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2016 NORTHERN AND REMOTE COLLABORATION ROUNDTABLE May 12-13, 2016, Saskatoon, Saskatchewan

Meeting Minutes

Roundtable Agenda Overview (see Appendix A for the full Agenda) May 12, 2016

Opening and Welcoming Remarks Overview of the Northern and Remote Collaboration Implementing Indigenous Cultural Competence Within Organizations

Cultural Competence as a Patient Safety Issue

Organizational Management Table Discussion: Cultural Competence Visioning the Future

Perspectives from clients: what does cultural safety look like to First Nations clients and families accessing health services?

CFHI’s Reconciliation Journey

Organizational Management: Leading an Organization to Respond to the Truth and Reconciliation Recommendations

Table Discussion: Taking action on cultural competence Closing Comments

May 13, 2016

Opening and Welcoming Remarks Wise Practices in Indigenous Mental Health and Wellbeing

Suicide Prevention: context, strengths and challenges, examples of what works.

Principals of effective service delivery and systems for Indigenous mental health and wellbeing. CFHI and TPF Partnership Agreement Pick-a-Table Discussions

Approaches to case management in teams for mental health

Successes and approaches in culturally based healing

Approaches to prevent secondary trauma in employees

Wise practices in evaluating client and community outcomes

Wise practices in reducing suicide clusters

Integration in mental health: best practices in a multi-sectoral approach (and who needs to be at the table)

Taking Action on Suicide Prevention Recap of Day 1 and 2 Closing Remarks

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Introduction and Context On May 12 and 13, 2016 in Saskatoon, Saskatchewan the Canadian Foundation for Healthcare Improvement (CFHI) held the third annual Northern and Remote Collaboration Roundtable. The Roundtable was part of four days of programming offered to the partners of the Northern and Remote Collaboration with an optional Indigenous Cultural Competence training session on May 11, 2016 and an optional site visit to the All Nations Healing Hospital in Fort Qu-Appelle on May 14, 2016. Approximately 50 participants attended the Roundtable, representing 25 organizations and 10 provinces and territories across Canada’s northern and remote regions (see Appendix B for Presenter Bios and Participant list). The goal of the event was to further the Collaborations sharing of wise practices that support health care delivery improvements in northern and remote Canada. The four objectives of the Roundtable were to:

1) Celebrate Collaboration partner successes over the past year, and provide networking opportunities to share wise practices in leadership and change management;

2) Discuss and build consensus on joint action to advance cultural competency, safety and humility on organizational and system levels;

3) Discuss and share approaches and learning from Indigenous experts in mental health and addictions, with a special focus on joint action on suicide prevention; and

4) Build consensus on joint action on suicide prevention. The Roundtable began with presentations that encouraged participants to define cultural competence at individual and organizational levels. To be culturally competent participants concluded that leadership is required to begin and maintain change, everyone must play a role and shoulder part of the responsibility. The importance of listening to Elders and patients (the experts), indigenizing health care access points, and institutionalizing the requirement for cultural competence, were also discussed. The second day focused on Indigenous suicide prevention and discussion of wise practices across mental health systems. Plenary presentations noted health disparities but emphasized strengths and actions to achieve equality. Participants spent a significant amount of time discussing two of six predetermined topics. A highlight of the Roundtable was the joint announcement of a new partnership between CFHI and Thunderbird Partnership Foundation (TPF). Carol Hopkins, Executive Director and Stephen Samis, Vice President of Programs, signed the partnership agreement on behalf of the respective organizations with the Roundtable participants as witnesses.

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Roundtable Day 1 – May 12, 2016 Opening and Welcoming Remarks Elder Florence Allen opened the meeting, protecting the space so participants could connect and discuss the agenda items in a good way. Rose LeMay, Director of Northern and Indigenous Health at CFHI welcomed participants and opened the meeting. Maureen O’Neil, President, CFHI thanked participants for attending the Roundtable. She shared CFHI’s expanded focus on northern and Indigenous health. “The Truth and Reconciliation Commission (TRC) pushed the door open and CFHI is doing our part to respond.” Significant time has been spent thinking about what the TRC Calls to Action mean to Canada, to health, and to CFHI. In response CFHI has drafted a declaration of reconciliation that will be publically released shortly. Cecile Hunt, Chief Executive Officer, Prince Albert Parkland Heath Region in Saskatchewan welcomed participants to Treaty 6 land. She provided a brief history of the Métis territory of Saskatchewan and described some of the ways the Prince Albert Parkland Health Region is working to better assist the population they serve. Overview of the Northern and Remote Collaboration Stephen Samis, Vice President of Programs at CFHI, provided an overview of the Foundation, including its mandate and model for improvement. The history and purpose of the Northern and Remote Collaboration was highlighted as well as the collaboration objectives for 2016-17:

