Changing Landscape of Public Health Changing Landscape of Public Health in Ontarioin Ontario

Dr. George PasutChief Medical Officer of Health (A)

May 14, 2007

2

CMOH UpdateProvide an update on the following items:

• Ministry Organization and Restructuring

• CMOH Recruitment Process

• Creation of Ontario Agency for Health Protection & Promotion

• The Health Protection and Promotion Act (HPPA) Amendments

• The Capacity Review Committee (CRC)

• Public Health Human Resources Initiative

• Public Health Network (PHN) – FPT

• Public Health Program Standards

3

MOHLTC – Organization Chart

Deputy MinisterDeputy Minister

Health System Information

Management

Health System Information

Management

Health System Strategy

Health System Strategy

Public HealthPublic Health

Health System Investment &

Funding

Health System Investment &

Funding

Health System Accountability &

Performance

Health System Accountability &

Performance

Drugs Office

Communications

Legal

Medical Advisory Secretariat

I& IT

Drugs Office

Communications

Legal

Medical Advisory Secretariat

I& IT

Corporate and

Direct Service

Corporate and

Direct Service

Health HumanResources

Health HumanResources

4

MOHLTC RestructuringLocal Health Integration Networks (LHINs)

• In March 2006, the government passed the Local Health Integration Act, 2006. • The legislation gives the LHINs the power to plan health care services in each

communityhttp://www.lhins.on.ca

• Future Role of the MOHLTC will be as “Stewards of the Health Care System“

• Strengthen accountability frameworks and mechanisms• Establish strategic directions and provincial priorities for the health system• Develop legislation, regulations, standards, policies and directives• Monitor and report on the performance of the health care system• Plan and establish funding models and levels of funding for the health system

5MOHLTC Strategic Directions

VISION

• “A health care system that helps people stay healthy, delivers good care when they need it, and will be there for their children and grandchildren.”

STRATEGIC DIRECTIONS

• MOHLTC has adopted the following strategic directions:• Renewed community engagement and partnerships in and about the health

care system;

• Improve the health status of Ontarians;

• Ontarians will have equitable access to the care and services they need no matter where they live or their socio/cultural/economic status;

• Improve the quality of health outcomes; and

• Establish a framework for sustainability of the health care system that achieves the best results for consumers and the community.

• In Spring 2007, MOHLTC will be releasing a 10-year Health Strategy Plan.

6

MOHLTC Public Health & CMOH – Organization Chart

Deputy MinisterMOHLTC

Ron Sapsford

Deputy MinisterMHP

Marg Rappolt

CMOHDr. George Pasut

ADMRuth Hawkins

DirectorEmergency Management

Allison Stuart

Director Operational Effectiveness

Becky Taylor

Executive DirectorPublic HealthRuth Hawkins

Executive LeadPH System

TransformationDr. George Pasut

DirectorChronic Disease Prev& Health Promotion

Pegeen Walsh

ACMOH/DirectorInfectious DiseasesDr. David Williams

DirectorEnvironmental Health

Brenda Mitchell

Medical DirectorPublic HealthLaboratories

Dr. Donald Low

ADM Health Services

Dawn Ogram

DirectorPublic Health Standards

Monika Turner

DirectorStrategic Planning &

ImplementationPhil Jackson

DirectorControllership & Resources

ManagementDawne Kamino

Executive LeadPH Info & IT Strategy

Ian BrunskillTransitional

Project DirectorSmoke-Free Ontario

Denis Gertler

ADMHealth Promotion

Jean Lam

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Mandate of Public Health

• In 2002, the F/P/T Advisory Committee on Population Health defined five core functions for public health in Canada:

• Population Health Assessment;

• Health Surveillance;

• Health Promotion;

• Disease and Injury Prevention; and

• Health Protection.

• Discussion has occurred as to whether emergency response and preparedness as well as population health advocacy should be added to the core functions for public health.

9CMOH Recruitment Process

• Dr. Basrur resigned for health reasons in the fall of 2006.

• Appointed as Acting Chief Medical Officer of Health on December 13, 2006

• Ruth Hawkins appointed Acting Assistant Deputy Minister (ADM), Public Health Division.

• There is currently a recruitment team composed of an all-party Legislative Committee with support from the Deputy Minister of the Ministry of Health and Long-Term Care and the Deputy of Health Promotion.

