ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic

 

3. Findings

3.9 Operational management

Background

Previous sections have addressed what worked well and areas for action across eight specific areas of response activity. This ninth section addresses the overall operational management of the response by the Public Health Agency of Canada and Health Canada, more specifically, issues of governance, emergency management and corporate services during the pandemic.

What worked well?

Key structures, resources, relationships, plans and tools were in place

Critical building blocks for the response had been worked out prior to the pandemic, including the creation of the Public Health Agency of Canada, the appointment of a Chief Public Health Officer of Canada, the existence of the National Microbiology Laboratory, and the development of the Canadian Pandemic Influenza Plan for the Health Sector, the Federal Emergency Response Plan, the Health Portfolio Emergency Response Plan and a Health Portfolio Emergency Operations Centre. Networks and tools such as FluWatch, the Global Public Health Intelligence Network, the Canadian Network for Public Health Intelligence, the Canadian Adverse Events Following Immunization Surveillance System, and the Canadian Public Health Laboratory Network were also up and running (as described in section 3.1, Surveillance, science and research). On the international front, the International Health Regulations and the North American Plan for Avian and Pandemic Influenza also helped lay the foundation for the Health Portfolio response to the H1N1 pandemic. A more recent addition, the Avian and Pandemic Influenza Preparedness Program, an interdepartmental federal initiative coordinated by the Public Health Agency of Canada, was also instrumental in preparedness (as described later in this section).

Staff showed remarkable dedication and endurance

It is important to acknowledge the enormous commitment, hard work and professionalism of staff across the Public Health Agency of Canada and Health Canada. For those directly involved, this often meant extremely long hours that included evenings, nights and weekends, dealing with the challenges of adjusting to extended hours, as well as balancing work with personal and family responsibilities and obligations. Unfortunately, in some cases, this resulted in fatigue, high levels of stress, burnout and staff departures. For those not directly involved in the response, it may have meant frustration at the inability to get attention for their important files. As one interviewee noted:

I don’t think we were prepared for how fast this took over our lives. But I think what took everybody by surprise – and not only our group – but what took everybody by surprise was the fact a pandemic was declared so quickly, that it had started in North America, and that Canada knew that it had something novel, from coast to coast – in other words from the west coast to the east coast – that happened overnight. (…) in the course of – and my memory may be a bit off on this – but in the course of six hours, we had gone from confirming that novel influenza existed in the (…) East coast – to within six hours later of being confirmed that it had hit the West coast.

The Health Portfolio’s initial response to the first wave of the pandemic had an exponential tempo. The Health Portfolio Emergency Operations Centre was activated quickly and ran 24 hours a day and seven days a week for about three weeks. To provide a sense of the intensity and length of effort for just one area of the Public Health Agency of Canada that was involved in the response, Figure 3.9.1 displays the activation levels of the Emergency Operations Centre, and the accompanying hours of operation, over the 237 days of activation from April 22, 2009, to February 10, 2010.

Figure 3.9.1 Description of H1N1 activation levels in the Emergency Operations Centre (EOC)
H1N1 Activation 2009-10
22-Apr 23-Apr 26-Apr 15-May 29-May 22-Jun 29-Oct 10-Feb TOTAL
Activation Level Activation Level 2 Activation Level 3 Activation Level 4 Activation Level 3 Activation Level 2 Activation Level 2 Demobilization of H1N1 Response
Number of Days at Activation Level 1 3 20 15 16 93 (managed by Taskforce) 69 237
08:00 -17:00 08:00-00:00 24 hours/day & 7 days/week 08:00-20:00 08:00-17:00
Hours of Operation Monday-Friday with on-call
Rotation 1: 08:00-16:00
Rotation 2: 16:00-00:00
Command Staff
Rotation 1: 07:00-19:00
Rotation 2: 19:00-07:00
General Staff
Rotation 1: 07:00-15:00
Rotation 2: 15:00-21:00
Rotation 3: 21:00-07:00
08:00-20:00 with on-call. May 16th-18th inclusive, the EOC was staffed from 09:00-17:00 EDT with continued 24/7 on-call coverage in all functional areas. Monday-Friday with on-call
No. of Rotations Hrs No. of Rotations Hrs No. of Rotations Hrs No. of Rotations Hrs No. of Rotations Hrs No. of Rotations Hrs
Rotations 1 8.5 2 8.5 Command Staff 11.5 General Staff 8 1 13.5 1 8.5
2 3
Identified IMS Function Day one staff complement unknown 48 28 4 41 37 13 32
FTEs/Day 96 56 12 41 37 13 32
Person Days 288 1,120 240 615 592 1,209 2,208 6,272
Person Hours 2,448 12,880 1,920 8,303 5,032 10,276 18,768 59,627

