Agenda Item #2 Provincial Council for Maternal and Child ... · Provincial Council for Maternal and...

Provincial Council for Maternal and Child Health | Minutes | February 22, 2016

Attending: Dr. Michael Apkon, Chair, (SickKids); James Meloche (PCMCH); Michael Barrett (SW LHIN); Leanne McCullough (STEGH); Dr. Jane Wilkinson (HHC -

Milton); Dr. Javeed Sukhera (LHSC); Alex Munter (CHEO); Dr. Paul Roumeliotis (EOHU); Dr. Madan Roy (MCH HHSC); Mari Teitelbaum (BORN); Lorraine Sunstrum-Mann (Grandview Children’s Centre); Laura Pisko (MOHLTC);

Dr. Astrid Guttmann (ICES), Vicki Van Wagner (Mid-wife, Toronto); Laurel Silenzi; Debbie Korzeniowski (MOHLTC); Dr. Reena Dhatt (NE LHIN) Teleconference: Karen Ingebrigtson (Firefly)

Guests: Dr. Peter Fitzgerald - Phone (MCH HHSC); Dr. Teresa Bruni - Phone (TBH); Dr. Nan Okun – Phone; Ruth Slater; Erica Gold - Phone

Regrets: Anne Stark, (MCYS); Joanne Plaxton (MOHLTC); Dr. Sean Murray (HSN)

Note: Items are documented in the order in which they were presented

Item Topic Discussion Action / Timeline

1.0 Welcome and Chair’s Remarks

M. Apkon announced the new members joining Council, Vicki Van Wagner and also introduced Laurel Silenzi joining Council temporarily, representing MNAC. M. Apkon noted that a lot had transpired in the last few months.

Gone through the strategic planning exercise, while the MOHLTC Patients First proposal, released back in December 2015, has created new challenges and opportunities.

Conducted a stakeholder session on Feb 12, working through what should be PCMCH’s approach to the Patients First White Paper.

M. Apkon requested a round-table introduction of Council members.

2.0 Approval of Minutes – October 26, 2015 Meeting

M. Apkon asked for the approval of the minutes from the last Council meeting held on October 26, 2015. The minutes were approved by Council, first motion from J. Wilkinson and seconded by L. Sunstrum-Mann. No amendments were made.

Be it resolved that Council approves the Minutes from the October 26th, 2015 meeting.

Provincial Council for Maternal and Child Health

DRAFT Meeting Minutes

Monday, February 22, 2016

1100 - 1600 hours

Atrium Board Room, 1st Floor Atrium, Room #1703, SickKids, Toronto

Agenda Item #2


3.0 Report from the Executive Director

J. Meloche reminded members to complete the evaluation form after Council meeting.

3.1 General Update J. Meloche noted that 3 items were to be discussed, the General Update, Work Plan (3 issues to be raised), and the Financial Report. He asked Council if they had any questions regarding his report – no questions were raised by the Council members.

3.2 2015-2016 Work Plan Update

J. Meloche made note of 3 items on the work plan.

Antenatal records revision – initially was on timelines, but took additional steps to do public consultation through PCMCH members, OHA, several associations and received almost 500 responses back with over 1000 specific suggestions or questions, which will be reviewed by PCMCH staff and committee members. Due to a significant amount of responses from the stakeholder engagement process, PCMCH is taking additional time which has pushed the planned timetable behind. Overall, comments were positive, which mostly related to the format of the antenatal record position, specifically moving it to more than one page.

Quality Assurance Screening – behind on the Maternal Child Screening Committee – starting that process the Fall of 2016, so hoping to be back on track.

Jaundice Education Tool – PCMCH is proposing to move this item off the work plan and make it a part of the deliverable of the post-natal discharge standards project. This was due to feedback received from clinicians who noted that the Jaundice Education Tool needed updating to reflect more recent clinical advice and rather than seeing this as a one-off project, the feeling was to include this within an entire package around the post-natal discharge standards initiative.

J. Meloche asked Council if there were any objections to take the Jaundice Education Tool off the PCMCH work plan, not the deliverable, but moving the item under the post-natal discharge work that is getting underway. A Council member inquired if this would delay the work. J. Meloche stated that this would not delay the work as the post-natal discharge project had just been started and that it would be up for discussion later in the meeting for Council’s approval. It has gone through M-CSC and M-NAC for their review and endorsement. J. Meloche asked if there were any objections from Council. No comments from Council.

3.3 Q3 Financial Report

J. Meloche stated in his general update to Council that there were no issues with the Financial Report as PCMCH is projecting a balanced position.


