1. SUMMARY OF PROGRESS REVIEW

• The intent of the review was to assist the Ministry of Health to further mitigate COVID-19 risks, improve co-ordination and ensure support for the sector moving into the fall and winter; as well as to identify opportunities to strengthen the funding and contracting models used by health authorities. In November and December 2020, the ministry began incorporating the progress review’s observations and recommendations into ongoing planning and efforts to better respond during a second wave, and into its work on longer-term changes for the sector related to funding and contracting.
• Ernst & Young (EY) conducted interviews with more than 40 stakeholders from the ministry, health authorities, BC Centre for Disease Control, seniors’ associations, care home operators, care providers, Hospital Employees’ Union (HEU), and several groups of managers and front-line staff. The first interview was conducted July 9, 2020, with the ministry's Seniors Services Branch, and the last interview was September 8, 2020 with the BC HEU. 
• Research also included a review of ministry policy and operational documents related to COVID-19, as well as data from the BCCDC, federal government and World Health Organization.
• The EY progress review highlighted the success of B.C. in managing and responding to COVID-19 as evidenced by the lower infection and mortality rates compared to other large provinces, lower death rates in community care facilities, and solid outbreak management. However, the intent of the review was to seek suggestions from key stakeholders for how the ministry could further strengthen its oversight, coordination and support for the sector for fall and winter. 
• EY organized its observations into four focus areas: governance and decision-making; policy; operations; and workforce. Within each area, strengths are identified, as are opportunities for addressing perceived gaps. EY made 14 short-term, and five long-term recommendations for consideration by the ministry related to the observations and suggestions from the stakeholders.
• A full list of Ministry of Health actions arising from the report follows. 
• The progress review has been used to further inform immediate actions and will also inform longer-term actions by the ministry to strengthen the performance of the sector in the care of seniors.

2. OBSERVATIONS, RECOMENDATIONS AND MINISTRY OF HEALTH ACTIONS

Governance and Decision-Making

Strengths

• A united and consistent presence by the minister and provincial health officer led to greater adherence and compliance to public health recommendations.
• Rapid mobilization of emergency response structures brought key leaders and representation from across the sector together, enabling effective information sharing, and issues identification.

Opportunities for Improvement

• The Health Emergency Coordination Centre (HECC) could have been better integrated into provincial decision-making and accountability frameworks, resulting in decisions being better coordinated, and addressing the decision-making powers and accountabilities of the HECC.
• Perception that the oversight, management, and support available to providers depended on whether a facility was health authority owned and operated or operated by a private or not-for-profit provider; inconsistent messaging amongst providers.
• Lack of centralized oversight, coordination and access to PPE supply in the early stages of the pandemic.
• Limitations on accessing LTC and AL sector data.

Ministry of Health actions

• On Sept. 9, 2020, while work was underway on the review, the ministry released the Management of COVID-19: Health Sector Plan for Fall/Winter 2020/21, the plan for the ongoing management of the COVID-19 response over the fall/winter: https://news.gov.bc.ca/files/COVID-19_fall-winter_preparation.pdf
• Early fall, the ministry established a streamlined COVID-19 Response and Health Emergency Management Division (CRHEM) to replace the HECC to improve coordination, decision making and oversight.
• At the same time health authority VP COVID-19 operational leads were put in place. Starting in late-November, the leads began to meet daily with the ministry, to focus on addressing challenges in acute and home and community care sectors, to enhance co-ordination, collaboration and data-sharing to strengthen decision-making, communication with the LTC sector. The ministry is using a weekly check-in with industry associations as a vehicle for increased communication, co-ordination, and policy discussions.
• Centralized supply chain, including provincially co-ordinated PPE access and supply, is now in place for the LTC/AL sector.
• The ministry had already begun work on several new data reporting structures to assist with both short-term and long-term collection of health human resource and financial data to better inform policy directives; these actions align with issues identified in the report. An example is the interim LTC monitoring tool that was introduced in late summer.
• Starting in November 2020, the ministry took additional action to enhance communication and coordination. This included increased contact with VPs pandemic/public health/ministry and a daily HA Daily Operations Check-In. The ministry continues its weekly meetings with the LTC sector.

Policy

Strengths

• BC’s policy responses were largely effective, both in the initial development of policy and the ongoing updates and revisions as necessary.
• The benefit of rapid development of policies, PHO orders, and other guidance, particularly recognizing the value of critical policies such as the single site order, wage leveling, visitor restrictions, and interfacility transfer guidelines as contributing significantly to reducing the spread of the virus in LTC/AL homes and in the community.
• Guidelines related to visitor restrictions and resident outings were seen as effective in limiting the spread of infection.

