Collaboration in HEM, Online Webinar Presentation

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PublicHealthOntario.ca 2 Public Health Ontario Seminar: Collaboration in Health Emergency Management

November 28, 2018

Welcome and opening remarks

Ms. Jill Fediurek Manager, Emergency Preparedness and Support Public Health Ontario

PublicHealthOntario.ca 2 About this presentation • The public health sector plays a key role in population health protection and emergency management. • Collaboration is important in emergency management and increasingly seen as essential for resilient health systems. • For public health agencies, collaboration and partnership-building for emergency management may involve health system and non-health system partners, as well as the community.

PublicHealthOntario.ca 7 Objectives This seminar aims to exchange knowledge on: • emerging research, • successful practices in health emergency management collaboration, and • building system resilience in the face of increasing emergencies.

PublicHealthOntario.ca 8 Speakers • Dr. Yasmin Khan, Physician, Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario ; Assistant Professor, University of Toronto • Dr. Tracey O'Sullivan, Associate Professor, Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa • Mr. Leonard Chu, Senior Consultant, Ministry of Health and Long-Term Care, Health System Emergency Management Branch

PublicHealthOntario.ca 9 Speakers • Ms. Stacey Laforest, Director of the Environmental Health Division, Public Health Sudbury & Districts • Ms. Teresa Clow, Senior Public Health Inspector, Smiths Falls service delivery site, Leeds, Grenville and Lanark District Health Unit • Dr. Shelley Deeks, Chief, Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario; Associate Professor, University of Toronto.

PublicHealthOntario.ca 10 What makes the public health system resilient?

Findings from the development of a public health emergency preparedness framework for Canada

Dr. Yasmin Khan, Public Health Ontario PublicHealthOntario.ca 11 Objective • Describe current science on collaboration in health emergency management • To explain a national research study on public health emergency preparedness (PHEP) exploring the essential elements of a resilient public health system

PublicHealthOntario.ca 12 Project overview

Method Output Timeframe Framework for public health 1 Focus Groups emergency preparedness Year 1 (PHEP) in Canada Performance measurement 2 Delphi Survey Year 2 indicators for PHEP Integrated Engagement of knowledge 3 Knowledge Years 1 & 2 users in research process Translation

PublicHealthOntario.ca 16 Phase 1: Structured Interview Matrix focus groups in 2016

Community, Health Government Public Health social services, System + + Policy- Total (all levels) or private Health Care makers industry

6 sites across 44 31 41 14 130 Canada

PublicHealthOntario.ca 17 Focus group questions 1. What are key elements of preparedness for the public health system pertaining to outbreaks and infectious disease emergencies? 2. What are key elements of preparedness for the public health system pertaining to natural disasters or anthropogenic emergencies? 3. What makes the public health system resilient? 4. Based on your emergency preparedness or response experiences, what situations have you encountered where you have had to consider values or fairness?

PublicHealthOntario.ca 18 Focus group questions 1. What are key elements of preparedness for the public health system pertaining to outbreaks and infectious disease emergencies? 2. What are key elements of preparedness for the public health system pertaining to natural disasters or anthropogenic emergencies? 3. What makes the public health system resilient? 4. Based on your emergency preparedness or response experiences, what situations have you encountered where you have had to consider values or fairness?

PublicHealthOntario.ca 19 What makes the public health system resilient? • We generated themes based on analysis of the full dataset • Some themes were discussed more in relation to resilience • In addition to themes, characteristics or abilities emerged as important in PHEP and resilience

PublicHealthOntario.ca 20 Framework

Khan Y, Sullivan T, Brown A, Tracey S, Gibson J, Généreux M, et al. Public health emergency preparedness: A framework to promote resilience. BMC Public Health. 2018; 18(1): 1344. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6250-7

PublicHealthOntario.ca 21 Governance and Leadership: Integrated structures, partnerships and accountabilities with clear leadership to support a coordinated, interoperable system

• “It’s breaking those silos down. But I think we need to do it long before an incident occurs… preparedness is the perfect time to begin building those relationships.”