4.0 Strategic Plan Update

J. Meloche presented a slide deck to Council. He informed them that there was recent correspondence received from the Ministry with regards to the evolution of the Strategic Plan and expectations. The MOHLTC letter, received February 5, 2016, reiterated Ministry’s expectations of an end-state PCMCH structure that is:

1. The voice for Maternal and Child health matters in Ontario supported by strong stakeholder relationships, the promotion of collaboration and trust toward a coherent system represented by PCMCH

2. Leader in system improvement and innovation in enhancing standardization and equity based on the expertise of the expert stakeholders

3. Outcome focused to the development performance measures and key indicators working closely with BORN

J. Meloche informed Council that while PCMCH is in the strategic planning process, the Ministry has stated that 2015-16 and 2016-17 should be seen as transition years. While PCMCH may have a strategic plan, the capacity building that is required or any additional work will continue this year based on the direction of the strategic plan. Council was asked to complete a survey in advance of the April meeting as way of gauging the consensus of members on some of the elements around the mission, the mandate and the vision statements. The summary of that outcome was presented to Council. J. Meloche requested Council’s decision making on a refreshed vision, mission and mandate, looking for endorsement for some key strategic themes to move forward with the next part of the strategic plan and to provide some information to the survey that Council completed based on those items. J. Meloche asked Council if that was a reasonable review of the process that PCMCH has taken on thus far because it would be moving into deliberations around next steps. There was agreement from Council to move forward with deliberations. PCMCH’s mandate remains unchanged from 2009. Some of its functions and some of the terms of reference have been tweaked, but the essential mandate remains unchanged since 2009. In 2014, the terms of reference was revised including some of the mission elements, however, given the stakeholder engagement process that was done, and since many of the Council members and ED were new to this process, it was an opportune time to review those key elements of a strategic plan. PCMCH has enhanced the language of the mission statement from 2009 by adding the key elements around leadership, monitoring, knowledge management and standards to minimize the transformational aspect and see that this is an iterative growth of what PCMCH’s mandate was back in 2009.

Be it resolved that Council approves the following Mandate, Vision and Mission Elements. These elements will be included in the new Strategic Plan to be presented in full to Council in April 2016.

New vision statement proposed - Healthy Babies, Children and Families for Lifelong Health in Ontario.

P. Roumeliotis motioned first and L. Sunstrum-Mann seconded the motion. 9 Council members approved the statement and 2 were opposed.


Using the survey, Council was asked what they felt about the new expanded statement. Generally, there was unanimity with everyone agreeing or strongly agreeing with the recommendations. On the vision statement, the current version is The Best Possible Beginnings for Lifelong Health, which is the same vision statement as BORN. During the external stakeholder engagement and Council strategic planning process, key elements were identified that might allow PCMCH to reconsider that vision statement and generally speaking, the paediatric population in response to the stakeholders, did not see themselves in that vision statement as the maternal population. Stakeholders also wanted to recognize the family as an important part of what PCMCH does. While children and newborns are essential to PCMCH’s focus, it cannot be at the exclusion of the health of mothers, women or of families because they are key elements of that population. 3 options for the refreshed vision element were put forward. J. Meloche presented the summary of Council’s responses and the greatest consensus was on the second option. Trying to find some grounds for consensus, if Council were to agree that family captures the maternal health which includes mothers and women without excluding the gender issues, the statement could be revised to say Healthy Newborns, Children and Families for a Healthy Ontario. M. Apkon asked for some discussion from Council. He gave some history of the first vision statement that dated back to 2008 and felt that the history was important because there were new Council members. He asked for questions and comments from Council. J. Meloche asked that before Council voted, the word newborn be changed to baby, so that it read Healthy Babies, Children and Families for a Healthy Ontario and proposed that option versus the first one which was Best Possible Beginnings for Lifelong Health. Council members discussed regarding option 1. Best Possible Beginnings for Lifelong Health versus option 2. Healthy Babies, Children and Families for a Healthy Ontario. J. Meloche proposed a new vision statement of Healthy Babies, Children and Families for Lifelong Health in Ontario. P. Roumeliotis motioned first and L. Sunstrum-Mann seconded the motion. 9 Council members approved the statement and 2 were opposed. The motion was passed.

5.0 Strategic Themes: Initiatives

J. Meloche updated Council with regards to thinking about the role of what PCMCH does now and what it would like to do more of in the future or what it would like to add to its work in the future. Five strategic themes were presented. 1. Building relationships and collaboration; 2. Creating a system perspective; 3. Developing standards and report progress; 4. Communicating with stakeholders and 5. Impact priority areas. J. Meloche stated that whatever PCMCH does, it should be aligned with its mission, vision statement as well as the actions. PCMCH took the current mission statement, reflected

