1. Barbara Raymond Maura Ricketts (presenting) Jess Rogers Lisa Paddle Valerie Palda Jill Skinner PHPC CPD Event 9 June 2013

2. Research Funding 1.National Collaborating Centre for Infectious Diseases M. Ricketts 2.Public Health Agency of Canada PHAC Centre for Effective Practice Canadian Medical Association 1

3. 2 PH response successful – Health care system strained – Front line health care provider planning did not advance as far as PH post-SARS Post H1N1 need to establish strategies & processes – guidance development rapidly & despite limitations of evidence – knowledge translation for front-line clinicians clinically relevant – communication with front-line clinicians information designed for clinical care providers Lessons Learned: 2009 H1N1 pandemic

4. 3 Strategy needs to be established now, in “peacetime”, to ensure an effective response during a PH emergency Strategy could be tested during inter-pandemic periods e.g. seasonal influenza, novel corona virus etc. Strategy should serve all-hazards response Lessons Learned: 2009 H1N1 pandemic

5. 4 Goal of Project 1 Evidence Review of Health Systems Strategies to Respond to 2009 pH1N1 – Literature review – Synthesis report

6. Health Systems Strategies 1.Linkages between Primary Care and PH (PH Lead) – Create processes, governance & capacity during inter- pandemic period – Integration of HC provider needs into pandemic planning – Health care system oriented surveillance 2.Diversion (Health Care Lead) – of the public away from the formal HC system through self-screening, expanded anti-viral access etc. 3.Triage (Health Care Lead) – Tools used in clinical settings to separate urgent from non- urgent 4.Medical Surge Management (Health Care Lead) – Emergency response plans, extension of HCP roles, human resources management etc. – Duration of surge management is extended 5

7. 6 Goal of Project 2 Maximize HCP clinical knowledge about how to effectively treat their patients by … Improving the quality and timeliness of clinical guidance provided to Canadian health care providers (HCP) … during an influenza pandemic/PH emergency… through the development of a strategic plan describing 1.infrastructure 2.processes & 3.products for clinical guidance 1.creation (guidance development) 2.communication, Dissemination and Implementation 3.evaluation made for Canada’s social, political, geographical and economic realities & … using what we already have | not “reinvent the wheel”

8. What is “Guidance” Guidance includes but is not confined to Clinical Practice Guidelines (CPG) CPGs are distinguished by practice of limiting the recommendation based on evidence Some guidance is relatively stable e.g. respiratory precautions Some guidance will be based on rapidly evolving and changing information, iterative and unstable 7

9. 8 Guidance Development Working Group (GDWG)  4 Meetings  10-12 Members Guidance Development Working Group (GDWG)  4 Meetings  10-12 Members Guidance Development Process and Tools 1.Pre-Pandemic 2.Intra Pandemic Guidance Development Process and Tools 1.Pre-Pandemic 2.Intra Pandemic Communication and Dissemination 1.Strategy 2.Plan (tactical ) Communication and Dissemination 1.Strategy 2.Plan (tactical ) Communication and Dissemination Working Group (CDWG)  4 Meetings  10-12 Members Communication and Dissemination Working Group (CDWG)  4 Meetings  10-12 Members Evaluation Framework Output Structure Advisory Committee 4 Meetings + attending Consultation Workshop 15-18 Members (TBC) Advisory Committee 4 Meetings + attending Consultation Workshop 15-18 Members (TBC)

10. – Dr. Bonnie Henry (BCCDC) – Dr. Adam Steacie (CMA – Madeleine Ashcroft (CNA) – Susan Bowles (CPharmA) – Dr. David Allison (CPHA) – Dr. Val Rachlis – Kristin Stewart (CHNC) – Dr. Allison McGeer – Dr. Cecile Tremblay (INSPQ) – Dr. Brian Schwartz (PHOn) – Dr. Barbara Raymond (PHAC) – John Wooton (SRuralPhysC) – Dr. Reka Gustafson (UPHN) Advisory Committee