Opportunities for Improvement

• Provincial policies sometimes lacked detail which led to operational variations as policies were interpreted by regional authorities. 
• Policies, guidelines and directions were created and released at a fast pace, based on the rapid growth of the pandemic, which often resulted in challenges to implementation and didn’t always consider operational constraints. Policies could be continuously evolved in the context of the changing pandemic.
• Policy challenges were communicated to contracted and private care providers through different means, and private operators reported feeling they were given less implementation support. The above was made more difficult by the ministry and health authorities having limited visibility into operations, and challenges in collecting some human resource and financial data.
• Care providers were sometimes unclear on governing body roles and authorities and were sometimes unsure who had primary authority when orders differed between the ministry and health authorities. Guidance from public health and the ministry could be more co-ordinated to mitigate this.

Ministry of Health Actions

• Communication structures have been improved and strengthened over the fall to ensure direction related to policies, public health guidance and other expectations is clearer when shared with health authorities, facility operators, and others. In December 2020, health authorities implemented weekly meetings with operators in their region to enhance communication. The ministry meets at a minimum weekly with the industry associations. When possible, policy changes are discussed and communicated in advance — in mid-November policy directives were updated for admissions, transfers, in-facility respite and adult day programs based on various potential COVID-19 scenarios and are being implemented. Measures such as the long-term care visitor guidance was released on Jan. 7, 2021, and is an example of the ministry’s commitment to improving communications on policy interpretation.
• The ministry had begun work on several new data reporting structures to assist with both short-term and long-term collection of health human resource and financial data to better inform policy directives; these actions align with issues identified in the report.

Operations

Strengths

• On-site support and the physical presence of health authority leaders at outbreak sites was noted as beneficial where adopted.
• Operators provided with health authority representation to manage media interest found this support helpful.

Opportunities for Improvement

• Operators reported a variation in timeliness and quality of support across health authorities for facilities experiencing outbreak.
• Operational variation arising from differences in interpretation of policy implementation and practice requirements could be minimized by clear and standardized direction.
• Gaps in Infection Prevention & Control (IPC) and emergency preparedness knowledge and training in LTC and AL.

Ministry of Health Actions

• Outbreak prevention and management protocols were embedded in the COVID-19 Lower Mainland Operational Management Response finalized Dec. 14, 2020. These outbreak prevention and management protocols have now been shared across all health authorities.
• Health authorities now deploy outbreak management teams to support facilities experiencing an outbreak, including the implementation of an outbreak management plan, additional staffing when needed, and ongoing support throughout the outbreak.
• Also, through the COVID-19 Lower Mainland Operational Management Response, the Ministry of Health has directed health authorities to provide daily updates on situations across facilities including any staffing challenges; IPC challenges; and other outbreak prevention activities. Health authorities work with long-term care operators to ensure infection prevention and control expectations are clear, and health authorities support any training or resource needs.
• Health authorities have established a process for improved operator communication through health authority leads, which includes all provider types within their geographic region, and maintains regular communication with operators to improve oversight of operations and better ensure consistent application of policy direction.
• Work is now underway to develop and introduce a new quality assurance and funding framework for the LTC sector to be complete by the end of the 2021-22 fiscal year.

Workforce

Strengths

• Early implementation of workforce-related policies, including the single-site order and wage-leveling policy had a significant and positive impact on reducing the overall spread of infection.

Opportunities for Improvement

• Identify and address pre-existing human health resource shortages, exacerbated by COVID-19.
• IPC and emergency preparedness were not at an adequate standard when the pandemic started. This lack of preparedness in the LTC and AL sectors highlighted an absence of clear and consistent practice on the proper use of PPE, lack of PPE stockpiles in facilities, and a gap in direction on how to handle (i.e., cohorting) residents who tested positive for COVID-19.
• The rationale for collecting personal health and other data was not well understood and contributed to a perception of the ministry’s lack of trust in operators' ability to report outbreaks.
• Real time supply chain data was not readily available, leading to reduced oversight and inefficient management of supplies.

Ministry of Health Actions

• The Ministry of Health will maintain the single-site order, as it is demonstrating a benefit within the sector.
• Using B.C. and national experience gained from COVID-19, the current staffing framework, which was developed in 2008, is actively being reviewed. This work will be linked into the new quality assurance and funding framework for the LTC sector.
• The Health Careers Access Program launched September 2020, will better address health care worker staffing challenges in long-term care and assisted living over the medium to long term.
• Centralized PPE procurement and supply is in place and will remain in place for all facilities.