Toronto Public Health Plan for an Influenza Pandemic

[Michael Hardner]

Since healthcare is offered to the public as a state-controlled monopoly, it is essential that we the consumers of health services pay close attention to ensure that services are run properly. Towards that end, I have been more than curious as to how Toronto (and other jurisdictions) experienced large line ups and confusion.

In looking into this problem, I happened across the City of Toronto website:

http://www.toronto.ca/health/pandemicflu/pandemicflu_plan.htm

Chapter 19 has it all laid out, in arithmetic that a high school student can understand.

Staffing Scheduling

Scenario 1A – 4 Week Immunization schedule utilizing internal and external staff with Alternate Immunizers 12 Hours per Day

Scenario 1A is based on a total complement of staff available to TPH.

1 MIC opened 12 hours per day, utilizing 30 immunizers, would allow THP to immunize 3,690 clients per day. 41 MICs opened 12 hours per day, utilizing 30 immunizers per clinic, would allow THP to immunize roughly 151,290 clients per day. To immunize 2.5 million people it would take 16.5 days with 41 MICs opened 5 days a week (see Appendices 19.4 MIC Summary Staffing Table for 12 Hour Work Day and 19.6 Total Number of Days Required to Use Available Vaccine).

Scenario 1B – 4 Week Immunization schedule utilizing internal and external staff with Alternate Immunizers 16 Hours per Day

Scenario 1B is based on a total complement of staff available to TPH.

1 MIC opened 16 hours per day, utilizing 30 immunizers, would allow THP to immunize 5,040 clients per day. 41 MICs opened 16 hours per day, utilizing 30 immunizers per clinic, would allow THP to immunize roughly 206,640 clients per day. To immunize 2.5 million people it would take 12.1 days with 41 MICs opened 7 days a week with 2 shifts per day (see Appendices 19.5 MIC Summary Staffing Table for 16 Hour Work Day with 2 Shifts and 19.6 Total Number of Days Required to Use Available Vaccine).

Scenario 2 – TPH staff only

Scenario 2 is based on the premise that all positions would be filled by THP staff.

1 MIC opened 12 hours per day, utilizing 20 immunizers, would allow THP to immunize 2,460 clients per day. 6 MICs opened 12 hours per day, utilizing 20 immunizers per clinic, would allow THP to immunize roughly 14,760 clients per day. To immunize 2.5 million people it would take approximately 169.4 days (3.5 months) with 6 MICs opened 7 days a week (see Appendices 19.7 MIC Summary Staffing Table – TPH Staff Only).

Scenario 3 – TPH staff plus additional external staff

Scenario 3 is based on the premise that all positions would be filled by TPH staff, except for Security Services and immunizers.

1 MIC opened 12 hours per day, utilizing 15 immunizers, would allow THP to immunize 1,845 clients per day. 10 MICs opened 12 hours per day, utilizing 15 immunizers per clinic, would allow THP to immunize roughly 18,450 clients per day. To immunize 2.5 million people it would take approximately 135.5 days (2.8 months) with 10 MICs opened 7 days a week (see Appendix 19.8 MIC Summary Staffing Table – TPH & Additional Staff).

If you look at the document, the plan looks fairly solid. See the staffing tables at the bottom.

I can't find any reference to which Scenario was selected, however we know that 10 MICs opened initially - which follows Scenario 3.

http://www.toronto.ca/health/cdc/h1n1/clinics.htm

City of Toronto - Influenza Pandemic Home Page

http://www.toronto.ca/health/pandemicflu/index.htm

If you're up to solving the mystery of where the plan went wrong, dive in and Google yourself some information - post here if relevant.

[Michael Hardner]

Check that - under scenario 3 - each MIC (Mass Immunization Clinic) would be open 12 hours.

According to this - they're open 6 hours per day.

City of Toronto - Clinic Schedules

Hmmmm.... so far, it looks like the staff did their job, and provided some solid plans, and the city went with the 2nd slowest roll-out, then only provided 1/2 the hours of service. The plot thickens.

[Michael Hardner]

Another email to the government, this time the media relations coordinator for the City of Toronto.