Be it resolved that Council approves the following Strategic Themes that will be incorporated into the Strategic Plan, helping


on the feedback during the consultation process and then looked at how to maintain or enhance the existing mission statement to reflect that feedback in a more comprehensive way. The proposal for Mission Element 1: Be the provincial forum in which clients, caregivers, clinical and administrative leaders in maternal, child and youth health can identify patterns and issues of importance and improved opportunities in health and healthcare delivery for system support and advice. Overall, there was strong agreement on that statement. There was some reference to the word client that the use of terminology was lacking, so a modified version of that would be the provincial forum in which families and caregivers, clinical and administrative leaders in maternal, child and youth health can identify patterns, issues of importance and improvement opportunities in health and healthcare delivery. Mission Element 2: Improve the delivery and experience of care – the proposed new element reads; Enhance the delivery and experience of maternal, child and youth health care services by engaging patients and families and their care providers in building provincial consensus regarding standards of care, leading practices and priorities for system improvement, and monitoring the performance of Ontario’s maternal and child health system. There was very good consensus on this. There was a question around duplications of role between BORN and PCMCH, but overall there was strong agreement, so J. Meloche proposed no changes to this. Mission Element 3: A trusted leader and voice. This speaks more to the advocacy role and the convener of ideas around the provincial table. PCMCH added the concept that was important around Improve patient experience and overall health system performance. While there was some disagreement, generally 8 participants agreed or strongly agreed. While some time could be spent on this, J. Meloche felt that it would be important to get Council’s opinion on whether to move forward with this or not. Mission Element 4: Mobilize and spread knowledge. This was an area that came very strongly in the stakeholder engagement process which was translating the work at PCMCH to the frontline providers as well as to the consumers of the health system. PCMCH had suggested that the mission statement could be redone to read Mobilize and spread knowledge and tools that will support patients, caregivers, health care providers and planners, improve the health and wellbeing of parents, children, youth and families. There was a good degree of agreement on the mission statement, but there were some concerns around terminology, including mobilizing and spreading knowledge, so it was suggested that it can be rephrased to read Facilitate knowledge to action that will support patients, caregivers, healthcare providers and planners in improving the health and wellbeing of children, youth and families. After some discussion from Council, it was suggested to use the word individual rather than patient or client. J. Meloche agreed that patient and client will be changed to individuals in the final version.

to shape immediate priorities and activities for PCMCH.


A Council member stated that the mission elements were more like mission statements and asked if the strategic themes would become the objectives of Council. J. Meloche agreed that the strategic themes will become the objectives. J. Meloche informed Council about what the next steps might be around the objectives of the strategic plan. The strategic objectives or themes and goals should help close the gap between where PCMCH is today as an organization and where it wants to be in the future. J. Meloche proposed to Council that based on the chart that was done in the October strategic planning session and the project charter that was approved for the strategic plan around building relationships and collaboration, the first process needed is to undertake a governance review. In particular, highlighting the Ministry’s direction to PCMCH, which was to continue to build an inclusive, trustful, collaborative process with stakeholders and is often reflected in the governance work. Part of PCMCH’s work should be around building relationships and collaboration internally, undertake a governance review including how to maximize its effectiveness as a group as well as its representation. There were areas that PCMCH might collaborate with other parts of the system that have come up with the Patients First proposal as well as the Community Mental Health Services and Home and Community Sector. This was for future discussion around creating a system perspective. J. Meloche noted in order to round that perspective, one thing that Council had not yet done was to embrace a framework to engage clients, citizens, individuals and families. He felt it was an important gap that needed to be closed between PCMCH’s vision and mission statement which clearly expressed family, caregivers and individuals and felt the need to develop a framework for patient, individual and family engagement. He stated that PCMCH needed to look into developing an accountability framework, that came out of the strategic plan, which was how to situate PCMCH most effectively within an existing accountability structure, mainly the Ministry and the LHINs, around initiatives and around the Levels of Care for both maternal, newborn and paediatric and how that system is organized and how the system was held accountable through those existing structures. On developing standards and reporting progress, J. Meloche suggested that PCMCH should have a performance framework strategy for Council including key indicators, what is used for evaluation, what is used for internal monitoring and what is also used for external reporting. He suggested a conversation was needed with PCMCH’s partners and with members of its committees. On communicating with stakeholders, he stated that one of the things that PCMCH committed to in the project charter, was developing a communications and branding exercise following the completion of the strategic plan. He stated that there was a need to close the gap with PCMCH’s front-end users, to build an inclusive framework that educates people about PCMCH’s work, it was transparent and they turn to PCMCH for guidance, advice or support and finally, improving impact priority areas. J. Meloche stated that one area PCMCH should be focusing on is knowledge transfer strategy, how PCMCH can better translate the policy work that it does at Council or at its advisory committees to the frontline providers so that it is effectively communicated and utilized and finally, some criteria around a clear roadmap for making decisions on PCMCH’s work plan that can be put forward.


J. Meloche asked Council, notwithstanding the vision statement that was already adopted, for the adoption of the mandate statement, which was as proposed, the only exception was to remove the references that PCMCH was created by the Ministry in 2009. He stated that the mission statement should reflect as proposed, patients and clients, be removed and replaced with the term individuals, so that it would read individuals, families and their caregivers. He also asked for endorsement from Council to continue on with the 5 strategic themes for objectives as PCMCH moves forward in its planning to complete the strategic plan which will come back to Council in April of 2016. M. Apkon asked Council to move the motions and then an open discussion. The vision statement was already settled on, he asked Council to adopt the mandate statement, the mission statement and the 5 strategic themes. L. Sunstrum-Mann was first to move the motion forward and it was seconded by J. Wilkinson. All Council members were in favour of adopting the mandate statement, the mission statement and the strategic themes with the exception of the change around language on patients and families to say individuals, families and their caregivers. None were opposed. No further discussion. M. Apkon stated that in addition to next steps, the terms of reference needed to be revised to make sure that it is aligned with the language that was discussed in the meeting and then be brought back to Council at the April meeting to be adopted.

