2. Final Report Manitoba First Nations (MFNs)Patient Wait Times Guarantee Pilot Project Process Mapping Workshops

3. Process Mapping Workshops This power point provides a brief overview of the final report on the process mapping workshops. This is not an executive summary. Four workshops were held with members of the MFNs Diabetes Committee on the following dates: – April 3rd and 4 th, 2007 (Winnipeg, MB) – April 26 th and 27 th, 2007 (Winnipeg, MB) – June 11 th and 12 th, 2007 (Winnipeg, MB) – August 27 th, and 28 th, 2007 (Thompson, MB)

4. Purpose of the workshops Identify the current processes used in the diagnosis and treatment of diabetes in MFNs Communities Identify gaps in health care continuums for MFN clients with diabetes, that could have an impact on the wait times experienced when undergoing treatment for diabetes related foot and lower limb injuries that could lead to amputation. Analyze the possible causes of gaps in those health care continuums Begin the process of considering realistic and workable responses to those gaps Identify the basic elements of a model for developing programs of foot care in MFN communities that will promote and enable appropriate health care (including health promotion, prevention and care) for clients with diabetes.

5. The Current Situation Early in the first workshop it was determined that there was no overall consistent sequence of routine events or activities for diagnosing and treating clients with diabetes that could be identified through a typical process map. Participants noted that diagnosis and treatment varied greatly from region to region, First Nation to First Nation and situation to situation.

6. Reasons for Variances Different government policies for Nursing Stations and Health Centers Level of funding for specific programs, services and operating expenses Scope of practice for Nursing Station and Health Centers nurses Different infrastructure for individual First Nations Different approaches by Tribal Councils Inconsistency between individual medical practitioners, especially specialists, when treating clients The large number of different individuals and agencies involved in diagnosis and treatment

7. Common Elements Impacting the Current Situation Inconsistent involvement of clients in their own diagnosis, preventative activities and treatment Diabetes recommendations not always followed Inconsistent access to timely and appropriate health care in some communities for many reasons Inconsistent access to timely and appropriate health care outside of community for many reasons Inconsistent access to traditional healers and approaches

8. Common Elements (continued) High nursing staff turnover for many First Nations Different levels of care provided by community-based, non- traditional health care providers Inconsistencies in providing support services (counseling, home care, nutritional and educational activities) in different First Nations Inconsistent access to, and levels of treatment by medical specialists Inconsistent follow-up on client appointments and treatment Inconsistent levels of foot care programs in different First Nations Inconsistent impacts of policies on program delivery

9. Root Causes The root causes and impacts of the issues and gaps were classified at the second workshop and through follow-up conference calls. Classification was based on: – The degree to which an issue could affect the ability of the health care system to provide proper diagnosis, prevention and treatment to clients with diabetes – Whether the issue was a result of systemic, policy or funding circumstances.

10. Key Considerations The process map identified two key considerations: Nurses in the Nursing Stations and Health Centres play a dual role for the client. They serve as the primary health care provider They are the contact for the client for community-based support staff and services and for external health care providers, services and institutions. They must be key players in the design, development and implementation of any model and activities designed to prevent and treat clients and reduce wait times.

11. Key Considerations (continued) The map demonstrated that preventative measures take place primarily in the community. Once an injury to the client occurs, much of the health care takes place outside of the community. The focus on taking action at the community level is consistent with the MFNs Health and Wellness Strategy which calls for community controlled health care systems that promote and prevent and the World Health Organizations' Alma – Ata Declaration that states that it is best to address health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly

12. Key Elements of the Model The final process mapping workshop identified 10 key elements necessary to build an effective model for the prevention, care and treatment of diabetic foot ulcers. These elements are: Systems Coordination Human Resources Programs Infrastructure Financial Resources Education Wait Time Innovation Polices and procedures Communication

13. Systems Coordination Seamless integration with federal, provincial, community programs, Non-jurisdictional approaches; Alignment with existing Manitoba diabetes programs Alignment with other relevant health and social programs Coordinated and collaborative partnerships and relationships

14. Human Resources Case coordinators Case managers Foot care nurses Wound care team Traditional healers

15. Programs Case Management Advanced foot care Foot wear for diabetes Access to wound care Complication and risk factor analysis Traditional Healing

16. Infrastructure Databases Case management tools Integrated and standardized data management tools Electronic health records Electronic wound care management systems

17. Financial Resources Project budgets Adequate funding Possible foundation funding Long term funding (3-5 years) for all diabetes programs

18. Education Education for all health care providers Peer education Standardized and ongoing education and training programs and activities Engagement for clients Online education

19. Wait Time Wait list management processes Day access to wound specialists Patient navigator Electronic tracking

20. Innovation Technology Assisted Wound Care Examination of other ways of delivering education and care Examine new ways to maximize human resources

21. Policies and Procedures Best Practice guidelines for everyone Standardized policies and procedures Footwear for individuals with diabetes Scope of practice Care pathways

22. Communications Communications strategies – Provincial - Tribal Council – community Client the centre of the holistic care model – not health care provider knows best Bring everyone to the table to decide whats best: FNIH – Manitoba Health – Tribal Councils- Province – Federal Government and Regional Health Authorities

23. Conclusion Considerable progress on identifying key issues for consideration during the design, development and delivery of the pilot projects model of care were identified as part of the four highly interactive workshops. This work would not have been possible without the knowledge, experience and enthusiasm that workshop participants displayed throughout all the workshops. Their experiences and expertise kept the workshop discussion focused on the realities of the care of individuals with diabetes in MFNs communities throughout, and the practical possibilities for a model that will work under real world circumstances.

24. Thank you Miigwech Ekosani Mahsi Wopida

25. More information? Thank you for your interest in the MFNs Patient Wait Time Guarantee Pilot Project. The full report of the Process Mapping Workshops can be downloaded from this website. For more information on the Process Mapping Workshops or the Pilot Project please contact us at fnwaittimesguarantee@saintelizabeth.com.