PublicHealthOntario.ca 22 Collaborative networks: Develop relationships, partnerships and strong networks

“Many groups working together, being able to understand what each other’s roles are and what their strengths and weaknesses they bring; it’s that collaborative framework that’s going to make your public health system resilient.”

PublicHealthOntario.ca 24 Community Engagement: Understand and engage with the community

“But on the cultural side of things, if you’re serving a community which has different priority populations, in developing your emergency plan, isn’t this as much about reaching out to those communities…? ”

PublicHealthOntario.ca 26 Workforce capacity: Develop and support knowledgeable, skilled and resilient staff

“It’s about proper training and redundancy…you have people that are well trained and there is enough of them…Staff resilience coming from being adequately funded, trained.”

PublicHealthOntario.ca 28 Learning and evaluation: Evaluation as a strategy to build resilience

“It’s broader than feedback, I think you need to have an evaluation strategy on the ground as you go… how do we course correct it when we need to… how you are going to tell whether your plan is working?”

PublicHealthOntario.ca 30 Framework

PublicHealthOntario.ca 32 The complex system • Collaboration within the system and with the community are essential elements for resilient systems • The connections within public health agencies and its workforce are also important • Resilience-oriented approaches relevant to the public health system needs to prioritize social infrastructure and characteristics that promote relationships, adaptability and learning

PublicHealthOntario.ca 33 How? • Ethical values and processes discussed • Equity was built in to data collection

PublicHealthOntario.ca 34 Ethics and values

Ethical value Ethical process Public protection Accountability Trust Inclusiveness Duty to care Responsiveness Equity Transparency Stewardship Reasonableness

• Ethical values and processes at the core of framework

PublicHealthOntario.ca 35 PublicHealthOntario.ca 36 Acknowledgements • Tracey O’Sullivan, Associate Professor, University of Ottawa • Brian Schwartz, Vice-President, Science and Health Protection, Public Health Ontario • Sara Lacarte, Research Coordinator, PHO • Alexa Caturay, Resident Physician, Public Health Preventive Medicine, Queens University • CIHR study co-investigator and knowledge user team

PublicHealthOntario.ca 37 PHOTEAM CHART Yasmin Khan Co-Investigators Brian Schwartz Tracey O’Sullivan Shannon Tracey Adalsteinn Brown Sara Lacarte Anna Gagliardi Jennifer Gibson Content Expert Alison Thompson Collaborators David Etkin Daniel Kollek Team Knowledge User Laurie Mazurik Co-Investigators Daniel Barnett Bonnie Henry Jamil Bayram Victoria Lee Brenda Phillips Mark Lysyshyn Kirsty Challen Mélissa Généreux Andrew Lee Eileen de Villa Knowledge User Jean-François Collaborators Duperré Jill Courtemanche Clint Shingler David Williams 38 Unpacking the Elements that Support Collaboration in Public Health Emergency Preparedness

Tracey O’Sullivan, PhD. Interdisciplinary School of Health Sciences University of Ottawa

Webinar Presentation for Public Health Ontario November 28, 2018 In this presentation …

• Collaboration as an essential element of disaster risk reduction and climate change adaptation – upstream and downstream

• Common ground and asset literacy as foundational processes for collaboration in public health

• Collaboration in different types of complex adaptive systems

• Pitch for institutional support and investment in processes that support collaborative practice

Sendai Framework for Disaster Risk Reduction

http://www.unisdr.org/files/43291_send aiframeworkfordrren.pdf Sendai Framework – Priorities for Action

“… there is a need for focused action within and across sectors by States at local, national, regional and global levels in the following four priority areas:

Priority 1: Understanding disaster risk Priority 2: Strengthening disaster risk governance to manage disaster risk Priority 3: Investing in disaster risk reduction for resilience Priority 4: Enhancing disaster preparedness for effective response and to “Build Back Better” in recovery, rehabilitation and reconstruction”

United Nations Office for Disaster Risk Reduction (UNISDR) (2015). Sendai Framework for Disaster Risk Reduction, available at: http://www.unisdr.org/files/43291_sendaiframeworkfordrren.pdf (p.7) Current study by our EnRiCH team … exploring discourse within emergency planning documents Collaboration is a core element upstream to downstream … and back upstream

• Prevention / mitigation and preparedness are upstream

• Response and recovery are downstream … but recovery transitions upstream again

• All points in the knot require collaboration of different types

O'Sullivan T.L., Kuziemsky, C.E., Corneil, W., Lemyre, L., & Franco, Z. (2014). The EnRiCH Community Resilience Framework for High-Risk Populations. PLOS Currents Disasters, Open access available at: http://currents.plos.org/disasters/article/the-enrich- community-resilience-framework-for-high-risk-populations/ So what is collaboration?