This effort represents just one piece of the response. It does not include: the Communications, Policy and Operations Groups within the Incident Management System; the Human Resources Directorate; members of the Health Portfolio Executive Group; technical experts in the Centre for Immunization and Respiratory Infectious Diseases; staff at the National Microbiology Laboratory; the work done by the Public Health Agency of Canada’s Regional Operations in regional coordination centres across Canada; or any of the Health Canada efforts.

A financial framework for pandemic influenza had already been established

Federal Budget 2006 provided $1 billion over five years to improve Canada’s general preparedness to respond to the threat of pandemic influenza. This included $600 million for the Avian and Pandemic Influenza Preparedness Program, and $400 million for a Pandemic Contingency for the Public Health Agency of Canada, Health Canada and the Canadian Food Inspection Agency to address short-term pressures associated with the elevated risk of pandemic influenza. The existence of this contingency allowed the Health Portfolio to access needed resources to implement additional activities in response to the pandemic. Contingency resources for 2009-10 and 2010-11 were accessed for the first and second waves of the pandemic.

Although the policy framework for access and use of the contingency was helpful in guiding the principles and triggers for accessing resources, the process for accessing the contingency was viewed by some as cumbersome and lengthy. Options should be examined to streamline access to the contingency reserve.

Internal communications with staff began early and was extensive

During the H1N1 pandemic, internal communications played a large role in keeping Health Canada and the Public Health Agency of Canada’s employees informed of current events and expectations regarding health issues and work priorities. Communication activities with employees began on April 24, 2009, and continued well into 2010. For instance, Public Health Agency employees were sent messages from the Chief Public Health Officer and the Associate Deputy Minister in a variety of formats and an employee toolkit was developed to provide information on the response, and its implications and opportunities for employees.

Areas for action — Governance during significant public health events

Given the involvement of so many organizations during the pandemic, coordination of decision making and information sharing was complex, challenging and time consuming. It will be helpful for future response efforts to continue to clarify structures, roles and responsibilities, as well as decision-making and approval processes at various levels.

Examine the Incident Management System used in the Health Portfolio Emergency Operations Centre and adapt it for future responses

The H1N1 response was the first time the Health Portfolio’s Incident Management System was fully implemented by the Health Portfolio Emergency Operations Centre, which is managed by the Public Health Agency of Canada (see Figure 3.9.2). The Incident Management Structure is a key component of the System. Clarity of roles and responsibilities, accompanied by clear operating procedures, is critical. Special attention should be paid to further clarifying the division of operational roles and responsibilities across all aspects of emergency response between the Public Health Agency of Canada and Health Canada. Similarly, during a public health event, the respective roles of the Health Portfolio Emergency Operations Centre and the Government Operations Centre, managed by Public Safety Canada, need to be reviewed and formalized. It will be important to ensure a shared understanding of how the Incident Management System used during a significant public health event relates to ordinary business-as-usual governance structures and business processes.

Develop a common understanding of the decision-making process during an emergency when public health and public policy issues intersect

Not surprisingly, at times throughout the pandemic, some of the public health decisions that were required had public policy implications. Sequencing guidelines is one example where public health and public policy issues intersected. Going forward, it will be important to ensure that there is a shared understanding between federal/provincial/territorial Ministers, the Public Health Agency of Canada and Health Canada, as well as central agencies, of decision-making roles, processes and timelines in emergency situations.

Look for opportunities to streamline briefings and meetings involving senior management

During the pandemic response, senior managers were immersed in a myriad of briefings and meetings for various existing and new structures (known internally as the Executive Business Cycle). In some cases, the number of briefings and meetings was higher than expected.

For instance, from May 1 to December 24, 2009 (171 calendar days), eight of the Public Health Agency senior managers very involved in the response attended a total of 1,030 meetings and briefings. The situation was similar for Health Canada senior managers. Four types of pandemic-specific meetings required the most involvement of senior managers:

  • Health Portfolio Executive Group (141 meetings)
  • Minister of Health’s Office (94 briefings)
  • Federal/provincial/territorial Special Advisory Committee (74 meetings)
  • “Four Corners,” which included the Public Health Agency of Canada and Health Canada senior managers, the Minister of Health’s Office, the Privy Council Office, the Prime Minister’s Office, Public Safety Canada and the Minister of Public Safety’s Office (71 meetings).