Hello Susan,

I received your contact from this page: http://www.toronto.ca/health/media/relations.htm. I'm a Blogger with Maple Leaf Web - Canada's Premier Political Education Website. http://www.mapleleafweb.com/forums//index.php?showuser=201

I'm writing a story about Toronto's H1N1 planning effort and have a few questions:

From Chapter 19 of the Public Health Plan - 4 scenarios are described for establishing clinics in Section 4.0:

http://www.toronto.ca/health/pandemicflu/pandemicflu_plan.htm

"Scenario 3 is based on the premise that all positions would be filled by TPH staff, except for Security Services and immunizers.

1 MIC opened 12 hours per day, utilizing 15 immunizers, would allow THP to immunize 1,845 clients per day. 10 MICs opened 12 hours per day, utilizing 15 immunizers per clinic, would allow THP to immunize roughly 18,450 clients per day. To immunize 2.5 million people it would take approximately 135.5 days (2.8 months) with 10 MICs opened 7 days a week (see Appendix 19.8 MIC Summary Staffing Table – TPH & Additional Staff)."

Questions:

How was the scenario selected and when was that decision made ? Which scenario was selected from the plan ? Based on the number of clinics - it seemed to be the case that scenario 3 was selected - however the clinics are not opened for 12 hours per day as outlined in that scenario. Why is that ?

How many immunizers are available at each MIC ?

What were the estimates for the numbers of Group 1 persons to receive the vaccine and how was that number arrived at ? What were the actual numbers ?

Thanks for your consideration,

Michael Hardner

To: Susan Sperling

Media Relations Coordinator

Tel: 416-338-7974

email: [email protected]

This sounds like I'm taking up some kind of banner, and I suppose I am. But I'm doing it because various people in the system are not doing their jobs. I'm very sad that I have to be the one to ask these questions - but there clearly is nowhere in the media where I can find out answers. Go ahead and try to find out how many immunizers are at each MIC, or who made the decision to open 10 MICs for 6 hours.

These are decisions that affect our lives each and every day, yet there's no feedback, and no response when anything goes wrong. If my Big Mac is cold, I can take it back right away and get it fixed. What do you do if the city has poorly executed a pandemic plan ?

[capricorn]

What do you do if the city has poorly executed a pandemic plan ?

You say that your supply of vaccines will run out.

Some immunization clinics in Ontario may have to close in the next few days because the province's vaccine supply is expected to run out by the end of the week.

Health Minister Deb Matthews can't comment when each health unit is expected to run dry but said the situation means many in the high priority groups won't get their flu shot for a while.

http://www.680news.com/more.jsp?content=20091105_064339_6188

Ontario received 2.3 million doses. According to the Globe only 322,000 have been administered. The only way clinics will run out "in the next few days" is if they can't accept a shipment because they don't have the facilities to store the vaccine before it spoils.

http://www.theglobeandmail.com/life/health/h1n1-swine-flu/more-than-half-of-vaccine-doses-sitting-in-storage/article1351752/

Something doesn't add up.

[Michael Hardner]

Shorter lineups yesterday and today.

http://www.cbc.ca/canada/toronto/story/2009/11/02/toornto-h1n1.html

Still - why did they go with Scenario 3 ?

[Michael Hardner]

Update - nothing has come back from my inquiries via 'contact us'.

From all reports, though, it seems that the crowds may have been due to non-priority people not being screened in the first week, coupled with media hype and general low-level panic.

Although it seems like there was a plan in place, we the public and our agents the media aren't asking specific enough questions, especially when things appear to go wrong.

[eyeball]

Update - nothing has come back from my inquiries via 'contact us'.

The inability to deliver a response could be for several reasons, most of which should be neither here nor there. Above all else making our institutions more transparent will have to involve making them more physically accessible. Things like your experience should be auditable and taken together with other client experiences to score or rate the institution. When a particular government departments accessibility score drops below a certain point, it should trigger more rigorous methods of making its information available, such as regular data dumps in which all internal memos, emails amd meeting minutes etc can be posted. If this still doesn't work then 3rd party independant human observers or process guardians if you will should be deployed to oversee that departments operations first hand.