5.1 Charter: PCMCH Branding and Communications Plan

J. Meloche brought forth to Council two pieces of work related to PCMCH’s branding and communications and performance and measurement framework. On the branding and communications plan, he asked Council to recall back in the early Fall of 2015, PCMCH updated the communications strategy for Council and considered that a draft. It was felt that the work could not be completed until the strategic plan was refreshed around the vision, mission and mandate and developed some of the strategic priorities. PCMCH would like to move forward with the piece of work called the Branding and Communication Plan with the objective of closing the gap between how PCMCH describes and reframes itself and what hits the ground. He asked Council to look at the charter around the aims statement. The aims statement is to raise awareness, to engage and inform stakeholders in the role of PCMCH and Ontario’s maternal and child healthcare system, to increase its reach and to clarify the image held by the minds of PCMCH stakeholders, not just those directly involved, but those who PCMCH seeks to influence, assist or reach and provide clear differentiation of PCMCH and the role as a key voice for maternal child healthcare system. J. Meloche went on to inform Council that the communications and branding work is a key enabler to do some of PCMCH’s other pieces of work around from its reach, the knowledge transfer work as well as to engage the end-users of the system and their care providers. He proposed to Council to take advantage of the information from the stakeholder engagement that was done for the strategic plan and use that to help shape some of the work around branding and communication because it would be relevant. He also informed Council what also would be discussed is a potential name change for PCMCH.

Be it resolved that Council approves the Branding and Communications Plan project charter, as circulated.


The goal would be to work with Council, taking the direction from the Charter and coming back to Council both in April and more firmly in September, with a proposed and refreshed brand including PCMCH’s visual identity that would match with the release of the strategic plan. It is a critical time for PCMCH to complete the strategic plan and then do the communication and branding piece. PCMCH has staff that have professional expertise in this area as well as some small consulting work to help do the focus groups. PCMCH has approximately $15,000 in the budget to do some of the focus group work. J. Sukhera stated that he thought the idea of leveraging the resources that had gone into the stakeholder engagement made sense, but asked the question if it had to happen now or would it be better for Council to flush out what it is establishing as a strategic direction in Council before getting into branding and communication. The other concern that he stated was there was an area that Council had not done much on that was addressing what was happening with mental health in Ontario. He stated that to internally support resourcing a communications plan when Council had not done anything relating to mental health was difficult. M. Apkon added that it could be valuable to establish what the specific priorities are that would then fold into the communication plan as opposed to focusing on branding first. The second item that J. Sukhera was raising was that this was a matter of priority in terms of attention and money doing this as opposed to other things that might be on the plate. Council members continued to discuss further. M. Apkon stated that the most immediate issue was to work through how to communicate PCMCH’s strategic vision and the work that was just approved. He suggested that it be a starting point that could be brought back to Council with a plan around that piece which manages the scope of the work that could be expanded, but also manage the scope both in terms of time and money and it would allow Council to weigh in and have further discussions about that at the next meeting. J. Meloche agreed with M. Apkon’s suggestion.


5.2 Charter: Performance and Measurement Framework

M. Apkon asked that the discussion be deferred on the Performance and Measurement framework. He stated that the Patients First discussion had some urgency because PCMCH was in the final days of public commentary and he felt that it would be important to provide some time for feedback. J. Meloche agreed to defer, but informed Council that there are ongoing discussions with HQO and BORN. Further, that PCMCH has refreshed its benchmarking report and is discussing issues with BORN around how to align measurement work and take advantage of that. J. Meloche asked Council if they would be comfortable, without having to take a formal vote, to get endorsement to move forward with the ground work with the project charter. M. Apkon asked the Council members if they were comfortable with J. Meloche’s request. Council was agreeable. The item was deferred for April’s meeting.