It is important to note that significant infrastructure is required to manage and maintain the Executive Business Cycle (e.g. scheduling, preparation of agendas and records of decision, development of briefing materials). The daily schedule was packed and the timing between meetings/calls was often very tight. There seemed to be good systems in place for agendas and records of meeting discussions and decisions; however, there is room to improve on being clear up front on the precise purpose of the meeting and specific agenda topics of the various teleconferences and meetings. This effort will assist in determining which senior manager or technical expert is best suited, and required, to attend. Attempts should continue to be made to reduce the burden of calls and meetings on senior managers, to the extent possible.

Senior managers still needed to attend regular meetings that were not pandemic-specific. One example is “Daily Update”, which is an ongoing forum for Public Health Agency senior management discussion and decision making concerning issues that pose significant risk to the health of Canadians, or other risks to the Minister, the Public Health Agency of Canada or its employees. There were 153 Daily Update meetings during the same time period.

The number of meetings and briefings peaked during the height of vaccine discussions in October 2009.

Figure 3.9.2 Example of the Incident Management System

Text Equivalent - Figure 3.9.2

This organization chart is composed of four levels.

The Health Portfolio Executive and Policy Group are at the top, supported by an Executive Liaison Officer with a Briefing Unit Group.

The second level is headed by the Emergency Manager who is supported by the Deputy
Emergency Manager, and liaises with the Primary Department Agency Officer.

The third level, reporting to the Emergency Manager, is composed of: a Legal Officer, Communications (which also reports directly to the Health Portfolio Executive and Policy Group), a National Security Advisor, Field Epidemiology Support, a Regional Representative and Other Government Department and International Liaison personnel.

The fourth level is composed of four functional groups, each with its own Chief who reports to the Emergency Manager:

  1. The Operations Group Chief leads: Public Health Measures, Infection Control, Surveillance, Epidemiology and Labs, Geographic Information Systems, the Global Public Health Intelligence Network, Travel and Borders (comprising Quarantine and Conveyances), Workplace Health and Safety, Vaccines, Clinical Care and Antivirals, Zoonoses, Briefing Coordination and Antivirals Purchase.
  2. The Advanced Planning Group Chief addresses: Public Health Measures, Infection Control, Surveillance, Epidemiology and Labs, Travel and Borders, Workplace Health and Safety, Vaccines, Clinical Care and Antivirals, and Zoonoses.
  3. The Coordination and Logistics Group Chief coordinates: an Emergency Operations Centre Support Unit Leader, an Emergency Operations Centre Manager, Technical Information Technology Support, Geographic Information Systems, a Logistics Support Unit Leader, a Senior Emergency Team Operator, an Emergency Team System Administrator, a Registration Officer, Records, Clerical, Reception and an Electronic Information Officer.
  4. The Finance and Human Resources Chief leads: an Emergency Finance and Administrative Officer, Human Resources and the Workplace Health and Public Safety Program Employee Assistance Program.

In addition, Health Portfolio senior managers prepared H1N1 briefings for the House of Commons Standing Committee on Health and participated on calls with Committee members. The Committee held a total of 13 meetings under the topic of “H1N1 Preparedness and Response” between August 12 and November 25, 2009. The meetings started with two ministerial appearances in the summer of 2009 (the House of Commons was on summer recess). Canada’s Chief Public Health Officer appeared as a witness on both occasions. Most of the meetings were used as general briefings for Committee members. Senior officials from the Public Health Agency of Canada and Health Canada would typically appear for one hour, give an overview of activities of the last week, and then answer questions from members. In total, Public Health Agency officials appeared on nine occasions.

There were also 27 briefings with Opposition critics. Members of Parliament also visited the Health Portfolio Emergency Operations Centre.

Based on the H1N1 experience, as well as other recent significant public health events (such as the 2008 listeriosis outbreak), the Public Health Agency of Canada and Health Canada should prepare for intense briefing requirements. In the future, consideration should also be given to possible streamlining and simplification of the briefing process. In addition, a liaison function should be put in place to ensure that a senior advisor is assigned to each senior manager at all key meetings to ensure post-meeting information sharing and briefing, as well as follow-up on action items arising out of meetings. The consistency and continuity of this kind of support to senior managers is essential.