From all reports, though, it seems that the crowds may have been due to non-priority people not being screened in the first week, coupled with media hype and general low-level panic.

Although it seems like there was a plan in place, we the public and our agents the media aren't asking specific enough questions, especially when things appear to go wrong.

You're making it sound like its all your's and the media's fault. It's not.

I think media hype is something we need to control, not the media but the hype. I think as 'agents' of ours they have served us very poorly by feeding the panic. I suspect the reason why is that the media is no more capable of getting timely information than we are. Of course they still have a product to sell so they either just make stuff up or create new often inappropriate contexts in which what they do know can be re-presented differently - like anyone they use their imaginations to fill the gaps. If everything within the public's domain was actually made public in its entirety, the media's ability to hype things could be effectively curtailed without having to resort to the drastic act of trying to control the media. Put another way we have to take as many of the physical controls off public information as possible. i.e. the data dumps I mentioned. These should be like daily or weekly feeds at the least although the previous week's information should be posted the following Monday morning before everyone knocks off for the weekend and forgets about it.

Edited November 9, 2009 by eyeball

[Michael Hardner]

eb,

The inability to deliver a response could be for several reasons, most of which should be neither here nor there. Above all else making our institutions more transparent will have to involve making them more physically accessible. Things like your experience should be auditable and taken together with other client experiences to score or rate the institution. When a particular government departments accessibility score drops below a certain point, it should trigger more rigorous methods of making its information available, such as regular data dumps in which all internal memos, emails amd meeting minutes etc can be posted. If this still doesn't work then 3rd party independant human observers or process guardians if you will should be deployed to oversee that departments operations first hand.

Sounds good on the surface. Not all internal memos, emails and meeting minutes though, it's just not practical. But more transparency, yes.

You're making it sound like its all your's and the media's fault. It's not.

I think media hype is something we need to control, not the media but the hype. I think as 'agents' of ours they have served us very poorly by feeding the panic. I suspect the reason why is that the media is no more capable of getting timely information than we are. Of course they still have a product to sell so they either just make stuff up or create new often inappropriate contexts in which what they do know can be re-presented differently - like anyone they use their imaginations to fill the gaps. If everything within the public's domain was actually made public in its entirety, the media's ability to hype things could be effectively curtailed without having to resort to the drastic act of trying to control the media. Put another way we have to take as many of the physical controls off public information as possible. i.e. the data dumps I mentioned. These should be like daily or weekly feeds at the least although the previous week's information should be posted the following Monday morning before everyone knocks off for the weekend and forgets about it.

I didn't mean for it to sound like that. The public information needs to be used to manage expectations and keep people well informed. In the case of Toronto's H1N1 - we were a lot closer to a smooth rollout than I thought.

[eyeball]

eb,

Sounds good on the surface. Not all internal memos, emails and meeting minutes though, it's just not practical.

No it wouldn't be practical for every department every day, which is why it should be viewed as a consequence that's reserved for special cases. If you were a former manager of a government department that had to be subjected to a full audit would you want this on your resume? I know skippers who are having a hard time finding jobs because they screwed up their paperwork so badly that no one wants to risk hiring them. That said I know of investment bankers that are still farting in silk despite losing millions of other people's money.

But more transparency, yes.

How though? There has to be an applicable consequence or else its just so much talk about more transparency.

I didn't mean for it to sound like that. The public information needs to be used to manage expectations and keep people well informed. In the case of Toronto's H1N1 - we were a lot closer to a smooth rollout than I thought.

How can you use something you don't have? I think a lot of people also thought they were closer to death and disease.

[Michael Hardner]

eyeball,

It's just not practical or useful to release internal memos, meetings, everything. It's good to have them available for audit, but there only needs to be summary information available to the public - tailored to a reasonable attention span and level of interest.

How do you do it, and how do you use the public ?