Item was Deferred but endorsement was received to move forward with the ground work with the project charter

6.0 Patients First Summit J. Meloche stated that the participant feedback was very positive. PCMCH prepared a report that

summarized some of the key findings that would be submitted on Council’s behalf through PCMCH to the Ministry for its consideration. Themes were broken down to 3 client populations, maternal and newborn health, early childhood, and child and youth services. PCMCH had particular themes for each of those populations, did a matrix to provide a summary of those recommendations back to the Ministry where it lumped the key recommendations around informed choices for parents, patients and families, inter-professional collaboration, culturally sensitive and appropriate services, the development of a comprehensive prevention strategy, the integration of patient perspectives and exploring innovative solutions to the funding model of maternal newborn health. Those were the 6 themes that were pulled from the entire day that spanned across those 3 individual and family populations. J. Meloche stated that he would like to have Council answer two questions: 1. Shall we move forward to present this report to the Ministry on behalf of the participants of the Feb 12 event? 2. Are there additional elements not articulated in the above report that Council would like to consider specifically as it speaks its mandate as PCMCH? For example, does Council want to provide advice to the Ministry on the organization, structure, funding for maternal and child health care services in Ontario that are relative to the Patients First proposal? And shall we submit that advice in a separate report that speaks on PCMCH’s mandate? M. Apkon asked the members if anyone had reservations about J. Meloche’s first proposal which is to deliver the detailed report of what came out of the Patients First Summit just as the work product of a collaborative day, the challenges and opportunities without necessarily endorsing it or singling out any specific recommendations. It is a broad stakeholder engagement opportunity that provides input with a particular lens on children and mothers. Council agreed it should be sent to Ministry.


J. Meloche stated that PCMCH would like to post it on-line, as well as all the information and the panel presentations. PCMCH has approval from the participants that any of the material for that day could be available on-line. M. Apkon stated it was data that was collected from productive stakeholder engagement session. It is not a specific recommendation coming from the Council. He stated that the proposal would be to submit it as this is the work product of this day and that it represents a range of stakeholder perspectives across the set of important issues that the government might benefit from the input on. He stated that the second issue warrants more discussion which if Council does want to make specific recommendations that ought to be incorporated as the LHINs, the government, CCAC and primary care think through their individual and collective responses to the Patients First white paper. After discussion from the Council members, M. Apkon stated that the decision was made to send the summary document. He stated that it comes down to whether or not Council will submit a letter to the Ministry with some high level considerations for them to incorporate into their thinking. He stated that he didn’t think that Council had sufficient time to give government a model to embrace. He stated that four items were coming out of the conversation from Council. 1. Unless there is a perspective on maternal/child care that is deliberately focused there that there would likely be unintended consequences of trying to incorporate them into a broader approach that will be overwhelmingly influenced by the other end of the age structure. 2. There needs to be approaches that work across the LHIN and subLHIN boundaries because of the dynamics of the children’s healthcare system and the fact that expertise is highly concentrated, at every point along the continuum, so there needs to be approaches that work across those levels, but works back into them in a way that builds capability and doesn’t move the problem away from them, but helps to support them. 3. It is important to get it right. Investments in maternal/child care have a lifelong impact on the health of the population and the unintended consequences that we might suffer, have a long-term impact for not only the citizenry but also the advisory healthcare system down the road that will have to deal with unintended consequences. 4. Offer to work with government to look at models that might help address those first three points. Keep it at that very high level. J. Meloche stated to Council that PCMCH can draft up correspondence that reflects those points that were made earlier, and that the letter will be circulated to Council with a quick turn-around time and focus on an offer to help in the future without necessarily laying out a specific role for PCMCH.


6.1 Summit Report Back See 6.0 above.

6.2 Key Considerations – PCMCH Feedback to the Patients First Proposal

See 6.0 above.

7.0 Complex Care for Kids Ontario Update

L. Kitchen gave an update to Council on the current implementation of CCKO to discuss the work being done with communication strategy and also the work in parallel around the CCKO evaluation, the family engagement sessions and then continuing to build CCKO’s momentum, and next steps for CCKO. L. Kitchen provided slides and spoke to Council highlighting milestones that have been achieved to date since starting implementation in the Fall of 2015. Since the last Council meeting in October 2015:

An evaluation symposium was put together in November 2015.

Drafted, completed and submitted from the local tertiary partners, the business plans for how the funding will be allocated that will be received.

Provincial evaluation group had first initial kick-off meeting and now looking to the future as to how to build momentum locally and have implementations developed at each of the four paediatric health regions.

Slide was presented in October 2016; however, it was prior to having it endorsed by the CCKO Leadership Table partners. It is the funding for both the readiness assessment and the implementation that will carry CCKO through for the next five years and it is proportionally determined based on the number of kids that meet the CCKO criteria. Across the province there are just over 6,200 kids.

Described in the proposal, the model of care for coordination, trying to get an understanding from each of the centres and each of the regions how they are going to use their funding. For year 1, each region received $30,000 for their readiness assessment development and the total for year 1 is just over $600,000. For year 2-5, it is over $1,000,000.

L. Kitchen showed slides and spoke to Council regarding CCKO’s Business Plan specifically around the resource plan as well as partner accountabilities. Jennifer Churchill will be joining the CCKO table for the next meeting on March 8, 2016. PCMCH will work with M. Barrett to find a LHIN representative to join CCKO Leadership Table. Communications strategy: Meetings were held with all four of the regional hospitals and it took place in November – December 2015. Feedback was incorporated into the Strat plan.