• Continue to strengthen and expand a learning collaborative for sharing and spreading knowledge and innovations;

• Continue to build and spread improvement and measurement capacity among Collaboration members and their organizations;

• Share locally-based approaches among Collaboration members on innovations relevant to common healthcare issues;

• Look for opportunities to identify, implement and spread improvement work which address common priorities;

• Increase the capacity to address the challenges of aligning policy and practice; and • Evaluate improvement projects and share successes and evidence-informed solutions.

Stephen also gave a summary of the key messages from the 2015 Northern and Remote Collaboration Roundtable and reviewed the objectives for the 2016 Roundtable in that context:

1) Celebrate Collaboration partner successes over the past year, and provide networking opportunities to share wise practices in leadership and change management;

2) Discuss and build consensus on joint action to advance cultural competency, safety and humility on organizational and system levels;

3) Discuss and share approaches and learning from Indigenous experts in mental health and addictions, with a special focus on joint action on suicide prevention; and

4) Build consensus on joint action on suicide prevention.

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Implementing Indigenous Cultural Competence Within Organizations The purpose of this session was to improve understanding of cultural competence at an organizational level with an emphasis on concepts of measuring and evaluating success. The facilitator introduced the two speakers for the session: Dr. Margo Greenwood of the National Collaborating Centre on Aboriginal Health, and Lori Keith of the First Nations Health Managers Association (FNHMA). The slide decks for both of these presentations will be posted on CFHI’s website along with the final roundtable report.

1) Cultural Competence as a Patient Safety Issue Dr. Margo Greenwood presented the differences between epistemic, structural, and symbolic racism and how racism in general can lead to health inequalities.

2) Organizational Management

Lori Keith provided an introduction to the FNHMA, a national, nonprofit, professional association with the goal of advancing First Nations health. The association has 300 members and 86 Certified First Nation Health Managers. Lori continued with a change management approach to cultural competence. The phases of change management were highlighted with a focus on mindset and organizational capacity and resources.

Participants had an opportunity to ask questions or comment on the presentations from Dr. Greenwood and Ms. Keith.

One commented on the acceptance of health system change within the mainstream. “Culturalizing” the health system would benefit from relationships and negotiations, and will take time.

Elder Allen shared her thoughts on the need to educate and train service providers, and there was agreement.

There was a concern expressed for already burdened health workers, and how this may affect their willingness and ability to change.

Table Discussion: Cultural Competence Participants were asked to discuss two questions around the theme of cultural competence. Participants were encouraged to consider these questions from an organization and systems level. Representatives from each table presented a brief report back to all participants.

Question One: Wise practices on setting the stage: what has worked in your organization to build consensus and commitment to cultural competence? The following were identified as ways of enhancing organizational commitment to cultural competency:

Develop an organizational cultural competence leadership statement for management and staff to sign. Renew this statement annually.

Develop, train and transition staff.

Make cultural competence a priority – deliver training to all staff.

Identify and build on current strengths.

Keep community members engaged and informed.

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Remediate challenges early and report back to community, allies and within the organization on progress often.

Hire and recruit indigenous people at the highest level.

Ensure the vision and mission statements of your organization incorporates cultural practices and beliefs.

Promote cultural practices in the workplace (e.g. morning prayer, smudges).

Include Elders at the management level to ensure values are reflective and part of all processes (and ensure that their contributions are acknowledged and that the positions are paid ones).

Senior leaders must drive change and hold their teams accountable.

Build understanding and make it relevant – why is cultural competence important to organizational outcomes?

Question Two: Wise practices to address challenges: are there obstacles which have been/could be

barriers? What have you done/could you do to address the obstacles? Participants identified a number of obstacles/barriers and what was (or could have been) done to address them, such as:

There can be support at the leadership level but it doesn’t filter down. It is process and everyone is at a different stage.

Difficult to create something that is meaningful for everyone when they are at different stages – cultural competence as to be a part of hiring, orientation, performance planning and mentoring.

