Minutes - May 22, 2025 - Quality and Governance Committee Meeting

Thursday, May 22, 2025 at 6p.m.
MLHU Board Room – CitiPlaza
110-355 Wellington Street
London, ON N6A 3N7

Members Present: 

Aina DeViet (Committee Chair)
Michelle Smibert
Matthew Newton-Reid
Michael Steele
Emily Williams, Chief Executive Officer (ex-officio) (Secretary and Treasurer)
Dr. Alexander Summers, Medical Officer of Health (ex-officio) (attended virtually)

Others Present:

Stephanie Egelton, Clerk, Board of Health (recorder)
Jennifer Proulx, Director, Family and Community Health
Sarah Maaten, Director, Public Health Foundations
Omar Ozaldin, Director, Environmental Health, Infectious Diseases and Clinical Services
Ryan Fawcett, Associate Director, Operations/Privacy Officer
Cynthia Bos, Associate Director, Human Resources and Labour Relations
Lilka Young, Strategic Advisor, Risk and Records Management
Parthiv Panchal, End User Support Analyst, Information Technology

At 6:05 p.m., Chair Aina DeViet called the meeting to order.

Disclosure of Pecuniary Interest

Chair DeViet inquired if there were any disclosures of conflicts of interest. None were declared.

Approval of Agenda

It was moved by M. Smibert, seconded by M. Newton-Reid, that the AGENDA for the May 22, 2025 Quality and Governance Committee meeting be approved.
Carried

Approval of Minutes

It was moved by M. Steele, seconded by M. Newton-Reid, that the MINUTES for the February 20, 2025 Quality and Governance Committee meeting be approved.
Carried

New Business

Q1 2025 Performance Reporting (Report No. 06-25QGC)

Dr. Alexander Summers, Medical Officer of Health provided highlights of the Health Unit’s public health program performance reporting for Q1. Dr. Summers added that the full performance reporting was affixed as Appendix A.

Highlights for public health programming included:
• The ongoing development and implementation of the Management Operating System (MOS);
• Preliminary work for the Health Unit’s strategic plan was started;
• Progress for inspections for most programs except personal service settings and low-risk food premises;
• Resources for the measles outbreak response in Southwestern Ontario; and
• Growing the Health Unit’s capacity in healthy public policy development.

Emily Williams, Chief Executive Officer provided performance highlights from the Corporate Services division. The audit for the 2024 year has been moved to the first week of June at the Health Unit request to KPMG LLP. The Health Unit has also engaged the services of a consulting firm to support the financial services of the Health Unit.

There were no questions or discussion.

It was moved by M. Smibert, seconded by M. Newton-Reid, that the Quality and Governance Committee recommend to the Board of Health to receive Report No. 06-25QGC re: “Q1 2025 Organizational Performance Reporting” for information.
Carried

2023-25 Provisional Plan 2025 Q1 Status Update (Report No. 07-25QGC)

Sarah Maaten, Director, Public Health Foundations presented the Q1 2025 Provisional Plan status report. S. Maaten noted that continued progress has been made on many of the Provisional Strategic Plan initiatives within the first quarter (Q1) of 2025 (labeled in Appendix A as green), noting that some initiatives have experienced delays (labeled as yellow). Some initiatives that were previously on pause resumed in Q1 of 2025 including the Partnership Engagement Framework, Partnership Inventory and the Intervention Description and Indicator Development Project. Two types of risks were identified within the tactics in Q1 2025, Operational/Service Delivery and Financial.

Committee Member Matthew Newton-Reid inquired on the reason for the delayed initiative under “program excellence”. S. Maaten explained that this was related to the social determinants of health (SDOH) project. The SDOH project has four (4) teams involved in the work and there has been lower participation, partially related to complexity of data systems. S. Maaten noted that this will improve with enhanced data governance work ongoing at the Health Unit.

It was moved by M. Steele, seconded by M. Newton-Reid, that the Quality and Governance Committee recommend to the Board of Health to receive Report No. 07-25QGC re: “2023-25 Provisional Plan 2025 Q1 Status Update” for information.
Carried

Q1 2025 Risk Registry Update (Report No. 08-25QGC)

Ryan Fawcett, Associate Director, Operations/Privacy Officer introduced Lilka Young, Strategic Advisor, Risk and Records Management to present the Q1 2025 Risk Registry.

L. Young noted that there are nine (9) risks in Q1, with three (3) of these risks being new. These risks include:
• Three (3) significant residual risks within the Financial and People/Human Resources categories:
o Financial risk related to sustained financial pressures as the provincial government 1% funding increase is not sufficient to offset contractual obligations and general inflation.
o People/Human Resources risks related to union negotiations. Mitigation efforts included the development of a labour disruption plan.
• Three (3) moderate residual risks within the Political, Operational/Service Delivery, Legal/Compliance and People/Human Resources categories.
o Political risk related to the Strengthening Public Health Strategy and the uncertainty of how directive public health programming may change.
o Operational/Service Delivery risk related to the Health Unit requiring a new website provider. Quotes and funding secured for a website build.
o Legal/Compliance risk related to costs associated with completed and ongoing union arbitration. Ongoing preparation for second arbitration scheduled for Q3 of 2025.
• Three (3) minor residual risks related to Technology, Legal/Compliance, and Operational/Service Delivery risk categories, all of which have been mitigated to an acceptable level of risk.

