the AITF does not believe that information retrieval services in place that are modern the Agency should be a granting body for external and effective in both electronic and print form built into investigator-initiated research This role is already filled by the organisational structure of the Agency from the a number of national and provincial organisations and the outset will assist in all areas of the Agency’s work, Agency should not duplicate this function. particularly in the central knowledge exchange function.

Knowledge Exchange The Agency’s library can also play a role in facilitating Considerable knowledge generation and synthesis is access to relevant information not only to the Agency’s currently being carried out in Ontario, but often in a staff but to Public Health Units, partner Ministries and fragmented manner which is not always easy to access other client groups. or well-coordinated. This function is also envisioned as providing a technical A large portion of public health publications can also quality check on ensuring appropriate references in be classified as grey literature, and as yet there is no technical documents, intellectual property oversight, comprehensive repository for these materials in Ontario copyright management, and dissemination and and for much research undertaken, no single point of classification of reports and documents. access at the present time. Much valuable work is, therefore, funded and undertaken, yet, remains unseen Laboratory Services and unused beyond very narrow boundaries. This results The AITF feels strongly that strengthening the linkages in both duplication of effort and lack of uptake of new between the laboratory and clinical, research and public knowledge. health expertise is essential to ensuring a well coordinated and effective interface between the In its role as a knowledge broker, the Agency should laboratory testing and research functions with the facilitate improved access to the best available evidence broader epidemiology and surveillance functions required in a relevant and timely manner that takes into account to ensure that the Agency can meet its mandate. local circumstances and knowledge. Research, knowledge exchange and surveillance functions often cannot be effectively accomplished The Agency should also have a role both in generating without direct access to and links with laboratory data. new action-oriented knowledge, stemming from applied This area of focus is discussed in more detail in Chapter research and surveillance activities, and in synthesising 6 later in this Report. and translating existing knowledge through processes such as systematic literature reviews, advisory expert Professional Development panels, and the development of best practices, The AITF sees professional development as a function guidelines and consensus statements. of the Agency. Training support potentially could be made available to providers and practitioners from Participants at the roundtable discussions identified the various disciplines on a range of topics. For example, development of provincially applicable best practices, this might include professional development for guidelines and protocols that can be tailored to meet communicable disease control staff from Public Health specific local needs as an early accomplishment for the Units on infection prevention and control in acute care Agency and an action that could promote greater and long-term care settings. Approaches such as this can consistency in approaches to key issues at a local level. only complement the work underway to strengthen the working relationships in this area across and between

46 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion sectors. Discipline specific sessions might, for Second, the Agency should be structured to assume example, include epidemiologists at working sessions a supportive role in crisis communication in times on non-traditional forms of surveillance. where that support may be requested or directed through the overall Provincial emergency management We do not envision that the Agency will be engaged in support framework. Crisis communication aims to the formal education and training of health care de-escalate an emergency through effective professionals. It would, however, assist in addressing dissemination of information. Within the Agency, two challenges we currently face: a) the shortage of this role should be integrated into an overall response placements for those wishing to pursue public health as plan in an IMS structure and operating within the a career, and b) the need for strengthened continuing Provincial emergency framework. education initiatives for front-line health care providers and public health practitioners. The Agency’s role in crisis communication would also be in the form of scientific and technical advice to the With these placements and professional development MOHLTC which would have a key role in crisis activities, the Agency would also be a benefit from an communication during an emergency or exigent ongoing and direct link to the needs of those in training, circumstance with health sector implications. The and those working in front-line health care and public MOHLTC could also delegate certain crisis health. This can only help ground the work of the Agency. communication support functions to key individuals or experts within the Agency as required in the specific Communications circumstances of the event. The roles of the Ministries and the Agency in communication should be clearly delineated and set out Support in Emergency and in the MOU with the obligation of mutual notification Exigent Circumstances agreed to by each party. The Agency’s role should be to develop effective mechanisms of conveying information The AITF feels that support in emergency and to its primary clients and not upon public communications exigent circumstances is both a function and an area campaigns. That is not to say that the Agency should be of specialisation of the Agency. Best practices in invisible to the public; rather, the orientation of its work emergency management aim to reduce the potential should be to serve the public primarily indirectly, through impact of a disaster by making long-term plans to science, research and technical support to the field and mitigate negative consequences and improve partner Ministries. preparedness. Emergency management activities take place at three stages: before, during and after The AITF sees the Agency as having a role in two types the emergencyb. of communication. First, the Agency should have a role in developing risk communication expertise. Risk The AITF recommends that the Agency play a communication exchanges information among concerned supporting role in emergency management within a stakeholders about an actual or perceived risk from a defined provincial and Ministry command structure. behaviour or an exposure; for example, exchanging During a health-related emergency, the chain of information about the expected type of outcome, its command should follow a well-defined IMS structure intensity and duration, and what is known about it. with clear pre-determined roles and responsibilities, while Risk communication should come from a trusted and leadership rests with the formally designated authority. credible source and be validated by other trusted and Proposed roles for the Agency in supporting response to credible sources. emergency and exigent circumstances are spelled out in Chapter 7. Effective risk communication helps people make choices about taking a particular action or about adjusting to Areas of Specialisation something that is happening or has already happened4. Given its anticipated capacity in surveillance, research and The AITF recommends the following areas of expertise knowledge exchange, the Agency would be well positioned for the Agency’s operations. to provide credible scientific and technical expertise to a See also National Framework for Health Emergency Management, F/P/T Network on inform and support risk communication activities. Emergency Preparedness and Response, 2004.

Final Report of the Agency Implementation Task Force 47 Infectious Diseases and Infection Prevention PIDAC and the Agency and Control The extensive work that has been carried out by PIDAC The Final Report of the Walker Panel pointed to the has been accomplished first and foremost through the need for a centralised resource to better anchor and volunteer commitment of leading experts in the fields of support a more comprehensive and systematic approach infectious diseases and infection prevention and control to infectious diseases in Ontario5 across different parts drawn from a wide geographic area. of the health care system (e.g. public health, long-term care, acute care). This position is also reflected in The voluntary nature of the Committee always raises the Operation Health Protection,6 reiterated in the recent possibility that, in a crisis, individuals will have competing report on the Legionnaire’s disease outbreak in Toronto7 commitments between their home organisations and and the CMOH’s Report to the Legislature8, and fully PIDAC. As a result, we see a need to broaden the supported by the AITF. The Agency’s area of expertise in areas of expertise (e.g. linkages to occupational health infectious diseases and infection prevention and control research) and move toward a less volunteer and more would encompass surveillance, and support improved stable structure to support needs in the area of infection prevention and control of these diseases and other prevention and control. As such, the AITF recommends epidemiologically significant organisms in both health transferring, over time, the responsibility for the support care and community settings through technical guidance, of PIDAC to the Agency while retaining formal Ministry training and support. involvement and connection. We would see PIDAC’s composition and structures as evolving and serving as Significant improvements have recently been made to one important source of expertise with which the the infectious disease landscape in Ontario but much Agency could formally engage. more needs to be done. The Provincial Infectious Diseases Advisory Committee (PIDAC) was established The Agency’s flexible staffing arrangements (e.g. in June 2004 as part of the commitments under Operation cross-appointments for experts in infectious diseases) Health Protection, to be an advisory body to Ontario’s and its research and dissemination functions would CMOH on the surveillance, prevention and control of ensure that necessary human resources are available in a infectious diseases and facility-acquired infections. stable and consistent manner. Establishing and formalising PIDAC brings together experts from areas of health expert working groups is a way that the Agency could care that have not traditionally worked together efficiently build breadth and expertise in any of its areas consistently such as pre-hospital care, acute care, of specialisation (e.g. Environmental Health). long-term care, Public Health Units, and academia and animal health. PIDAC is comprised of a main The MOHLTC is also in the process of implementing committee and four sub-committees: Regional Infection Control Networks (RICNs) dedicated to • Infection Prevention and Control (across the health infection prevention and control. The first networks have care continuum); been established. The mandate of these regional • Surveillance; networks is to maximise coordination and integration of • Communicable Diseases (including infection activities related to the prevention, surveillance and prevention and control in community-based non control of infectious disease across the health care health care settings); and continuum on a regional basis. • Immunisation. The role of the RICNs in promoting greater consistency Each sub-committee makes evidence-based expert and cross-sectoral coordination fits well with the recommendations in multiple areas including: philosophy of the Agency. Therefore, the AITF • Standards, guidelines and best practices; recommends that there should be clear links established • Benchmarks and core indicators; between the RICNs once fully operational and the • Research priorities; Agency as set out in Dr. Naylor’s and Dr. Walker’s • Epidemiologic and surveillance activities; and recommendations. The proposed formal linkages with • Support in infectious disease outbreaks as the RICNs to facilitate knowledge exchange are one way requested through the CMOH. to assist in ensuring that the Agency remains connected to field relevant issues in prevention and control across the health care continuum and throughout Ontario.

48 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion There is also a well identified need for improving access THE AGENCY’S ROLE IN to evidence-based education in infection prevention NOSOCOMIAL INFECTIONS (AN EXAMPLE) and control for all front-line health care providers and for those in community settings where procedures that Rates of nosocomial infections seem to be rising in may be high risk (e.g. tattooing, piercing, electrolysis, recent years. While there are protocols and legislative etc.) are being carried out. The goal should be to provide requirements for the reporting and tracking of certain standardised, evidence-based and easily accessible infectious diseases, many are not required to be infection prevention and control training tools for front-line reported. As such, research on their occurrence and health care providers based on core competencies. Given transmission is often difficult. the proposed mandate of the Agency in knowledge exchange, the AITF feels that the Agency could play a The Agency has an important role to play in closing this significant role in initiatives such as these. gap by providing surveillance and tracking of nosocomial infections. This surveillance and epidemiological analysis Professional Development would help to inform researchers in the Agency as well as The Agency would also be well positioned to support in the field to be able to better understand the causes and enhance ongoing professional development in and spread of nosocomial infections as well as determine infectious diseases, including infection prevention and why some people are more susceptible to these control, is provided. It should play a coordinating role infections than others. in ensuring that this is disseminated through colleges, universities, regulated health professionals’ organisations The Agency would synthesise and analyse the research and the community. findings along with new and existing epidemiological data and disseminate key findings of early research to Health Promotion, Chronic Disease and appropriate Ministries, Public Health Units, health care Injury Prevention providers and other key stakeholders in the field in order Health Promotion for them to develop policy recommendations specific for Health promotion is a public health strategy distinct from their needs. disease prevention and health protection strategies. Health promotion begins with the positive concept of Working with the field, the Agency could develop health, recognising that health is about much more than guidelines on infection control ensuring that these are ‘a lack of illness’. A key component of health promotion practical and tailored to specific health care settings is the recognition that being in control or empowered (e.g. acute, home care, long-term care etc.). The Agency promotes and supports individual and community health. would take a lead in disseminating these guidelines, but Health promotion strategies range from interventions to also accompanying this with appropriate area specific influence individuals’ decisions about lifestyles or training supports through electronic and other means. behaviour (for example, counselling or education The Agency should also work with continuing education campaigns about tobacco use, healthy eating, and physical experts for professional and allied health workers to activity) to advocacy, policy and legislative work to affect develop and deliver continuing education modules the social environment in which individual decisions are through distance learning, on-site demonstrations and made (for example, municipal zoning decisions affecting train-the-trainer initiatives. access to trails or green space).

The scope of health promotion work is extremely broad and spans the lifecycle, including maternal and child health, healthy growth and development, youth and teens, adults and seniors. Effective health promotion initiatives partner with diverse sectors and occur in many settings such as workplaces, schools, clinics and community-based organisations. The outcomes of effective health promotion interventions extend beyond reducing disease and ill health to positive states such as

Final Report of the Agency Implementation Task Force 49 healthy growth and development, healthy sexuality and and disseminate findings pertaining to them, including supportive environments. an emphasis on longitudinal impact research; • Improve the centralised availability of key The Ministry of Health Promotion was recently created to population health indicators drawn from key highlight the importance of a health promotion and national and provincial surveys and data holdings population health approach. The MHP has developed a and break this information out to allow for trend, strategic approach and delineated priorities. geographic, and population-based analysis by Public Health Units; and The CMOH has a dual reporting relationship and serves • Undertaking by Year 3 a comprehensive health as the ADM of MHP. While the Agency would be status report. accountable to the MOHLTC, processes and mechanisms should be in place to ensure that the MHP’s plans and Chronic Disease and Injury Prevention priorities are taken into account in the strategic planning Chronic diseases are the leading cause of death and of the Agency. disability in Canada. In Ontario, the estimated burden of illness from from cardiovascular and respiratory There will be no absence of work in health promotion disease, cancer, and musculoskeletal, endocrine, for the Agency to undertake in its first three years. The neurological and psychiatric disorders amounts to critical challenge will be determining priority areas of 55% of total health care expenditures.9 Further, engagement and defining the most effective relationship there are many indirect costs associated with between the Agency and the complex web of bodies at chronic diseases such as those incurred by families. different levels engaged in health promotion activities. To Given this burden, chronic diseases should be one of help inform the new Agency in refining and prioritising the Agency’s key areas of specialisation. operational alignments, we had strongly recommended in our Part One Report, that a detailed review be Preventable injuries, such as falls, motor vehicle accidents, undertaken of current and potential future roles of the drowning, pedestrian injuries, poisoning and fire, have Ontario Health Promotion Resource System (OHPRS). also become an increasing threat to health. The annual This work is needed and timely not simply for defining cost of these unintentional injuries is estimated to be working relationships, but also for the Province to have a $2.9 billion in Ontario.10 Injury prevention should therefore more holistic and coordinated approach to this important be a key area of specialisation for the Agency. area of activity. From the perspective of the AITF, however, the following are important early contributions Operation Health Protection commits to incorporating that the Agency could make: health promotion together with chronic disease and • Increase awareness and access to the best of the injury prevention, as part of the Agency’s work research evidence already developed through a beginning in its first year of operation.11 The AITF coordinated scan of resources available; deliberated extensively on whether health promotion • Promoting research emphasis on shared risk should form part of a distinct area of specialisation, or factors which cut across a range of chronic whether it should be a strategy that is part of all of the diseases and conditions; Agency’s activities. However, not including it as an • Develop mechanisms for grading or ranking area of specialisation may result in health promotion available evidence based on a level of evidence being “lost,” particularly in light of other jurisdictions’ framework, where appropriate, and peer difficulties in trying to incorporate health promotion assessment, where not applicable; into their mandate. For example, the BCCDC has faced • Facilitate greater coordination and priority setting numerous challenges in trying to incorporate heath in core areas of future research; promotion as part of its mandate in recent years. • Develop a specialised capacity in behavioural analysis, research and social marketing. This would Ontario has significant capacity in the areas of health enhance access at the Provincial and local levels to promotion, chronic disease and injury prevention. At the expert supports in campaign and intervention provincial level, with the support of the MOHLTC and the design and increase capacity to employ effective MHP, the OHPRS12 supports practitioners by building strategies to change behaviour; capacity, through the provision of training, consultation, • Undertake evaluations of health promotion initiatives resources (print and electronic), network-building

50 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion opportunities and referrals. A number of health and Public Health Units have been involved in food issues for disease-specific non-governmental organisations are also many years, and more recently has begun to address major players in these areas and offer a range of broader environmental health issues, particularly those opportunities for building on work to date to promote related to air and water. These endeavours, although not greater coherence and a common centralising focus. carried out consistently throughout the province, have been critical in developing and establishing initiatives to Despite this existing capacity and expertise, there is a support local and regional environmental health priorities need for Public Health Units and partner Ministries to and needs. harness the best independent evidence available in the areas of health promotion, chronic disease and injury Environmental health focusses on complex problems prevention and translate into useful tools and practical and requires the contributions of many specialties information for evidence-based practice and policy. and areas of expertise. Working collaboratively with Roundtable participants who brought forward their other players in environmental health such as the perspectives to the Task Force identified a clear need MHP, the Ministry of the Environment, the Ministry of for stronger centralised support in non-communicable Agriculture, Food and Rural Affairs, and Public Health disease and risk factor surveillance. In this area, the Units, the Agency could be a hub for resources to AITF suggests there is clearly a valuable role for the support environmental health, research and science. Agency in working with others to enhance the existing The Agency would also be well positioned to develop RRFSS and, over time, to consolidate a range of available surveillance and information management capacity data sets to have in place a comprehensive central related to such areas as environmental issue capacity to measure and assess our ability to modify identification and the effectiveness of various risk factors through public health and related interventions. prevention, mitigation, and control strategies. As a central resource, we suggest that the Agency first focus on enhancing coordination and improving Creating an area of specialisation in Environmental Health access by building on existing resources in the field. would allow the Agency to: As such, the review of the OHPRS will be instrumental • Direct research to support more evidenced-based in guiding the future work required to align its role in decision making in what is a developing area health promotion with that of the MHP, the MOHLTC of focus; and the Agency. • Help Ontario anticipate and prepare for emerging environmental health challenges; Environmental Health • Provide researchers with the ability to link Chemical, physical and biological factors have great impacts environmental health knowledge and evidence on human health. Attention to these factors in our water, with other fields such as genomics, urban planning food and air is of paramount importance in preventing a and ecology; and range of communicable and non-communicable diseases • Provide access to established and evolving centres and in promoting health and well-being. Environmental of environmental health expertise in Ontario and health issues became top of mind following the beyond (e.g. the newly formed NCC in province’s recent experiences with the breakdown of Environmental Health housed at the BCCDC). safe water and food systems. The Agency would also act as a source of scientific In addition, there is a growing demand for specialised and technical expertise to inform such things as a capacity within the public health sector to respond to much-needed program standard for environmental health existing and emerging environmental issues13 and to within the MHPSG14 and the development of tools and respond to an increasing array of concerns associated methods for risk assessment and evaluation related to with environmental factors of disease, such as suspected environmental hazards and associated effects on health. cancer-causing agents with, for example, many forms of breast cancer. Although environmental health was not Clients addressed in the Walker Report nor committed to in Operation Health Protection, the AITF sees Clients represent the direct beneficiaries of the Agency’s environmental health as an important area of work: the people and organisations for which the specialisation for the Agency. Agency should provide its services. In keeping with the

Final Report of the Agency Implementation Task Force 51 recommended mandate of the Agency, its clients should include the health sector in the broadest sense. To this end, the AITF believes that the Agency’s main clients should be as follows: • Health care providers, including clinicians, public health professionals, academics, health care facilities and institutions, including hospitals, long-term care facilities, community clinics and health centres; • Public Health Units; and • Partner Ministries.

Although the Ontario public will not be a direct client, the public would be served by the Agency through publicly available information posted on the Agency’s website and, perhaps more importantly, through strengthened support and assistance available to practitioners.

52 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Chapter 5 Legislative Authority

Legal Framework

Currently, the Health Promotion and Protection Act (HPPA)1 spells out the duties and responsibilities of Boards of Health. The Act also delineates the reporting requirements of multiple bodies to the Medical Officers of Health (MOHs) and from the Public Health Unit to the Ministry.

Justice Campbell has, in the Second Interim Report of the SARS Commission2, undertaken an extremely detailed and thorough review of the HPPA, from which he has outlined a comprehensive set of proposed changes to modernise and strengthen this legislation and in particular the powers held by both MOHs and the CMOH.