Firstly, people have be generally be aware that things are changing and as such their behavior will be expected to change. This means everybody. Initially, top bureaucrats will have to plan more, and take the public into account more. Government members will have to get used to less direct control of their reports. Individual staff will likely have to work harder, however they should also be consulted more as to what they're delivering.

And it's especially important to put away the big stick, at least in the beginning. Openness withers and dies if somebody tells the truth and gets in trouble for it. The system will be a mess for the first period, until people get used to talking opening about problems without sharing blame, so that problems can be addressed.

[Oleg Bach]

Glad you have the time to oversee said system of care. Keep going my friend. Democracy only works when the nobody tells the somebody to get things done. You are a nobody. Funny - I had a powerful investment banker tell me that I was "in a very powerful position" I guess being a nobody is powerful - You have nothing to lose so you can speak freely - and always sign your work with your real name. If you are going to spew things through electo publishing..better take credit for it - Good or Bad. One must stand up and be counted...in real life they might swat you. It's stunning who runs for pubic office these days. The same nerds in public school who were never naturaly popular and they still remain the same.

[Michael Hardner]

If you notice it's always the nobodys that 'get it' in gangster films... they're the ones that you have to watch...

[Oleg Bach]

If you notice it's always the nobodys that 'get it' in gangster films... they're the ones that you have to watch...

Michael Micheal...Michael... stop that! It's usually the nobody in the gangster film that takes over the operation of gangstertorial activity (if there is such a word). Personally I don't "get it." The problem we have here is middle management. The big dogs on top have simply run out of good middle management - whether it is at city hall - the courts or buisness for that matter..smart people are all on welfare and have bailed out - The butt kissers are in postions of light weight authority . The "gangsters" have a problem..no one smart wants to work for them - and even within the family buisness- sons and daughters don't want the responsiblity that being a gangster entails...nor do they want to practice neo-conish cruelty...seems that the very children of the men in charge are now liberals - looks like their plan back fired and they are the ones who now "get it" with their own hand...

[Michael Hardner]

A new 'open' data policy is being tried in Toronto at toronto.ca/open.

The backstage intrigue began in earnest this week when somebody requested performance statistics and another poster anonymously said something like "there is no way you will ever see this".

This seems minor and is under the radar right now, but it will be front page news someday I predict.

[Oleg Bach]

Just to add - I don't have a problem with the supper powerful and rich - who have been that way for a few generations - it's the upstarts that have no ethics..and they are the ones who want to make sure that someone "gets it" - Those that are not used to money and power are dangersous - I think they are the new breed of bureacrat - give it ten years and these lunitics will have taken over fully - then you and I might "get it" for know to much and more than they - but I will be very old by then and be walking on water - hello Buffalo here I come!

[Michael Hardner]

OB

Just to add - I don't have a problem with the supper powerful and rich - who have been that way for a few generations - it's the upstarts that have no ethics..and they are the ones who want to make sure that someone "gets it" - Those that are not used to money and power are dangersous - I think they are the new breed of bureacrat - give it ten years and these lunitics will have taken over fully - then you and I might "get it" for know to much and more than they - but I will be very old by then and be walking on water - hello Buffalo here I come!

The supper powerful will often be seen at a power lunch, though, won't they ?

Buffalo wings are delicious.

Edited November 13, 2009 by Michael Hardner

[eyeball]

A new 'open' data policy is being tried in Toronto at toronto.ca/open.

The backstage intrigue began in earnest this week when somebody requested performance statistics and another poster anonymously said something like "there is no way you will ever see this".

This seems minor and is under the radar right now, but it will be front page news someday I predict.

Michael, did you make the request via Rypple?

[Michael Hardner]

eyeball - It wasn't my request, and it was requested via the dataTO.org site.

Edited November 13, 2009 by Michael Hardner

[eyeball]

Thanks for letting me know. I'll check it out.

[Oleg Bach]

OB

The supper powerful will often be seen at a power lunch, though, won't they ?

Buffalo wings are delicious.

Thanks for the invite..wings? mmmmmmmm.....I like that. You sound like a fine person...but I am a pirate..and you won't really like me...maybe another time when I can pay for the wings and maybe the whole chicken.