All the hospitals agreed that they are going to establish a local working plan and the plan was reviewed and was endorsed at the last leadership team meeting on January 14, 2016. Council received the one page communiqué which CCKO was using to disseminate to all of the partners and also had a question and answer pamphlet that talks about what the vision of CCKO is, what it is not, and how families are being engaged as well as local stakeholders. L. Kitchen presented Council with slides on the Evaluation Update and what are CCKO’s next immediate steps. Amongst other items, in September CCKO is partnering with SickKids to do a family engagement session as they work towards the celebration of their 10th year milestone in complex care. M. Apkon asked that as CCKO thinks through the measurement approach that was spoken about, there was a need to make sure that it captures some aspect of impact on utilization, as that was one of the key objectives of the Ministry and stated that he felt it will be key to sustainability.

8.0 Low Risk Maternal Newborn Strategy Update

P. Nigam informed Council that work was in progress and there will be more of a substantial update at the next meeting. There were no questions from Council.

9.1 a Maternal Newborn Advisory Committee Update

L. Silenzi and P. Nigam presented an update to Council regarding MNAC. Regarding the vaginal birth after caesarean (VBAC) project, there was a strong response from the call for nominees. The Coroner’s Request 2014-12803 – Feasibility of prostaglandin availability in Ontario hospitals was discussed as M-NAC as a potential work group. The objective of the work group would be to develop recommendations regarding access to PGE1 and relevant educational tools to support hospitals and providers, working under the advice of a neonatologist, to provide prostaglandin therapy when required for management of neonates suspected of having a ductal-dependent congenital cardiac defect. A draft project charter was developed in collaboration with the chair of the Maternal-Child Screening Committee for M-NAC review and approval in the April 2016 M-NAC meeting. The MNAC indicator/scorecard is in the early stages of development and will focus on three major items: breastfeeding, mother-baby dyad care and retro-transfer.

9.1 b Post-Natal Care Project Charter

M. Apkon requested Council’s approval of the post-natal care project charter. P. Nigam introduced Diana An, senior program manager, who will be leading the post-natal care project. This project is about developing standards for post-natal care for mothers and babies in the immediate postpartum period and looking at interventions such as newborn screening, hearing screening and physical exams. It is a joint initiative by both the screening committee as well as MNAC and they have both approved the project charter. It has a timeline of one year, March 2016 – March 2017.

Be it resolved that Council approves the Standards of Post-Natal Care for Mothers and Babies, as presented.


It is on the agenda for approval from Council. M. Apkon asked if Council had any reservations about adopting on this charter. No comments from Council.

9.2 a Committee Update A. Munter stated that there wasn’t a need to discuss the CYAC update as Council had the documentation in their package. Most of the committee’s agenda has migrated to the main Council agenda.

9.2 b Hospital Paediatric Levels of Care Update and Implementation Considerations

Drs. P. Fitzgerald and T. Bruni, Co-Chairs of the Paediatric Levels of Care Work Group, and B. Guttman, Senior Program Manager, provided a status update regarding the group’s activities (slides distributed). The update included content specific to the draft levels, considerations pertaining to medical/surgical acuity and ASA scores, a brief overview of DI/Allied Health requirements and how the framework will be positioned within a systems of care approach. It was noted that potential system indicators have also been identified. A comprehensive vetting process is now underway with:

Senior clinical and administrative representatives from hospitals (complete)

Critical Care Services Ontario (complete)

CritiCall Ontario (complete)

Tertiary Leadership (beginning of March) Input was sought from Council members regarding implementation considerations including:

How should LHINs be engaged in the implementation process?

Should accountability be built into the process, for example, through hospital accountability agreements?

What should the process be if a hospital is currently functioning at one level but wants to change to a lower level?

What should the process be if there is a question about a hospital’s self-assessment? The following points were raised in the discussion:

There are several lessons that can be learned from the implementation of the Maternal/Newborn levels of care including building accountability into the process as soon as designation occurs and having a process for changing levels once they have been defined – if that is even permitted.

In response to the question regarding whether the group addressed bed capacity within the work, it was acknowledged that paediatric inpatient resources are limited and have decreased over the years, likely in part due to patients being managed on an outpatient instead of inpatient basis. As paediatric units have become smaller, this has had an impact on critical mass and the expertise in taking care of paediatric patients. It is hoped that implementation of the levels of care will help achieve adequate paediatric critical mass and expertise in community hospitals by facilitating working within a system of care (so that patients are not automatically “leapfrogged” to a higher level of care unless necessary) and repatriation of patients to the level of care needed.


The point was raised that in order to have sustainable levels, capacity planning needs to be included in the process. It was reiterated that the group’s mandate was to define and set standards for the levels of care; that being said, it is recognized that this is a process, one that creates a common lexicon on which broader system planning, integration and quality improvement can occur in the future.

One way to drive the dialogue may be to include organizational obligations in the designations, for example, paediatric nursing requirements, child life competencies, etc., that are essential in order to provide safe and effective paediatric care.