Keast & Mandell (2014) describe collaboration as an ‘elastic term’ for working together – and define it as: “… a distinctive form of working together, characterised by intense and interdependent relationships and exchanges, higher levels of cohesion (density) and requiring new ways of behaving, working, managing and leading.” (p.9)

The C’s (coordination, cooperation, collaboration) are more of a continuum for type of working relationships - with conceptual distinctions (such as increasing relational intensity and commitment as you move right) (Elmarzouqi et al. 2008)

Coordination Cooperation Collaboration Do we need all 3?

Would it be better as a triangle? Collaboration can be great – but sometimes it is messy (Noble, 2017) Need to consider which tasks require collaboration and which ones are better with coordination or cooperation

Sometimes organizations have to be cooperative and then focus inward – other times collaborate for common goals (eg. think of how to engage the private sector or NGOs)

Coordination Collaboration

Cooperation Interprofessional Collaboration (Canadian Interprofessional Health Collaborative, 2010)

Interprofessional Education Improved Health Outcomes Collaborative Practice 6 Competency Domains for Interprofessional Collaboration (Canadian Interprofessional Health Collaborative, 2010)

1. Interprofessional communication 2. Patient/client/family/community centred-care 3. Role clarification 4. Team functioning 5. Collaborative leadership 6. Interprofessional conflict resolution

Common ground is essential … But how does it develop?

• Early literature on common ground focused on communication

• Clarke (1991) explained common ground (CG) in terms of shared knowledge, vocabulary, and belief systems that set a foundation for communication

• Kuziemsky & Varpio (2010) identified different components of common ground – • moments when it is needed (or missing) • fabric (context) in which CG occurs • barriers to developing CG • consequences (when CG is present or absent)

• CG is dependent on the environment, people, processes and context where it occurs (Tveiten et al., 2012)

• CG is dynamic and complex and must occur upstream to be effective downstream (Kuziemsky & O’Sullivan, 2015)

Model for Common Ground Development to Support Collaborative Health Communities

“individuals share their cognitive maps to develop mutual understanding and collective cognitive maps” (Popova-Nowak & Cseh, 2015 p.317)

… this supports common ground

Kuziemsky, C.E. & O’Sullivan, T.L. (2015). A Model for Common Ground Development to Support Collaborative Health Communities, Social Science & Medicine, 128, 231-238; DOI:10.1016/j.socscimed.2015.01.032. Available at: http://www.sciencedirect.com/science/article/pii/S0277953615000581

Funded by Defense Research and Development Canada (CRTI Program) Structured Interview Matrix

Facilitation technique for community consultations 4 questions – 1 per table 3 Steps: 1-1 interviews, small group deliberation, large group discussion

O'Sullivan, T.L., Corneil, W., Kuziemsky, C.E. & Toal-Sullivan, D. (2014). Use of the Structured Interview Matrix to Enhance Community Resilience Through Collaboration and Inclusive Engagement, Systems Research and Behavioral Science, 32(6), 616-628, DOI: 10.1002/sres.2250. Instructional Video for the SIM available at: http://www.enrichproject.ca/publications-and-resources.html Progressing through different stages of common ground So we really heard kind of three common themes. I think the shared information and the shared best practices is probably a good one.

