Audit Committee Report BH.02.JUN1516.R03

June 15, 2016

Report to: Audit Committee, Board of Health

Submitted by: Dr. Nicola Mercer, Medical Officer of Health & CEO

Subject: ANNUAL UPDATE ON WDGPH COMPLIANCE WITH THE ONTARIO PUBLIC HEALTH ORGANIZATIONAL STANDARDS (ORGANIZATIONAL STANDARDS

Recommendations

(a) That the Audit Committee makes recommendation to the Board of Health to receive this report for information.

Background

The Ontario Public Health Organizational Standards (Organizational Standards) establish the management and governance requirements for all boards of health and public health units.    Currently, there are 44 requirements within six (6) categories related to board structure and operations, leadership, trusteeship, community engagement and responsiveness and management operations. 

Public Health and/or Financial Implications

Compliance with the Organizational Standards is a requirement under the Public Health Funding and Accountability Agreement (Accountability Agreement).  In 2015, WDGPH conducted an internal audit to assess compliance with the Organizational Standards [see Audit Committee Report BH.02.APR2215.R03 – Ontario Public Health Organizational Standards (Organizational Standards) – WDGPH Internal Compliance Audit].  At that time, WDGPH demonstrated overall compliance across the six requirement categories.  There were several areas for improvement identified, and areas where work was in progress to meet or improve compliance with the standards.    The purpose of this report is to provide an update on the work completed since 2015.

Table 1

Organizational
Standard

Requirement
Summary

2015 Status

2016 Update

2.10
Board of Health
Policies

Policies required for
procurement of
external advisors and
confidentiality

WDGPH policies
were under review
and development.

Confidentiality: Board of
Health policy CA.42.01.109
(Code of Ethics and
Conduct) and By-law No. 1
have been revised and
approved to include
confidentiality.   Board of
Health members also signed
a confidentiality agreement
upon appointment to the
Board of Health.

External Advisors to the
Board of Health:
This
policy has been drafted and
will move forward to a
Standing Committee in 2016.  

 

3.2
Strategic Plan

Strategic plan shall
describe how equity
issues will be addressed in the
delivery of and
outcomes of
programs and services.

A framework for
health equity and
implementation of the
health equity assessment tool were
under development as
part of a multi-year
project.

Healthy Equity is a strategic
direction in the 2016-2020
WDGPH Strategic Plan. 
Strategic goals and
objectives link to the health
equity framework and
implementation of the health
equity assessment tool.

5.5
Client Service
Standards

Develop and implement a set of
client service
standards which
ensures accessibility,
responsiveness to
enquiries and
provision of timely
information to the
public.

Client services
standards were under
development. 

Accessibility policies have
been updated and a Multi-
Year Accessibility Plan has
been developed.  The plan
and policies are posted to
the WDGPH website.   

Work on the development of
client service standards is
ongoing. A Board of Health
policy is currently in draft
and awaiting presentation to
a Standing Committee.

6.2
Risk
Management

Develop strategies to
monitor and respond
to emerging issues
and potential internal
and external threats
to the organization in
a timely and effective
manner. 

A risk assessment
tool was under
development for
implementation
across all
programs/services. 
In addition, WDGPH
was investigating
strategies for the
development of a
comprehensive risk
management
program.  Both were
part of a multi-year
initiative.

A risk management strategy
and framework have been
drafted.  The risk assessment
template (or risk register)
has been expanded to
include risk identification,
assessment, control and
monitoring.  It is currently
being reviewed and updated
to reflect the current
WDGPH environment.

6.12
Information
Management

Develop an
appropriate records
retention process (or processes) as part of
an information
management
infrastructure.

Work on the
development and
implementation of a
formal records
management process
was ongoing.

WDGPH is currently
developing a document
management system using
SharePoint 2013.  This
project is ongoing through
2017. 

6.14
Human
Resources
Strategy

 

Establish policies
and procedures in support of human resources strategies, including:

  • Occupational health and safety

The fire plan for the
Guelph office was
under development.  

 

The fire plan has been
completed. 

  • Succession planning

Consideration was
being given to a more
formal approach and documentation of
succession planning activities.

Consideration of strategies
to formally review and
document succession
planning are still under
investigation (including
inclusion in the risk
management framework and
a review of various
approaches).

As demonstrated by the table above, WDGPH has made significant progress towards addressing identified areas of improvement.  It should be noted that a number of the activities identified represent multi-year initiatives which have been reflected in the 2016-2020 Strategic Plan, Building Healthy Tomorrows Today.  Monitoring of progress towards completion of these initiatives will be incorporated into the regular review of the 2016-2020 strategic plan. 

Appendices

None.

Prepared by:  Meighan Finlay
Standards and Accountability Officer, Family Health and Health Analytics

Reviewed by: Andrea Roberts
Director, Family Health and Healthy Analytics 

Approved by: Dr. Nicola Mercer,
Medical Officer of Health  & CEO