Parallel to the ongoing work of Justice Campbell, the CRC is currently examining the structure, governance and organisation of Public Health Units. At this stage, it is not known what the final recommendations of the CRC will be. However, given the nature of the topics that the CRC has been addressing, it is clearly possible that legislative changes may be proposed to the HPPA. We do not therefore anticipate that the legal roles and expectations within the public health system will remain static in the coming years. On a matter as central as formal reporting of infectious diseases, however, there needs to be absolute clarity and certainty, particularly once the Agency comes into being.

The backdrop to our thinking on the legislative authority for the Agency is therefore one of anticipated legislative changes. However, we are not yet in a position to determine the exact form that these reforms might take at the central or local level.

Clearly, if our goal is to create a more coherent and aligned system then any final determination of powers and reporting obligations associated with the Agency would need to be undertaken and understood as part of a whole system and not in an isolated manner. Furthermore, we are very cognisant of the need for any new organisation to walk before it can run.

Powers

We therefore have recommended that the Agency not be vested with powers and duties currently held by the Minister, CMOH, Board of Health and MOH. Vesting the Agency with these powers early on in the mandate would not only be a piecemeal approach, it would also be premature. The vesting of powers is always premised upon the capacity to exercise them. This is a challenge

Final Report of the Agency Implementation Task Force 53 for an Agency yet to come into being and, for this Authority to Collect, Use and Disclose reason, we do not recommend that supplementary Personal Health Information powers or reporting obligations be created when the Agency is first established. The role of the Agency in undertaking surveillance activities, laboratory testing and epidemiology will, of The AITF recommends that no specific additional necessity, require that the Agency have in place powers be vested with the Agency at this time for both appropriate designation under both the Personal Health practical and philosophical reasons. The responsibility Information Protection Act (PHIPA)3 and the Freedom of and authority to take action in response to a health Information and Protection of Privacy Act (FIPPA).4 risk is currently vested first and foremost at the local level, and we see no reason to change this. Public Ability to collect use and disclose Personal Health Health Units are close to the communities they Information (PHI), ability to share information between serve and are best placed to be able to take such the Agency, Ministry and the field, should also be action locally to prevent a threat from escalating. In undertaken in a manner that authorises the disclosure of this regard, we concur with the observations of Justice PHI to the Agency for the purpose of meeting its Campbell that the role of the Agency is not to supplant objectives while binding the Agency to having in place existing authorities but to support and supplement the policies and procedures required to guarantee the the ability of the system to act locally and regionally, security of this information. as required. To this end, it is recommended that the Agency, as a Reporting matter of good business practice, agree to a review of its policies, procedures and practices by the Information The question of where and to whom the reporting of and Privacy Commissioner within the first three years of infectious diseases should occur has been discussed by its operations. the AITF. The existing regime is clearly dated and in need of reform both in terms of who is required to report to a Authority of the CMOH to Activate Public Health Unit and which conditions they are required Agency’s Involvement to report. However, the basic philosophy is correct and we see no reason to recommend changing the Recognising the need for clarity in both emergency and underpinnings of this regime. exigent circumstances, it is recommended that there be specific legislative provisions put in place to ensure that With regard to reporting centrally from the Public Health in emergency or exigent circumstances, the CMOH is Unit to the MOHLTC, while we have recommended vested with the appropriate authority to activate the that the Agency have a mandate for surveillance, we Agency to provide assistance that is or may be required. would suggest that dual formal reporting or split In the context of an emergency situation, equivalent reporting is not operationally feasible or desirable for provisions will need to be in place to ensure that the reportable diseases. Agency functions within an overall health sector response structure. At this stage, we would recommend that formal reporting remain as is required under the HPPA, from the Public Laboratory Services Health Unit through to the MOHLTC. However, this does not imply that there is no role for the Agency in In anticipating the recommending Agency role with supporting and supplementing epidemiological analysis regard to laboratory operations, it is proposed that of reported information. This should be undertaken existing legislative regulatory requirements regarding using a single common data set, with supplemental sample transfer to the OPHL be retained and remain analysis being undertaken by the Agency as required. unchanged. Upon completion of the recommended We suggest that a more appropriate time to re-examine review of the testing mandate, this issue may this question would be after the Agency’s first three require reconsideration. years of full operation.

54 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Chapter 6 Ontario Public Health Laboratories

Introduction

The Ontario Public Health Laboratories (OPHL) form one of the larger public health laboratory systems in North America. The system consists of a central laboratory located in Toronto and 11 regional public health laboratories across Ontario. The Ontario system is also a central part of a national public health laboratory network which includes public health laboratories in other jurisdictions and the Level 4 National Microbiology Laboratory in Manitoba.

Over 600 staff in the OPHL perform over four million laboratory tests annually diagnosing diseases, such as tuberculosis, AIDS, SARS, hepatitis, influenza, and West Nile virus and testing drinking water from private wells.

While we often think of laboratories in narrow terms, such as simply performing tests on samples, the OPHL are in reality first and foremost providers of information.

Laboratory generated information informs diagnostic, clinical and public health decision making right across the health system. For the public health system, the laboratories play a vital role in infectious disease surveillance, supplying the test information required locally and provincially to assess the nature and spread of a disease.

There is a long history of public health laboratory services in Ontario; the first public health laboratory grew out of initiatives undertaken at the beginning of the twentieth century by the then Ontario Board of Health, the precursor to the MOHLTC. For many of these early years, there was an extremely strong affiliation with research and with the University of Toronto, in particular. Today’s Connaught Research Laboratory shares a common genealogy with the OPHL.

Even up to two decades ago, perhaps less, the OPHL maintained this emphasis on research and was internationally renowned for the studies undertaken, for the testing methodologies developed, and for its general contribution to the field of laboratory science.

That reputation has eroded over the years for a range of reasons: • Intense funding challenges in the 1990s; • Increasing imbalance in the competitiveness of salaries for senior-level medical, scientific, and technical staff; and • Changes in the emphasis and shifting priorities set by different governments on: • Public health in general; and • Direct research at the laboratory level, in particular.

Final Report of the Agency Implementation Task Force 55 The net result is that today the OPHL faces a series of The renewal of the OPHL is, therefore, not simply a very significant challenges. These have been at least question of operational alignment with the Agency; this partially documented in a range of federal and provincial must go hand in hand with a process to implement a reports undertaken in the aftermaths of SARS and the modern integrated LIS. recent Legionnaire’s outbreak. Some of the more pressing challenges are laid out below. Testing Mandate The testing mandate of the OPHL has grown over Recruitment many decades by both conscious choice and through The OPHL today is faced with a pressing shortage in happenstance. In some cases, the OPHL took on particular certain critical areas of expertise. This is most acutely tests because, at the time, it was the only laboratory felt in those professions in shortest supply, particularly with adequate capacity. In other cases, it was the microbiology. The challenges in attracting medical expedient choice. In yet other cases, testing has in effect microbiologists, scientists, and medical laboratory been off-loaded from the acute care sector to the OPHL. technologists to the OPHL are acute and have been for a number of years. Competition is greater for the qualified The net result is that, in 2006, the OPHL is currently individuals that do exist and the OPHL has struggled to undertaking certain tests which are now routine tests, keep pace with the conditions of employment in place for and the focus upon emerging diseases, confirmatory certain positions in academic health sciences centres and testing and upon developing approaches to testing for other research centres both within Ontario and nationally. novel pathogens, the core mandate of the OPHL has This imbalance is not only shown in terms of remuneration been weakened. A component of modernising the OPHL, levels for certain positions, but in terms of the culture of therefore, involves not simply improving how work is research and innovation that many leading scientists now performed, but what testing is appropriate. actively seek out when choosing where to work. Viewed together, this constellation of factors points to an Physical Infrastructure organisation that has functioned under less than ideal The current physical plant of the both the existing Central circumstances for far too long. In part, we have likely Public Health Laboratory and at least two of the regional achieved the position we are in today because of the laboratories are aging and in need of significant relative invisibility of laboratory functions in the face of far upgrading. In the case of the Central Laboratory, facility more visible and loud demands for scarce resources for age, layout and location of the site mean that regardless other parts of the system. It is time for us to make the of any recommendations from this Task Force, ongoing laboratory more visible. additional expenditures will be required over the coming years simply to maintain the Central Laboratory. Most recently, the CMOH’s 2005 Annual Report presented to the Legislature in January 2006 stated plainly: Information Technology In an era where the timeliness of test results is critical, in “In Ontario, the staff at both the central and regional which more and more laboratory testing is automated, public health laboratories have been called upon the OPHL operations lack a single integrated Laboratory repeatedly in crises over the past decade to perform Information System (LIS). massive test volumes rapidly for Public Health Units and health care providers. SARS, West Nile, and tuberculosis This raises a series of challenges, not least of which is in Toronto’s hostel system are but a few examples. The the high level of manual recording and reporting of test ability to rise to these challenges reflects the tremendous data at OPHL, as well as the duplicated effort put into effort and dedication of the professional and technical data entry by health care facilities reliant on test data staff within the public health laboratory, not withstanding from the laboratory. the chronic and increasingly urgent need to stabilise and strengthen these facilities.”1 This situation results in a number of issues: delays in test results needed for patient care, duplicate testing, and As stated by the CMOH, there is an urgent need for challenges in coordinating data for trends, outbreaks and renewal, as well as an acknowledgement that the epidemiological analysis. This is not only a vulnerability; it system and the people who work in it have risen to the is neither cost-effective nor time-efficient for the system. challenge many times.

56 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion The real challenge we see is reshaping, re-equipping and system, creating the conditions for rekindling the re-focussing the OPHL so that the individuals working in research focus and thereby creating the conditions that system are enabled with the tools, processes and to address the critical recruitment challenges support that they require and that we require of them, now faced. not just to cope with challenges, but also to feel valued • Through the focus on linkages and affiliations and to excel. proposed for the Agency, we see immense potential for innovative scientific partnerships such Modernising and strengthening the role of the OPHL will as with the Ontario Veterinary College, University not only help us be better prepared to identify infectious of Guelph (e.g. for zoonotic diseases, such as and communicable disease outbreaks across the Methicillin Resistant Staphylococcus aureus province, but it will also benefit the system as a whole. (MRSA) transmission from domestic animals to humans), and, over time, in the pursuit of joint or We see that part of the route to rebuilding the OPHL lies shared research agendas with comparable centres in deepening and strengthening the emphasis and or agencies in Canada (e.g. BCCDC and INSPQ). opportunity offered by research and academic partnerships. Ironically, these were the very conditions that actually These opportunities provide the foundation and rationale fostered the growth of the OPHL in the first place, and for the AITF to recommend integrating the OPHL into the returning to these values is a core part of renewal. organisational domain of the Agency.

The OPHL and the Agency Phased Transfer

Creating a new vision for the OPHL, recreating the The AITF recommends a phased transfer of the OPHL to OPHL as a centre of research and innovation for the Agency by 2008. The AITF had originally considered the future can only be aided through convergence only recommending that certain components of Central of the OPHL, with the proposed Agency. It is for this Public Health Laboratory functions transfer to the Agency reason that we propose the Agency incorporate the with the Ministry retaining routine testing procedures. responsibility for the operations of the OPHL under This approach was revised based on further analysis and the auspices of the Agency. This approach is consistent the Task Force has concluded that partial transfer would with the organisational approach increasingly in place be largely unfeasible and operationally divisive. across public health agencies globally and would we believe serve the Agency well. See Figure 10 for a OPHL testing currently undertaken in the regional description of laboratory services in public health laboratories is not based solely on geographic location agencies in other jurisdictions. but rather is shared between regions. Furthermore, the Agency will rightly be expected to serve the There are several clear benefits that would result from needs of all of the Province. It will, therefore, require the transition of the OPHL to the Agency. province-wide surveillance data, access to data and • The transition to the Agency would address the reference testing capabilities. current organisational split identified in the Walker Report, between public health and the OPHL2. In The AITF believes that it is important for the OPHL to addition, the OPHL would have the benefit of remain intact; dividing the OPHL could fragment an going from being a small voice in a large Ministry already challenged system and would not enable either which is not focussed first and foremost in direct the OPHL, or the Agency to fully meet their needs. service delivery, to being a vital component of a smaller and more focussed organisation with a The AITF has also considered the timing of any proposed complementary mandate. transition, recognising the complexity and care that will • As has been stated in multiple other reports, be required in realigning the OPHL under the the shift would facilitate a far greater link with organisational authority of the Agency, while continuing the related work areas of surveillance and to provide a vital service in the midst of reform. If this epidemiology. approach is to be fully pursued it will take careful • We see the move as also improving access and planning and implementation and dedicated transitional links to external research expertise and within the resources over and above the base costs for the Agency.

Final Report of the Agency Implementation Task Force 57 BC Agency for Disease Institut national de US State Public Health UK Health Protection Control santé publique du Laboratories Agency Québec (England & Wales)

Authority and Role Legislation, regulation Legislation, regulation State legislation and Legislation, regulation Delineation regulation

CDC contracts Laboratory Organisation BC Agency for Disease Institut national de santé Part of State Departments Public Health Laboratory Control (BCCDC) is an publique du Québec of Health, there may be Service is part of the new (Note: Levels of agency of the Provincial (INSPQ) is an arm’s length several sites. Health Protection Agency involvement vary) Health Services Authority. government institute and (HPA); testing is done in includes the: the Central PHL, several of • Québec Public Health the regional PHLs around Laboratory; the country: • Centre d’expertise en • 14 sites dépistage (Screening (total of 22 labs). Expertise Centre); and • Centre de toxicologie du Québec (Québec Toxicology Centre). Surveillance and Part of BCCDC Part of INSPQ Part of State Departments Part of HPA, each Epidemiology of Health laboratory carries out functions for its designated pathogens. Additional Roles Training for technologists, Health study and Varied training Training for technologists, medical residents and surveillance medical residents and scientists Research and development scientists Research and development Research and development Research and development International cooperation Allow staffing flexibility and training which A wide variety of scientific from environmental includes: and medical staff bacteriology to create • teaching and training surge capacity to meet positions; increased workloads. • seminars, symposiums; • continued training; and • improvement of basic public health training. Field Support Use capacity created in Using capacity created Using capacity of central legislation (Public Health through agreements with and regional laboratories. Act). local PH, clinical laboratories and through Laboratory Response Network (bio-terrorism).

Figure 10. Laboratory Services in Public Health Agencies

58 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion The AITF recognises the magnitude of this undertaking Phase 1 – Immediate Laboratory and proposes the immediate establishment of a Activities Required Laboratory Transition Team (the role of which is Establish Laboratory Transition Team expanded upon further in this section) to aid in planning The AITF recommends that a team be put in place to lead for the successful realignment. It recommends that the the transition of the OPHL , as part of the overall Agency following be in place, or well underway, before implementation team, with dedicated staffing and access transferring the OPHL to the Agency: immediate expert resources in key areas to assist with: • Agency established as a legal entity under • Workforce strategy and planning; legislation; • Logistics associated with the acquisition and • Agency’s founding Board in place (see section on move to new laboratory space for core Central governance); Laboratory functions; • Areas of specialisation and functions in place, with • LIS; a defined and structured operational and • Test mandate criteria; management support capacity in place to allow the • Long-term vision planning; OPHL to smoothly transition to the Agency; • Financial planning; and • A fully developed human resources plan in place • Project management. and accepted by all parties, allowing for the transfer while maintaining continuity of service and Once the Transition Team is in place, a detailed phased staffing stability; and implementation agreement should be prepared, forming • LIS planning and funding secured. Initiation of this the basis of the final plan to be brought forward to the critical piece of work should be a key priority. It is first Board of the Agency and the MOHLTC for adoption. therefore important that the groundwork and financial commitments are in place early to assist Establish the Agency as a Legal Entity the Agency in modernising operations. The Agency can only begin to play any direct role once it is established as a legal entity with a Board of Directors To achieve these pre-conditions, the AITF recommends a and core early staffing in place. Once in existence, a key phased approach to transitioning the OPHL to the Agency. priority in the initial year of operations of the Agency will need to be the creation of an infrastructure to support Revitalisation of Ontario’s corporate, administrative and human resources activities Public Health Laboratory System required to ensure the OPHL’s smooth transition period. As such, both transitional support and early action on Immediate Activities Required the part of the Agency to have in place senior staffing experienced in laboratory operations will be required to Phase 1 meet these ambitious timeframes. (06/07) Phase 2

1. Transition Team (07) Phase 3 established Co-Location of Select Testing Functions with 1. Transition plan agreed (07/08) 2. Space for re-located to by all parties the Agency testing, identified, 1. Physical relocation of designed and secured 2. LIS implementation core central laboratory The Walker Report had originally recommended locating for Agency/core underway services to Agency central laboratory the Central Public Health Laboratory within the Agency.3 functions 3. Laboratory service 2. Operational policies, procedures responsibility transfers The government supported this recommendation through 3. Agency Board, and supports fully in to Agency laboratory operations place at Agency commitments made in Operation Health Protection.4 and leadership 3. Testing menu review positions secured and 4. Regional laboratory initiated in place physical plant upgrades underway 4. Agency research In taking this step, the AITF wishes to highlight several 4. Funding fully secured partnership agreements for Laboratory in place factors which should be considered in undertaking this Information System implementation transition. The location should: Immediate Activities Required • Provide easy direct access to Ministries, to the CMOH, the Emergency Management Unit (EMU) and other critical service partners; Figure 11. Revitalisation of Ontario’s Public Health Laboratories • Improve the ability for access and collaboration with the research and scientific communities nearby; and

Final Report of the Agency Implementation Task Force 59 • Assist in promoting a stronger research and undertaking the regional renewal, it is suggested that innovation focus through increased links and close attention be paid by both the MOHLTC and the collaboration with the academic health Agency to locating regional functions to support better sciences centres. linkages with appropriate academic health sciences centres and other centres of concentrated expertise (e.g. Begin Implementing the Laboratory in zoonotic diseases). The future Agency and MOHLTC Information System are also encouraged to examine in detail the concept of The physical co-location of core components of testing developing more specialised regional centres. currently undertaken at the Central Public Health Laboratory is one mechanism of strengthening the Phase 3 – Long-Term Revitalisation to linkages required between public health and the OPHL. Support the Agency’s Mandate Equally important, however, is early action to improve Overlapping with the immediate changes to modernise the cohesion and ability to share data electronically the OPHL is the longer term vision for the future of the among the components of a highly decentralised OPHL, OPHL in Ontario. The AITF recommends a number of key as well as between the OPHL and its clients. components that will help create a strengthened OPHL.

The norm across Ontario for the acute care sector and Restructuring Regional Laboratories into Centres the broader laboratory system is the use of an LIS to of Excellence manage data pertaining to tests undertaken. The fact that The AITF recommends that three regional centres of the OPHL currently does not operate with an LIS poses excellence be created by restructuring the regional operational and practical challenges which mitigate laboratories. There should be medical and scientific against the best use of resources and the most timely staffing in microbiology and in specialised diagnostics provision of information to clients. in these key regional locations and all other locations should have access to this medical and scientific As time goes on, and the MOHLTC moves to support leadership on a coordinated basis. improved linkages between laboratories through the province-wide OLIS project, the OPHL will be unable to Review of Testing Mandate link to OLIS due to the absence of a single integrated In modernising the OPHL, there is also the clear need to LIS at the OPHL. review in detail current testing that is undertaken and determine whether this is still the appropriate testing A clear early requirement to be executed between the mandate. We would clearly see this work as being MOHLTC and the Agency is to ensure that an LIS is undertaken not by the Agency in isolation, but in developed and implemented to support laboratory partnership with the MOHLTC and others. As part of modernisation. Transporting components of laboratory renewing the OPHL in the coming years, there is also testing to a new facility cannot possibly achieve the goals going to have to be a far clearer vision and criteria we all expect without ensuring that the OPHL, as a whole, established articulating what attributes a test must have is equipped to act as a system and communicate in a for it to be an OPHL test. We would envision that this timely and effective way with other health care partners. review would identify specific criteria for the new testing mandate. Further, should any tests be determined to be Phase 2 – Regional Public Health outside the OPHL’s mandate, then terms, conditions, Laboratory Renewal quality assurance and data transfer requirements would The physical plant challenges faced by the Central have to be in place before the OPHL would cease testing Public Health Laboratory are also faced by a small in any area. number of the regional laboratories. Three sites face existing challenges with physical space that is aging The review of testing needs to be undertaken from two and requires replacement. screens: a) appropriateness and fit with an OPHL mandate and b) an assessment of the test results (e.g. Decisions associated with regional laboratory renewal data capture) that would still be required for the purpose will need to be faced regardless of the creation of the of ongoing surveillance purposes. Certain areas of testing Agency. Attention to physical plant needs in London may now be considered routine and not a suitable focus and Thunder Bay should be a priority area of focus. In for the OPHL. That said, the data generated by these

60 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion tests may well have significant importance for overall monitoring purposes. For this reason, care and attention will be required in ensuring that data loss does not accompany changes to the testing menu.

