Thank you for the question.
A few themes arose out of the report on our observations, certainly echoing what has been said by other witnesses. Staffing was a huge concern. When we arrived, many of the facilities had as little as 20% staffing, irrespective of what their nursing ratios were pre-pandemic. That made a huge impact on the outcomes of patients.
Second was infection prevention and control and really having that situational awareness of who was positive and who was negative. There were delays with having the results. Sometimes there was a lag of a week or up to 10 days, so by the time you got your results, you no longer had a good situational awareness of where the outbreak was. Also, the IPAC stream has centralized and/or standardized IPAC protocols. We within the CAF had a central IPAC member who provided us that advice, but IPAC was very different among each of the facilities in terms of donning, doffing, what the standard was for PPE, etc.
Finally, there's training. I think when you are looking at a degradation within the health status of a large population, having individuals who are trained in that acute care is paramount.