Excerpts from SIM I think this idea of relationship-building discussion on collaboration and …

Do you think that's all in one or is that a Examples of coordinative, separate one you figure? cooperative and collaborative common The relationship-building, kind of sharing ground best practices … Um, I kind of see them as separate. I mean I'm all for sharing best practices, but knowing that I can also pick up the phone and phone you and say ‘here's what's going on’ in the middle of something is to (Kuziemsky & O’Sullivan, 2015) me is just as important Common Ground – Individual Level

Knowledge - “because some organizations didn't know the other resources that were out there or they didn't know how to engage better with Public Health …” “Some of the organizations I've just heard of about this morning, which is kind of scary … in the event of an emergency you can't have them not connected, so how can we get that connection going?”

Perspectives - “And he said also what would hinder the response and the recovery would be the public attitudes and he said that clients do not understand the roles of the responding emergency people and they have unrealistic expectations sometimes.”

Engagement - “So if everybody feels individually empowered then it's a little bit easier to then say well this is what I could do in my organisation or this is what I could do in my business. ” (Kuziemsky & O’Sullivan, 2015) Asset Literacy - Components

1. Identify assets – across multiple levels (micro, meso, macro)

2. Recognize their potential contribution

3. Understand how to mobilize them – culture of empowerment

4. Self-efficacy / motivation to move from awareness and to action

O'Sullivan T.L., Kuziemsky, C.E., Corneil, W., Lemyre, L., & Franco, Z. (2014). The EnRiCH Community Resilience Framework for High-Risk Populations. PLOS Currents Disasters, DOI: 10.1371/currents.dis.11381147bd5e89e38e78434a732f17db. Open access available at: http://currents.plos.org/disasters/article/the-enrich-community-resilience-framework-for-high-risk-populations/

O’Sullivan, T., Fahim, T. & Gagnon, E. (2017). Asset Literacy Following Stroke: Implications for Disaster Resilience, Disaster Medicine and Public Health Preparedness, 1-9. DOI:10.1017/dmp.2017.66. https://www.ncbi.nlm.nih.gov/pubmed/29039291 Common Ground – Group Level

Leadership - “… I think it does take leadership though, to start bringing folks together, and some dedication to do that because it's not easy to bring people together and then to keep them together even if there is a willingness to do so.”

Relationship building - “… we had a pandemic session and invited all of the public sector people that were involved in the emergency preparedness … and out of that one session, we kept meeting, and there's now 23 different organizations and agencies from both the public and private sectors that continue to meet quarterly to build these relationships, and I don't know if we’re accomplishing the amount for a difference in the community, but we are building relationships”

Non-competitive culture (equalization) - “What we have expressed in the stroke recovery organisations, is a key word of: non-competitiveness. We need to come together in a non-competitive fashion so that we can equalise the experiences and knowledge that we have as individual groups.” (Kuziemsky & O’Sullivan, 2015) Elements of Collaboration in Complex Adaptive Systems

(Leduc et al., 2018)

• Core elements depend on the type of system - how is it coupled?

• Tightly-coupled • Loosely-coupled

Photo credit: Jamb.ca Loosely-coupled systems

Some Characteristics (Perrow, 2011)

Processes can be delayed

Sequences can be changed

Alternative methods possible

Variable resources

Buffers and redundancies

Possibility for substitutions

Leduc et al. (2018) Understanding Collaboration in the Context of Loosely- and Tightly-Coupled Complex Adaptive Systems , Masters thesis available at: http://hdl.handle.net/10393/37087 Tightly-coupled systems

Some Characteristics (Perrow, 2011)

Little tolerance for delays

Processes follow prescribed sequences No variance in methods

Little slack possible (supplies, equipment, personnel) Buffers and redundancies are designed-in Limited substitutions (supplies, equipment, personnel)

Facilitators Barriers

- Holding regularly scheduled meetings - Staff limitations - Collaborating in the development of - Time restraints response plans in order to meet the - Low funding unique needs of the community - Lack of understanding of the role of the - Working together daily on both disaster health center by emergency planners and non-disaster related activities - Lack of strong leadership - Strong leadership driving the collaborative relationship - Shared resources - Leveraged funding to accomplish goals The pitch …

• Collaboration as an essential element of disaster risk reduction and climate change adaptation – it is acknowledged planning frameworks across multiple levels • Khan Y, O’Sullivan T et al. BMC Public Health. Forthcoming 2018.