Completion of Relocation In this phase, we anticipate that the physical re-location of core OPHL functions to the Agency would be completed, with a component of Level 3 laboratory capacity retained at the existing site. At this stage, we would anticipate the full operational transfer of the system to have been completed.

Final Report of the Agency Implementation Task Force 61 Chapter 7 Support in Emergency and Exigent Circumstances Context

The AITF has spent considerable time in mapping out the specific place of the Agency within the overall emergency management framework currently in place in the MOHLTC and in the Province. The AITF has been extremely cognisant of the lessons learned from SARS, especially for the need to have clear role definitions. As such, the AITF has tried to ensure that recommendations for the role of the Agency in providing support in an emergency or exigent circumstances would fit into the existing framework and that the chain of command would be clear.

The word ‘emergency’ has a defined meaning in statute (Bill 56: An Act to amend the Emergency Management Act, the Employment Standards Act 2000 and the Workplace Safety and Insurance Act, 1997)1 to describe situations that constitute danger of major proportions that could result in serious harm or damage. However, there are instances such as outbreaks, localised incidents or other exigent circumstances, which fall short of a formal declaration of an emergency at both the provincial and local levels, but where the expertise of the Agency may still be required. The AITF, therefore, has used the phrase, ‘support in emergency and exigent circumstances’ to cover situations where in the opinion of the CMOH, the situation is below the level of a declared emergency but would warrant activating the assistance and support of the Agency.

Under the auspices of the Ministry of Community Safety and Correctional Services (MCSCS), Emergency Management Ontario (EMO) provides overall monitoring, coordination and leadership for emergency management in the Province. While EMO has specific skills and expertise in emergency management coordination, it often works closely with other Ministries in order to obtain specific areas of content expertise. As such, the Ministry of the Environment would need to play an important role in chemical spills, the Ministry of Natural Resources for forest fires and the MOHLTC for an emergency that has health sector impacts.

Since SARS, there has been considerable progress in the area of health sector emergency management. Within MOHLTC, the EMU has been established with the responsibility to coordinate the Ministry’s planning and response to health related emergencies. The EMU is part of the Public Health Division and reports to the CMOH/ADM of Public Health.

62 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion The AITF recognises the value in the work undertaken the promotion, development, implementation and by the province and MOHLTC in improving readiness maintenance of emergency management programs and responsiveness to emergency situations. The throughout Ontario. AITF does not see the Agency duplicating work that is being undertaken but rather sees the Agency as a MOHLTC’s Emergency Management Unit vehicle to supplement and support the Province in its The EMU supports emergency management activities emergency planning and response by providing improved within the MOHLTC and the health care system. The access to a broader range of scientific and technical EMU is part of the Public Health Division and reports to areas of specialisation on an organised, permanent the CMOH/ADM of the Public Health Division. and ongoing basis. In addition to deepening the pool of support resources available, the Agency could also The mandate of EMU is to: play a role in facilitating scientific partnerships in the • Identify and develop the infrastructure required to areas of risk analysis and modelling, as well as being ensure sustainability of emergency readiness; available for deployment and direct field support, • Identify and coordinate the business continuity when required. plan for the MOHLTC; • Develop Ministry emergency readiness plan(s) and In its Part One Report, the AITF provided a brief outline response protocols that are consistent with EMO’s describing the proposed role of the Agency in emergency expectations and MOHLTC and health care system management support. The following roles were proposed needs; and for the Agency to undertake to support the management • Ensure Ministry emergency plans are transparent of an emergency: with clear accountabilities within the health care • Support hazard, risk and vulnerability assessments; system and with Ontarians. • Participate in mitigation and preparedness activities; Executive Emergency • Provide back-up response capacity, which could Management Committee include human resources and technical resources The MOHLTC has established the EEMC with the such as diagnostics; Deputy Minister of Health and Long-Term Care as • Provide access to technical and scientific expertise its chair, and includes the CMOH, Director of EMU, and support during an emergency; and EMO liaison, and others. We recommend that there • Support planning based on lessons learned from is value in having the Agency represented by the CEO an emergency. on the EEMC. This would serve to formally link the capacity and resources of the Agency to a single The Task Force emphasises that the Agency’s role in an response structure directing the spectrum of activities emergency is to provide support, not to lead. The AITF within the health sector. sees the Agency as providing support and operating within the single chain of command via the IMS The Agency’s Support Function within structure, in place through EMO and, in the case of the an Emergency Command Structure MOHLTC, the Executive Emergency Management Committee (EEMC). The EMO and the EMU currently draw upon external experts as required to help shape and inform the Current Emergency Management development of specific processes and protocols. The Structure in Ontario AITF suggests that the Agency’s role would be to provide on a formal basis a larger pool and range of specialised Emergency Management Ontario scientific and technical skills related to the health aspects The EMO, under the mandate of the MCSCS, coordinates of an emergency. overall emergency management in the Province of Ontario. The EMO takes a leadership role during large The AITF recommends that the Agency’s support role in scale, Provincial emergencies and a support role for emergency and exigent circumstances include: local emergencies where primary responsibility and • Provision of scientific advice and technical authority for managing emergencies are at the expertise to support and enhance emergency municipal or regional level. EMO is responsible for capability before, during and after an emergency;

Final Report of the Agency Implementation Task Force 63 • Identification of trends, unusual occurrences, conjunction with the the MOHLTC and CMOH and modelling of risk analysis and identification of ensure that these are coordinated with others. potential health threats based on surveillance activities; In order to ensure that the Agency is able to provide • Conducting research into the science of emergency support in an emergency or outbreak situation as well as management to augment best practices; redeploy staff, the AITF recommends that there be a • Expanding provincial capacity in modelling related mechanism in place to ensure supplementary funds can to outbreak response planning; and be readily made available equal to approximately three • Providing field support capacity as required months of the Agency’s operating budget. These funds and when triggered in an emergency or exigent would need to be readily available in order to: circumstance. • Cover services, supplies and equipment in an emergency or outbreak; This proposed role would serve to augment the • Allow for business continuity and project infrastructures already in place at the EMO and commitments to be met; and EMU. The Task Force recommends that an Office • Cover excess costs associated with redeployment of Emergency Management Support (OEMS) should (travel, accommodation etc). be created at the Agency to provide internal leadership and external support for emergency preparedness If this contingency fund were held by the MOHLTC, in and support activities. Although not employing a order to ensure accountability, the access to it could be large number of staff, this Office would provide the under the authority of the CMOH and linked to the MOHLTC with a single window of access to ensure instances where the CMOH used his or her authority to that appropriate liaison and alignment is in place. direct the Agency to deploy staff or otherwise participate We would view the Agency’s OEMS being engaged in an emergency or outbreak. not only during emergencies, but also in providing valuable capacity in engaging with others in the The Agency’s Support Role crafting of strategies for prevention, mitigation and Although the EMO describes the phases of the preparedness. The responsibilities and expectations emergency management framework as: preparedness, for local response and planning should remain at the prevention, mitigation, response and recovery, the Task local level. Force finds it useful to consider the Agency’s role in emergencies to be in three phases: before, during and As mentioned above, the AITF sees the Agency providing a after the event. supportive role not only during emergencies but also during outbreaks and other exigent circumstances where in the Before Event Activities – Modelling Risk opinion of the CMOH, the situation is such that it warrants Analysis and Reciprocal Notification the directed assistance and support of the Agency. Activities before an event are primarily focussed on preventing or minimising the impact of a health The AITF recommends that the Agency function in all emergency. Risk assessments are the first step in the external emergency and exigent circumstances within process. Before attempting to mitigate or plan a the IMS chain of command. In circumstances outside response to a potential threat, the threat must be of a formal local or provincial emergency, the Agency identified and its potential risk assessed. Any threats would be redeployed at the initiation of the CMOH, identified can then be prioritised based on their who would provide the link between the MOHLTC’s probability of occurring and potential impact. EMU and the Agency. When Public Health Units and MOHs need on-site assistance in exigent circumstances, Identifying and assessing possible risks to the health of the CMOH would be in a position to ensure the provision Ontarians frequently depends upon epidemiologic and of this support through the Agency. This arrangement surveillance data. Currently, this type of information is would also be buttressed by mutual notification available in Ontario but there are areas that clearly require requirements between Public Health Division staff and strengthening. The Agency’s added value would be to: the Agency. The AITF recommends that the Agency, • Expand the scope of surveillance activities into as an early priority, have in place formal redeployment areas where such activity is currently limited, protocols and procedures that are developed in e.g. facility-acquired infections;

64 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion • Strengthen links between animal and health THE AGENCY’S ROLE IN A LONG-TERM CARE surveillance; FACILITY (NO EMERGENCY DECLARED) • Expand capacity to do detailed modelling and RESPIRATORY OUTBREAK risk analysis; • Take epidemiological data from multiple sources A respiratory outbreak occurs at a long-term care and cross-walk it between data sets to be able home in a medium sized municipality. Many residents to identify trends or unusual occurrences before and staff from the long-term care home have fallen ill they become widespread in the population; and and there have been several deaths. The Public • Examine and assess potential opportunities for Health Unit calls the CMOH for assistance. The CMOH non-traditional surveillance (e.g. potential use of directs the Agency to help. pharmacy sales data to identify unusual peaks in demand for anti-diarrhea medication that could Before the event, support provided by the Agency could indicate a water- or food-borne pathogen). include: • Enhancing surveillance capacity; A timely example is preparedness for a potential • Providing training supports for long-term care influenza pandemic where significant progress has home staff in infection prevention and control best already been made. In planning for a complex practices; and emergency with many unpredictable factors such • Providing scientific and technical support to improve as a pandemic, access to well developed modelling screening tools available to long-term care homes. capacity is useful to test and retest potential plans as more information becomes known. Improving our During the event, once called upon by the MOHLTC capacity to undertake this sort of work might assist through the CMOH, Agency support roles could include, in informing who might be most affected by an outbreak as required: and how best to deploy potentially limited supplies of medications. This capacity is currently being developed Communications in a number of jurisdictions and is one area of activity • Knowledge exchange staff could support the for which the Agency can play a valuable key role. In information officer on site. addition, Ontario has, based on the experience from SARS, valuable information and experience that could Operations be harnessed to better anticipate the psychological • Clinical staff could support on-site clinical staff dimensions of response which drive the behaviour involved in treatment; of public health practitioners and health care providers. • Infection control experts on staff or in Agency The focus on behavioural science would assist in advisory committees could provide this regard. recommendations and technical support on containment; and The co-location and incorporation of OPHL with the • Laboratory staff could perform tests on samples to Agency should also assist in building a quicker transfer identify the pathogen that has caused the outbreak. of test information to Ministry and Agency experts especially when coupled with the implementation of Planning an LIS. • Clinical experts could provide recommendations on treatment strategies; and The science and best practice of incident management • Agency staff could provide technical support for and emergency preparedness in general are also both data collection, analysis and reporting and other fairly new to the health care and public health fields. epidemiological activities locally or provincially. Several of the areas of specialisation proposed for the Agency include knowledge exchange and research Finance/Administration support. These areas could play a valuable role in • Agency staff could support administrative supporting existing efforts to assist organisations activities. building emergency preparedness into their practices as part of an overall plan.

Final Report of the Agency Implementation Task Force 65 Reciprocal Notification such, a joint approach to call triage should be used to As mentioned earlier in this Report, it is recommended manage such circumstances. that clear communication protocols be in place between MOHLTC and the Agency and that these be spelled out After Event Activities – Contingency in an MOU and include partner Ministries’ requirement Planning, Lesson Learned for reciprocal notification of unusual events. These The recovery process leads back to mitigation by protocols should also outline how the MOHLTC, implementing policies to prevent similar occurrences in through the CMOH and the Agency ensure that there the future. The AITF would envision the Agency being is timely mutual notification of unusual events through drawn upon where required as both a participant in surveillance, reporting or exchanges with the field. This post-event debriefings and by participating as required is important so that early expertise, technical advice and in recovery activities. support can be provided before a situation escalates. This mutual notification will assist in ensuring that both Synopsis of the Agency’s Role the CMOH and the Agency are aware of any unusual • The Agency would not have a mandate to be a occurrences and that action can be taken in a primary response agency in an emergency but can coordinated manner early to mitigate threats. As the be triggered by the EEMC to provide support when Agency becomes operational, these protocols will need local officials do not have the resources in place or to be reviewed and refined on an ongoing basis. available regionally to manage the incident without external assistance. During Event Activities – • Support for responses to emergency or exigent Communication, Protocols, Re-Deployment circumstances could involve deploying Agency and Field Support staff to the field to help local officials manage the In its early days, the Agency should focus on ensuring emergency. Support may also involve internal that its processes and plans for working effectively with activities such as increasing laboratory capacity to others are developed early and widely understood. These deal with an increase in the volume of samples or processes and plans must also be regularly tested and to aid in diagnosing an unknown agent. reviewed with key partners, continually kept current and • Should the Agency staff be redeployed to the field, clearly conveyed to all affected parties. It is recommended they should be networked to support and integrate that the Agency should be structured with the ability to into the local response structure and not displace redeploy staff for rapid on-site field support in an local command and control structure. emergency, when directed. • While the Agency will not subsume the responsibility of other primary agencies to manage Communication the emergency, its staff shall be expected to work The Agency could be called upon by the MOHLTC to alongside other agencies at all levels within a provide the scientific and technical information to single coordinated IMS structure to execute an support the Important Health Notices that are released effective response. by MOHLTC during an outbreak. As well, the Agency could also play a valuable role by participating in devising the guidance materials/directives to help support the field during an outbreak. This is in keeping with its support role within the overall framework.

In times of emergency, it is not recommended that there be multiple advisors functioning in isolation. As such, the role of the Agency in providing technical advice should be part of a clearly established process worked out in advance and activated as part of an overall framework. In order to ensure that information is consistent, the Ministry, in the past has set up a central number to call to assist the field with technical questions. It is not envisioned that this will change. As

66 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Chapter 8 Phasing-in

As part of its deliberations, the AITF discussed priorities for phasing-in, over a three-year period, from both an organisational start-up perspective and from a functional perspective. These priorities are outlined as a high-level Implementation Plan for consideration by the Agency and the MOHLTC in the coming months. The AITF, in its advisory capacity, is not in a position to make final determinations on the timing and priority placed upon various components. The task of adopting a Strategic Plan for the Agency would require consideration by the founding Board and CEO, in concert with the appropriate Ministries and the priorities emerging at the time in the field. We do, however, offer our advice on what a roadmap for implementation could look like. On this basis, we would see the following markers ahead.

Priorities for Agency Start-Up

The priorities to establish the Agency should be first thought of as building the organisation’s foundation. Without certain basic organisational structures and processes in place, the Agency cannot begin its operations or meet its mandate. While these tasks may appear largely internally focussed, the reality is that they are the rudimentary steps that any new organisation has to go through and they will have to occur to start the Agency on stable footing.

Upon receiving the legal status of an Agency, the following activities should be in place in the first two years of the operations:

In order to support the Agency in undertaking these activities, the MOHLTC will also have key responsibilities which include: • Providing transitional assistance in set-up; • Establishing the Intra-Ministry and Inter-Ministry Committees responsible for identifying Provincial priorities for the Board’s consideration; • Reviewing and approving the Agency’s Business Plan and budget; • Undertaking alignment planning within the Public Health Division to address the operational liaison requirements and assessing project specific areas which may be better undertaken by the Agency; and • Establishing appropriate protocols regarding communication and liaison.

Primary Initiatives for the Agency to Undertake

In discussing the potential priority areas for the first three years of operations of the Agency, the AITF recognised that there are clear

Final Report of the Agency Implementation Task Force 67 Priorities for Agency Start-Up Year 1 Year 2 1-6 mo 6-12 mo

Establish founding Board Founding Board recruit, select and hire CEO Identify, select and recommend for appointment of remaining Board members Board create and approve by-laws, policies, guidelines, etc. Board establish Standing Committees MOHLTC/MHP establish Intra-Ministry and Inter-Ministry Committees and identify key priorities and activities for a three-year time frame for the Board’s consideration Strategic Planning Committee of the Board to develop initial Strategic Plan for inclusion in the Business Plan and adoption by the Board Audit Committee and Board develop budget for inclusion in the Business Plan Board submit Business Plan and proposed budget to the Minister Board complete audited financial statement and submit to the Minister Board submit annual report to the Minister for tabling in the Legislature

Figure 12. Sequencing of Recommended Priorities for Agency Start-up: Years 1 and 2 general activities that need to be undertaken in a range Criteria of areas. We are very conscious that specific areas of Given the shifting tides, the AITF recommends that a technical activity will be set and shaped by the specific set of basic criteria be put in place and used as a filter to demands and expectations from the Ministries , Public screen the first areas of work, either generated through Health Units and the broader health care field at the time Ministries’ input or through field identified needs. the Agency becomes operational. Identified Gaps We have, for example, identified the need for early action The degree to which the specific initiative addresses a to be taken to strengthen surveillance of AROs in health need identified by the appropriate Ministries or through care and community settings, but we cannot predict engagement with the field. For example, enhancing where the new strains of resistance will occur, in which public health surveillance and surveillance products in communities or facilities the next outbreak will happen and general have been highlighted as important gaps not only what specific guidance and assistance may be required. for the field, but also for various levels of government.

It is also anticipated that the public health and health Level of Risk care landscape will change by the time the Agency is As with any prioritisation process, the AITF suggests fully established and operational. Health care is never considering the level of risk that different initiatives static, and that is probably truer today than it has been in are intended to address. Thus, priorities which are linked many years. The work of the Agency will obviously not be to an existing or anticipated public health threat should exempted from demands resulting from these changes be identified as key priorities. For example, in an and will need to adapt as the landscape evolves. This may environment where the public’s anxiety is growing in affect not only what tasks are undertaken but for whom. anticipation of an influenza pandemic, any initiatives, which could assist and strengthen Ontario’s response to For example, we fully anticipate that additional priorities a potential outbreak, should be ranked as a first priority. for the Agency will emerge in response to the MOHLTC, MHP, or field needs stemming from initiatives such as Consistency with the Mandate of the Agency the establishment of the LHINs, the report of the CRC, The initiatives proposed must be aligned with the Agency’s the updating or replacement of the MHPSG in Public Health, mandate and, as such, vigilance will be required by all the issues and needs identified through the recently involved in ensuring that the mandate of the Agency is established RICNs. All of these activities are either respected for what it is and what it is not. This will require underway or planned now. and all of which will have a direct discipline and focus from all levels. If the Agency is to be bearing on what the Agency may be required to address. successful, it cannot be asked to be all things to all people.