Resistance from front-line staff may be due to the time required to take training. Organizations need to make information easily available (i.e. posters, pamphlets) and support these conceptual ideas into operational change and action.

Contract nurses that come and go can have a hard time building relationships and receiving the appropriate training. This must be built into their contracts.

We need to move past the idea that its Indigenous history to understanding that its Canadian history. Following the table report backs, participants had an opportunity to ask questions or comment on cultural competence.

A participant commented that for change to occur, the commitment must be shared. It must be owned by everyone so it is sustained if one person leaves.

A question was posed to participants: How do we measure outcomes in the area of cultural competence? Visioning the Future The three speakers for the session were introduced: Karen Blondin-Hall of the Government of the Northwest Territories, Maureen O’Neil of the CFHI, and Dr. Vianne Timmons from the University of Regina.

1) Perspectives from clients: what does cultural safety look like to First Nations clients and families accessing health services? Karen Blondin-Hall shared her experience as a First Nations woman accessing healthcare and the importance of patient centred approaches. To achieve this, she emphasized that the “person with the most control has the greatest responsibility to change.”

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2) CFHI’s Reconciliation Journey

Maureen O’Neil presented the foundation’s reconciliation journey and provided an update on the work of the Northern and Indigenous Health division. The work will be based on values of partnership and cultural competence; and the view of CFHI to be a model of reconciliation.

Commitments include: a vision and accompanying work plan, all staff to complete the cultural competency course delivery, public release of our declaration of reconciliation, continued support for the Northern and Remote Roundtable, a strengthened relationship with the First Nation Inuit Health Branch and Public Health Agency of Canada, and potentially two new Spread Collaborative(s). Maureen announced that CFHI will host an International Roundtable on Indigenous Suicide Prevention in partnership with TPF, in contribution to indigenous wellbeing.

3) Organizational Management: Leading an Organization to Respond to the Truth and Reconciliation

Recommendations Dr. Vianne Timmons, President, University of Regina shared her leadership experience and efforts to Indigenize the university. Her presentation focused on action, the First Nations University and the role of management in achieving change. Dr. Timmons challenged participants to consider how health could be indigenized, with the goal that Indigenous view the health system and hospitals as their own.

Table Discussion: Taking Action on Cultural Competence Participants were asked to discuss three questions around the theme of taking action on cultural competence. This session was facilitated by Jim Corkal, Karen Blondin-Hall and Robert Tordiff.

Question One: Who are some of the key partner/sector leaders who need to be involved in this change management exercise? Participants shared a number of partners and sectors, including:

Health authorities, indigenous people, clinicians, politicians, communities, elders and youth, colleges and universities, tribal councils, community groups, service providers, patients, etc.

Question Two: Are there best practices in changing policy/policies to anchor the new approach as a

permanent way of working? Numerous best practices to anchor the new approach as a permanent way of working were suggested, including:

A public leadership statement, communication of changes, ongoing and appropriate training.

Moving deliberately from policy to practice – operationalize change into everyone’s work.

Support for staff regarding change (training, team leader support, etc.)

Anticipate what might go wrong, prepare responses.

Mobilize champions & support them.

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Question Three: What can the Northern and Remote Collaboration partners do together over the next two years?

The following partner activities were suggested by participants:

The Roundtable needs to stay connected, to continue discussions.

Continuation of webinars.

Spread and network the strength of CFHI. Closing Comments Stephen Samis summarized the first day of discussions, which focused on cultural competency and change models. It is very apparent that a lot of work has already been done and that we are not starting from ground zero. He then presented three themes that emerged from the first day of presentations and discussions:

1) If not now, when? 2) We need to continue to build on the 2015 Roundtable theme of “nothing for us without us” 3) It is OK to be unsure about exactly how we will get there as long as we are moving forward toward

the goal of cultural competence.

What is required in order for an organization to be culturally competent was also highlighted, including statements of the need for:

Strong leadership to begin and maintain change and ensure that everyone plays a role and shoulders some of the responsibility.

To listen to Elders and to patients, they are the experts. To Indigenize health care access points and informational material to make it more accessible. To institutionalize the requirement for cultural competence – in mandates, priorities, performance

systems, etc. From the discussions throughout the day, it appears cultural competence within health care is currently a compassionate effort not a coordinated effort. As such, the following question was posed to participants to consider overnight: what can we as healthcare leaders in Canada do to improve coordination of the effort to improve cultural competence in our organizations?