Paediatric staffing also has applicability to the provision of newborn services. There may be opportunities to leverage technology such as Telehealth to help deal with staffing issues in newborn and paediatric units and even EDs. When paediatric services are reduced, major issues occur in how other services are resourced.

All agreed that the LHINs need to be involved earlier in the process (than for the maternal newborn levels) because they are responsible for capacity planning/management at the local level; the right structure therefore needs to be created which will be key to the success of implementation.

The Levels of Care committee will take this feedback from Council members as they move forward in developing implementation approaches which they will bring back to Council for final approval.

9.3 a Committee Update Council members did not have any questions about the M-CSC update previously distributed in the agenda package. The key items requiring discussion are included below.

9.3 b Confirmation of Future Prenatal Screening Target

N. Okun, Co-Chair of M-CSC, provided an overview about the process used by M-CSC members to select

Rh and Kell Antigen status as a future prenatal screening target; the work would involve completion of

an in-depth review of the literature and work done in other jurisdictions regarding prenatal screening for

this target. Upon completion of the review, the information will inform the development of a report and

recommendation for submission to the MOHLTC regarding whether or not this target should be included

as a systematized prenatal screening target in Ontario.

Currently, all mothers for whom there is a possibility of having Rh incompatibility with their fetus are treated with Rhogam (RhiG) which is used to prevent fetal hemolytic disease or anemia in untreated women. In Ontario, 14,244-21,376 Rh negative unsensitized women/year get RhIG at 28 weeks - in case the fetus is RH positive and are at risk for disease. These women get repeat testing during pregnancy and at birth to measure the levels of Rh antibodies in the blood. Approximately 40 % of Rh negative unsensitised women who are receiving Rhogam (RhiG) have fetus that are also Rh negative meaning that they receive Rhogam RHiG and repeat testing unnecessary. The screening test to determine Rh and Kell Antigen status specifically tests the fetus for its Rh status, using non-invasive prenatal testing (i.e. tests fetal cell free DNA circulating in maternal serum). The test is administered at 11 weeks gestation; its sensitivity is 96.8 (CI 94.9-98.0) and specificity is 94.4 (CI 91.5-96.3). Should the test show incompatibility with the mother’s status, RhiG is administered. The screening test therefore allows for

Be it resolved that Council approves identification of Rh Incompatibility as the Prenatal Screening Target that will move to the next step of completion of an in-depth review in order to determine whether or not a recommendation should be made to the Ministry that this target be included as a systematized prenatal screening target in Ontario.


targeted treatment and prevents a large number of women from receiving unnecessary treatment. In Ontario, a cost and outcomes analysis is being conducted by an expert group consisting of a Haematologist with expertise in haematological disorders during pregnancy, a Fetal Medicine expert who works with affected patients, a Maternal Fetal Medicine specialist with expertise in prenatal screening, laboratory staff with expertise in cell free fetal DNA (the test used to determine Rh status) and a Health Economist. In addition, at the recent Canadian Perinatal Research Meeting, there was great interest in building a Canadian Consensus group to push this initiative forward nationally. Representatives at that meeting included Maternal Fetal Medicine, Genetics, Lab Genetics and Canadian Blood Services (Western provinces). It was noted that in Sweden, this screening has become routine. The plan is to submit a consensus statement to one or more sites to call for the development of this screening nationally, likely via Canadian Blood Services or its agencies in different provinces. Both of these pieces of work will be critical components of evidence gathering and will help inform the deliberations. The following points were raised in the discussion:

Even if done nationally, each province would have some degree of uniqueness re: how the test is processed

It was noted that historically, PCMCH has had a role in recommending screening, for example, pulse oximetry testing for CCHD, severe combined immunodeficiency (SCID)

This work would need to include collaboration with the Ontario Health Technology Advisory Committee (OHTAC), Health Canada and others, both provincially and nationally, who are also considering this as a future target.

9.3 c Prenatal Screening Strategy Progress Report

J. Meloche mentioned that J. Clarke was on teleconference to discuss the development of the prenatal screening strategy. There was an SBAR in Council’s briefing note and a group of provincial stakeholders had been assembled to review various options around how to organize and govern a strategy. PCMCH is in the process of doing that work and hope to have something back to Council in April 2016. He asked Council if there were any questions on the briefing note in their package. Council members gave their comments. A point was raised noting that a very tertiary care based approach is often taken, whereas the world of primary care and those in the North is very different. Primary care/family physicians deliver a lot of the care that we are talking about - antenatal and postnatal care, and 90-95% of the paediatric care. Despite this, there is no standard for what should be done/how (e.g., 18-month well-baby visit) across the province. The primary care providers don’t know what these guidelines/recommendations are about and there are no links/ pathways. There may be a lot of well-baby/well-mother recommendations, but they are not done. M. Apkon commented that this point highlights one of the challenges that is the difference between knowing and doing. The focus of the group has been mostly on reviewing the knowledge base to determine what can be introduced as recommended standards, but the group has struggled with knowledge translation. One of the things that came out of the strategy


work is to focus on how recommendations can be introduced in ways that will promote more consistent practice and continuous learning at all levels. Don’t have to look at it as tertiary versus primary care, but instead should try to figure out what does the continuum look like and how do you collectively make decisions that will drive consistency. J. Meloche added that there are primary care providers involved in the prenatal screening strategy in order to make sure that the perspective of frontline providers is included. He acknowledged that this work is only as good as it is interpreted by the people who are delivering the care, and so this is something that the group will continue to work on. J. Meloche welcomed any suggestions regarding resources and other bodies of work that could be leveraged to help with this.