• Application period closes today!

10

Health System Improvements Act (Bill 171)

• December 12, 2006 the Health System Improvements Act (Bill 171) was introduced in the House. Bill 171 includes the Ontario Agency for Health Protection and Promotion Act.

• HSIB• Received Second Reading on March 20-26, 2007. • Went to the Standing Committee on Social Policy April 23-24, 2007.• Received Clause-by-Clause Reading on May 7, 8 and 14• Third Reading May 31• Awaiting Royal Assent and Proclamation of components (different

timing)

11Health Protection and Promotion Act (HPPA) Amendments

• Emergency powers when there is an immediate and serious, or immediate risk to the health of persons anywhere in Ontario (e.g., directives re: precautions and procedures; supply chain powers).

• Strengthening, streamlining and clarifying the control and management of infectious diseases (e.g., providing MOH powers to issue orders re: outbreak of communicable diseases in hospitals or institutions).

• Strengthening public health service delivery (e.g., streamlining lab results reporting, enabling nurse practitioners to work with their full scope of practice).

12

Capacity Review Committee• Final CRC report, Revitalizing Ontario’s Public Health Capacity,

received May 2006• Comprehensive government response in development

• 50 recommendations in 7 key areas on how to improve the function and configuration of the Public Health system:

• Ensuring quality governance

• Building stronger public health units

• Revitalizing the public health work force

• Stable and predictable funding

• Demonstrating accountability and measuring performance

• Research and knowledge exchange

• Strategic partnerships

13

Public Health Human Resources Initiatives

• Consistent with the recently announced HealthForceOntario Strategy, PHD is working with the Health Human Resources Strategy Division on the following areas:

• A Health Human Resources marketing and recruitment centre, including a comprehensive website

• Opportunities to increase enrolment in public health programs e.g., five new Physician Re-Entry program positions created for 2007 for physicians interested in pursuing community medicine or master’s in public health (MPH) or equivalent)

• PHD supports Medical Officer of Health in Training Bursary Program for physicians currently working in public health to pursue master’s education

14

Origins of the Public Health Network (PHN)

History

• Recommended by the F/P/T Special Task Force on Public Health (Partners in Public Health Report)

• A commitment by First Ministers in the 10-Year Plan to Strengthen Health Care

• Publicly announced & launched by F/P/T Ministers of Health on April 22, 2005

• Fulfills a critical gap identified in the Naylor Report

• First Council Meeting – June 6 -7, 2005

15

Origins of the Public Health Network (PHN)

Early PHAC Activities to Support Network Start-Up

• June 2005 – brainstorming between Healthy Living and the CCDPC on the emerging network and what the issue groups might be for the new Health Promotion and Non-Communicable Disease and Injury Prevention and Control Expert Groups.

• Environmental scan on various issue areas to help us better understand the work being done

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Mandate

The Public Health Network will:

• Support the public health challenges jurisdictions face during emergencies

• Collaborate on day-to-day operations of public health

• Provide advice and regular reporting to CDMH on public health matters and the activities of the Network

• Facilitate information sharing among all jurisdictions and disseminate information regarding best practices in public health

• Respect jurisdictional responsibilities in public health

• Be accountable to the CDMH

17Network Structure

CouncilF/P/T

members

Issue Groups

Expert Groups(permanent expertise)

Conference of F/P/T Deputy Ministers of

Health

Canadian Public Health Laboratory

Emergency Preparedness & Response

Communicable Disease Control

Public Health Surveillance & Information

Chronic Disease & Injury Prevention & Control

Population Health Promotion

Public Health Human Resources Task Group

Is accountable to

Task Groups(time limited)

CCMOH

Reporting through respective Expert Groups on key issues

Task Groups

18Revised Structure of the Pan-Canadian Public Health Network as of August 2006

19

Environmental Health Branch

• Director of Environmental Health position – recently created.• New Director (Brenda Mitchell) - began Jan 2007.

• Environmental Health Branch• Formally created in Feb 2007.• To provide strategic and policy leadership for environmental issues with human

health impact.

• Mandate includes:• Public health policy re: air quality, drinking water, adaptation to climate change.• Enhance capacity of medical officers of heath to respond to environmental

hazards.• Support implementation of mandatory programs (food, water, health hazards).• Coordinate with federal, provincial and municipal agencies / governments.