68 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Appropriateness and Vancomycin Resistant Enterococci (VRE) and a The initiatives proposed should also be examined to number of other nosocomial infections; assess whether the project or task fits as a priority for • Enhancing, in partnership with others, RRFSS to a Provincial Agency. Over time, there will be a delicate expand the depth and reach of this valuable data balance to be achieved between responsiveness to set on chronic disease risk factors; and identified needs and a possible risk of over-reliance. This • Improving both awareness and linkages between may be some time out, but it is a risk that has faced animal health surveillance activities undertaken at a other agencies of this type. There is and will remain a range of levels, such as the Canadian Cooperative clear need for strong Public Health Units, strong infection Wildlife Centre, the Ontario Veterinary College at control programs across all facilities, better coordination; the University of Guelph, and the broader health the Agency will not replace this need. An example in this surveillance system. regard, is getting the balance right in what should be expected of each Public Health Unit and each RICN before Emergency Management Support it is considered appropriate to draw on central resources. From the end of Year 1 and throughout Years 2-3, the AITF recommends a focus on the following issues and The following are suggested for the Agency’s activities related to emergency management support: consideration as primary initiatives to undertake: • Developing the required re-deployment and communication protocols and agreements with the Epidemiology and Surveillance CMOH and MOHLTC; • Synthesis, analysis and dissemination of existing • Establishing effective working relationships with epidemiological data, which might include the existing structures, and, in particular, the EMU; development of a more comprehensive version of • Developing internal IMS framework for the the Public Health and Epidemiology Report Ontario Agency; (PHERO)1 along with an enhanced frequency of • Assessing and evaluating available outbreak distribution and greater retrospective analysis on modelling capacity; and temporal and geographic trends where data allows. • Developing and strengthening links to the field • Access to relevant environmental monitoring through establishing partnerships and linkages data from the Ministry of the Environment on with others. pollutant criteria and the quality of air and water. In Years 2-3, this data should be analysed with Research and Knowledge Exchange respect to better understanding health impacts and The AITF recommends that the Agency undertake the where possible health outcomes. following activities at the end of Years 1-2 to support its • A priority for Year 3 should be the development research mandate: of an Ontario Health Status Report (OHSR) with • Establishing initial partnership and affiliation the following themes: infectious disease, selected agreements between the Agency and academic non-communicable diseases, environmental health sector (e.g. colleges, universities, academic health and population-based analysis, with a particular sciences centres) and others; focus on perinatal and paediatric populations and • Developing in collaboration with the MOHLTC and other groups. The OHSR, developed based on supporting regional research and knowledge existing surveillance data from multiple sources exchange network specific to public health; and upon health indicators and health outcomes, • Initiating a three- to five-year province-wide public should serve to identify gaps in surveillance and health research and knowledge exchange agenda data, including data quality. of relevance to Ontario public health practice and policy. Using a collaborative and consultation In addition to the above, surveillance activities should process, this agenda should include strategic focus on known gaps and needs in Ontario, including: directions and priorities for action; • Responding to a range of infectious diseases which • Undertaking a process to establish field presence are a) currently not reportable b) of increasing impact to support research, knowledge exchange and and c) for which existing surveillance is limited. professional development; These would include Clostridium difficile, both • Assuming direct oversight for the PHRED Program; facility- and community-acquired strains of MRSA and

Final Report of the Agency Implementation Task Force 69 Priorities Year 1 Year 2 Year 3

Epidemiology and Surveillance Enhance analysis and dissemination of existing epidemiological data findings including developing a regularly enhanced and updated epidemiological bulletin to the field (replacing PHERO) Increase access to existing environmental monitoring data and relevant data on environmental health criteria pollutants and where feasible support linkages to existing data sets Enhance and expand provincial surveillance initiatives for chronic disease risk factors beginning with RRFSS Undertake work to support indicator development for MHPSG Undertake a comprehensive Ontario Health Status Report Develop ongoing surveillance on targeted nosocomial infections and antibiotic resistant organisms (those currently non-reportable) Enhance coordinated laboratory-based surveillance beginning with formal linkage with Animal Health Laboratory and Ontario Veterinary College in Guelph and the Ministry of the Environment Initiate assessment of newer non-traditional surveillance methods (e.g. syndromic surveillance and pharmacy data for potential adoption) Support in Emergency and Exigent Circumstances Undertake a review of existing outbreak/scenario modelling capabilities for potential adoption Develop with MOHLTC re-deployment protocols and processes for field support Provide scientific and technical assistance as required on emergency risks Develop and test communication protocol with MOHLTC Research and Knowledge Exchange Establish initial research affiliations with core areas of partnerships Establish foundational data sharing agreements with MOHLTC, partner Ministries and agencies Undertake with MOHLTC the development of the proposed public health research and knowledge exchange network Release a province-wide research and knowledge exchange agenda for public health Establish field presence to support research, knowledge exchange and professional development Undertake specific activities to support the research and knowledge exchange agenda (e.g. training in research methodologies, gap analysis of projects underway, regular priority setting, and consultation sessions) Assume direct oversight for the PHRED Program Develop and disseminate training tools and supports to assist implementation of updated Mandatory Programs Professional Development Organise an on-going roster of training opportunities focussed on core areas Develop and deliver regular tele-rounds and support tools on best practices in a range of areas of specialisation Deliver competency-based tools and training products on infection control for all health care settings Implement formal placement and field exchange program Information Technology and Library Support Assess and implement Agency’s information and information technology needs as well as data requirements and library support

Figure 13. Suggested Primary Initiatives for the Agency to Undertake

70 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion • Developing and disseminating evidence-based best upon and utilise to the extent feasible the investments practice documents, including guidelines and that have already been made in information technology protocols aligned with areas of specialisation in the infrastructure in the Province. Agency and identified needs. Topics may include: • Infectious disease (building on PIDAC In the area of public health, there is clearly a need endeavours); for the Agency to link into work underway through • Environmental hazard assessment and the Public Health e-Health Council. This would response; provide an opportunity for effective synergies • Best practice models for health promotion between broader system planning and minimise interventions in defined areas of need; and the risk of unnecessary duplication by the Agency. • Multi-risk factor intervention and research While we would not see the Agency as a deliverer models. of IT solutions to the broader public health system, there are clearly roles that the Agency could play Professional Development as a supportive partner in future approaches. As In terms of professional development, the Agency should a potential future user of data and information consider prioritising for Year 1, the development and collected and a potential developer of content to subsequent implementation in Years 2-3 of workshops, optimise the use of existing systems, the Agency summer institutes, web-based training and support, and will clearly need to be linked to the broader efforts other continuing professional education initiatives in currently underway. partnership with colleges, universities, academic centres, Public Health Units and the Ontario NCC on both general In addition, we would urge that full advantage be taken and area specific topics (e.g. sessions on health of the investments that have gone into: data storage promotion) and other key themes, such as: capacity through Smart Systems for Health, information • Research methods and data limitations; management through MOHLTC efforts, dissemination • Core competencies; capacity through the Public Health Portal and other such • Systematic literature reviews; mechanisms. Where these investments can assist the • Social marketing; and Agency in meeting its objectives, we would encourage • Emerging issues updates. both the MOHLTC and the Agency to take full advantage of such opportunities. In addition to formal face-to-face activities, it is strongly suggested that partnerships be in place to In areas where the Agency may require specialised support other forms of professional development, such tools (e.g. in the area of outbreak and incident modelling), as the Public Health Portal, the broader telemedicine we would suggest that this be developed with the network, and distance and virtual training and goal of collaboration and connectivity (with both Ministries information sharing. and the field) in mind and not as an isolated stand alone solutions. Information Technology and Library Support There is a need to establish library support within the Funding Agency to promote improved access to information, sources, tools and services to a range of users. This can Dr. David Walker had, in the final report of the Expert be achieved through the collaboration of the Agency’s Panel on SARS and Infectious Disease Control, library with information and information technology in the recommended an annual operational budget of assessment of network and technology requirements $45M2 excluding existing base expenditures associated that will address library needs, facilitate data sharing and with laboratory operations. Dr. Walker had further provide remote access for external users. recommended a $35M capital allocation and an allocation of $3.5M in design and development costs. While there are a range of areas where new information technology supports will be required to support the We have studied a range of comparable agencies with Agency in its operations (the most critical being comparable mandates across a range of jurisdictions. In modernising laboratory services). In a number of other truth, the budgets for these organisations range broadly areas, however, we would urge that the Agency draw based upon a series of factors:

Final Report of the Agency Implementation Task Force 71 • Degree or absence of direct service delivery; be considered as additional costs over and above • Degree or absence of a direct funding role through any base allocation for the Agency. to state or local health organisations or agencies • Areas of specific project funding which align most for the purpose of executing programs; and with the Agency mandate should be examined for • Length of time in existence – typically incremental consideration for transfer to the new organisation growth based upon being called upon to address at a later date. In particular, existing PHAC funding a new or emergent area of work has shaped for the NCC in Public Health Tools and their growth. This is particularly true with Methodologies should be re-assigned to the significant infusions of resources at the national Agency by 2007/08. level in the UK and US associated with • The Agency should be permitted and indeed bioterrorism preparedness. encouraged to seek access to third-party funds, particularly in the area of research, to supplement In examining the budgets of the INSPQ and the its base allocation without affecting its base funding. BCCDC and adjusting for population size, we would concur with the overall proposal put forward by Dr. Under the scheme we have proposed, we anticipate the Walker. For budgeting purposes, the role, mandate and development of both Strategic and Business Plans structure of the CDC is of limited use in the Ontario involving direct engagement on project deliverables context even adjusted for population. The CDC role in between the MOHLTC, partner Ministries and the new providing direct project-based funding, its close to fifty Agency. It is through this process and the related year history and the sometimes compensatory role that accountability provisions that we would see the most the CDC plays for areas of weak local public health in rational approach to settling the specific sub-allocations the US tend to mitigate against its use as a population from within an overall funding envelope. adjusted comparator. Conclusion A range of variables which are outside the responsibility of this Task Force further complicate final approaches to In concluding, we would like to acknowledge and thank funding. Firstly, and most significantly, until the OPHL all those who have provided us with their advice, support review is completed, the costs associated with the and guidance throughout this process. We have recommendations cannot be known. Secondly, the benefited greatly from this input. decision and timing of OPHL transition will adjust the overall budget totals significantly. Creating a new Agency is an enormous undertaking and will take time to get right. We will need to learn as we The phasing-in of funding for the Agency is also go, as those who have gone before us have had to do. contingent, first and foremost, upon the formal creation We cannot possibly know all of the answers today, nor of the Agency as a legal entity. This is a decision that can all of them be prescribed in advance by this Task this Task Force is not in a position to make and will Force. Looking back to SARS and forward to the risks impact the levels and nature of funding required in the that may face us in the coming years, we are in no doubt first three years. In addition, timing of the appointment whatsoever that creating the Ontario Agency for Health of the full board appointment and the hiring of the CEO Protection and Promotion is the right thing to do for are also variables beyond the control of the Task Force. Ontario. That said, this process will need to be a collective endeavour that evolves and is refined over time In addition, project reviews, such as the review called for as the Agency becomes a reality. in our Part One Report of the OHPRS, are required to determine what, if any, roles of existing entities funded We need to forge a new partnership between the way by the Province in the area of health promotion might be that Ministries, health care providers and researchers assumed by the Agency. interact around the shared objectives of equipping ourselves with the best available knowledge, tools and Acknowledging these significant variables, we would supports to protect and promote the health of all recommend an allocation consistent with the range Ontarians. To do this, we need to harness and draw on offered by Dr. Walker but with the following considerations. the skills and knowledge buried in structures that too • OPHL transition and modernisation costs should often are isolated and disconnected from each other.

72 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion We are honoured to have had the opportunity to contribute to this historic undertaking and hope that our work can provide some assistance in meeting some of the challenges ahead. It is our earnest hope that a few years from now Ontario and Ontarians will be justly proud of their Agency and truly see a Province that indeed fully learned from SARS, remembered and acted.

Final Report of the Agency Implementation Task Force 73 Appendix 1 Terms of Reference for the Agency Implementation Task Force

Background Membership The Chief Medical Officer of Health will appoint the Co- As outlined in “Operation Health Protection – An Action Chairs and the members of the Task Force. Plan to Prevent Threats to our Health and to Promote a Healthy Ontario”, the Ministry of Health and Long-Term The Co-Chairs will be professionals with recognised Care (“MOHLTC”) is committed to the establishment of public health expertise and experience in the provision a Health Protection and Promotion Agency (“Agency”) by of strategic advice. Membership will include provincial 2006/07. An Agency Implementation Task Force will be and national experts representing the proposed struck to provide advice to the Ministry of Health and functional areas of the Agency (e.g., research, laboratory, Long-Term Care on the design, development and infection diseases, health promotion, chronic disease implementation of the Agency. and injury prevention, etc.) as well as a member with financial expertise. Purpose Accountability The Task Force will advise the MOHLTC on the operationalization of the Agency. This advice will centre Through the Co-Chairs, the Task Force will report to the on a number of areas such as validation of core activities, Chief Medical Officer of Health and Assistant Deputy organizational and functional operations, development of Minister of the Public Health Division. An ad-hoc an implementation plan, relationships with other public intra-Ministry Committee will be established to liaise health organizations, as well as capital and ongoing with this committee. operating budget requirements. Staff Support Responsibilities The responsibilities of the Agency Implementation Task The task force will be supported by staff from the Force will be to: Strategic Planning and Implementation Branch (SPIB) of • Validate the Agency’s proposed mandate, key the Public Health Division of the Ministry of Health and functional areas, structure, governance and Long-Term Care. oversight. • Recommend operational public health Term of Appointment responsibilities for the Agency, and delineate its role and responsibilities in relation to those of the Task Force members shall be appointed for a term of one MOHLTC and academia and the broader public year. This term may be extended, upon the needs of the health system, the Federal Public Health Agency Ministry of Health and Long-Term Care. and its collaborating centres, etc. • Recommend a comprehensive three-year Time Frame implementation plan for the Agency (including infrastructure, financial requirements, human The Task Force will complete its work over a one year resources, transition, arrangements etc.). period, recognizing that the Ministry of Health and Long-Term Care is committed to the establishment of The Task Force may wish to establish sub-committees the Agency in 2006. and/or undertake consultations with Ontario health care providers and other stakeholders in developing its The Task Force will present interim recommendations recommendations. to the Ministry of Health and Long-Term Care in the Summer of 2005. A Final Report will be presented in the Fall of 2005.

74 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Appendix 2 Terms of Reference for the Reference Panel

Background Purpose

In June, 2004, the Minister of Health and Long-Term The purpose of the RP is threefold: Care released Operation Health Protection – A Three Year • Provide a forum to update public health Action Plan to Prevent Threats to our Health and to practitioners/associations on the activities of Promote a Healthy Ontario. This Action Plan confirms the the AITF. commitment of the Ministry of Health and Long-Term • Provide a forum for public health Care (MOHLTC) to implementing the recommendations practitioners/associations to share their knowledge of the Expert Panel on SARS and Infectious Disease and expertise relating to public health and issues Control as per the following strategic directions: that emerge from the AITF. • Creating the Ontario Health Protection and • Provide feedback to the AITF on specific matters Promotion Agency related to the development of the Ontario Health • Renewing the Public Health System Protection and Promotion Agency. • Health Emergency Management • Infection Control and Communicable The Co-chairs of the Reference Panel will be Dr. Terry Disease Capacity Sullivan and Dr. Geoff Dunkley. • Health Human Resources • Infrastructure for Health System Preparedness Terms of Membership

An Agency Implementation Task Force (AITF) has been 1. The RP will have a sunset date of December 31, established to provide advice to the MOHLTC, via the 2005, unless the AITF and the MOHLTC agree to CMOH, on the design, development and implementation extend this date. of the Ontario Health Protection and Promotion Agency. 2. The RP will operate by consensus to the fullest The responsibilities of the AITF will be to: extent possible. • Validate the Agency’s proposed mandate, key functional areas, structure, governance and 3. The RP members will be reimbursed for travel oversight. expenses as per Management Board Guidelines. • Recommend operational public health responsibilities for the Agency, and delineate its 4. The proceedings of the RP are intended to occur role and responsibilities in relation to those of the in an atmosphere where all members, including MOHLTC and academia and the broader public the Co-Chairs, can speak freely and where health system, the Federal Public Health Agency discussions and materials shared among the and its collaborating centres, etc. participants are kept confidential and are not • Recommend a comprehensive three-year discussed or distributed outside the proceedings implementation plan for the Agency (including of the RP. Any reports of the proceedings prepared infrastructure, financial requirements, human by the Chair of the AITF will not attribute the resources, transition, arrangements etc.). contents of the discussions to any person. RP members must respect these confidentiality The Co-Chairs of the AITF are Dr. Terry Sullivan and Dr. requirements unless disclosure is required by law. Geoff Dunkley. If a RP member believes that he or she may be required to make a disclosure by law, the RP The AITF is creating a Reference Panel (RP) to advise and member will notify the Chair prior to such assist in meeting its mandate. disclosure being made.

Final Report of the Agency Implementation Task Force 75 5. Participation in the deliberations of the RP shall not be construed as limiting the ability of any organization to make whatever representations they so choose to other processes currently in place.

6. All documentation produced by the RP will be the property of Her Majesty the Queen in right of Ontario.

Support to the Reference Panel

1. The RP will be supported by the Strategic Planning and Implementation Branch (SPIB) of the Public Health Division of the MOHLTC.

Meetings

1. The RP will convene for a minimum of two meetings.

76 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion Appendix 3 Terms of Reference for the Research and Knowledge Transfer Sub-Committee

Background The Co-Chairs of the AITF are Dr. Terry Sullivan and Dr. Geoff Dunkley. In June, 2004, the Minister of Health and Long-Term Care released Operation Health Protection – A Three Year A core function proposed for the Agency is research Action Plan to Prevent Threats to our Health and to and knowledge transfer. Operation Health Protection Promote a Healthy Ontario. This Action Plan confirms the noted that this function would be undertaken through commitment of the Ministry of Health and Long-Term creating, reinforcing and strengthening partnerships with Care (MOHLTC) to implementing the recommendations research, academia, and healthcare institutions to of the Expert Panel on SARS and Infectious Disease support the generation of evidence-based public health Control as per the following strategic directions: policies and practices. • Creating the Ontario Health Protection and Promotion Agency 2. Public Health Renewal • Renewing the Public Health System One of the key goals of renewing the public health • Health Emergency Management system is to review the organization and capacity of • Infection Control and Communicable Disease local Public Health Units and the Public Health Education, Capacity Research and Development (PHRED) Program. This • Health Human Resources review will inform the development of long-term • Infrastructure for Health System Preparedness strategies to enhance capacity to plan and implement optimal public health programs and services that Research and knowledge transfer has been identified as effectively respond to the needs of Ontarians. This a priority for the creation of the Ontario Health Protection review is being supported by the CRC. and Promotion Agency and in the renewal of the public health unit system. CRC advises the CMOH and, through her, the MOHLTC on options to improve the function and configuration of 1. Ontario Health Protection and the local Public Health Unit system. The advice to be Promotion Agency provided encompasses the following: An Agency Implementation Task Force (AITF) has been • core capacities required (such as infrastructure, established to provide advice to the MOHLTC, via the staff, etc.) at the local level to meet communities’ CMOH, on the design, development and implementation specific needs (based on geography, health status, of the Ontario Health Protection and Promotion Agency. health need, cultural mix, health determinants, etc.) and to effectively provide public health services The responsibilities of the AITF will be to: (including specific services such as applied • Validate the Agency’s proposed mandate, key research and knowledge transfer); functional areas, structure, governance and • issues related to recruitment, retention, education oversight. and professional development of public health • Recommend operational public health professionals in key disciplines (medicine, nursing, responsibilities for the Agency, and delineate its nutrition, dentistry, inspection, epidemiology, role and responsibilities in relation to those of the communications, health promotion, etc.); MOHLTC, academia, the broader health, the • identifying operational, governance and systemic Federal Public Health Agency and its National issues that may impede the delivery of public Collaborating Centres. health programs and services; • Recommend a comprehensive three-year • mechanisms to improve performance implementation plan for the Agency (including management systems and programmatic and infrastructure, financial requirements, human financial accountability; resources, transition, arrangements, etc.).

