Audit Committee Report BH.02.JUN1516.R04

June 15, 2016

Report to: Audit Committee, Board of Health

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

Subject: COMPLIANCE MONITORING AND IMPROVEMENT POLICY

Recommendations

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

(b) That the Audit Committee makes recommendation to the Board of Health to accept the Compliance Monitoring and Improvement Policy, CA.45.01.302, as attached hereto as Appendix “A”.

Background

In keeping with the overall board governance model, the Board of Health has its own policy and procedure binder which is maintained at the Guelph Office (160 Chancellors Way).  Electronic access is currently available on the Board of Health Sharepoint site and will be moved to a dedicated Board of Health site with the redevelopment of the agency website.  The following policy has been developed and is attached hereto as Appendix “A”:

Compliance Monitoring and Improvement Policy:

This policy outlines that Wellington-Dufferin-Guelph Public Health (WDGPH) Board of Health (BOH) shall ensure the establishment of a compliance monitoring and improvement program at WDGPH that includes a risk management strategy and framework, compliance with all applicable legislation, relevant standards of practice, performance targets and agency policies, procedures and internal controls and annual reporting to the BOH.  The program shall be the responsibility of the Medical Officer of Health.

Public Health and/or Financial Implications

Ontario Public Health Organization Standards state:

“Leadership functions at the board of health level require that the board of health assess and take action to improve its governance processes to accomplish its objectives of strategic direction setting, promotion of appropriate ethics and values within the organization, effective organizational performance management and accountability, and effective coordination of board of health activities at all levels of the organization.”

Appendices

Appendix “A” – CA.45.01.302 Compliance Monitoring and Improvement Policy.

POLICY - DRAFT

CATEGORY: Board of Health
NUMBER: CA.45.01.302
SUBJECT: Compliance Monitoring and Improvement
EFFECTIVE: September 7, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A

POLICY STATEMENT:

The Board of Health (BOH) shall ensure the establishment of a compliance monitoring and improvement program for Wellington-Dufferin-Guelph Public Health (WDGPH) which includes:

  • Development of a risk management strategy and framework;
  • Development and implementation of policies, procedures, codes of conduct and internal control practices;
  • Ongoing monitoring and auditing of compliance with applicable legislation, relevant standards of practice, Ministry performance targets, Agency policies and procedures and internal controls;
  • Implementation of quality improvement activities to address identified compliance or quality issues;
  • Regular reporting to the Ministry on performance targets and other reports, as required;  and
  • Annual reporting and updates to the BOH on the compliance monitoring and improvement program. 

The establishment, implementation and maintenance of the compliance monitoring and improvement program shall be the responsibility of the Medical Officer of Health in consultation with the senior management of the Agency. 

SCOPE

This policy applies all members of the BOH.

DEFINITIONS:

Legislation – all legislation pertaining to boards of health and public health units, including, but not limited to the Health Protection and Promotion Act and its Regulations, the Ontario Public Health Standards (OPHS), and the Ontario Public Health Organizational Standards.

Contact for inquiries:  
Office of the Medical Officer of Health/CEO

Original document signed by:   
Chair of the Board of Health 

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