There were no questions or discussion.

It was moved by M. Smibert, seconded by M. Newton-Reid, that the Quality and Governance Committee recommend to the Board of Health to:
a) Receive Report No. 08-25QGC re: “Q1 2025 Risk Registry” for information; and
b) Approve the Q1 Risk Register (Appendix A)
Carried

Governance Policy Review for May 2025 (Report No. 09-25QGC)

R. Fawcett presented the Committee with the Governance Policy Review report for May 2025.

The policies that the Committee reviewed for the May meeting were:
• G-180 Financial Planning and Performance
• G-200 Approval and Signing Authority
• G-205 Borrowing
• G-430 Informing of Financial Obligations

R. Fawcett noted that all four (4) policies had proposed minor changes to reflect new titles of staff and new titles of provincial ministries. It was proposed to the Committee to remove any references to Program Budgeting Marginal Analysis (PBMA) in Policy G-180 Financial Planning and Performance and to remove the Annual Cycle (Appendix A) as timelines have changed within the budgeting cycle.

There were no questions or discussion.

It was moved by M. Smibert, seconded by M. Steele, that the Quality and Governance Committee recommend to the Board of Health to:
1) Receive Report No. 09-25QGC re: “Governance Policy Review for May 2025” for information; and
2) Approve the governance policies as amended in Appendix B.
Carried

Governance Policy Follow-Up – Investing and Donations (Report No. 10-25QGC)

R. Fawcett provided follow-up information from the October 17, 2024 Governance Committee (now disbanded) meeting regarding two (2) policies: G-210 Investing and G-320 Donations. The Committee inquired during their policy review for G-210 Investing adding language that speaks to approval pending a certain threshold to invest, and for G-320 Donations on why donations of securities cannot be accepted (such as real property and stocks).

R. Fawcett noted that within Policy G-210 that the “Treasurer shall be authorized to enter into arrangements with banks, investment dealers and brokers, and other financial institutions for the purchase, sale, redemption, issuance, transfer and safe-keeping of securities in a manner that complies to applicable legislation.” R. Fawcett added that the Treasurer has pre-determined authority to invest on behalf of the Board of Health.

In regard to Policy G-320, R. Fawcett noted that in five (5) years, there has been one (1) financial donation, which was to the Home Visiting program.

Staff recommend keeping the current language for policy G-320 Donations. For Policy G-210, staff recommend that a line be added to the policy to indicate that the Treasurer (currently the Chief Executive Officer) would inform the Board of any major changes to investments.

There were no questions or discussion.

It was moved by M. Newton-Reid, seconded by M. Steele, that the Quality and Governance Committee recommend to the Board of Health to:
1) Receive Report No. 10-25QGC re: “Governance Policy Follow-Up – Investing and Donations” for information;
2) Approve Policy G-210 Investing as amended; and
3) Approve Policy G-320 Donations.
Carried

2025 Board of Health Self-Assessment (Report No. 11-25QGC)

Stephanie Egelton, Clerk, Board of Health provided information and the draft 2025 Board of Health Self-Assessment for the Committee’s consideration. It was noted that the Ontario Public Health Standards require that boards of health complete a self-assessment of their governance practices and outcomes at least once every two (2) years. The Board of Health last completed a self-assessment in May 2023.

The Clerk will administer the Board of Health Self-Assessment in the coming days and will give Board Members until Friday, June 27 to answer the survey. Anonymous results will assist to identify recommendations for improvement in Board effectiveness and engagement. The assessment findings will be submitted to the Quality and Governance Committee in September, and recommendations will be brought forward to the Board of Health for approval in October.

There were no questions or discussion.

It was moved by M. Newton-Reid, seconded by M. Smibert, that the Quality and Governance Committee recommend to the Board of Health to:
1) Receive Report No. 11-25QGC re: “2025 Board of Health Member Self-Assessment” for information;
2) Approve the Board of Health Member Self-Assessment Tool as Appendix A; and
3) Direct the Clerk to initiate the Board of Health Member Self-Assessment for 2025.
Carried

Other Business

The next meeting of the Quality and Governance Committee is Thursday, September 18 at 6 p.m.

Adjournment

At 6:22 p.m., it was moved by M. Newton-Reid, seconded by M. Steele, that the meeting be adjourned.
Carried

AINA DEVIET
Committee Chair

STEPHANIE EGELTON
Clerk

EMILY WILLIAMS
Secretary