Final Report of the Agency Implementation Task Force 77 • strengthening compliance with the Health Terms of Membership Protection and Promotion Act, associated Regulations and the Mandatory Health Programs 1. The Research and Knowledge Transfer and Services Guidelines; Sub-Committee will report to the AITF and • organizational models for Public Health Units that CRC via its Co-chairs. optimize alignment with the configuration and functions of the Local Health Integration Networks, 2. The Research and Knowledge Transfer primary care reform and municipal funding Sub-Committee will have a sunset date of partners; and December 31, 2005 unless the CRC, the AITF • staffing requirements and potential operating and and the MOHLTC agree to extend this term. transitional costs. 3. The Research and Knowledge Transfer The Chair of the CRC is Dr. Susan Tamblyn and the Vice- Sub-Committee will operate by consensus chair is Mr. Brian Hyndman. to the fullest extent possible.

Purpose 4. The Research and Knowledge Transfer Sub-Committee members will be reimbursed The Research and Knowledge Transfer Sub-Committee for travel expenses as per Management will support the AITF and the CRC by sharing its Board Guidelines. expertise and making recommendations to produce the following deliverables: 5. All documentation produced by the Research • An assessment of lessons learned from existing and Knowledge Transfer will be the property of and former models of public health research and Her Majesty the Queen in right of Ontario. knowledge transfer in: • Ontario (e.g., the Public Health Research, Support to the Sub-Committee Education and Development (PHRED)/ Teaching Health Unit Program). 1 The Research and Knowledge Transfer • Other jurisdictions (i.e., British Columbia, Sub-Committee will be supported by the Quebec, etc.) Strategic Planning and Implementation • An assessment of gaps and analysis of needs with Branch (SPIB) of the Public Health Division respect to public health research and knowledge of the MOHLTC. transfer. • An environmental scan of other key sources of Process research and knowledge transfer for public health units, such as universities, ICES, CIHI, Health 1. The Research and Knowledge Transfer Intelligence Units, Ontario Health Promotion Sub-Committee will convene at the call Resource System members. of the Co-chairs, Mr. Brian Hyndman and • Recommendations for an appropriate vision to Ms. Jennifer Zelmer. inform the design of the mandate and structure for a research and knowledge transfer system, including the potential roles of the Health Protection and Promotion Agency, that support and enable more effective public health programs and policies and that is anchored in public health needs.

The Research and Knowledge Transfer Sub-committee will be Co-chaired by Mr. Brian Hyndman, Vice-chair of the CRC and Ms. Jennifer Zelmer, AITF member.

78 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion References

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11. Development Corporations Act, R.S.O. 1990, c. D.10. [online]. 6. Ontario. Ministry of Health and Long-Term Care. Operation Accessed January 7, 2006 from: http://www.e- Health Protection: an action plan to prevent threats to our health laws.gov.on.ca/DBLaws/Statutes/English/90d10_e.htm and promote a healthy Ontario. Toronto, Ont.: Ministry of Health and Long-Term Care; 2004. [online]. Accessed November 12, Chapter 3: Ministry/Inter-Ministry Liaison 2005 from: 1. Ontario. Ministry of Health and Long-Term Care. Mandatory http://www.health.gov.on.ca/english/public/pub/ministry_reports/ health programs and services guidelines. Toronto, Ont.: Ministry consumer_04/oper_healthprotection04.pdf of Health and Long-Term Care; 1997. [online]. Accessed November 20, 2005 from: 7. Ontario. Expert Panel on the Legionnaires’ Disease Outbreak in http://www.health.gov.on.ca/english/providers/pub/pubhealth/ma the City of Toronto, Walker D, Henry B, Young J. Report card: nprog/mhp.pdf progress in protecting the public’s health: report of the Expert Panel on the Legionnaires’ Disease Outbreak in the City of 2. Haines RJ. Farm to fork: a strategy for meat safety in Ontario: Toronto – September/October 2005. Toronto, Ont.: Ministry of report of the Meat Regulatory and Inspection Review. Toronto, Health and Long-Term Care; 2005. [online]. Accessed January 7, Ont.: Ministry of the Attorney General; 2004. [online]. Accessed 2006 from: October 11, 2005 from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ http://www.attorneygeneral.jus.gov.on.ca/english/about/pubs/me walker_legion/rep_final_120505.pdf atinspectionreport/ 8. Basrur SV. Building the foundation of a strong public health Chapter 4: Organisational Design system for Ontarians: 2005 annual report of the Chief Medical 1. Curran J. Keynote Lecture: 25 Years of the HIV Pandemic: Officer of Health to the Ontario Legislative Assembly. Toronto, Lessons Learned. Presented at the 13th Conference on Ont.: Ministry of Health and Long-Term Care; 2005. [online]. Retroviruses and Opportunistic Infections. Denver, Colorado. Accessed January 9, 2006 from: February 5, 2006. http://www.health.gov.on.ca/english/public/pub/ministry_reports/ ph_ontario/ph_ontario_011706.pdf 2. Chambers LW, Ehrlich A, Picard L, Edwards P. The art and science of evidenced-based decision-making… 9. Ontario. Ministry of Health and Long-Term Care. Ontario’s epidemiology can help! Canadian Journal of Public Health health system performance report. Toronto, Ont.: Ministry of 2002;93(1)(Special insert):l1-l8. [online]. Accessed on December Health and Long-Term Care; 2004, p. 33. [online]. Accessed 16, 2005 from: http://www.phac-aspc.gc.ca/csc- December 14, 2005 from: ccs/pdf/epidemiology_e.pdf http://www.health.gov.on.ca/english/public/pub/ministry_reports/ pirc_04/pirc__04.pdf 3. National Health Surveilland Network Working Group, Integration Design Team. Proposal to develop a network for health 10. SmartRisk. The economic burden of unintentional injury in surveillance in Canada. [Ottawa, Ont.]: Health Canada; 1999, Ontario. Toronto, Ont.: SmartRisk; 2003, p. 30. [online]. p.6. [online]. Accessed December 16, 2005 from: Accessed January 5, 2006 from: http://www.phac-aspc.gc.ca/csc-ccs/pdf/Propos17.pdf http://www.smartrisk.ca/ContentDirector.aspx?tp=78&dd=3

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82 From Vision to Action: A Plan for the Ontario Agency for Health Protection and Promotion 11. Ontario. Ministry of Health and Long-Term Care. Operation Ont.: Ministry of Health and Long-Term Care; 2005, p. 20. Health Protection: an action plan to prevent threats to our health [online]. Accessed January 9, 2006 from: and promote a healthy Ontario. Toronto, Ont.: Ministry of Health http://www.health.gov.on.ca/english/public/pub/ministry_reports/ and Long-Term Care; 2004. [online]. Accessed November 12, ph_ontario/ph_ontario_011706.pdf 2005 from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ 2. Expert Panel on SARS and Infectious Disease Control (Ont.), consumer_04/oper_healthprotection04.pdf Walker D. For the public’s health: a plan of action: final report of the Ontario Expert Panel on SARS and Infectious Disease 12. Ontario Health Promotion Resource System. Home page. Control. Toronto, Ont.: Ministry of Health and Long-Term Care; [online] Last updated November 2, 2005. Accessed November 2004. [online]. Accessed October 15, 2005 from: 15, 2005 from: http://www.ohprs.ca/ http://www.health.gov.on.ca/english/public/pub/ministry_reports/ walker04/walker04_mn.html 13. OPHA Environmental Health Working Group. Building environmental health capacity within public health. [Toronto, 3. Ibid, p.231. Ont.]: Ontario Public Health Association; 2004. [online]. Accessed December 15, 2005 from: 4. Ontario. Ministry of Health and Long-Term Care. Operation http://www.opha.on.ca/ppres/2004-02_res.pdf Health Protection: an action plan to prevent threats to our health and promote a healthy Ontario. Toronto, Ont.: Ministry of Health 14. Ontario. Ministry of Health and Long-Term Care. Mandatory and Long-Term Care; 2004. [online]. Accessed November 12, health programs and services guidelines. Toronto, Ont.: Ministry 2005 from: of Health and Long-Term Care; 1997. [online]. Accessed http://www.health.gov.on.ca/english/public/pub/ministry_reports/ November 20, 2005 from: consumer_04/oper_healthprotection04.pdf http://www.health.gov.on.ca/english/providers/pub/pubhealth/ma nprog/mhp.pdf Chapter 7: Emergency and Outbreak Support Chapter 5: Legislative Authority 1. Bill 56, An Act to amend the Emergency Management Act, the 1. Health Protection and Promotion Act. R.S.O. 1990, c. H.7. Employment Standards Act, 2000 and the Workplace Safety and [online]. Accessed January 10, 2006 from: http://www.e- Insurance Act, 1997. [Government Bill.] First reading: December laws.gov.on.ca/DBLaws/Statutes/English/90h07_e.htm 15, 2005. Toronto, Ont.: Legislative Assembly of Ontario. [online.] Accessed February 2, 2006 from: 2. Ontario. SARS Commission, Campbell A. SARS Commission http://www.ontla.on.ca/documents/Bills/38_Parliament/session2/ second interim report: SARS and public health legislation. b056.pdf Toronto, Ont.: Ministry of Health and Long-Term Care; 2005. [online]. Accessed April 20, 2005 from: Chapter 8: Phasing-in http://www.health.gov.on.ca/english/public/pub/ministry_reports/ 1. Public Health and Epidemiology Report Ontario (PHERO). Home campbell05/campbell05.pdf page. Last updated: December 7, 2004 Accessed February 28, 2006 from: 3. Personal Health Information Protection Act, S.O. 2004, c.3, http://www.health.gov.on.ca/english/providers/pub/pub_menus/p Sched. A. [online]. Accessed January 11, 2006 from: ub_phero/pub_phero.html http://www.e- laws.gov.on.ca/DBLaws/Statutes/English/04p03_e.htm 2. Expert Panel on SARS and Infectious Disease Control (Ont.), Walker D. For the public’s health: a plan of action: final report of 4. Freedom of Information and Protection of Privacy Act, R.S.O. the Ontario Expert Panel on SARS and Infectious Disease 1990, c. F.31. [online] Accessed January 11. 2006 from: Control. Toronto, Ont.: Ministry of Health and Long-Term Care; http://www.e- 2004, p. 266. [online]. Accessed October 15, 2005 from: laws.gov.on.ca/DBLaws/Statutes/English/90f31_e.htm http://www.health.gov.on.ca/english/public/pub/ministry_reports/ walker04/walker04_mn.html Chapter 6: Public Health Laboratory System 1. Basrur SV. Building the foundation of a strong public health system for Ontarians: 2005 annual report of the Chief Medical Officer of Health to the Ontario Legislative Assembly. Toronto,

Final Report of the Agency Implementation Task Force 83

Exhibit B

IN THE MATTER OF AN INTEREST ARBITRATION UNDER THE HOSPITAL LABOUR DISPUTES ARBITRATION ACT

BETWEEN

Ontario Agency for Health Protection and Promotion (OAHPP) (Employer)

AND

The Ontario Public Service Employees Union (OPSEU) (Union)

BEFORE: Gerry Lee, Chair.

APPEARANCES:

For the Employer: Craig Rix , Counsel David Ross, Co-Counsel Robert Blewett Nicholas Paul Mark Coulter Cary Luner

For the Union: Michèle Dawson Haber, Senior Research Officer Roy Storey, Negotiator Sabrina Parkinson Ellen Goslin Nino Lombardi David LeDrew Robert Heath

Hearing held on July 30th, 2013.

Award

The parties have appointed me as sole arbitrator under the Hospital Labour Disputes Arbitration Act (HLDAA) to adjudicate the outstanding issues that remain in dispute in respect of the negotiation of the Parties’ second collective agreement. There is no dispute with respect to my authority in this regard.

Ontario Public Health Laboratories (OPHL) was divested by the Ontario Government to the newly created Ontario Agency for Health Protection and Promotion (OAHPP) on December 15, 2008. All employees at the time of divestment were either OPSEU or AMAPCEO members of the Ontario Public Service. These employees formed new bargaining units in the divested Agency. OAHPP operates across Ontario at eleven worksites and has the mandate of protecting and promoting the health of all Ontarians and reducing inequities in health. OAHPP provides laboratory services, expert scientific and technical advice and support relating to:

• infectious diseases • infection prevention and control • surveillance and epidemiology • health promotion, chronic disease and injury prevention • environmental and occupational health • emergency preparedness and incident response

On July 1, 2011, OAHPP inherited another group of employees (“PHA employees”) from the Public Health Division of the Ontario Public Services. These employees came over with the Management Board of Cabinet and Ontario Public Service Employees’ Union collective agreement (expiry December 31, 2012).

The Parties’ first collective agreement was concluded by my award dated July 13, 2011. This award provided no across the board wage increases during the

- 2 - first two years of the collective agreement and a 1% across the board wage increase effective March 1, 2011. The award also provided targeted wage “market” adjustments to classifications which were well below the comparator classifications in the hospital sector. My award did not cover the monetary terms and conditions of the PHA employees or “scope/post-scope” employees as described below because they were incorporated into the bargaining unit after the term of the first collective agreement.

In the instant matter, the Parties successfully resolved most of the outstanding issues and agreed on a number of items. I award the Parties’ agreed items which are attached as Appendix A to this award. The only outstanding issue before me is wages. I specifically note that the Parties provided me with the jurisdiction to award a 3 year term instead of the 2 year term mandated by the Hospital Labour Disputes Arbitration Act (HLDAA).

Interest arbitration has been used as a means for settling disputes in Ontario since the late 1940s. Since that period of time, certain basic principles have emerged and those principles have been outlined in numerous arbitration awards. Section 9 (1.1) of HLDAA requires a Board of Arbitration to take into consideration all criteria it considers relevant, including the following “HLDAA Criteria”:

1. The Employer’s ability to pay in light of its fiscal situation; 2. The extent to which services may have to be reduced, in light of the decision or award, if current funding and taxation levels are not increased; 3. The economic situation in Ontario and in the municipality where the hospital is located; 4. A comparison, as between the employees and other comparable employees in the public and private sectors, of the terms and conditions of employment and the nature of the work performed; and 5. The Employer’s ability to attract and retain qualified employees.

- 3 - The statute does not direct me to attribute any specific weight to each of the criteria, nor can these criteria be considered a comprehensive list of matters that are to be taken into consideration.

Wages

The Union submitted proposals requesting general wage increases and wage parity for classifications which the union identified as significantly below the comparator wage rates in the Participating Hospitals and OPSEU Central collective agreement. This included a request to add steps to the MLT1 classification.

The Employer requested me to award no net increases to compensation based on the Government’s directives to organizations in the broader public service to negotiate two years of no net increases to base compensation; funding restrictions; and the collective bargaining trend of no increases to base compensation in 2011 and 2012.

I would like to start by noting that these Parties have unique and challenging features to their relationship and I echo Arbitrator Steinberg’s comments in his award of the Ontario Agency for Health Protection and Promotion and the Association of Management, Administrative and Professional Crown Employees of Ontario (unreported, October 24, 2012) at paragraph 8:

Because of the unique and challenging circumstances of the process giving rise to this Award, extreme caution should be exercised in utilizing this Award as a precedent should anyone be tempted to do so.

Arguably the most challenging aspect in this case is the fact that there are currently three separate and distinct groups of employees (“market adjusted” employees, “non-market adjusted employees”, “scope”/”post-scope”

- 4 - employees), each with unique and identifiable interests. This makes it difficult, if not impossible, to treat all of the employees similarly in order to replicate what the Parties would have done had free collective bargaining been permitted to run its course. The three groups relevant to this award are as follows:

1) “Market adjusted employees” These employees are in classifications which received market adjusted wages increases in the Parties’ first award. These classifications are all in the public health laboratories and have comparable positions in hospitals. The Parties identified the following comparators to those in the collective agreement between Participating Hospitals and O.P.S.E.U. : OAHPP Participating Hospitals and OPSEU MLT1 Registered Technologist MLT2 Senior Technologist MLT4 Charge Technologist LA2 Technician 3

I note that the above-noted collective agreement between the Participating Hospitals and O.P.S.E.U. provides for across the board wage increases of 0%/0%/2.75% over the same term as the instant collective agreement. These general increases form the starting point of my analysis.

However, both Parties noted that the job rate, that is the highest rate of pay for the respective classifications are approximately 7 – 12% lower in the Employer’s collective agreement than the Participating Hospitals and O.P.S.E.U. collective agreement. The respective gaps were closed substantially in my last award, which demonstrates how far behind the “market” these respective classifications were at the time of divestment, and why “market adjusted” increases were, and continue to be appropriate for this group of employees; despite the current economic and collective bargaining environment.

- 5 -

Within these classifications the reasons for the differential between the “MLT1” and the Registered Technologist classifications is exacerbated due to the fact that the Participating Hospitals and OPSEU collective agreement provides for 2 additional steps on the grid.

Both Parties also made extensive submissions regarding the principle of total compensation and the difference in the value of other monetary benefits between the OAHPP collective agreement and the Participating Hospitals/OPSEU Central collective agreement for me to consider. In issuing my award, I make no finding on this question.

In determining my award, I have attempted to replicate what the Parties would have done if free collective bargaining had taken its course. My award is as follows:

General Increases:

April 1, 2011 – 0% April 1, 2012 – 0% April 1, 2013 – 2.75%

I find that the Parties would have replicated the trend of general increases established by the Participating Hospitals and OPSEU Central collective agreement. The 2.75% increase on April 1, 2013 is awarded to keep pace with the bargaining units’ closest Hospital comparator, otherwise, the gap between OAHPP laboratory classifications that received market adjustments in the last round and Central hospital classifications will widen in 2013, which would counter the impact and intent of the market adjustments awarded below.

- 6 - Market Adjustments:

MLT1 I award no market adjustments from April 1, 2011 – March 31, 2012 for this classification.

On April 1, 2012, I award that the wage grid provide two additional steps with a 3% increment between each new step (Step 8 and Step 9). Eligible employees will move to “Step 8” on their anniversary date following April 1, 2012. Eligible employees will move to “Step 9” of the grid on their next anniversary date following April 1, 2013. The addition of steps is to replicate the 9 Step grid found in the Participating Hospitals and OPSEU Central agreement.

MLT2, MLT3 and LA2

I award the following market adjusted increases to close some of the gap between the Employer’s wage rates and the comparator Hospital wage rates:

April 1, 2011 – 2% April 1, 2012 – 2%

I also award that any wage rate that is or becomes higher than the respective step on the Participating Hospitals and OPSEU Central agreement’s grid as a result of my award(s) will be changed to mirror the Participating Hospitals and OPSEU wage rate. The intent of providing market adjustments is to help close some of the gap to market comparability but not to exceed them at any step of the grid.

