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The Review and Implementation Committee looking at the Manitoba Pediatric Cardiac Surgery Inquest presented its report to Health Minister Dave Chomiak today.

The report indicates that a repeat of the tragic events of 1994, which led to the deaths of 12 infants, is unlikely given the changes that have been implemented throughout the health care system.

The report commends a number of changes that have already been made in different areas of the health care system and offers 51 recommendations to guide future actions.

"This is a tragedy that has touched the hearts of all Manitobans. It has profoundly affected 12 families who have endured a personal loss in a public spotlight," said the minister. "I hope the demonstrated changes that have already taken place, and our commitment to continue to implement recommendations for change, helps bring some closure to this tragedy for the 12 families."

The Review and Implementation Committee was chaired by Paul Thomas, professor in the department of political studies at the University of Manitoba. The committee included Gail Bagnall, the superintendent/chief executive officer of Lord Selkirk School Division No. 11, and Helga Bryant, vice-president of acute care and diagnostic services for the Brandon Regional Health Authority.

"Throughout our review process we were struck by both the complexity of the health care system and the individual commitment of health professionals," said Thomas. "Progress has been made in many areas and we offer recommendations to further improve the health care system's service to the public. Our committee sincerely hopes that changes made to date and those initiatives anticipated in the future provide the 12 families with some closure and the knowledge that the system has learned and changed as a result of the tragedies they went through."

The report notes that positive changes have been made, including:

• an improved policy on informed consent developed by the Health Sciences Centre (HSC) that could become a model for other hospitals;
• the establishment of a Nursing Practice Council at HSC; and
• the establishment of a new critical incident reporting policy at HSC.

The committee also noted that significant work had been done in the areas of accountability, risk management, quality assurance and handling patient complaints, and offered additional suggestions for further improvements.

Chomiak said Manitoba Health will co-ordinate the response to the committee's recommendations and committed to providing a progress report on the implementation of the recommendations by June 1, 2002.

Other immediate steps to address the recommendations include:

• Manitoba Health will work with the College of Physicians and Surgeons to look at the development of physician profiles.
• Manitoba Health will take the lead in developing a policy framework for internal disclosure policies as a guide for individual health care facilities and will monitor their effectiveness.
• Manitoba will continue to play a lead role in the development of the Western Canadian Children's Heart Network and accepts the recommendation that another pediatric cardiac surgery program should not be established in Manitoba.
• Manitoba Health will be reorganized to reflect its new role in a regionalized health care delivery system.
• Manitoba Health will develop a guide to health services in Manitoba for the general public.

The committee also recommends additional actions be taken in other areas including:

• increasing the public profile of the College of Physicians and Surgeons, with an emphasis on increasing the awareness of the college's complaint processes;
• acknowledging formally, culturally and operationally the role of nurses, given the increased levels of training and skills of nurses; and
• changing cultures within health care systems to be more open and accepting of processes that catch mistakes early, and in dealing with mistakes as learning experiences.

The committee was appointed by Chomiak following the release of the Manitoba Pediatric Cardiac Inquest Report by then associate chief judge Murray Sinclair. The committee was asked to look at the inquest report and make recommendations on how to implement the recommendations of the inquest. In 1994, 12 infants died after cardiac surgery resulting in the disbandment of the pediatric cardiac surgery program and the subsequent inquest.

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Review and Implementation Committee

for the

Report of the Manitoba Pediatric Cardiac Surgery Inquest

- General Background -

 Manitoba Health will fill the role of formal oversight for the implementation of the recommendations from the Review and Implementation Committee. The recommendations apply to a range of health care organizations including: the Winnipeg Regional Health Authority, Health Sciences Centre, College of Physicians and Surgeons and Office of the Chief Medical Examiner. In different ways, the health care system has been examining and changing the way it operates in response to the 1994 deaths of 12 children and the subsequent inquest. The effort to improve health care delivery will continue with the recommendations of the Review Committee Report.

There are four key areas where the report of the Review and Implementation Committee and the Sinclair Report recommendations fall: information, health professionals, health services delivery and culture.

Information

• Manitoba Health will work with the regional health authorities to develop a framework for internal disclosure policies.
• The Protection for Persons in Care Act has protection for staff who disclose problems or wrongdoing. The effectiveness of these provisions will be monitored.
• The informed consent policy developed by Health Sciences Centre will be looked at as a possible model for other institutions.
• The Western Canadian Children's Heart Network will be asked to consider enhancing patient and parent interactions and look at patient experience and patient satisfaction as part of the evaluation of the program once launched.
• Manitoba Health will develop a guide to Manitoba's health services to provide accurate and useful information about the health care system to the general public.
• The College of Physicians and Surgeons has been asked to increase public awareness about its role and its complaint process.

Health Professionals

Extensive recruitment and retention efforts for qualified physicians and nurses have been a focus of significant efforts by regional health authorities and the department. These include financial supports for medical students, increased enrolments for nurses, refresher courses for nurses returning to the workforce and improved opportunities for international medical graduates.

• Manitoba Health and the College of Physicians and Surgeons will look at physician profiles for public use.
• The establishment of the Nursing Practice Council at Health Sciences Centre provides a voice for nurses.
• The Registered Nurse Act will be proclaimed this summer.

Health Services Delivery

• Manitoba Health will be re-organized in recognition of its new role in a regionalized health delivery system. The new role will focus on policy direction, monitoring, evaluating and ensuring accountability of the health care system to Manitobans.
• Manitoba has played a lead role in the development of the Western Canadian Children's Heart Network. Manitoba has committed $347,000 to the development of the network.
• Health Sciences Centre has increased the use of multi-disciplinary teams made up of a variety of health professionals for hiring purposes and for operating clinical programs.

Culture

• Significant work had been done in the areas of accountability, risk management, quality assurance and handling patient complaints.
• Changes in culture and attitudes take years, not months, and are the responsibility of health care professionals and the general public.