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Appendix 3

pH1N1 Symposium 'Large Group Lists'

pH1N1 Symposium 'Large Group Lists'

Each table of participants were asked to discuss the research questions as they were posed to them, individually, by the facilitator and then to create and submit their Small Group Lists of responses to the central computer. These were then discussed by the group-as-a-whole, condensed and assembled into Large Group Lists. All active participants (n=44) were then asked to choose a number of responses from the list (typically, 4 to 5 - as in 'if we could implement four, which concepts would you choose?'). Each individual's choice was entered into the central computer and, when tallied, the votes produced a ranked order of the large group's preferences.

The Large Group List from each consensus building exercise, as ranked by the group-as-a-whole, are presented in Appendix 3, Tables A3.1 to A3.5, below.

Appendix 3.1 - Mass Immunization Models - Components and Issues

Table A3.1.1 - What are the characteristics of a good Mass Immunization Model?
Rank	Votes (Top 4 by 42 voters)	Response / Comment
1	35	Communication: Clearly communicated plans are a means of informing the plans of our partners and stakeholders ...consistent simple messaging. Clear, consistent, timely media messaging from one source.
2	27	Logistics: Efficient delivery, easy access, defined procedures. Effective, safe, easily administered vaccine. Web-based booking system (accessible by physicians, public health, VDAs).
3	23	Need a culture of "whole system responsibility" for immunization so that all resources in the system can be leveraged (I.e. Specialist offices, paramedics, pharmacists, etc.) Uses collaboration with the public health and the existing infrastructure, example being primary care, to deliver vaccine.
4	20	Pre-planning with primary care, public health, hospitals etc. to have a model in place before it's needed. A Hybrid vaccine delivery model (public health AND primary care) - local engagement and integration.
5	16	The model must be uniform and consistent in the principles of delivery, and flexible in the operationalization of the delivery of the immunization. Model must be adaptable to local needs.
6	10	Recommendations and operationalization is responsive to the understanding of the current epidemiology.
7	9	Data collection-real time data collection including ability to track adverse events
8* [tied]*	7	Model must be "scalable" both in terms of human resource availability and vaccine accessibility.
8*	7	Modes of delivery are matched with the characteristics of the targets groups. Ex: school children call for school immunization vs. adults with chronic condition in clinic settings.
9	5	An organized primary care structure
10	4	Patient & provider acceptability: have to be ok with how the vaccine is administered.

Table A3.1.2 - What should we do to improve our ability to respond the next time?
Rank	Votes (Top 4 by 40 voters)	Response / Comment
1	35	Pre-planning (funding, waiting areas, scheduling, vulnerable populations outreach, partners) ... Develop a plan and the relationships NOW (between public health and primary care) - both generally and specific to pandemic planning. Vaccines (packaging, timing, two types caused confusion, menu of options for vaccine delivery).
2	33	Communicate early and often. Dynamic messaging. Communicate importance of vaccination before vaccine is available. Educate - on target populations ... the why for the who. Develop a communication process to be followed during pandemics that identify a single central communication centre from the leader of the process.
2	33	Have logistics in place: electronic database, stockpile of supplies and memorandum of understandings with partners such as EMS, nursing schools, etc., to assist with immunization. Ensure surge capacity e.g. immunization competency training, logistics planning ... decision making trees.
3	22	Communication with family physicians: early open communication. Simplified protocols. Ongoing communications. Direct line of communications for health professionals.
4	11	Improve access to accurate local epidemiology ... Surveillance (international, national, local real time with meaningful measures, sentinel) ... Develop concise and accurate tracking systems.
5	7	Apolitical - evidence based decision making.
6	6	Build local capacity of public health for dramatically increased resources and powers (e.g.: commandeer people and facilities) to deliver vaccine quickly and efficiently.
7* [tied]*	5	Health system integration through governance changes ....align LHIN and PHU boundaries.
7*	5	Create a collection of past successes (and failures). Create a culture of sharing between regions to promote best practices.
8	3	Ability to use other vaccine delivery agents, such as private nursing agencies, physicians, using "carrot" ($) and "stick" (legislation) models.