• Recommendations for an ‘all-of-society approach’ require consideration of how to engage different organizations and agents within the population for true implementation

• Common ground and asset literacy as foundational processes for collaboration in public health … but they take time and high-level support for investment

• If collaboration is an essential element – can we afford not to invest time and money in creating opportunities for people to develop common ground and asset literacy?

Merci! Thank-you!

Email: [email protected]

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Collaboration in the development of a local interagency emergency response plan for opioid poisonings

Stacey Laforest Director, Environmental Health November 28, 2018 Health Emergency Management (HEM) Opioid Workshop Held in response to increasing trends in opioid use and related harms: • Identified need for local cross-sectoral plan. • Clarify roles and responsibilities amongst partner agencies. • Identify strengths and areas for improvement within existing emergency response plans. Requirement to annually test Public Health Sudbury & Districts’ emergency response plan. HEM Opioid Workshop Who was involved? • Planning—Public Health Sudbury & Districts in collaboration with Public Health Ontario. • Participation—members and member agencies of local emergency management committees, local drug strategy committees, and other partners in the Sudbury and Manitoulin districts. Collaboration in planning of HEM Opioid Workshop • Collaboration with Public Health Ontario • Cross-divisionally within Public Health Sudbury & Districts • Following R.S.V.P. date, one-on-one follow-up with agency partners • Pre-circulation of participant materials for preparation and reflection Public Health Sudbury & Districts service area HEM Opioid Workshop

• All relevant partners were invited to participate in the one-day workshop as a first step in developing the local plan. • Workshop consisted of: • Providing education related to opioids and surveillance from a national, provincial, and local level. • Table-top exercise and discussion amongst same-sector service providers (morning) and cross-sector community partners (afternoon). HEM Opioid Workshop

Workshop objectives:  Clarify roles and responsibilities of local and provincial level agencies in preparing for, responding to, and recovering from a local mass casualty overdose event secondary to opioids.  Identify how surveillance (numbers and narratives) informs our actions.  Identify needs, including coordination of response processes and communication, within organizations and amongst cross-sector partners. HEM Opioid Workshop

Workshop objectives:  Identify steps to foster strengths and address gaps in preparing for, responding to, and recovering from a local mass casualty overdose event secondary to opioids.  Take steps to establish and strengthen relationships between sectors.  Gather knowledge to inform the development of an interagency Sudbury and districts emergency response plan for opioid poisonings to ensure an effective and timely multi-agency response and community recovery. Collaboration during HEM Opioid Workshop

Workshop structured around locally relevant tabletop scenarios to support group discussions of objectives: • Clarify roles and responsibilities • Importance of surveillance • Needs (surveillance, coordination of response, and communication) • Foster strengths and address gaps • Establish and strengthen relationships between sectors • Gather knowledge to inform development of a local plan Collaboration in development of interagency emergency response plan for opioid poisonings

• Public Health Sudbury & Districts reviewed all information gathered. • Findings used to inform the development of a draft framework for an interagency Sudbury and districts emergency response plan for opioid poisonings. • Draft report and framework circulated to all workshop invitees and attendees for input and comments prior to finalizing. Lessons learned

• Incident Management System (IMS) vs. Cross- Functional Team approach • Need for a plan to address the unique needs of each community • Strong sense of community and commitment • Importance of having all relevant partners involved • Importance of pre-existing relationships This presentation was prepared by Public Health Sudbury & Districts.

This resource may be reproduced, for educational purposes, on the condition that full credit is given to Public Health Sudbury & Districts.