- 7 - 2) “Non-Market Adjusted employees”

These employees consist of the classifications which transferred from the Ontario Public Service at divestment (which includes the classifications which transferred on July 1, 2011), but do not have an identifiable, comparable classification in the Hospital sector. This group of employees received no increases in the 2009 or 2010 calendar year.

I do not award the same general increases for this group of employees as the “market adjusted” employees because doing so would mean that over two awards, this group of employees would receive four years of no increases to base compensation aside from the 1% I awarded on March 1, 2011. Neither Party identified any other group of comparable employees in the broader public or healthcare sectors which had two awards of no increases to wages over the same period of time.

Also, it is notable that had this group of employees stayed within the Ontario Public Service (although not identified by the Union as a comparator), they would have received approximately 7.5% in general wage increases from 2009 – 2012. Notwithstanding, I do find it appropriate to award no increases to base compensation in 2013 given the current economic climate and bargaining trends. Instead, I award a lump sum payment. My award for this group is as follows:

April 1, 2011 – 1% October 1, 2011 - 1% April 1, 2012 – 1% October 1, 2012 – 1% Date of Award – $750 lump sum payment.

3) “Scope” and “Post Scope” employees “Scope” employees became part of the Union after March 31, 2011, and hold positions, for the most part, outside of the public health labs. As a result of tri- partite negotiations between the Employer, OPSEU and AMAPCEO (the

- 8 - Employer’s other bargaining agent), the Parties agreed to fundamentally alter the recognition clauses of both collective agreements to reflect more “functionally” based bargaining units.

The Parties entered into a transition agreement which governed the terms and conditions of these employees until the next collective agreement was concluded (the instant collective agreement). Therefore, my award incorporates the “scope” employees into the collective agreement for all purposes and replaces the applicable terms of the transition agreement.

“Post-scope” employees are employees hired in new classifications after March 31, 2011. Since the classification is new, no wage grid has yet been established in the collective agreement.

The primary challenge with this group is that they were hired in classifications which did not previously exist within the Employer and their monetary terms and conditions of employment were governed by their individual employment contract until the issuance of this award. The Parties mutually agreed on the hearing day to allow me to consider their competing submissions with respect to appropriate wage grids for these employees. Both presented wage grids for my determination. The wage grids differed in a number of respects and each party argued that their proposal was the more reasonable one. The wage rates in the Employer’s wage grids were not uniformly lower compared to the Union’s (in fact, some were higher), but the Employer argued that overall, the total compensation impact was lower than the Union’s proposal. The Employer also argued that its wage grids had more internal consistency than the Union’s. For both of these reasons, I award the Employer’s proposed wage grids. The wage grids are attached at Appendix B. Each employee in one of the classifications contained at Appendix B will be placed on the closest step on the grid without having their wage rate reduced effective the date of this award. Such employees will progress to the next step of the grid if eligible on their next anniversary date.

- 9 -

Summary of Award The summary of my awarded items are as follows:

1) “MLT1” will receive the following wage grid effective April 1, 2012:

28.43 29.53 30.30 31.11 31.92 32.87 33.86 34.88 35.92

Eligible employees will proceed to Step 8 of the new grid on their first anniversary following April 1, 2012. Such employees will proceed to Step 9 of the grid on their next anniversary date following April 1, 2013.

2) “MLT2, MLT3 and LA2” classifications will receive the following market adjusted increases:

April 1, 2011 – 2% April 1, 2012 – 2%

Any wage rate that is or becomes higher than the respective step on the Participating Hospitals and OPSEU wage grid shall be changed to the Participating Hospital rate. The respective grids will be as set out below:

MLT2 01-Apr- 11 2% 32.37 32.26 34.16 35.11 36.07 37.15 38.26 01-Apr-12 2% 32.60 33.90 34.84 35.81 36.79 37.89 39.03

LA2 01-Apr-11 2% 23.51 23.89 24.25 24.98 25.73 01-Apr 12 2% 23.53 24.37 24.73 25.48 26.25

3) The Employer’s wage grid for “scope” and “post scope” employees is awarded. The wage grids are set out in the attached Schedule B. Employees will be placed on the appropriate grid at the next closest step to their current wage rate, without having a reduction in wage rate. Movement thereafter will be on their next anniversary date from the date of the award

- 10 -

4) The Union’s proposal with respect to the MLT4 (“Charge Technologist”) is awarded. The wage grid will be as follows:

MLT4 01-Apr- 12 34.46 35.83 37.20 38.57 39.96 41.30 42.71

5) All other classifications not covered by 1 - 4 listed above will receive 1% effective April 1, 2011, 1% effective October 1, 2011 and 1% effective April 1, 2012 and 1% October 1, 2012.

6) Effective April 1, 2013 the MLT1, MLT2, MLT3, MLT4 and LA2 classifications will receive a 2.75% market adjusted increase.

7) Effective April 1, 2013, all other classifications not listed in #6 above nor “scope employees” (in recognition of the scope employees receiving pay for performance prior to the implementation of the grid) shall receive a lump sum of $750, prorated based on regular hours worked in lieu of foregoing a general wage increase from April 1, 2013 to March 31, 2014..

8) Any employee with a salary above the respective wage will be red circled. This means that the employee will not have a wage increase until the wage grid meets or exceeds his or her current salary.

9) Any retroactive payments will only be paid to current employees, retired employees during the term of this agreement and employees laid off by the Employer during the term of this agreement.

10) All payments will be made within 150 days of this award.

11) All other agreed items attached at Appendix A are incorporated into the collective agreement.

- 11 - Finally, I will remain seized until the parties enter into a collective agreement.

Dated at Markham, Ontario, this 4th day of October, 2013.

______Gerry Lee – Chair

- 12 - Ag ree d I te m s - Fe b r u a ry 8 , 20 1 2

A RT I C L E I - R E C O G N I T I O N

Th e On ta r i o Pu b l i c S e rv i ce Em p l oye e s U n i o n ( O PS E U ) i s recog n i zed a s t h e exc l u s i ve ba rg a i n i n g a g e n t fo r a l l e m p l oye e s e n g a ge d i n l a b o ra to ry te st i n g se rv i ce s a n d a d m i n i st ra t i o n s a ve a n d except p e rs o n s : w h o exe rc i s e m a n a g e r i a l fu n ct i o n s ; a re em p l oye d i n a co n fi d e n t i a l c a p a c i ty i n m atte rs re l a t i n g to l a bo u r re l a t i o n s ; p h ys i c i a n s e m p l oyed i n t h e i r p rofe ss i o n a l c a p a c i ty ; h u m a n res o u rces p e rs o n n e l ; l awye rs e n g a g e d i n t h e i r p rofe ss i o n a l ca pa c i ty ; a d m i n i s t ra t i ve a ss i sta n ts to t h e P re s i d e n t a n d CEO , V i ce P re s i de n ts , C h i ef O ffi ce rs a n d t h e D i re cto r o f H u m a n Res o u rce s ; o r e m p l oyee s cove red by a n o t h e r co l l e ct i ve a g re e m e n t i n a d i ffe re nt ba rg a i n i n g u n i t .

Fo r c l a r i ty , a d m i n i st ra t i o n i n c l u d e s b u t i s n ot l i m i te d to fin a n ce ; i n fo r m at i o n te c h n o l ogy ; p ro c u re m e n t; fa c i l i t i e s ; a n d a d m i n i s t ra t i ve a ss i sta nts .

Fo r g re a te r c l a r i ty, t h i s b a rg a i n i n g u n i t i n c l u de s b u t i s n ot l i m i te d to th e p o s i t i o n s/c l a s s i fi ca t i o n s s et o u t i n S c h e d u l e A a n d B of t h e Me mo ra n d u m of Ag re e m e n t s i g n e d on M a rc h 2 5 , 2 0 1 1 ( a s a tta c h ed ) .

A RT I C L E 2 - D E F I N I T I O N S

2 . 4 I n te r n s h i p P ro .q ram / I n i t i a t i ve s a d d

N o F u l l -t i m e , Pa R-t i m e o r Tem p o ra ry E m p l oyees s h a l l h ave a ny h o u rs o f wo r k re d u c e d a s a res u l t o f t h e u se o f I n te r n s .

A RT I C LE 5 - MA NAG E M E NT R I G H TS

5 . 1 ( e ) m a n a g e t h e e n te r p r i s e i n w h i c h t h e Ag e n cy i s e n g a g e d a n d w i t h o u t re st r i ct i n g t h e g e n e ra l i ty of t h e fo reg o i n g , t h e r i g h t to p l a n , d i re c t a n d c o n t ro l o p e ra t i o n s , syste m s a n d p ro ce d u re s , d i re ct i ts p e rs o n n e l , dete r m i n e n u m be r a n d typ e of s taff req u i red , o rg a n i za t i o n , m e t h o d s a n d t h e n u m be r , l o c a t i o n o f o p e ra t i o n s , b u i l d i n g s, e q u i p m e n t a n d fa c i l i t i e s, wo r ks i te s , p ro g ra m s , t h e s e rv i ce s to b e p erfo r me d , t h e s c h ed u l i ng o f a s s i g n m e n ts a n d w o r k , t h e exte n s i o n , l i m i ta t i on , c u rta i l men t o r ce s sa t i o n of o p e ra t i o n s a n d a l l ot h e r r i g h ts a n d re s p o n s i b i l i t i e s n ot s p e c i fi c a l l y mod i fi e d e l s e w h e re i n t h i s Ag re e m e n t . - 2

A RT I C LE 6 . t - UN I O N S EC UR I TY

6 . 1 T h e Ag e n cy s h a l l de d u ct from e a c h b i -we e k l y p a y o f e a c h b a rg a i n i n g u n i t e m p l oye e fro m t h e fi rst d a y of e m p l oy m e n t , a n a m o u n t e q u i va l e n t to s u c h U n i o n d u e s a s t h e U n i o n a dv i se s t h e Age n cy . I n a d d i t i on , t h e Age n cy s h a l l d e d u ct U n i o n d u e s fro m a ny ret ro a ct i ve wa g e p a yme n ts a a d a ny ot he r paym e n ts a s adv i s ed by t h e U n i o n , m a d e to t h e e m p l oye e s . Th e Age n cy a g ree s t h at i t w i l l re m i t t h e tota l a m o u n t of s u c h d e d u ct i o n s to t h e Acco u n t i n g De pa rt m e n t of t h e U n i on , n o l a te r t h a n t h e 1 5 t h d a y of ea c h mo n t h fo l l ow i n g t h e mo n t h t h a t d e d u ct i o n s we re m a de .

ART I C L E 9 = G R I EVA N C E AN D A RB I TRAT I O N P RO C E D UR E

9 . 4 ( e ) U n i o n Co u n te r p ro p o s a l

Pr4or-ta 4 eq PA:i eti ate-l ei s h c d , t h c p e4Cies-wit4 - c-ume di qeser_e_om_a t4 eut_ o-4e a , . g heth-p -v,4L4T" hhe-o ppeFL u n l W to u n d c rsLead4hegr4eva c c a n d to p repare4er4he resolu n )

Ame n d a s fo l l ows : e) [f' req ueste cl , t he E m p l oye r sha l l p rov i de t he U n i o n w i t h re l eva n t pa rt i cu n a rs re l a t i n g to a g r i eva nce f i l ed by t he U n i o n o r1 b e h a l f of a m em b e r o r t h e U n i o n i ts e l f d u r i n g t h e g r i eva n ce p roced u re . f} : f re q u ested, t he U b i o n sh a l l l rov i d e t he E m p l oye r w i t h re n eva n L pa ± i cu l a rs re l a t i re g to a g r i eva nce f i l ed by t h e U r i o n on be h a l f of a m e i b e r o r t h e U n i o n i ts d f d o t i n g the g r i eva n c e p roced u re .

( N EW) At a n y s tage e f t h e g r i eva n c e p ro ced u re t h e pa rt i e s m ay exte n d t he t i m e l i m i ts w i t h m u t u a n co n s e n t of t h e Ag e ncy a n d t h e U n i o n . - 3

9 . 1 2 No p e rs o n m ay b e a p p o i n ted a s a n a r b i t ra to r w h o h a s b e e n i n vo l ve d i n a n a tte m p t to n e got i a te o r se tt l e t h e g r i eva n c e, u n l i - ot h e rw i s e a g reed .

ART I C L E 2 7 - E N T I T LE I EN T O ND EATH

Am e n d as fo l l ows :

2 7 . 1 W h e re a fu l l -t i rn e e m p l oye e w h o h a s s e rv e d m o re t h a n s i x ( 6 ) mo n t h s d i e s , t h e re s h a l l b e p a i d t o h i s o r h e r p e rs o n a l rep re s e n t at i ve o r , i f t h e re i s n o p e rs o n a l re p re s e n ta t i ve , to t h e e s ta te of t h e e m p l oyee th e s u m of ,

( a ) o n e -twe l fth ( 1 / 1 2 ) of h i s o r h e = a n n u a l s a l a ry ; a n d ( b ) h i s o r h e r s a l a ry fo r t h e pe r i o d o f va ca t i o n l eave o f a b s e n c e a n d o ve t -[ i rn e c re d i ts t h at h ave a c c r u e d .

2 7 . 2 W h e re a fu l l -t i m e em p l oye e d i e s , t h e re s h a l l b e p a i d to h i s o r h e r p e rs o n a l re p re s e n t a t i ve o r , i f t h e re i s n o p e rs o n a l rep re s e n ta t i ve , to t h e e m p l oyees es ta te per " es , a n a m o u n t i n re s p e ct of a tte n d a n c e c re d i ts o r te rm i n a t i o n pay c om p u te d i n t h e m a n n e r a n d s u bj e ct to t h e c o n d i t i o n s s e t o u t i n t h e Le tte r of U n d e rsta n d i n g re : Te rm i n a t i o n P aym e n ts . A n y te rm i n a t i o n p a y to w h i c h a n e m p l oyee i s en t i t l e d s h a l l b e re d u c e d b y t h e a m o u n t eq u a l to o n e -twe l ft h ( 1 / 1 2 ) of h i s o r h e r a n n u a l s a l a ry . - 4

L ETTE R S O F UND E RS TA ND I N G

# i Re : S e l f F u n d e d Le a ve o Re new

#2 Re : Te r m i n a t i o n P a ym e n ts = Re n ew

D a ted t h i s 8 h d ay of Fe b r u a ry , 2 0 1 2 :

F o r t h e U n i o n Fo r t h e E m p l o ye r

. 2, fH// " __

,/ Ag ree d I te m s - Feb r u a ry 8 , 2 0 1 2

T h e P a rt i e s a g re e to i m p l e m e n t t h i s a rt i c l e i mmed i a te l y u p o n exe c u t i o n .

A RT I C L E 2 ( d ) - S t u de n ts

Defi n i t i o n : A st u d e nt i s a f i xe d te rm e m p l oyee o c c u py i n g a ' s t u d e n t p o s i t i o n ' d u r i n g h i s o r h e r re g u l a r s c h oo l , co l l e g e o r u n i ve rs i ty va c at i o n pe r i od d u r i n g h i s o r h e r reg u l a r s c h oo l , c o l l e g e o r u n i ve rs i ty s e s s i o n o r va c a t i o n p e r i od Va c a t i o n pe r i o d : A " re g u l a r va c at i o n p e r i o d " w i t h i n t h e m e a n i n g of a st u d e nt p o s i t i o n i n c l u d e s s u mme r v a c at i o n , i n te r- s e me s te r b rea ks , a c a dem i c b rea ks , De cem b e r H o l i d ays , t h e h o l i d ay s i n A rt i c l e 1 9 a n d a p e r i o d of t i m e of s i x ( 6 ) m o n t h s fo l l ow i n g t h e c o m p l e t i o n of t h e re q u i re m e n ts fo r g ra d u a t i o n from a n ed u c a t i o n a l i n s t i t u te .

S t u d e n t p os i t i o n : A " st u d e n t p o s i t i o n " i s a f i xe d -te rm p os i t i o n w i t h te r m s a n d c o n d i t i o n s s pe c i f i ca l l y a p p l i c a b l e t o s t u d e n ts .

Wag e Ra tes : L eve l 1 = $ 1 0 . 2 5 Leve l 2 = $ 1 ! . 1 0

A p p l i ca b l e A rt i c l es : T h e fo l l ow i n g A rt i c l e s s h a l l a pp l y t o s t u d e n t e m p l oy ee s a s d e f i n ed : A rt i c l e 1 - Re c og n i t i o n , Art i c l e 3 - N o d i s c r i m i n at i o n o r H a ra s s m e n t , Art i c l e 5 M a n a g em e n t R i g h ts , A rt i c l e 6 - U n i o n S e c u r i ty ( D u e s D e d u ct i o n ) , Art i c l e 9 - G r i e va n ce a n d A r b i t ra t i o n P ro c e d u re a n d Art i c l e 2 8 - Te r m of Ag reem e n t . N o o t h e r a rt i c l e s s h a l l a p p l y .

B e re avem e n t Leave : A s t u d e n t w i l l b e e l i g i b l e fo r be rea ve m e n t l e ave p u rs u a n t to A rt i c l e 1 5 . 4

S i g n ed o n t h i s 8 t h d ay of Feb ru a ry , 2 0 1 2 ,

Fo r t h e U n i o n F o r t h e E m p l oye r - 2

" /// " . .SJ Ag re e d I t e m s = M a rc h 28 , 2 0 1 2

A RT I C LE 8 - H E A LTH A ND SA F E TY

C h a n g e t i t l e :

8 . 1 0 A c c e s s t o Acc i d e n t a n d H e a l t h a n d S a fe ty I n c i de n t Re p o rts

A RT I C LE 9 - G R I EVA N C E A N D A R B I T RAT I O NP RO C E D UR E

9 . 1 7

Ad d

At a ny s t a g e o f t h e g r i eva n c e p ro ced u re t h e p a rt i e s m ay ext e n d t h e t i m e l i m i ts w i t h m u t u a l c o n s e n t of t h e Ag en cy a n d t h e U n i o n ,

9 . 2 2

Am e n d to :

I n t e re s t W h e re a m o n e ta ry a w a rd i s i s s u e d a r i s i n g o u t of a g r i e v a n c e o r a rb i t ra t i o n awa rd , i n t e re s t s h a l l b e p aya b l e a s fo l l ows :

( a ) fo r t h e p e r i o d co m. m. .e n c .i n g . h.. . . . ,J, W( . m" J "",4 . , , 'o v,. ... ., . {. .. t h e d a t e t h e g r i e va n c e wa s f i l e d o r fr o m t h e f i rs t d o c um e n te d re c o rd o f t h e c o m p l a i n t i n a c c o rd a n c e w i t h A rt i c l e 9 . 4 ( a ) , w h i c h eve r i s e a r l i es t , u n t i l t h e d e c i s i o n : , ( 1 ) i n t e re st s h a l l b e c a l c u l a t e d a t t h e . q u a rte r l y . p [i m e ra te s , s et b y t h e B a n k o f C a n-.ad a , ave ra g e d ye a r l y fo r t h a t p e r i o d .

( 2 ) i n t e re st w i l l . b e p a i d , o n a l l a mo u n t s o w i n g , e x c e p t w h e re c o m p e n s at i o n i s p aya b l e ' fo r be c k p ay o r a n y o t h e r a m o u n t t h a t a c c r u e s o ve r t i m e , i n t 6 re st s h a l l b e c a l c u l a t e d o n o n e h a l f of t h e c o m p e n s a t i o n .