Appendix 3.2 - Influenza Assessment Centres

Table A3.2.1 - What do we need to do differently to improve our ability to respond?
Rank	Votes (Top 5 by 40 voters)	Response / Comment
1	36	Pre planning. Have an implementable plan, predetermine resource/financial implications Clinical guidelines, pre-arranged equitable funding for staffing, equipment, etc. Needs to meet occupational health and safety & infection prevention and control standards.
2	34	Determine who is responsible for operating FACs and delineate clear lines of governance. Primary care is best equipped to provide flu assessment centres. Make LHINs accountable for that. Establishment, clarify accountabilities, roles and responsibilities.
3	28	Clearly identified triggers to implement FAC protocols, e.g.: syndromic surveillance systems, ER visits, etc. ... Is this the correct way to increase capacity? (Given insurance, logistics, etc.). If yes, determine who leads up front and who follows. Province should decide and fund.
4	17	Improve surveillance system so that impact on local health care system can be identified and timing of opening of IAC can be most appropriate. In addition to this, adequately identifying resources (HR, space and funding) must be done in a way that the opening of the IAC does not significantly impact the delivery of other services in the FHT/hospital/community.
5	15	Integrated, coordinated collaboration with primary care and the acute care sector that includes an evaluation process ensuring economic, equitable, efficient use of resources.
6	14	Funding for urgent situations (non-declared emergency) needs to be set aside at the provincial level.
7	13	Evaluation: Let us debrief, and review the evidence for flu assessments centers. Did they change outcomes and processes?
8	8	Communication: If you have the flu, stay home. If you have symptoms X, Y, Z, go to an FAC.
9	7	Ensuring alignment of priorities from different branches of the funder (MoHLTC) and health care system partners. ...reallocate existing people... business continuity.
10	6	Staffing models established in planning stages with compensation models
11	5	We need to supplement primary care with independent flu assessment centres for patients without a primary care provider or primary care offices that are overwhelmed.
12	4	Involve Aboriginal Health Authority and Aboriginal health stakeholders to help to develop models that are appropriate to their communities / populations (on and off reserve) and incorporate those models in the planning process for IAC's / vaccine rollout.
13	3	Need to understand the capacity of local primary care and support primary care with guidelines.
14	2	Flu assessment centres need equipment/supplies support from public health

Table A3.2.2 - Roles/Responsibilities: who should take the lead?
Rank	Vote (1st choice by 40 voters)	Response / Comment
1	12	LHINs
2	10	Hybrid Model: A collaboration of multiple health system partners
3	7	Public Health Units
4	5	Primary Care: (e.g., Family Health Teams, Community Health Centres, Ont. College of Family Physicians, Nurse Practitioners Association of Ontario, Local Family Medicine Departments in Hospitals)
5* [tied]*	3	Acute Care (e.g., Hospital Chief of Staff, Emergency Department)
5*	3	MOHLTC
6	0	Emergency Management Ontario

Appendix 3.3 - Effective Partnerships : Public Health & Primary Care

Table A3.3.1 - What can public health or other government organizations do to facilitate partnerships and better engage primary care?