9.4 Maternal Child Transport Advisory Committee Update

M. Apkon commented that for informational purposes, an update from M-CTAC went out to Council and asked if there were any questions. No comments or questions were raised by Council.

9.5 a Recommendations Report from PDN Transition to Adult Care Working Group

Co-chairs from the PDN Transition to Adult Care Working Group were not able to attend the Council meeting. The endorsement of items 9.5a and 9.5b were discussed simultaneously.

9.5 b Recommendations Report from PDN Mental Health and Psychosocial Working Group

A. Gatto introduced the co-chairs of the PDN Mental Health and Psychosocial Working Group. Dr. Ruth Slater, who attended the Council meeting in person, and Dr. Erica Gold, who attended the meeting via teleconference. The co-chairs from the Transition Group were not able to attend the Council meeting. A. Gatto asked for Council’s endorsement for the two reports being put forth by the Paediatric Diabetes Network. These reports were circulated and have gone through an iterative development and review process with the two working groups. CYAC had also provided some feedback on the reports in 2015. Both reports were developed by working groups whose membership had broad representation both geographically and by specialty. A. Gatto asked for endorsement from Council for the Mental Health and Psychosocial Care Working Group report. There were 7 recommendations put forth at the patient, program and the system level.

J. Meloche asked A. Gatto what the next steps are if endorsement is provided.

A.Gatto responded that the group would look to conduct a prioritization exercise of the recommendations put forth to determine which ones are most feasible, important and relevant for the paediatric diabetes education programs. They would move forward to conducting a process with the working group to identify the implementation plan for those priority recommendations. Council members made some comments.

A.Gatto noted that the staffing benchmarks for the paediatric diabetes education programs had been reviewed in 2010 and is still based upon numbers from 2000, so it is something that would need to be reassessed. This work ought to be led by the LHINs as they are responsible for allocating funding and program accountability. It is not within the scope of the network to make these changes.

For Endorsement from Council for the Mental Health and Psychosocial working group report.

Back to the committees for prioritization around implementation efforts. Update to be provided at next Council meeting.


J. Meloche informed Council that the recommendations go back to the committees for prioritization around implementation efforts. M. Apkon asked if Council had reservations about endorsing the report and allowing the committees to go through and choose those priorities. J. Meloche informed Council that PCMCH would be happy to receive additional comments following the Council meeting. Any feedback would be sent back to the working groups.

10.0 Quality Based Procedures (QBPs) Update

J. Meloche informed Council that there were short briefing notes in their packages and he asked if there were any questions or comments from Council. Some comments were made by Council.

Summary M. Apkon asked Council if there was any other business to discuss. No further discussion from Council. M. Apkon summarized the Council meeting. The strategic plan – Council adopted the vision mandate and mission elements and have asked J. Meloche to bring a revised ToR to the next meeting. Strategic themes around branding and communications – J. Meloche and PCMCH team will focus on communicating Council’s strategy as a starting point and to think about where that would go with respect to the rest of the elements of branding and communication. Deferred the discussion of performance measurement framework until the next meeting. Patients First - PCMCH will submit the materials from the summit, as the product of the summit, and draft a one-two page letter that will look at the unintended consequences if Council doesn’t address the needs of children and that it will look at the need to work across LHIN and SubLHIN boundaries and offer to work with Ministry in ways that will help figure it out over time and keep it at a very general level. Good discussion about CCKO and looking forward to watching the progress. The Level of Care discussion – there is a piece around implementation of the development of standards that is still getting worked through- the implementation is going to be part of where the challenges are and there may be a need to spend some time on a capacity assessment and development piece. The MCSC approved the work around Rh and Kell Antigen and encouraged the group to work with OTAC and others at the federal and provincial level. Pushed forth the recommendations on the Diabetes Network.

M. Apkon adjourned meeting until April 18, 2016, and informed Council there would be an in camera discussion. M. Barrett requested a one page summary of the Council meeting and it was agreed upon by J. Meloche.

One Page Briefing Summary of the Council Meeting to be Circulated.

11.0 Adjournment

12.0 In Camera

Next Meeting Monday, April 18, 2016, 11:00 am – 4:00 p.m. in the Atrium Board Room, SickKids.

Agenda Item #2 Provincial Council for Maternal and Child ... · Provincial Council for Maternal and...

Documents

Transcript of Agenda Item #2 Provincial Council for Maternal and Child ... · Provincial Council for Maternal and...