11. CEP Team – Dr. Valerie Palda – Jess Rogers – Caroline Higgins WG members – Dr. Todd Hachette (AMMI) – Dr. Daniel Kollek (CAEP) – Dr. Michael Christian (CCS) – Yvone Burland (Nursing, FNIHB) – Alfred Gin (Pharmacy, CPhA) – Dr. John Maxted (CFPC) – Patty Lindsay (guidance specialist) – Michael Bingley (nurse practitioner) – Irmajean Bajnok (RNAO) – Dr. Eliana Castillo (SOGC) – Althea House (PHAC) Guidance

12. Guidance Development WG Modifications to existing guideline methodology to adapt to the needs of a guidance process used during a pandemic Products 1.Guidance Inventory 2.Search & AGREE II assessment 3.Inter-Pandemic Guidance Process (Handbook) 4.Pandemic Expedited Guidance Process (Handbook) 11

13. CMA Team – Dr. Maura Ricketts – Jill Skinner – Marion Fuller Supported by Survey Group – Lynda Buske – Anna Murphy Dow WG members – Dr. Bonnie Henry (BCCDC) – Dr. Jane Brooks (CMA) – Coleen Brooks (CNA) – Elizabeth Moreau (CPS) – Eric J Mang (CFPC) – Dr. Ada Bennet (PHPC) – Erin Henry (FNHIB) – Dr. Lee Donohue (OMA) – Cecilia Van Egmond (PHAC) – Nicole Kain (researcher) – Natalie Wright (SOGC) – Jess Rogers (CEP) Communications, Dissemination & Implementation

14. Goal 1.Develop a strategy for the effective delivery of clinical guidance to HCPs providing front-line clinical care during influenza pandemics. 2.Make recommendations regarding 1.the structure and processes needed to efficiently deliver clinically-relevant knowledge products (HCP- adapted clinical practices) to front-line HCPs 2.identify and propose solutions for the management of communication barriers to the adoption of the knowledge products by end-users

15. Framework Development Examine the ‘lived experience’ of HCP using published information from pH1N1 Identify strategies used during pH1N1, implemented after pH1N1 or recommended following pH1N1 Identify strategies (of known effectiveness) to address those barriers Information sources – In principle, using peer-reviewed KT/implementation literature – In practice, using published reports – Surveys

16. K2A: Evidence-based input Lavis et al. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Quarterly, 2003

17. 16 If we know what clinicians prefer in general, what would they have preferred to have during pH1N1? What worked?

18. Framework for Report (1) Products (1.1) Tailored communications products (1.2) Evaluation (2) Processes (2.1) Joint planning and collaboration (2.2) Delegation of clinical decisions to HCPs (2.3) Improved intergovernmental communication (3) Infrastructure (3.1) Creation of structures to serve HCPs (3.2) Improve PH’s capacity to link with the acute-care system

19. Preliminary Data from Stakeholder Surveys Jill Skinner (Public Health Group, CMA) Lynda Buske & Anna Murphy Dow (Surveys Group, CMA)

20. Stakeholder Organization Survey 48 Surveys sent 68 Responses (140% response rate!) Preliminary Results 71% produce guidance 62% developed guidance during pH1N1 94% willing to distribute guidance 72% could distribute emergency guidance in <24 hr 70% prefer email channel 19

21. Stakeholder Organization Survey Structured queriesWhat do they want? Emerging Clinical Information (98%) Expert Review (90%) Infection Control (84%) interventions /treatment (82%) special populations (68%) Algorithms (90%) Email bulletins (94%) Summary Guidance in 2-5 pages (92%) Web-based updates (90%) Email (86%) Websites (73%) 20 Important Supports Guidance for Preferred formats Preferred routes

22. Survey of Individual HCP Based on 559 ResponsesDistribution Survey distributed through 6 national HCP organizations, FNIHB, Centers for Effective Practice newsletter Target audience: – Physicians – Nurses – Pharmacists 21

23. Survey of Individual HCP What do they want?Preferences (74%) Interventions/treatment (71%) Infection Control (67%) For special populations (94%) Email bulletins (92%) Summary guidance in 2-5 pages (90%) Web-based advisories (79%) Decision trees or algorithms (77%) Point form (89%) Email (55%) Dedicated website (9%) Social media (58%) PHAC or HC (50%) Prov/Terr (50%) International (48%) Local PH 22 Most requested guidance Top 3 formats Preferred layouts Preferred Channels Where would they look?