( b ) fo r t h e p e r i o d fro m t h e d a te of t h e d e c i s i o n ' dnt i J ' t h e m o n e t a ry awa rd i s p a i d , i n t e re st s h a l l b e paya b l e o n a l l a m o u n t s ow i n g , p aya b l e a t t h e p r i m e ra t e s e t b y : t h e B a n k of C a n ad a , i fo r t h e q u a rte r b efo re t h e d e c i s i o n . - 2

1 2 . 7 . 1

1 2 . 7 . 1 Be fo re i s ; u i n g n ot i c e o f l ayoff pu rs u a n t to A rt i c l e 1 2 . 9 , a n d fo l l ow i n g n ot i ce p u rs u a n t to A rt i c l e 1 2 . 4 a ) , t h e Age n cy w i l l m a ke offe rs o f e a r l y ret i re me n t a l l ow a n c e i n a cco rd a n ce w i t h t h e fo l l ow i n g c o n d i t i o n s :

a ) T h e Age n cy w i l l fi rst m a ke offe rs i n o rde r of s e n i o r i ty i n t h e s a m e re g i o n a l s i te a n d i n t h e s a m e c l a ss i fi ca t i o n s w h e re l a yo ffs wo u l d o t h e rw i s e o cc u r , Th e Ag e n cy w i l l offe r t h e s a m e n u m b e r o f e a r l y ret i re m e n ts a s t h e n u m b e r of l a yoffs i t wo u l d ot h e rw i s e m a ke . S u c h offe rs w i l l b e m a d e i n w r i t i n g a n d r es p o n d e d to by e m p l oye e s w i t h i n fo u rte e n ( 14 ) c a l e n d a r d ays o f r e ce i v i n g t h e offe r , J

b ) Th e Ag e n cy w i l l m a ke offe rs to e m p l oye e s e l i g i b l e fo r e a r l y ret i re m e n t u n d e r t h e O PT o r H O O PP p e n s i o n p l a n s ( i n c l u d i n g r e g u l a r p a rt - t i m e ) .

E m p l oyee s w i t h t h e O PT m ay b r i dge to t h e i r p e n s i o n a s p e r t h e Lette r o f U n de rsta n d i n g re : P e n s i o n B r i d g i n g . A n e m p l oye e w h o o pts t o b r i dge to t h e i r p e n s i o n w i l l b e p l a ce d o n a l e a ve w i t h o u t p a y i n a c co r d a n c e w i t h t h e Le tte r of U nd e rsta n d i n g re g a rd i n g Pe n s i o n B r i d g i n g . U p on c o m p l et i o n o f t h e l e ave w i t h o u t p a y , t h e e m p l oye e 's e m p l oy me n t w i l l b e de e m e d s e ve re d a n d t h e e m p l oye e w i l l re ce i ve h i s/ h e r ret i re m e n t a l l ow a n c e a s p e r A rt i c l e 1 2 . 7 d ) l e s s t h e tota l c o s t o f t h e e m p l oye e 's a n d Age n cy 's p e n s i o n co n t r i b u t i o n s d u r i n g t h e l e a ve w i t h o u t p a y fo r t h e p u r p o s e s o f p e n s i o n b r i d g i n g .

It i s u n d e rs to o d t h a t t h e p rov i s i o n s o f t h e Lette r o f U n d e rsta n d i n g re : S u r p l u s Fa cto r 8 0 do n ot a p p l y to Art i c l e 1 2 . 7 .

c) T h e n u m b e r o f e a r l y ret i re m e n ts t h e Ag e n cy a p p rove s w i l l n o t exc e e d t h e n u m b e r o f e m p l oye e s i n t h a t c l a s s i fi ca t i o n w h o wo u l d o t h e rw i s e b e l a i d o ff .

d ) A n e m p l oye e w h o e l e ct s a n e a r l y ret i re m e n t o p t i o n s h a l l r e c e i ve a ret i re m e n t a l l ow a n c e of two ( 2 ) we e ks s a l a ry fo r e a c h ye a r of s e rv i c e , to a m ax i m u m of fi fty - tw o ( 5 2 ) we e ks s a l a ry .

It i s u n d e rsto o d t h a t o n l y t h o s e e m p l oye e s w h o t ra n s fe r re d to t h e Age n cy o n De c e m b e r 1 5 , 2 0 0 8 o r J u l y 1, 20 1 1 s h a l l h ave s e rv i c e ca l c u l a te d to i n c l u de a l l ye a rs w i t h t h e O PS a n d w i t h t h e Age n cy .

- 4

D e l e te c u r re n t A rt i c l e 2 3 a n d re p l a ce w i t h :

A RT I C L E 2 3 - A LTE RNAT I V E WO RK AR RA N G E H E NTS

2 3 . 1 A l te r n a t i ve Wo r k A r ra n g em e n ts ( AWAs ) i n c l u d e : c o m p re s s e d wo r k we e k , f l ex i b l e h o u rs , j o b s h a r i n g a n d te l e com m u t i n g . AWA s m a y b e e n te red i n to by m u t u a l a g ree m e n t b etw e e n a n e m p l oye e a n d h i s o r h e r m a n a g e r a n d t h e u n i o n . I n c o n s i d e r i n g a n y AWA , t he m a n a ge r w i l l c o n s i d e r , i n go o d fa i t h , b o t h t h e e m p l oye e 's re q u e st a n d t h e o p e ra t i o n a l v i a b i l i ty o f t h e AWA fo r t h e wo r k s i te .

2 3 . 2 A r ra n g e m e n ts re l a te d to c o m p re ss e d wo r k wee k , f l ex i b l e h o u rs a n d j o b h a r i n g e n te re d i n to by a n e m p l oyee a n d h i s o r h e r i mm e d i a te s u p e rv i s o r s h a l l b e a dj u s ted a n d a me n d e d to re f l e ct t h e p rov i s i o n s of t h i s co l l e ct i ve a g ree m e n t w i t h n e c e ss a ry m o d i fi ca t i o n s . T h e p a rt i e s ' i n te n t i s t h a t co m p e n s a t i n g l e a v e wo u l d a p p l y , i n a c co rd a n c e w i t h Art i c l e 1 7 a s m o d i fi ed to a dd re s s p a rt i c u l a r h o u rs of w o r k a r ra n ge m e n ts .

2 3 . 3 W h e re a m a n a ge r o r e m p l oyee s e e ks to c a n ce l o r a me n d a n AWA , t h e m a n a g e r o r e m p l oye e s h a l l p rov i d e n ot i ce to t h c , , A . . .. . oy ,, j i n w r i t i n g a t l e a st o n e ( 1 ) mo n t h p r i o r to t h e p ro p o s e d c a n ce l l a t i o n o r a m e n d m e n t .

Le tte r of U n d e rs ta n d i n g #3 ( C o n t ra c t i n g O u t) - a g r e e d to m ove t o 1 2 . 1 . 2 ( ren umb er c urren t 1 2 . 1 to 1 2 . 1 . 1)

L e t t e r of U n d e rs t a n d i n g #4 ( H a ra s s m e n t a n d V i o l e n c e i n t h e Wo r k p l a c e ) R e n ewe d

Le tte r o f U n d e rs t a n d i n g #7 ( S e a s o n a l E m p l oye e s ) - R e n e w e d

Da t e d t h i s 2 8 th d ay of M a rc h , 2 0 1 2 :

Fo r t h e U n i o n Fo r t h e E m p l oye r - 5 Ag re e d I tem s - A u g u st 9 , 2 0 1 2

T he fo l l ow i n g i te m s a re .a g ree d betwe e n the Pa rti e . D ated t h i s 9t h t h day of A u g u st , 2 0 1 2 at To ro nt - .43 nta r i o F O R T H E E M P LOY E R F OR TH E UN I O N

FO R TH E U N I O N F O R TH E EM P LOYE R - 2

APP E N DIX A ART I C L E9 - GR I EVANC E P ROC EDURE

9 . 4 C o m p l a i n t S tage a) I t i s t h e m u tu a l de s i re of h e pa rt i e s h e reto t h at c o m p l a i n ts s h a l l be a d j u ste d a s q u i c k l y a s p o s s i b l e , an d i t i s u n d e rsto o d t h at a n em p l o y ee h a s n o 'g r i ev a n ce u nt i l he has f i rst g i ve n h i s o r h e r i mm e d i ate s u pe rv i s o r t he op p o rt u n i ty of a d j u st i n g h i s o r he r c om p l a i nt . S u ch c o m p l a i nt s ha l l be d i s c u s s ed w i t h h i s o r h e r i mmed i ate s u p e rv i s o r wt hiet hei nmtpe lnoy( e1 0e) swhoo rukl di n gh advaeysref arosmo ntah bel y ev b encot mg i vei n a gwar i sree otof tthhee egvrei envat gni cvei n, go r i sfreomto wtheh e n c o m p l a i n t . F a i l i n g s ett l e me n t w i t h i n te n ( 1 0 ) wo rk i n g d ay s , i t s h a l l t h e n be ta ke n u p a s a g r i ev a n ce w i th i n t h e te n ( 1 0) wo r k i n g d ays fo l l ow i ng h i s o r he r i mm e d i ate s u p e rv i s o r ' s de c i s i o n i n t h e fo l l ow i n g m an n e r a n d s e q ue n ce : d ) SDtuerpi n g1 t h e twe nty (2 0 ) wo r k i n g d ay re s o l ut i o n p e r i o d refe r red to a b ove , t h e p a rt i e s w i l l atte m pt to re s o l ve t h e matte r (s ) i n d i s p u te t h ro u g h a S te p 4 meet i n g o r a s e r i e s of meet i n g s wh i c h s h a l l i nvo l ve th e i n d i v i d u a l s w i t h a ut h o r i ty to re s o l v e t h e g r i eva n c e . f) SI nterpe s 2o l v i n g t h e d i s p ute , th e pa rt i e s w i l l h o l d a S te p 2 meet i n g a n d a n y oth e r m eet i n g s a s m ay b e ag reed , to t h o ro u g h l y c o n s i d e r t h e g r i ev a n ce a n d a ttem p t to f i n d a re s o l ut i o n . T h e g ove r n i n g p r i n c i p l e w i l l b e t h at th e pa rt i e s h a ve a m u tu a l i n te re st i n the i r ow n s o l u t i o n s a n d avo i d i n g , i f at a l l p o s s i b l e , h av i n g t h e d e c i s i o n m ad e by a n a rb i t r ato r .

9 . 8 Fa ih " n g s e tt l e m e n. t. u n. d e. r t h e fo r.e g o.iLn:g. ._ p r.o, ..c emd uavre b, ea nsy u gb mr i ei ttveadn ct eo, ai nr bc ltud rati ni o gn aafte r tqhu ee sStti oenp a2smtoew e thi negt h ea sr m h e reg irni evap ronv ci deedi s . a /I fu nuo wu , r i tt, e...n .re q u e st fo r a rb i t rat i o n i s re ce i ve d w i t h i n te n ( 1 0) wo r k i n g d a y s afte r t h e d e c i s i o n u n d e r t h e fo re g o i n g p ro ce d u re i s g i ve n , t h e g r i e v an ce s h a l l be d e em ed to h ave b e e n a b a n d o n e d .

ART I C LE 4 1 - S E N I O R I TY L I ST

t l . 3 S e n i o r i ty L i s t

Am e n d to : A n ag e n cy-w i d e s e n i o ri ty l i st , i n c l u d i n g th e em p l oyee s ' n ame s , d ate of h i re , s e n i o ri ty , el omc aptl iooynmsehnatl lcbeatemg oariyn t(afui nle l tdi maen,dpap rrot vt iimd eed, stoeat hsebTuanl ,i oonr twemi cpe oaran ryr u) a, cJ l yl a. sAs i fci coapyt i o onfae nda ch s e n i o r i ty l i st s h a l l b e p o ste d e l e ct ro n i c a l l y a n d at e a c h wo r k s i te o n o r a ro u n d Ap r i l 1 a n d O ctob e r 1 ea ch ye a r . A copy of e a c h s e n i o r i ty l i st s ha l l a l s o b e g i ve n to th e AE RC . - 3

In cluded on th e p os ting will b e no tice tha t employee 's w i l l h ave a m ax i m u m o f s i xty ( 6 0 ) days to c h a l l e nge th e i r s e n i o r i ty ca l c u Jl a t i o n .I f no c h a l l e n g e i s re c e i ve d w i t h i n th i s t i m e l i m i t , the e m p l oyee ' s s e il r ity w i l l b e d e e m e d to be co r rect .

A RT I C L E 1 4 . 1 . 5 RE LO CAT I O N AL LOWANC E

1 4 . 1 . 5 Re l o c at i o n e x p e n s e s s h a l l b e p a i d i n a c c o rd a n ce w i t h t h e p rov i s i o n s of t h e E m p l oye r ' s p o l i cy . Re l o c a t i o n expe n s es s h a l l n o t be pa i d to e m p l oyees wh o a p p l y fo r a n d a re a c ce p te d to a j o b p os t i n g .

ART I C L E 1 8

Te l e ph o n e Co n s u l ta t i on

1 8 . 4 . 2 W h e re a n em p l oye e i s co nta cted by t h e Age n cy o u ts i d e t h e wo r kp l a ce p r i o r to t h e sta rt i n g t i m e of h i s o r h e r next s c h e d u l e d s h i ft, E , , c l rc 'a m sta n c c s w h c rc s 'a c h ...... =...... '...... ^, b c ,, .. ,. ,. hv . . ,. . ...... "." b u t t h e e m p l oyee i s n ot req u i re d to p h ys i ca l l y a tte n d a t t h e wo r kp l a ce, t h e e m p l oyee s h a l l b e p a i d a m i n i m u m of feue-(4-) heur two ( 2 ) ho u rs ' o f pay a t o n e a n d o n e - h a l f ( 1 V2 ) t i mes h i s o r h e r b a s i c h o u r l y ra te . Th e i n i t i a l ca l l a n d a ny s u bse q u e n t c a l l s d u r i ng th a t s a me feue two- h o u r p e r i o d , w i l l b e t re a ted a s a s i n g l e " c a l l b a c k to wo r k" fo r p ay p u r p o s e s . I t i s a g re e d th a t Art i c l e 1 8 . 4 . 2 d o es n ot a pp l y to e m p l oye e s de fi n e d i n Art i c l e 2 . 3 c) ( i ) . Th i s p rov i s i o n s h a l l a p p l y to te l ep h o ne co n s u l ta t i o n s o n ho l i days a s d e s c r i b e d i n A rt i c l e 1 9 . 1 .

ART I C LE 1 9 - H O L I DAYS

1 9 . 1 An e m p l oyee s h a l l b e e nt i t l e d to t h e fo l l ow i n g p a i d h o l i d ays ea c h yea r :

N ew Ye a r 's Da y C i v i c H o l i d a y

Fa m i l y D a y La bo u r D a y

Good F r i d ay Th a n ks g i v i n g Day

V i cto r i a D ay Ch r i st m a s D ay

Ca n a d a D a y Box i n g Da y

Two ( 2 ) F l o a t H o l i d a ys - 4

E m p l oyees s h a l l b e c red i ted w i t h two ( 2) fl oa t ho l i days o n J a n ua ry I st o f each ca l e n da r each , N ew l y h i red em p l oyees s h a l l be c red i te d w i th two ( 2 ) float ho l i da ys i f h e o r sh e co mm e n ces e m p l oym e n t befo re J u l y I st, a nd o n e ( 1 ) floa t h o l i day i f he o r s h e co m me n ce s e m p l oym e n t o n o r a fte r J u l y I st . Ea c h e m p l oye e m u st p rov i de t h e Age n cy n ot i c e of twen ty ( 2 0 ) c a l e n d a r d ays p r i o r to ta k i ng a fl o a t h o l i d a y . T h e Ag en cy s h a l l g ra n t t h e e m p l oyee t h e fl o at ho l i d ay, s u bj e ct to o p e ra t i o n a l re q u i re me n ts . I t i s u n d e rstood t h a t t h e s e flo a t h o l i d a ys w i l l n ot b e c a r r i e d ove r o r pa i d o u t a t th e e n d of t h e yea r o r e n d of t h e em p l oym e n t re l a t i o n s h i p i f t h ey a re n ot u s e d .

I n t h e eve n t th e Fe de ra l o r P rov i n c i a l G ove r n me n t d e c l a res a n a d d i t i o n a l h o l i d ay d u r i ng t h e te r m of t h i s Ag re e m e n t, s u c h h o l i d a y w i l l b e s u bs t i t u te d fo r o n e 9 f t h e a bove m e n t i o n e d h o l i d ays .

1 9 . 3 H o l i d a y P a ym e n t W h e re a n e m p l oyee wo r ks o n a d e s i g n ate d h o l i d ay i n c l u de d u n d e r A rt i c l e 1 9 ( H o l i d ays ) of t h e Ag re e m e n t, h e o r s h e s h a l l b e p a i d a t t h e ra te o f two ( 2 ) t i m es h i s o r h e r re g u l a r h o u r l y ra te fo r a l l h o u rs wo r ked w i t h a m i n i m u m c re d i t o f s eve n a n d o n e q u a rte r ( 7 t/4 ) o r e i g h t ( 8 ) h o u rs , a s a pp l i ca b l e . I n a d d i t i o n , a n e m p l oyee s h a l l re ce i ve e i t h e r a d ay off i n l i e u to b e ta ke n w i t h i n fou r ( 4) mo n t h s of t h e h o l i d a y, s u bj e ct to t h e o p e ra t i o n a l re q u i re m e n ts of t h e Ag e n cy o r h o l i d a y p a y a t h i s o r h e r ba s i c h o u r l y ra te . I f t h e d a y o ff i n l i e u i s n ot ta ke n w i t h i n th e fo u r (4) mo n th t i m e fra m e , i t s h a l l b e p a i d o u t d u r i n g t h e e m p l oye e 's n ext p ay p e r i o d . It i s u n d e rsto o d t h a t i f a n e m p l oyee i s ca l l ed i n to wo r k o n a day t h a t i s a p p roved a s a floa t ho l i day, t h e e m p l oyee w i l l rece i ve reg u l a r pa y fo r a l l h o u rs wo r ked a n d t he fl o at h o l i d ay w i l l be re t u r n e d to t h e e m p l oyee .

DU RAT I O N 2 8 . 1 T h i s Ag reem e n t s h a l l b e i n e ffe ct from Ap r i l 1 , 20 1 1 u n t i l M a rch 3 1, 20 1 3 a n d s h a l l co n t i n u e a u tom a t i c a l l y t h e rea fte r fo r th e a n n u a l p e r i od s of o n e ( 1 ) yea r u n l e s s e i t h e r p a rty n ot i fies t h e ot h e r i n w r i t i n g t h a t i t i n te n d s to a mend o r m o d i fy th e Ag reem e n t . N ot i ce to b a rg a i n s h a l l b e g i ve n i n a c co rd a n c e w i t h t h e O n ta r i o La b o u r Re l a t i o n s Act, 1 9 95 . - 5

E l R E BATE

Eac h e m p l oyee w i l l re c e i ve a l u m p s u m p a y me n t i n l i e u of t h e E .I. Re b a te a s of t h e d ate of ra t i f i c at i o n .