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Roundtable Day 2 – May 13, 2016 Welcome and Opening Remarks Participants were welcomed to day two of the Roundtable. Wise Practices in Indigenous Mental Health and Wellbeing This plenary focused on Indigenous suicide prevention and identification of wise practices across mental health systems. The two plenary speakers, included Brenda Restoule, Chair of the First Peoples Wellness Circle and Carol Hopkins, Executive Director of the Thunderbird Partnership Foundation.

1) Suicide Prevention: context, strengths and challenges, examples of what works. Brenda Restoule opened with an overview of the risk factors for indigenous suicide. Including:

Living and coping with poverty, and the resulting trauma for families, was presented as a factor in Indigenous suicide. The “inability to provide care”, the “capacity to manage life challenging events.”

Lack of voice and power to make change – vulnerability and power inequalities.

Colonization and the lack of acknowledgement of indigenous contributions to Canadian society, may contribute to risk of self-esteem.

Perpetuating hopelessness – lack of resources, jurisdictional issues, unresolved social determinants of health, violence, trauma and addictions, etc.

An overview of the protective factors for indigenous suicide were also presented. Including:

The importance of early childhood education/experiences, which is a significant factor in the health and wellness of children.

Nurturing a strong sense of history and pride in community and culture.

Promotion of resiliency, nurturing of strengths.

Sense of ownership and leadership.

Enhanced social connections.

2) Principals of effective service delivery and systems for Indigenous mental health and wellbeing. Carol Hopkins presented the Mental Wellness Continuum Framework, emphasizing culture as the base for any intervention or partnership. Other key points of her presentation were: Respect is the ability to look twice. Respect is investing in understanding from a different perspective. Too much time is spent discussing health disparities. We need to discuss strengths and action to

create equalities. Participants communicated their support for the holistic nature of the Continuum Framework.

Participants had an opportunity to ask questions or comment on the presentations from Dr. Restoule and Ms. Hopkins.

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There was agreement on the need to act now, and the importance of creating an economic base in communities.

There was a question to Ms. Hopkins regarding how the Mental Wellness Continuum Framework can be used.

o Mrs. Hopkins responded that a new document to guide and support the Continuum’s application has been drafted, and can be shared with Roundtable participants.

A number of comments regarding the need to rebuild the natural connections of support between communities were shared. Divisions between indigenous people were created by governments and jurisdictions, the significance and legal implications of the Daniels decision may contribute to bringing down barriers.

CFHI and TPF Partnership Agreement To support indigenous mental health, CFHI and TPF signed a partnership agreement. The three key areas of joint work outlined in the agreement, are:

Information sharing and capacity development initiatives to develop and deliver information, knowledge, training and development services that benefit the members of both organizations.

Mental health system initiatives to support the continued implementation of the First Nations Mental Wellness Continuum Framework in the best interests of the wellbeing of Indigenous people in Canada.

Mental health leadership initiatives to support Indigenous leadership in mental wellness (addressing substance use and mental health issues).

Pick-a-Table Discussions Participants were asked to participate in two of six table discussions during two discussion periods. The pre-set discussion topics and they key feedback discussion points from the discussions are outlined below:

1) Approaches to case management in teams for mental health – facilitator: Patricia Wiebe, FNIHB o Where there is not case management and team-based care, we see recidivism. o Needs to be a Principle-Based Approach:

Start with asking “What are your needs and strengths?” of clients and communities. Based on community development Bring clusters of communities together in a strength-based way. Community determines who the providers on their teams are – MD, NP, Nurses, etc. Navigator roles can be helpful.

2) Successes and approaches in culturally based healing – facilitator: Lori Lafontaine, MHCC

o Culturally based healing needs to be the primary approach, and not an add-on. o Need to value our Elders – they have the knowledge and need to be paid and valued. o Need to make traditional healing part of the core funding; integrated into budgets. o A combination of indigenous and mainstream knowledge and practices in clinics and hospitals.

3) Approaches to prevent secondary trauma in employees – facilitator: Meghan McKenna, CFHI

o Identify where the primary and secondary traumas are taking place, to reduce risk. o In the ER for providers – risk of trauma spreading to family members, the community. o Training in compassion and recognition of stress needed.

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o Need for philosophical shift – trauma and secondary trauma reactions are normal and human. o Need to support the existing, natural practices in Indigenous communities, to support recovery o Integrated and family-centered approach needed. o Need to change the language – instead of crisis response terminology – recovery or resiliency

response.

