Minutes - September 18, 2025 - Quality and Governance Committee Meeting

Thursday, September 18, 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 (attended virtually)
Michael Steele
Emily Williams, Chief Executive Officer (ex-officio) (Secretary and Treasurer)
Dr. Alexander Summers, Medical Officer of Health (ex-officio)

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, Records and Health and Safety
Abha Solanki, End User Support Analyst, Information Technology
Sue Clarke, Community Member

At 6 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. Steele, that the AGENDA for the September 18, 2025 Quality and Governance Committee meeting be approved.
Carried

Approval of Minutes

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

New Business

Risk Register Reporting Dashboard (Report No. 12-25QGC)

Ryan Fawcett, Associate Director, Operations/Privacy Officer introduced Lilka Young, Strategic Advisor, Risk, Records and Health and Safety, presented the new Risk Reporting dashboard.

L. Young explained that the new dashboard will take a proactive approach, instead of a reactive approach regarding risk, and will include current and anticipated risks as opposed to past risks. The new dashboard will also display the identified risks in a visually appealing format. L. Young noted that the previous dashboard in a spreadsheet was less visually appealing, and the new dashboard will summarize pertinent information for the Committee to be aware of.

L. Young advised that Chair DeViet and Board Chair Steele met with the Risk team in August to preview the dashboard, and their feedback was incorporated.

Chair DeViet noted that she was pleased with the new dashboard as it provides the Committee and Board Members with integrated thinking about risk with better understanding of mitigation strategies.

There were no questions or discussion.

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. 12-25QGC re: “Risk Register Reporting Dashboard” for information.
Carried

Q2 2025 Risk Register Update (Report No. 13-25QGC)

L. Young presented the Q2 2025 Risk Register Update.

L. Young noted that of the seven (7) risks identified on the Q2 2025 Risk Register Reporting Dashboard:
• One (1) carries significant residual risk within the Financial category:
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.
• Three (3) carry moderate residual risk within the Political, Operational/Service Delivery, Legal/Compliance 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 was secured for a new 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) carry minor residual risk related to Technology, Legal/Compliance, and Operational/Service Delivery risk categories, of which all have been mitigated to an acceptable level of risk.

The two risks (one significant, one minor) removed from the risk register from the last quarter were related to union negotiations classified under the People/Human Resources category. The six emerging risks that are being monitored and are not embedded into the Risk Register are centered around potential litigation and staff capacity to meet agency deliverables and goals.

L. Young concluded that going forward, the Committee would be reviewing risks in the new dashboard format.

Committee Member Michelle Smibert inquired on the status of the new website project. R. Fawcett indicated the target for the new website launch is late October to early November.

It was moved by M. Smibert, seconded by M. Steele, that the Quality and Governance Committee recommend to the Board of Health to:
a) Receive Report No. 13-25QGC re: “Q2 2025 Risk Register Update” for information; and
b) Approve the Q2 Risk Register Reporting Dashboard (Appendix A)
Carried

Governance Policy Review for September 2025 (Report No. 14-25QGC)

L. Young presented the Committee with the Governance Policy Review report for September 2025.

The policies and by-laws that the Committee reviewed for the September meeting were:
• G-080 Occupational Health and Safety
• G-100 Privacy and Freedom of Information
• G-120 Risk Management
• G-500 Respiratory Season Protection
• G-B10 By-law No. 1 Management of Property
• G-B20 By-law No. 2 Banking and Finance
• G-B40 By-law No. 4 Duties of the Auditor

L. Young noted that the proposed amendments included housekeeping items (such as title changes) and minor wording changes. The next group of policies and final policies of 2025 will be brought forward to the November 20th Quality and Governance Committee meeting.

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:
1) Receive Report No. 14-25QGC re: “Governance Policy Review for September 2025” for information; and
2) Approve the governance policies as amended in Appendix B.
Carried

2025 Board of Health Self-Assessment Results (Report No. 15-25QGC)

Stephanie Egelton, Clerk presented the 2025 Board of Health Self-Assessment Results.

S. Egelton noted that survey (for the self-assessment) was open throughout the summer (May to July) for completion. Eight (8) out of eleven (11) Board Members and Ex-Officios (73%) completed the Self-Assessment. In 2023, the participation percentage was also 73%.

In high level themes:
• The Board overall feels they are doing a good job of their governance abilities
• There was a comment about staff presentations resulting in sometimes longer meetings
• The Board feels they have had average opportunity to interact with guests at meetings
• There were comments about wishing for more engagement from partners such as delegations
• The Board are pleased with their performance individually

S. Egelton noted that recommendations from the self-assessment would be presented to the Board of Health at the October meeting.

There were no questions or discussion.

It was moved by M. Steele, seconded by M. Smibert, that the Quality and Governance Committee recommend to the Board of Health to receive Report No. 15-25QGC re: “2025 Board of Health Self-Assessment Results” for information.
Carried

2023-25 Provisional Plan 2025 Q2 Status Update (Report No. 16-25QGC)

Sarah Maaten, Director, Public Health Foundations presented the Q2 2025 Provisional Plan status report.

S. Maaten noted that several projects have been completed and there are several projects expected to take a few years, but they are also progressing well. Progress continues to be made on the development of the 2026-2030 Strategic Plan, details of which were shared in July 2025.

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. 16-25QGC re: “2023-25 Provisional Plan 2025 Q2 Status Update” for information.
Carried

Q2 2025 Performance Reporting (Report No. 17-25QGC)

Dr. Alexander Summers, Medical Officer of Health provided highlights of the Health Unit’s public health performance reporting for Q2. Dr. Summers added that the full performance reporting was affixed as Appendix A.

Highlights for Q2 include:
- Continued development and implementation of the Management Operating System, including operational planning, indicator development, program prioritization, and quality improvement. The strategic planning process continued and accelerated throughout Q2;
- On-track progress in inspections related to most programs, excluding low-risk inspections of food premises; however, ongoing operational pressures may challenge the completion of moderate-risk inspections in 2025;
- Gradual decrease in resources allocated to responding to the ongoing measles outbreak in southwestern Ontario throughout Q2;
- Increase in rabies and zoonotic investigations and associated increase in post-exposure prophylaxis doses administered;
- Successful funding secured for continuation and expansion of the iHEAL intervention until December 2026; and
- Growing capacity in healthy public policy development.

Committee Member Matthew Newton-Reid inquired on how many Public Health Inspectors would be required to meet the current needs of inspecting food premises in Middlesex-London. Dr. Summers explained that the number of outbreaks that could happen are unknown and unpredictable, noting that there is currently limited surge capacity to address those situations. Dr. Summers indicated that an estimate would be an increase of 4-5 FTE in Public Health Inspectors would ensure adequate capacity to meet current inspection needs.

It was moved by M. Steele, seconded by M. Smibert, that the Quality and Governance Committee recommend to the Board of Health to receive Report No. 17-25QGC re: “Q2 2025 Organizational Performance Reporting” for information.
Carried

Other Business

The next meeting of the Quality and Governance Committee is Thursday, November 20, 2025 at 6 p.m.

Adjournment

At 6:23 p.m., it was moved by M. Newton-Reid, seconded by M. Smibert, that the meeting be adjourned.
Carried

AINA DEVIET
Committee Chair

STEPHANIE EGELTON
Clerk

EMILY WILLIAMS
Secretary