This resource may not be reproduced or used for revenue generation purposes. © Public Health Sudbury & Districts South Eastern Ontario Incident Management Committee Collaboration In Practice

Public Health Ontario Seminar November 28, 2018 Teresa Clow Senior Public Health Inspector Leeds Grenville and Lanark District Health Unit Brenda Conway, Manager, Emergency Management, Parking and Security Operations Centre Kingston Health Sciences Center, Providence Care Hospital South East LHIN

Challenges For the Health Care Sector in Emergency Planning

 Healthcare sectors as a whole are sometimes isolated from municipal or other sector emergency planning, and may have internal gaps that need to be addressed

 Roles of various agencies are often not understood at the municipal/ county level and sometimes between agencies (often due to emergency management being an add on to someone’s regular job)

 Emergency management must be integrated into the wider community context

Background

 Emergency preparedness and planning activities often were completed with agencies working in silos which resulted in gaps

 The Health Care Network of Southeastern Ontario Incident Management Committee was innovative in that it brought stakeholders together to collaborate on emergency planning around the health care sector

 Started in back in 2004 with Terms of Reference Mandate

 Foster and promote regional leadership with a focus on regional collaboration, coordination & strategic planning  Build a regional capacity to prepare for, respond to and recover from scalable overall community emergencies  Facilitate and coordinate linkages between regional healthcare organizations, first responders, municipal partners, the Ministry of Health and Long-Term Emergency Management Branch (EMB) to build a SEO regional culture of emergency preparedness

Guiding Principles

 Identify external and internal risks with associated gap analysis using the Hazard Identification Risk Assessment (HIRA) process  Develop a communication framework, notification and information sharing protocols  Support sustainability, business continuity and recovery  Provide opportunities for shared training  Develop common “code response” protocols through sharing of best practice Committee Membership

Original Members (2004) Additional Members (2006-2013)  Hospitals  South East Local Health  Community Care Access Integration Network Centres  South Eastern Ontario  Public Health Units (3) Infection Control Network  Paramedic Services and  County Emergency Central Ambulance Management Coordinators Communication Centre  Kingston Hospitals  Physicians Protection Services  MOHLTC representative or  Office of the Fire Marshal designate and Emergency Management

Collaborative Planning

Emergency Management is most effective when:

 Responsibilities, objectives and resources are merged through joint planning  Based on a similar set of principles, standardized systems, plans, processes and best practices  Fosters a sense of common purpose amongst organizations and a spirit of cooperation during the planning process and in actual emergency situations  Creates a forum in which problems are discussed and mutually acceptable solutions are sought

Benefits of Collaboration

 Members understand roles and expectations of each agency/department  Information can be brought back to our agencies to help identify gaps in planning and collaborate on how those gaps may be addressed  Share in educational and training opportunities  Provide situational awareness  Know the people we will be relying on to support us in the response and how to contact them Collaborative Successes

Regional approaches to address and raise awareness of issues that impact stakeholder organizations:  Emergency codes (orange and silver)  CBRN training  Community/Hospital tabletop exercises  Influenza- stockpile supplies/Tamiflu  Ebola  Northern Wildfire Evacuations impact on hospitals and host communities  Syrian Refugees  Queens’ University Homecoming Event  Code Silver/lockdown  Bomb Threats  Opioid Overdose Crisis

Requirements for Success

 A champion for emergency management who engages stakeholders  Regular review of mandate and terms of reference to ensure ongoing relevance for committee members  Format of the agenda for meetings should encourage participation and discussion on issues  Regularly scheduled meeting dates and times at relevant intervals  Options to attend meetings in person or via teleconference Building Health System Resilience  An advanced SEO regional level of emergency preparedness is achieved when our partners work together to : Identify emergency management concerns Develop strategies Determine parameters Explore possibilities

 Improve the level of regional system readiness through sharing of lessons learned from real life incidents and tabletops

Acknowledgements

A special thank you to Brenda Conway who assisted in the development of this presentation. Brenda has been integral in keeping this committee together and is a true champion for emergency preparedness and the collaborative approach. Jordan Pike who keeps us organized and documents our meetings.

Contact Information

Brenda Conway Manager, Emergency Management, Parking and Security Operations Centre Kingston Health Sciences Center, Providence Care Hospital [email protected] 613-544-4900 ext. 50252

Teresa Clow, Senior Public Health Inspector & Emergency Preparedness Lead Leeds, Grenville and Lanark District Health Unit [email protected] 613-283-2740 ext. 2411

Closing remarks

Shelley Deeks, Chief of the Communicable Diseases, Emergency Preparedness and Response Department, PHO

PublicHealthOntario.ca 48 For More Information About This Presentation, Contact: [email protected]

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