4) Wise practices in evaluating client and community outcomes – facilitator: Carol Hopkins, TPF o Need culturally appropriate indicators and for communities to determine them; inclusive

development with all partners. o This is critical to anchoring policy and program that is meaningful to context and people. o Pathways to outcomes has to be specific to local and context/population even when the outcome

targets are the same. o What gets measured has to be understood within cultural ways of being e.g. importance of natural

supports and values in response to suicide. o Community defined priorities and indictors.

5) Wise practices in reducing suicide clusters – facilitator: Brenda Restoule, FPWC

o Discussion around merging traditional cultural approaches and western medicine. o Create physical balance – keep kids away from too much technology and get them out on the land. o What to do when a suicide cluster exists

Bring partners around the table who have a stake in the ‘reasons’ around them – education, housing, employment – and ask the youth and Elders to be involved.

o Build trusting relationships so information can be shared within safety. o Interventions need to be ongoing and community defined. o Have helpers who people can identify with; youth, etc. o Use technology to reach youth. o Recognize that there are people within communities who can support and assist – need to grow their

capacity. o Need stability in social determinants of health.

6) Integration in mental health: best practices in a multi-sectoral approach (and who needs to be at the

table) – facilitator: Stephanie Priest, PHAC o Recognize that relationships take time and need to be nurtured. o Primary care integration – someone in community with varied skills; wrap around care model; bring

in other sectors to address social determinants o Capacity development/training and interdisciplinary teams are critical. o Building partnerships are critical – with sectors, organizations and across jurisdictions (physical

barriers too – between communities). o To have a fully integrated mental health care model there needs to be an integration of funding.

Taking Action on Suicide Prevention The final plenary provided an opportunity for participants to identify what they can achieve as a Collaborative in 2016. CFHI proposed a Spread Collaborative on Indigenous suicide prevention and participants requested a more detailed discussion at the next Northern Remote Executive Committee teleconference.

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Key factors to support Indigenous communities out of crisis were also discussed, including the need for leaders in communities who can see beyond the immediate; and support from people outside communities.

A participant asked if CFHI would allow a school district to participate in a Collaborative.

o CFHI replied that the partners involved identify the people who need to be around the table. A school district may be an appropriate team member given the fact that suicide prevention needs a multi-sectoral team approach.

A question was asked around the infusion of Metis. o CFHI committed to discussing the ways to best include them.

Recap of Day 1 and 2 Stephen Samis provided a recap of the Roundtable guided by three questions:

1) Where to from here? 2) What are the clear takeaways from the Roundtable for your organization? 3) How can the Northern and Remote Collaboration learnings be leveraged to ensure better care, better

health and better value in your organization? Stephen asked the group on their initial level of support for a spread collaborative on cultural competence, and a spread collaborative on Indigenous suicide prevention. With recognition that partners will need to return home to discuss internally, there was a very high level of support to start a spread collaborative on cultural competence implementation. A question was asked if the two collaboratives could be combined. Stephen responded that the topics may be at different starting points, but worth considering. Carol Hopkins voiced the commitment of TPF to support work on Indigenous suicide prevention. Regarding the principal of building on wise practices, a question was asked on how CFHI could support partners to better document best/wise practices. Stephen explained that within a spread collaborative, CFHI provides coaching, sharing of tools and capacity development as teams require it. Participants were asked to share one word to describe the Roundtable. Some of the responses received were:

o Promotion vs suicide prevention o Dedication o Action o Hope o Saw everyone coming together and helping each other o Strength-based o Powerful – learning from one another

Participants had an opportunity to ask questions and share comments before the closing of the Roundtable.

Laura Eggerton commented on the sharing of good ideas. She asked if she could compile and share them as concrete examples of building on wise practices.

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Stephen supported Laura’s point. If the Northern and Remote Roundtable is to do a collaborative in cultural competence or mental health it must be based on successful models.

Closing Remarks The Roundtable concluded with a commitment from CFHI to:

1) develop a web resource on Indigenous mental health and suicide prevention, which will be made available on the Thunderbird Partnership Foundation’s website;

2) develop and share stories on suicide prevention strengths; and 3) coordinate an Indigenous suicide prevention conference in November 2016 in Vancouver BC.

CFHI also committed to sharing the MWCF implementation document and TPF and CFHI partnership agreement online when possible. Elder Allen recapped and closed the meeting on behalf of the group.