Lette rs of U n de rsta n d i ng :

# 5 - Em p l oye r a g re e s to m ove A rt i c l e 1 7

# 6 - E m p l oye r a g re e s to re n e w a s p e r p rev i o u s s u bm i ss i o n s # 8 - l a n g u a g e n ee d s to be am e n d e d to ref l e ct po s s i b l e e x p i ra t i o n of e n t i t l em e n ts afte r J a n u a ry 1 , 2 0 1 3 O PT re n ewa l

# 9 - l a n g u a g e n ee d s to be a me n de d to re fl e ct p o s s i b l e exp i rat i o n of e n t i t l e m e n ts a fte r J a n u a ry 1 , 2 0 1 3 O PT re n ewa l Ag r e e d I te m s - M a rc h 2 , 2 0 1 3

R e p l a c e rate s w i t h t h e fo l l ow i n g :

1 8 9 I f a n e m p l oye e i s r e q u i re d t o u s e h i s o r h e r ow n a u t o mo b i l e o n t h e E m p l oye r' s b u s i n es s t he fo l l ow i n g r a te s s h a l l b e pa i d :

K i l o m e t res S o u t h e rn N o rl l e rn

D r i ve n On t a r i o O n t a r i o

0 - 4 , 0 0 0 k m 4 0 c e n ts /k m 4 1 ce n ts I k m

4 , 0 0 1 - 1 0 , 7 0 0 k m 3 5 c e n t s Ik m 3 6 ce n t s t k m

1 0 , 7 0 1 - 24 , 0 0 0 k m 2 9 c e n t s t km 3 0 c e n t s lk m

ove r 2 4 , 0 0 0 k m 2 4 c e n t s t k m 2 5 ce n t s tk m

K i l o m e t res a r e a cc u m u l a t e d o n t h e ba s i s o f a t i sc a l ye a r ( Ap r i l 1 to M a rc h 3 1 , I n c l u s i ve ) ,

Da t e d t h i s i 6 t h d ay o f J u l y , 2 0 1 3 :

F o r t h e U n i o n Fo r t h e E m p l oye r

Exhibit C

IN THE MATTER OF AN INTEREST ARBITRATION UNDER THE HOSPTIAL LABOUR DISPUTES ARBITRATION ACT

BETWEEN:

ONTARIO AGENCY FOR HEALTH PROTECTION AND PROMOTION OPERATING AS PUBLIC HEALTH ONTARIO (the “Employer”)

-AND-

ONTARIO PUBLIC SERVICE EMPLOYEES’ UNION (the “Union”)

Gail Misra, Chair Harold Ball, Employer Nominee Joe Herbert, Union Nominee

Appearing for the Employer: Craig S. Rix, Counsel David W. Foster, Co-Counsel Stephanie McLoughlin, Student-at-Law Eva Procter, Deputy Chief Laboratory Operations Officer Gregory McMillan, Manager Procurement Tony Ho, Controller Brenda Brown, Human Resources Business Partner Catherine Green, Senior Advisor Labour Relations

Appearing for the Union: Michele Dawson Haber, Senior Research Officer Andrew Ruszczak, Negotiator Karen Marchesky, Research Officer Negotiating Committee: Omid Nouri, Shah Nawaz, Selfa Pyentam, Casey McGuire, Vincent Fernandes

Hearing held on June 3, 2019 and Executive Session held on July 22, 2019, in Toronto, Ontario

Decision issued: September 16, 2019

AWARD

I. We were appointed by the parties pursuant to the provisions of the Hospital Labour Disputes Arbitration Act (“HLDAA”) to determine the outstanding issues related to the renewal of their collective agreement. The parties have agreed that the term of the collective agreement will be from April 1, 2018 to March 31, 2020.

2. The Employer (or “PHO”) operates in sites across Ontario, including eleven laboratories, and is dedicated to protecting and promoting the health of all Ontarians, as well as reducing inequalities in health. PHO provides laboratory services, expert scientific and technical advice, and support related to infectious diseases; infection prevention and control; surveillance and epidemiology; health promotion, chronic disease and injury prevention; environmental and occupational health; and, emergency preparedness and incident response.

3. The Ontario Public Health Laboratories were divested from the Ontario Public Service (“OPS”) on December 15, 2008. The PHO is funded solely by the Ministry of Health and Long Term Care. It employs approximately 1,010 employees.

4. OPSEU acquired successor rights pursuant to section 10 of the Crown Employees Collective Bargaining Act and section 69 of the Labour Relations Act, 1995 as a result of the divestment of PHO from the OPS. The HLDAA was amended to include this Employer. OPSEU represents approximately 624 employees of the PHO.

5. PHO also has a collective bargaining relationship with the Association of Management, Administrative, and Professional Crown Employees of Ontario (“AMAPCEO”). The PHO and AMAPCEO negotiated a renewal agreement in April 2018, which provided for normative across the board wage increases, along with other incremental changes patterned upon the agreement reached earlier between the Crown and AMAPCEO in the OPS.

6. This is the fourth collective agreement between the parties. The first and second collective agreements were awarded by Arbitrator Gerry Lee on July 13, 2011 (for a term of January 1, 2009 to March 31, 2011) and July 30, 2013 for a term of April 1, 2011 to March 31, 2013) respectively. It took the parties a long time to bargain the third collective agreement, such that by April 2016, more than three years after the expiry of the collective agreement, they finally reached a freely negotiated collective agreement with a four year term of April 1, 2014 to March 31, 2018.

7. In the first two collective agreements, the arbitrator awarded both across the board wage increases as well as market adjustment increases in the wage rates of a few specific classifications.

8. In the third collective agreement, the parties did not include targeted wage increases for any specific classifications of employees, but rather agreed to across the board wage increases for each of the four years for all classifications.

9. In the current round of bargaining, the parties were able to resolve some issues on their own, and eight others were referred to this panel for determination. In making our award, we have considered the parties’ oral and written submissions, the provisions of the HLDAA, and the jurisprudence provided by the parties.

10. The renewal agreement shall consist of any and all items agreed upon by the parties, any unamended terms of the expired agreement, and the changes set out below. Any proposals made to us by either party not set out below are dismissed. All changes shall take effect as of the date of this award unless otherwise specified.

WAGES

11. While the parties have agreed on an across the board wage increase of 1.4% effective April 1, 2018, and an across the board wage increase of 1.75% effective April 1, 2019, the Union is also seeking wage adjustments for three classifications: Medical Laboratory Technologist 1 [Registered Technologist] (“MLT 1”); Medical Laboratory Technologist 2 [Senior Registered Technologist] (“MLT 2”); and, Laboratory Attendant 2 [Technician 3-Laboratory Technician] (“LA 2”). For reasons which will become clear, the names of the classifications in square parenthesis are the comparator classifications in the Ontario Hospitals Association and OPSEU Central Hospitals collective agreement.

12. In essence, since the first round of bargaining, the Union has been seeking wage parity with hospital laboratory classifications for four classifications in this bargaining unit. OPSEU’s comparator has always been the Ontario Hospitals Association and OPSEU central wage grid. There is no dispute that historically hospital Technicians and Technologists have been paid at considerably higher rates than have these positions at the predecessor employer as well as at the PHO.

13. In the first interest arbitration award, Arbitrator Lee awarded the Union “market adjustment” increases for three MLT and one LA classification, which at the time lagged behind the maximum step of the Hospital wages for those classifications by between 11.3 and 13 per cent.

14. In the second interest arbitration award, Arbitrator Lee awarded the Union “market adjustment” increases for the three MLT and one LA classification, which at the time still lagged behind the maximum step of the Hospital wages for those classifications by between 5.9 and 12.6 per cent. By the end of that process, the MLT 4 classification had reached full parity with the Hospital rate for the equivalent position. It is noteworthy that these market adjustment increases were awarded despite the government directive at the time that there be no net compensation increase for two years over the same time period.

15. As already noted, the parties resolved their third collective agreement through bargaining. At the time that they were bargaining in April 2016, the OPSEU Hospital

Central pattern was known for 2014 and 2015, but the 2016 to 2019 rates had not been decided.

16. These parties signed a four year agreement with 1.4% increases across the board in each of the four years. The Union had believed at the time that it was likely that the OHA and OPSEU Hospital Central table would not match those increases, and that it would therefore get some catch up on the three remaining MLT and LA classifications that were still lagging behind the Hospital wage rates. According to the Union, it had never abandoned the goal of wage parity with the Central Hospital rates for MLTs and LAs. Ultimately however, the Hospital Central agreement did in fact include 1.4% increases for the years in question, so that no catch up was achieved over the term of the last collective agreement, and there remains a wage disparity for the classifications in question.

17. As of March 31, 2018, the end of the term of the third collective agreement, at the top step of their respective wage grids, the LA 2 rate remains 3.3% behind the Hospital Central rate, the MLT 1 rate is 6% behind, and the MLT 2 rate is 3.5% behind.

18. The PHO argues against any special wage adjustments in this collective agreement. It states that the across the board increases the parties have agreed to are reflective of normative increases in the broader public sector, and relies on the last round of bargaining between these parties for the proposition that they have now achieved a mature state, wherein no special wage increases are warranted. It also maintains that the current industry trend for freely-negotiated agreements is towards rollover agreements, with few substantive changes. It argues that the PHO is not a hospital; that the hospital labs perform some different types of testing; that the laboratory staff at hospitals largely work on 24/7 shifts, unlike at the PHO, where the lab staff work days and evenings, with some staff working on weekends; and, that there is no demonstrated need for parity with hospital lab staff.

19. We are of the view that in the last round of bargaining, the Union did not give up its quest for parity of wage rates of the laboratory classifications with those of hospitals. Rather, it made an assessment of what was likely to transpire in the central hospital bargaining, and was wrong. As such, the wage gap in the target classifications did not diminish over the course of the term of the last collective agreement.

20. We agree with Arbitrator Lee in the Ontario Agency for Health Protection and Promotion (OAHPP) and Ontario Public Service Employees Union decision dated October 4, 2013, at p. 5, that the MLT 1 and 2, and the LA 2 positions have comparable positions at hospitals. While the wage gaps between the PHO positions and those in the hospitals have been reduced substantially through the Lee awards, there remain significant differences in the rates. As such, market adjusted increases continue to be appropriate for these groups of employees despite the current economic and collective bargaining environment.

21. We have considered the parties respective submissions regarding the principle of total compensation, and the difference in the value of other monetary benefits between the PHO/OPSEU collective agreement and that of the Participating Hospitals/OPSEU Central collective agreement. We make no findings in that regard.

22. Having considered, in particular, the Employer’s submissions regarding the financial challenges and constraints facing PHO, this is not the time to completely close the wage gap for the three classifications, as argued by the Union. However, some special wage adjustment is in order given the differences between the rates for these classifications at hospitals and the PHO, and the general historic recognition in previous interest arbitration awards that closing that gap is warranted. Having taken into consideration all the relevant factors, including those outlined at section 9 (1.1) of the HLDAA, the current economic climate for the broader public sector, and the parties’ submissions, we award as follows:

- Effective April 1, 2019, and before the general wage increase, the Medical Laboratory Technologist 1 wage rate will increase by 1.5%, commencing at Step 3 of the wage grid.

- Effective April 1, 2019, and before the general wage increase, the Medical Laboratory Technologist 2 wage rate will increase by 1%, commencing at Step 3 of the wage grid.

- Effective April 1, 2019, and before the general wage increase, the Laboratory Attendant 2 wage rate will increase by 1%, commencing at Step 3 of the wage grid.

- Retroactivity shall be paid on wage increases, including any payments based on the wage rate (for example, the percentage in lieu of benefits, vacation pay and SUB).

- Current employees on staff, as of the date of the interest arbitration award, will be paid retroactivity, within five (5) full pay periods on the basis of hours paid.

- In the case of former employees, the PHO shall, within 30 days of the date of this award, notify such former employees at their last known address of the entitlement to receive payment. Such former employees shall then have a further 30 days within which to request payment. If no such request is made, no payment need be made. If a request is made, the payment must be made as soon thereafter as reasonably practical.

EXPERIENCE/MARKET DEMAND CREDIT, ARTICLE 14

23. Based on demonstrated need, and the fact that the OHA and OPSEU Central Hospital collective agreement contains such language, as do other public and private

6 sector agreements in this industry, we award the PHO’s proposed language as follows:

Wage Schedules – Experience/Market Demand Credit

Claim for recent experience, if any, shall be made in writing by the employee at the time of hiring. The employee shall cooperate with PHO by providing verification of previous experience.

Prior experience shall be credited at the rate of one (1) increment on the salary scale for every one (1) year of recent, related, full-time experience, as determined by the PHO. For the purposes of this clause, as it applies to part- time employees, part-time experience will be calculated on the basis of 1885 hours worked equaling one (1) year of experience.

SHIFT PREMIUM

24. Based on the PHO’s submission, 281 of its staff are required to work a weekend shift on a rotation system. Of that group, 61 employees work a weekend shift, which generally requires them to work on a Saturday. According to the Union, at ten of the 11 PHO locations, some staff are routinely scheduled to work a Tuesday to Saturday week.

25. It is common in healthcare workplaces that employees who work on a weekend shift are paid a premium, and we are of the view that employees should be compensated for working non-standard hours, especially in a workplace like this one, where the majority of employees work Monday to Friday.

26. We therefore award the following:

- Remove the current Article 18.3, which reads as follows:

Shift premium shall not be paid to an employee who for mutually agreed upon reasons works a shift for which he or she would otherwise be entitled to a shift premium.

- Weekend Premium – an employee shall receive a shift premium of two ($2.00) per hour for all hours worked between 2400 hrs. Friday and 2400 hrs. Sunday.

27. We shall remain seized in respect of any and all issues of interpretation and implementation and to correct any inadvertent errors or omissions in this award.

Dated at Toronto this 16th day of September, 2019.

“Gail Misra” Gail Misra, Chair

DISSENT OF THE UNION NOMINEE

While I do not doubt that the Chair has attempted to fashion a fair award, the award falls short of the mark in a number of areas, and I dissent in respect of the issues identified below.

1. Wage Adjustments.

The Chair’s award contains small adjustments to the rates of three laboratory- based classifications, which adjustments are in my view are inappropriately small. The pay rates for these classifications are driven by the rates contained in the central collective agreement between OPSEU and Participating Hospitals, which covers the largest group of comparable employees. This is not a matter of doubt, and these are the rates which the parties and previous arbitrators have utilized for comparator purposes. The Chair’s award, while closing the gaps somewhat, leaves an excessive disparity at the higher end of the Medical Laboratory Technologist 1 classification in particular (4.5%), and smaller disparities of 2.5/2.3% at the top of the Medical Laboratory Technologist 2/Laboratory Attendant 2 scales, respectively. In my view, replication mitigates toward a greater adjustment to these rates in view of the uniform rates paid to comparable employees in hospitals.

2. Prior Experience

While I agree with the Chair’s decision to award a provision in this respect, I would have amended the article to ensure that current employees with previous related experience benefit equally.

3. Benefits

Although I understand that wage adjustments will lessen the expected range of benefit improvements, in my view it was necessary in this round to address the deductible on the dental plan (which does not replicate external or PHO internal outcomes), as well as the cap on paramedical payments. At present, these benefits are inappropriately diminished by the current limitations and I would have awarded improvements in both areas.

Dated at Toronto, this 6th day of September 2019.

Joe Herbert Union Nominee

DISSENT OF THE EMPLOYER NOMINEE

I respectfully dissent with respect to the Market Adjustment to certain classifications that were awarded, for the following reasons.

We are mandated by HLDAA to consider the economic context, and the economic context of this round of collective bargaining is simply this – the PHO is in dire economic straights – which is a fact that is not in dispute between these parties.

This employer is facing a 12% funding deficit. As such, it simply does not have the resources to absorb such a significant total compensation increase awarded over and above the across the board increase the parties have already agreed to -which I would note is normative within the sector – without compounding the labour relations disruption that is about to come with respect to the negative impact this will have on both service and staffing levels.

The PHO has been doing its best to manage its operations and to balance its budget in the face of reductions in funding and increasing workloads over the past several years.

Work has been put on hold, positions are not being filled, and other efficiencies have been implemented. But they have now reached the tipping point, and I fear that the financial impact that will result from these market adjustments that have been awarded will force the PHO to make significant changes to their existing operating model.

We must apply the principle of replication, and for that matter demonstrated need, in this context. We must determine what these parties would have likely achieved if they were free to strike/lockout, given the current economic and fiscal circumstances that clearly define this round of collective bargaining.

In addition, when you examine what has taken place recently in the Health Care Sector, the clear trend has been towards “rollover” agreements, which while providing across the board increases, have not resulted in any significant changes to benefits, nor have there been any special market adjustments over and above the across the board increases, and I would submit that these parties would very likely have done the same in a free collective bargaining context.

Market Adjustments

Given my comments regarding the economic context, now is not the time to make any special market adjustments. It is not necessary and the PHO simply can’t afford

9 it. It would also not be fair to other employees to single out this group for special consideration, nor is an adjustment of any kind affordable under any scenario at this time.

With respect to Arbitrator Lee’s comments regarding comparable positions, which were made over six years ago, and while there are some similarities between these PHO positions and their hospital counterparts, they are clearly not identical, nor is the work of PHO employees performed in a critical care hospital setting.

Although Arbitrator Lee awarded market adjustments despite the government directive that was in place at the time with respect to net compensation increases, the PHO did not face the same internal budgetary shortfalls in either 2011 or 2013 as they do now, and I believe the result in 2011 and 2013 would very likely have been different had the context then been what it is now.

The best evidence, particularly when it comes to our obligation to replicate as closely as possible what the parties would have achieved if left to their own devices, is what they freely and consensually negotiated most recently, and which did not contain any market adjustments.

This is a powerful and normative consideration that cannot be lightly displaced.

The Award states that:

“We are of the view that in the last round of bargaining, the Union did not give up its quest for parity of wage rates of the laboratory classifications with those of hospitals. Rather, it made an assessment of what was likely to transpire in the central hospital bargaining, and was wrong. As such, the wage gap in the target classifications did not diminish over the course of the term of the last collective agreement.”

My recollection is that during the hearing the Union referred to their decision to settle in the last round of bargaining as a “tactical error,” in light of what eventually transpired in central hospital bargaining.

With respect, it is only the result that matters, and the result was a four year consensually negotiated agreement that, as noted above, contained no market adjustments, and the Union presented no actual evidence that would give us reason to “look behind the curtain.”

Moreover, replication dictates that it is not our function to shield the Union from the natural bargaining consequences that would follow from such a “tactical error.”

Recall also the retention statistics. No one in these three classifications at issue is leaving the PHO to work in hospitals. Other than wanting it, the Union presented no evidence of a demonstrated need that would justify the proposed increases.

By awarding these market adjustments, just after a freely bargained four year agreement (the fact that they locked into a very lengthily agreement is also telling about what the parties freely intended to do) when there are currently no other comparators in the sector where market adjustments are being provided is, respectfully, not replicating the collective bargaining process.

In the Long Term Care Sector, the ONA has been seeking wage parity with hospitals for over twenty years, and while they have closed the gap somewhat at times over that period, parity has not yet been achieved either through freely negotiated agreements or through interest awards.

In other words, it’s not a straight-line progression, but rather a journey that can take many years, and is subject to an ever changing set of circumstances/priorities within which collective bargaining invariably takes place.

While the award acknowledges that the Union has not abandoned its position with respect to parity in perpetuity, and is therefore not precluded from perusing it in subsequent rounds of bargaining, should they choose to do so, for all of the foregoing reasons, I would have declined to award any market adjustments, or any other monetary increases over and above the agreed to across the board adjustments under the present circumstances.

All of which is respectfully submitted. September 12, 2019

“Harold Ball” Nominee for Public Health Ontario