24. 23 Thanks to the Project Team CEP Jess Rogers Valerie Palda Caroline Higgins CMA Maura Ricketts Jill Skinner Marion Fuller Emilia Nowakowska PHAC Barbara Raymond Althea House Cecilia Van Egmond Lisa Paddle Maura Ricketts Director, Public Health Group Health Policy & Research Directorate Maura.Ricketts@cma.ca

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26. Critical to achieving our goal Broad range of health care professionals providing influenza care (e.g. family physicians, nurses, ER physicians, pharmacists, intensivists) Engage stakeholders throughout the project to understand needs, identify capacity and build from expertise Identify solutions for Canada Identify role/considerations for stakeholder organizations and individuals in the final deliverables 25

27. 26 Draft Deliverable: Handbook Overview Proposing a literature-based process modified to reflect pandemic needs o Building from existing, validated methods to ensure broad acceptance Guidance vs. Guidelines o “Guidance” is an umbrella term used to describe clinical recommendation documents of which a subset fit into the category of “guidelines”. The Handbook uses the broader term “guidance” so as to be inclusive of relevant prior work and potential future products that may not meet criteria for the term “guidelines”.

28. 27 Draft Deliverable: Handbook Overview Assumptions [from CEP meeting on Apr 17] Vaccines and antivirals are always separate Teleconferencing is a webinar Pandemic and Inter-pandemic processes are different but similar Pandemic evidence is always very low quality Faster is more expensive [from Handbook] A secretariat is required To meet sorter timelines, resources are available to provide facilitated relay of information to the Guidance Panel Commitment from Panel members to complete work between meetings

29. 28 Draft Deliverable: Handbook Section 1: Guidance Inventory: Preparing the Way Purpose: Assists [future Guidance Panel?] members to reflect on the quality of guidance developed These tables would become an inventory of recommendations – Consider that it become a searchable database (not static spreadsheet) Lays foundation for the development of a workplan that is efficient and responsive to the inter-pandemic and pandemic needs

30. 29 Draft Deliverable: Handbook Section 2: Inter-Pandemic Guidance Process Purpose: Through a cyclical workplan, a Panel reviews, maintains, updates, discards existing guidance in inventory of recommendations, and identifies novel topics which require evidence-based recommendations Guidance Panel undergoes a similar but different guidance development process that will be used in pandemic times o Benefits include: developing capacity of Panel members to develop guidance; building a reserve of individuals that can be called upon to develop guidance in pandemic situation; maintenance of relevant guidance that can be readily disseminated in [first wave?] pandemic situation

31. 30 Draft Deliverable: Handbook Section 3: Pandemic Expedited Guidance Process Purpose: A parallel process to the Inter-pandemic process that builds from European CDC technical report that addresses developing guidance when (1) timelines are short, and (2) required to use low quality evidence. Explicitly outlines the logistics of developing guidance for influenza care in a time of pandemic.

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33. Scope for Project 2 Will not develop, communicate or disseminate clinical guidance Will describe infrastructure needs, process requirements and products Will produce value for stakeholders (organizations and individuals) by describing – their guidance needs (content, channel & presentation) e.g. knowledge translation and knowledge transfer (KT) – the characteristics of processes that lead to seeking, trusting and using guidance e.g. implementation principles of fidelity & uptake 32

34. Section One: Principles of Communication Activities of Knowledge to Action (K2A) 1.Engagement & Communication – Identify the barriers – Brainstorm on solutions – Figure out how to maximize impact 2.Dissemination – Identify the target audience – Tailor the message and the medium 3.Implementation – Develop practical solutions that improve behavior oriented ‘access’ to the communication – Maximize Fidelity &Uptake

35. Step-wise Approach Use Knowledge to Action frame to identify the barriers to the effective dissemination and uptake of clinical guidance to front-line HCPs before, during and after a pandemic. Identify strategies of known effectiveness to address those barriers. Recommend a process, in sufficient detail and reflecting the realities of the Canadian health care system, that identifies effective communication channels and required resources for optimal guidance dissemination to the targeted populations. Provide recommendations regarding inter-pandemic strategies to engage stakeholders in the dissemination process, so that these individuals and groups may be ready in the event of a pandemic. Recommend a procedure to secure standing agreements for the activation of these channels of communication in the event of a pandemic.