Rank	Votes (Top 5 by 15 voters)	Response / Comment
1	12	Proactive approach to engage Public Health and Primary Care in areas of mutual interest for health. Build relationships with primary care but not in time of crisis. Create regular opportunities to communicate with primary care to establish relationships and communication pathways. This would create opportunity regarding services/programs of all sorts through PHU.
2	6	Develop primary care and public health networks in each region (primary care leaders, associate MOHs and staff.
3* [tied]*	5	Identify dedicated liaison for public health who has responsibility to communicate with primary care.
3*	5	Engage where primary care meets; go to them for clinic days, family medicine rounds, CME events.
4	4	Identify key leaders in the various local medical communities ...Public Health could engage primary care leadership / practice groups - physician leads of FHN/FHG/FHO's
5** [tied]	3	Public Health needs to understand that Primary Care is organized in some regions and in these regions should deliver a coordinated approach
5**	3	LHIN boundaries should be same as Public Health
5**	3	Align governance to enable system integrations across the health sectors
5**	3	Utilize primary care leaders as a conduit i.e. Chiefs of Family medicine, LHIN leads, LHIN primary care leads, OCFP and OMA reps and Academies of Medicine
5**	3	Make them (primary care) true partners involved early at the table in the decision making process
5**	3	Incentive or value-added engagement. Family physicians should be fairly compensated for their time in one way or another.
6*** [*tied]	1	Identify and develop relevant messages when communicating with primary care.
6***	1	To open up epidemiologists/data base to PC.
6***	1	Have a common workflow measurement tools.

Table A3.3.2 - What can medical organizations and local primary care do to better partner with and engage public health?

Rank	Votes (Top 4 by 23 voters)	Response / Comment
1	23	Establish & support networks which include primary care and public health to discuss common issues. Invite public health to meetings of family care teams. Collaborate with public health in presenting rounds, training residents, local academies etc. Get primary care associations (e.g. AOHC, etc.) working with public health associations
2	15	Require FHGs, FHTs, etc., to establish a lead contact person with Public Health
3	12	Shared accountability for guidelines documents by OMA, CPSO, OAHPP and MOHLTC
4* [tied]*	8	Better structure for medical organizations such as OMA to be the local integration of primary care and work as reps in engaging with public health
4*	8	Incentives (funding, accreditation) ... participate in development of population goals and their achievement through models of compensation structure
4*	8	Partnering through the electronic health record for population-based assessments
4*	8	Need to market public health (awareness, building profile of exactly what PH does)
5	6	Associations promote adopting a population lens and prevention approach - look at specific targets and indicators
6	3	Every primary care provider to have a privileged email address for public health information

Appendix 3.4 - Information and Research Needs

Table A3.4 - What additional information do we need from research or other sources to develop a better response?
Rank	Votes (Top 4 by 30 voters)	Response / Comment
1	17	Hospital information needs to be collected on a regular basis. Implement the Kingston model. Province wide real-time syndromic surveillance. What is the most reliable system of surveillance for pandemic flu?
2	16	Credible up to date and easily interpreted information and clinical guidelines in an easily accessible medium
3	15	Defining indicators and "trigger" points when system is overwhelmed in order to respond
4	12	Real-time service utilization to allow for timely resource reallocation ... Spatial mapping Severity index - an outbreak that affected X number of people (all stayed at home vs. all died)
5	10	How to change client behaviour in response to pandemic
6	9	Improve sentinel data from primary care physicians ...Information from Primary Care offices that see Influenza Like Illness (ILI) clients
7* [tied]*	6	Regular (daily?) local pandemic epidemiological data
7*	6	Data standardization between regions
7*	6	Quick turnaround for laboratory test results ..Early detection tools
7*	6	A two-way Interface allowing primary care physicians to find out which patients have had the vaccination already and to allow public health to assess which patients are being vaccinated within public health, and the number of ILI presentations.
8** [tied]	5	Enable vaccine efficacy and safety studies through access to the electronic health record. Integrated, more standardized electronic health record across primary care, linked with acute care on a provincial basis.
8**	5	Effectiveness of public health interventions - hand washing, isolation, anti-virals.
9	3	Use of new technologies to enhance service access e.g. pager to notify patients they are next in line for immunization.