Ontario Public Health Standards

Presentation to Ontario Society of Nutrition Professionals in Public Health

Dr. George Pasut June 1, 2007

21

Purpose

• On Monday, April 30, 2007, the Program Standards Technical

Review Committee (TRC) submitted its final draft of the

proposed Ontario Public Health Standards (OPHS), to the

Acting Chief Medical Officer of Health.

• The purpose of the following presentation is to:

• Provide an overview of the process to develop the proposed standards

• Highlight proposed scope for Infectious Diseases standards

Process to Develop the Standards

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Review Process Overview

ReportAdviseTechnical Support

Inter-Ministry Committee

(15 members)

Inter-Ministry Committee

(15 members) Program Standards

Development Teams

Program Standards

Development Teams

Expert AdviceExpert Advice

Acting CMOHActing CMOH

MinistersMinisters

Proposed StandardsProposed Standards

Technical Review Committee

Technical Review Committee

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Review Process Overview – Key Components

• TECHNICAL REVIEW COMMITTEE (TRC)

• Established to guide the development of renewed standards for public health (term: September 2006 - April 2007)

• Co-chaired by Dr. George Pasut and Dr. Bob Nosal (Medical Officer of Health for Halton Region)- following Dr. Pasut’s appointment as Acting Chief Medical Officer of Health, Ms. Monika Turner (Director, Public Health Standards Branch, MOHLTC) served as co-chair

• Comprised of 21 additional members from public health units, academia, the Association of Municipalities of Ontario and government (MOHLTC, MHP and MCYS)

• PROGRAM STANDARDS DEVELOPMENT TEAMS (PSDT)

• 10 PSDTs established in late October 2006 to develop initial drafts of standards for consideration by the TRC (IDPC, VPD, SH/STI, TB and 3 for EH)

• The PSDTs were comprised of representatives from local boards of health and government (Public Health Division and Ministries of Health Promotion and Children and Youth Services).

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Consultation Activities

• 8 Workshops in Summer and Fall with public health unit staff (~15-20 health units per workshop) to discuss challenges and opportunities for renewal

• Environmental Health workshop (June 20)

• Extensive consultation on first draft of Standards (February 19 – March 9, 2007)

• 141 stakeholders (public health units, health and social organizations, education and Aboriginal organizations) invited to complete an electronic survey (E-survey) on draft Standards

• 9 MOHLTC divisions and 15 Ministries invited to complete policy questions (alignment of Standards with legislation/regulations/policies, suggestions for revisions and identification of implementation challenges)

26

Communication Activities

• TRC Field Communiqués (8) sent to MOHs and other stakeholders

• Webinar with all 36 public health units to provide background on the review process and the E-survey

• Information Notice on Environmental Bill of Rights regarding the review process

• Meeting with key public health stakeholder associations

• Posting on MOHLTC & PH e-Portal websites (Terms of Reference, membership, communiqués, E-survey summary)

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Submission and Approval Timelines

APRIL 30Submission

of Standards to A/CMOH

MAYMHP,

MCYS & MOHLTC Review

ImplementationTBC

Ministers’ Approval

TBCRelease of Standards

• Development of Protocols*• Development of Implementation Resource Manual• Development of roll-out strategy• Development of performance management framework

* Protocols would be developed based on current scientific evidence, and would likely entail consultation with boards of health and would seek input from key stakeholders, including ASPHIO

The Proposed Standards

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Key Approach and Directions

• The approach for developing the proposed public health standards included:

• Moving towards standards that are measurable and linked with specific performance measures for increased accountability

• Integrating the standards into an overall performance management framework for public health

• Incorporating technical revisions to reflect new science, evidence and best practices in public health

• Balancing the need for provincial standardization of a number of program functions with the need to offer local flexibility

• Establishing ongoing review, enhancement and support processes so that the standards are continually evolving