36. Section One: Principles of Communication Knowledge to Action (K2A)

37. K2A: Implementation Elements in Action Plan 1.Target audience for the guidance 2.Key messages that explain why they should care 3.Categories of engagement to identify what are you asking them to do e.g. adopt a practice, promulgate and champion a practice, developer, owner, create a community of practice, practitioner etc. 4.Methods/tactics e.g. videoconferencing, teleconferences, website, grand rounds, mentoring, toolkit for providers, toolkit for patients, accredited CME etc. 5.How will you measure success? Plan to measure and measure in order to plan 6.Potential partners for producing products, developing and managing processes, and adapting or developing infrastructure 7.Where is the ‘home’ for your guideline and related materials? Who will take care of it until it is needed? 36 Awareness of guidance, practice, innovation etc Agreement with guidance, practice, innovation, etc Adoption try out the guidance etc in your setting Adherence abide by the new practice on all appropriate occasions Model for Change

38. K2A: Engagement Barriers & Facilitators “Knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators” Grimshaw, 2012 Barriers can be identified from the literature and our experiences e.g. (Légaré, 2010)  Confusion about roles and expectations of HCPs, PHP  Stodgy financial instruments  Legislation, regulations, policies, practices and standards that cannot respond to an emergency  Overestimating the availability, capacity and ability of individuals to respond  Underestimating the need for pre- pandemic ‘testing’ of ethics, training, and agreements with unions and licensing bodies 37

39. TABLE III Barriers (Légaré, 2010) Confusion about roles and expectations of HCPs, PHP Stodgy financial instruments Legislation, regulations, policies, practices and standards that cannot respond to an emergency Overestimating the availability, capacity and ability of individuals to respond Underestimating the need for pre-pandemic ‘testing’ of ethics, training, and agreements with unions and licensing bodies TABLE III Barriers (Légaré, 2010) Confusion about roles and expectations of HCPs, PHP Stodgy financial instruments Legislation, regulations, policies, practices and standards that cannot respond to an emergency Overestimating the availability, capacity and ability of individuals to respond Underestimating the need for pre-pandemic ‘testing’ of ethics, training, and agreements with unions and licensing bodies “During the H1N1 pandemic, there was a need for rapid, clear and authoritative clinical advice”. Dame Deidre Hines “During the H1N1 pandemic, there was a need for rapid, clear and authoritative clinical advice”. Dame Deidre Hines THEME Characteristics of desired products: Trusted source Reliable quality Reliable process Timely Brief Targeted to audience Clinically relevant THEME Characteristics of desired products: Trusted source Reliable quality Reliable process Timely Brief Targeted to audience Clinically relevant THEME: Establish plans “well ahead of any crisis” Alternate care site for remote regions Priority setting mechanisms for policies Negotiate data gathering requirements with clinicians ahead of time THEME: Establish plans “well ahead of any crisis” Alternate care site for remote regions Priority setting mechanisms for policies Negotiate data gathering requirements with clinicians ahead of time THEME: Clinical protocols are needed in order to preserve a consistent level of care THEME: Clinicians should guide clinical care The content of the Report will be used in Strategic Planning Table and Flow Diagrams:

40. Organization of the Report Section 1: Principles of Communication – an overview of the existing evidence about how to communicate with health care providers – KT, KTA and the emerging field of Implementation Science will be a source of evidence-based processes and methods Section 2: Environmental Scan: What was said? – Understand HCP communication requirements through the recorded experiences of pH1N1 2009 – Survey to test thesis Section 3: Environmental Scan: What was done and recommended? – Structured catalogue of products, processes and infrastructure that were used during pH1N1 or recommended post-pH1N1