Continue to distinguish roles and responsibilities among the Public Health Agency of Canada’s senior executives

The independent investigator into the 2008 listeriosis outbreak recommended that an Associate Deputy Minister position be created at the Public Health Agency of Canada to act as the second-in-command and assume a Chief Operating Officer role “to allow the Chief Public Health Officer to focus on his executive duties and responsibilities as the lead health professional of the Government of Canada in relation to public health.Footnote 69 An Associate Deputy Minister was assigned to the Public Health Agency of Canada in September 2009 and this helped to support the response to the second wave.

An event like the H1N1 pandemic demands, to some extent, the time and attention of all senior managers: Chief Public Health Officer (Deputy Head), Associate Deputy Minister (sometimes referred to the Executive Vice-President and Chief Operating Officer), Senior Assistant Deputy Minister of the Programs Sector (to whom the Assistant Deputy Minister of Infectious Disease Prevention and Control reports), and Assistant Deputy Minister of Emergency Management and Corporate Affairs (staffed as of June 2010). With these positions in place, it continues to be important that stakeholders and staff clearly understand the roles of the members of the senior executive group during significant public health events.

In addition, further clarity is needed on the respective roles of the Director General of the Centre for Emergency Preparedness and Response and the Director General of the Centre for Immunization and Respiratory Infectious Diseases during a pandemic. This leads into the next point.

Distinguish roles and responsibilities within the Public Health Agency of Canada between the emergency management and the operations groups

Roles and responsibilities were sometimes blurred among various functions within the Public Health Agency of Canada, such as emergency management and the operational group (in this case, immunization and respiratory diseases). Given the requirement for timely and informed decisions, the operational group often provided key input into the decision-making process; however, this involvement had the potential to cause the perception of encroachment on the roles and responsibilities of emergency management and to affect working relationships and staff morale. Therefore, clear roles and responsibilities should be assigned with an explicit delineation between the emergency management and operational/program parts of the pandemic response. A formal decision-making process should be followed at all times.

Areas for action — Corporate support during significant public health events

Put mechanisms in place to ensure responsiveness of the Public Health Agency of Canada’s corporate services

Some pandemic response activities were affected by a lack of sufficient capacity in a variety of internal corporate services such as human resources, procurement, accommodations, facilities management, personnel security screening, information management/information technology, executive correspondence, and janitorial and catering services. Work should be done to improve the responsiveness of corporate support at times when the Public Health Agency of Canada is called on to address significant public health events.

Pay particular attention to policies, plans and procedures for human resources management

As employees are at the heart of the response to any public health event, a standardized, yet flexible, model for managing human resources during emergencies is critical. This effort includes rapid and sustainable capacity management (identifying, mobilizing and demobilizing staff). The Health Portfolio Emergency Response Plan outlines some human resources management responsibilities, including:

  • providing advice on staffing, hours worked, leave, standby, deployment, overtime, childcare entitlements, management of stress and right to refuse dangerous work during an emergency
  • hiring casual or temporary staff as required
  • tracking time of personnel involved
  • processing claims for compensation
  • arranging for Employee Assistance Program services
  • arranging for employee crisis intervention and counselling, as needed.

The Public Health Agency of Canada’s Human Resources Directorate, which had experienced many changes prior to the onset of the pandemic, was understaffed. When the need to significantly increase Public Health Agency capacity became apparent during the pandemic, the Human Resources Directorate was not initially able to provide services such as staffing support in a timely fashion.

Through the course of the pandemic, the Public Health Agency of Canada’s Human Resources Directorate capacity did improve and provided important supports to the response, including:

  • making sure that the working conditions of Public Health Agency employees were respected and that deployed employees were covered with the necessary protection and insurance
  • consulting with union representatives and collective bargaining agents
  • negotiating agreements with the Public Service Commission for expedited hiring processes.

These Human Resources Directorate contributions were essential and should be considered in the planning of human resources management for future pandemic responses.

The Public Health Agency of Canada is currently implementing an overarching People Management Framework that includes an emphasis on emergency/event human resources management. A number of important areas should be considered, including:

  • sources for surge capacity, including within the Health Portfolio
  • succession planning (including senior executives, as well as medical and technical experts)
  • identification of essential, critical and key positions
  • tracking of financial expenditures (for preparedness or response activities)
  • shift work capacity
  • consultation with unions
  • employee assistance programming
  • insurance providers.
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