30

Proposed Ontario Public Health StandardsP

RIN

CIP

LE

S

POPULATION HEALTH ASSESSMENT

SURVEILLANCE

RESEARCH AND KNOWLEDGE EXCHANGE

PROGRAM EVALUATIONFO

UN

DA

TIO

NA

L

ST

AN

DA

RD

NEED IMPACT CAPACITY PARTNERSHIP & COLLABORATION

• Reproductive Health

• Child Health

FAMILY HEALTH

• Chronic Disease Prevention

• Injury & Substance Misuse Prevention

CHRONIC DISEASES AND INJURIES

• Infectious Diseases Prevention & Control

• Rabies Prevention & Control

• Tuberculosis Prevention & Control

• Sexual Health, Sexually Transmitted Infections, and Blood-borne Infections

• Vaccine Preventable Diseases

INFECTIOUS DISEASES

• Food Safety

• Safe Water

• Health Hazard and Prevention Management

ENVIRONMENTAL HEALTH

EMERGENCY PREPAREDNESS

• Public Health Emergency Preparedness

PROGRAM STANDARDS

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Proposed Structure and Format

• The Ontario Public Health Standards are organized as follows:

• Introductory Section – which outlines the purpose, scope and accountability, statutory basis and format for the proposed standards

• Foundations:• Principles – which encompass Need, Impact, Capacity as well as Partnership

and Collaboration

• Foundational Standard – which addresses population health assessment, surveillance, research and knowledge exchange and program evaluation; and

• Thirteen Program Standards – which address Chronic Diseases and Injuries, Family Health, Infectious Diseases, Environmental Health and Emergency Preparedness.

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Proposed Structure and Format (cont’d)

• The proposed standards have adopted the following format for each of the programs:

• Goal – a statement that reflects the broadest level of results to be achieved in a specific standard. The work of boards of health, in addition to community partners, non-governmental organizations and governmental bodies, contribute to the achievement of the goal

• Effects – the changes in health status, organizations, systems, norms, policies, environments and practices. The effects result from the outcomes and include the contributions made by public health and many organizations to the overall health of the population. Boards of health shall not be held directly accountable for effects

• Outcomes – the immediate results of activities or requirements that often focus on changes in awareness, knowledge, attitudes, skills, practices, environments and policies. Boards of health shall direct their efforts towards, and be held accountable for, outcomes

• Requirements – the specific statements of action

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Proposed Structure and Format (cont’d)

• Further, the requirements have been organized into four groupings based on key public health functions:

• Surveillance and Assessment – use of surveillance, epidemiological analysis and surveillance data for program planning and implementation;

• Health Promotion and Policy Development – work with community partners to influence the development and implementation of healthy public policies, create/enhance supportive environments and increase awareness;

• Disease Prevention – management and provision of services including preventive measures, reporting and responding to diseases; and

• Health Protection – including enforcement of applicable legislation, regulations and inspection.

• In addition, many of the requirements will be accompanied by protocols to further articulate the “how” of the standards – and thus, will be quite specific

• The TRC has recommended the review of existing protocols as well as the development of new protocols

34Ministry/Board of Health Accountability Framework for

Mandatory Public Health Programs

Health Protection & Promotion Act

Mandatory Health Programs & Services Guidelines (1997)

SettingExpectations

Monitoring Performance Assessment Enforcement

Planning & Evaluation

Education & Consultation

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Performance Management

• Build a performance management framework that:

• Links standards with specific performance measures to meet multiple information needs,

• Allows for continuous quality improvement, and

• Captures and reports on Board of Health performance and that of the overall public health system.

Performance Standards

Performance Measures

Performance Monitoring

and Reporting

Continuous Quality

Improvement

Organizational Standards

Program Standards

Legislated Requirements

Measures

Data Collection

Data Quality Control

Monitoring

Accreditation

Assessments

Public Reporting

Analysis & Learning

Revision & Adjustment

Foundations for the Performance Management Framework Funding, Human Resources, Integrated Data Systems

Public Health Performance Management Framework

Source: Final CRC Report, May 2006

36Silos to Systems: U.S. Public Health Foundation’s Turning Point Performance Management Framework

37

Compliance Measurement

Did we do what we

said we would do?

Performance Measurement

Did the program have the

impact we expected?

From Compliance to Performance…

Understanding the Performance Culture Shift:

• Measuring performance is about using data/information for assessing the gap between ministry expectations and Board of Health achievement and then identifying and implementing strategies for improvement

• Key difference is a subtle shift FROM measuring what we said we would do TO measuring outcomes--are we having the impact we want? And, if not, what do we need to do differently?

1997 2007

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Questions…?