Appendix 3.5 - Individual Comments and Policy Suggestions

Table A3.5 - What other things do we need to consider, do differently, or improve to develop a better overall response?
Theme (No. Ideas)	Idea / Comment
Governance & Policy - During a Pandemic (13)	Significantly increased powers, resources for local public health
Governance & Policy - During a Pandemic (13)	Funding policies on infection control- use/ mandatory use of N95 etc
Governance & Policy - During a Pandemic (13)	I think that when we talk about "Pandemic Planning" we need to be very clear where public health's responsibility lies. It seems to me that clarifying public health's role in primary prevention and the MOH's/acute care's role in secondary and tertiary prevention is critical. So MIM is public health's role, antiviral distribution is MOH's role, etc. Having a Pandemic Plan that is joint (Public Health and MOH) for all levels of management - primary, secondary, tertiary prevention - and that roles out at local levels (PHU/primary care/ hospitals) seems really important to me.
Governance & Policy - During a Pandemic (13)	Inter health unit jurisdiction planning
Governance & Policy - During a Pandemic (13)	Significantly more effective leadership skills from local public health, which needs significant powers and resources.
Governance & Policy - During a Pandemic (13)	Too many cooks in the kitchen; impossible to get clinical guidelines out in a timely fashion. As well these guidelines were meant to be evidence-based and ended up being vetted through the political process and looked quite different out the other end. As well, no communication between federal and provincial guidelines-- duplication and waste of expertise and high confusion quotient
Governance & Policy - During a Pandemic (13)	Distribution of antivirals
Governance & Policy - During a Pandemic (13)	Decisions regarding vaccine production should be evidence-driven including evidence from the Southern Hemisphere.
Governance & Policy - During a Pandemic (13)	We need to work on getting the various parts of the PH system in Ontario to work together better in a smooth, seamless response to urgent situations (i.e.: The field, The OAHPP, the CMOH & the PHD.) It needs to be coordinated, but done in a collegial rather than a coercive way.
Governance & Policy - During a Pandemic (13)	System wide integration needs to consider where gaps/needs are -in our area, we did not need a flu assessment centre but we needed more ICU capacity.
Governance & Policy - During a Pandemic (13)	Health system integration is critical (so that doctors, hospitals, public health are all accountable to the same organization and incentives are aligned). This will only be achieved at the provincial level with significant political will.
Governance & Policy - During a Pandemic (13)	We cannot forget the roles of other primary care providers as Ontario's models change - nurse practitioner led clinics, midwifery clinics, etc. I also think that including specialists in the expectation of responsibility for vaccination in their offices is not unreasonable and would significant expands the resources we would have to conduct immunizations to high risk patients (those who have significant illness, pregnant patients, etc.).
Governance & Policy - During a Pandemic (13)	We need improved alignment of accountability and funding- health Units and primary care should come under the LHIN management. LHIN management could be used to bring together leaders of primary care, public health and CCAC and the hospital sectors to improve our responses to our patients needs.
Public Education & Information (5)	Information given to a patient from the public health unit did not match up with the recommended guidelines at that time. How do we make sure everyone is on the same page?
Public Education & Information (5)	Effective use of social media.
Public Education & Information (5)	Have one provincial communication strategy instead of 36.
Public Education & Information (5)	It really is all about communication and relationships.
Public Education & Information (5)	Find a way to include pharmacists in the communication stream of the data and of the secondary prevention.
Research & Evaluation (3)	Everything we have discussed today has been based on our subjective impressions. There has not an objective quantitative analysis of any aspect of our pandemic response.
Research & Evaluation (3)	Need to understand the different H1N1 impact on aboriginal population
Research & Evaluation (3)	What is our evaluation plan for the next pandemic response?
Primary Care (3)	For primary care to be effective partners and to be included, they need to stop whining about money exclusively, and also care about the health system.
Primary Care (3)	$$ - doctors want $ to participate on committees, in facs, etc and this can be a significant barrier.
Primary Care (3)	Primary care cannot do assessment and mass immunization at same time.
Evidence- based Practice (2)	Web-based tools for patient self-assessment
Evidence- based Practice (2)	Decision tools for parents- web based
Ethics (1)	I would like to see much more importance be placed on public entitlement and behavioral changes to health care (should EVERYONE who has a flu be able to insist of being seen?)
Surveillance (1)	Did we need flu assessment centres? If not, what did we need? Integrated surveillance tool that incorporates primary care and acute care