1. Changing Landscape of Public Health in Ontario
Dr. George Pasut
Chief Medical Officer of Health (A)
May 14, 2007

2. CMOH Update Provide 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

4. MOHLTC Restructuring Local 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 community
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

5. MOHLTC 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

7. Public Health Division - Management Structure

8. 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.

9. CMOH 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)

11. Health 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
Report calls for major transformation of governance and configuration of public health units; these issues are under review by government and require policy approval.
Government is interested in engaging stakeholders to discuss feasibility of other recommendations that do not require government approval to proceed:
e.g. development of mutual aid agreements, enhancement of strategic partnerships with LHINs and Primary Care and facilitation of one time salary strategy development.
Some recommendations are dependent upon creation of Agency for Health Protection and Promotion:
e.g. development of province-wide public health research and knowledge exchange agenda.
Report is being carefully reviewed by government and a response can be expected in a couple of months.
We look forward to receiving comments and feedback on the report recommendations from this conference.

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
The province-wide job registry and vacancy portal is an example of information sharing through the health work force website.
Particular attention is being made to help increase enrollment in northern and rural public health programs.

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

16. 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
Launched April 22, 2005, the Network will function as a mechanism for intergovernmental collaboration and coordination on public health issues.
The mandate for the Network is two-fold: first, to promote and facilitate F/P/T collaboration on public health issues when needed, and second, to respond to direction from the Conference of Deputy Ministers of Health on any public health matter.
The Public Health Network will allow all governments to work together in public health –resulting in the best use of resources and enhanced responsiveness for Canadians.

17. Conference of F/P/T Deputy Ministers of Health
Network Structure
Expert Groups
(permanent expertise)
Communicable Disease Control
Issue Groups
Emergency Preparedness & Response
Canadian Public Health Laboratory
Reporting through respective Expert Groups on key issues
Conference of F/P/T Deputy Ministers of Health
Council
F/P/T members
Public Health Surveillance & Information
Is accountable to
Chronic Disease & Injury Prevention & Control
Functionally, the Network, through the Council, gets its mandate from and is accountable to the Conference of F/P/T Deputy Ministers of Health. It will report on an annual, and on as needed basis during public health emergencies. The Council provides leadership and oversees the day-to-day business of the Network.
The vast majority of the work of the Network will be executed through a series of Expert Groups and Issue Groups on various public health topics. The Task Force has recommended six initial Expert Groups.
Three of these Expert Groups (e.g. Lab Network and EPR and to a lesser extent, Communicable Disease) already exist and will be integrated into the Network, building on existing expertise and collaborative efforts that are working well.
Population Health Promotion
CCMOH
Task Groups
(time limited)
Public Health Human Resources Task Group
Task Groups

18. Revised 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.

20. 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

22. Process to Develop the Standards

23. Review Process Overview
Ministers
Acting CMOH
Inter-Ministry Committee
(15 members)
Technical Review Committee
Program Standards Development Teams
Expert Advice
Report
Advise
Technical Support
Proposed Standards

24. Review Process Overview – Key Components
TECHNICAL REVIEW COMMITTEE (TRC)
Established to guide the development of renewed standards for public health (term: September 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).

25. 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)

27. Submission and Approval Timelines
APRIL 30
Submission of Standards to A/CMOH
MAY
MHP, MCYS & MOHLTC Review
TBC
Ministers’ Approval
TBC
Release of Standards
Implementation
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

28. The Proposed Standards

29. 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 Standards

31. 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.

32. 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

33. 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

34. Ministry/Board of Health Accountability Framework for Mandatory Public Health Programs
Mandatory Health Programs & Services Guidelines (1997)
Planning &
Evaluation
Setting
Expectations
Monitoring Performance
Assessment
Enforcement
Health Protection & Promotion Act
Education & Consultation

35. 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.
Public Health Performance Management Framework
Source: Final CRC Report, May 2006

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

37. From Compliance to Performance…
1997
2007
Compliance Measurement
Did we do what we
said we would do?
Performance Measurement
Did the program have the
impact we expected?
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?

38. Questions…?