Minutes - February 20, 2025 - Board of Health Meeting

Thursday, February 20, 2025 at 7 p.m.
MLHU Board Room – CitiPlaza
110-355 Wellington Street
London, ON N6A 3N7

Members Present: 

Aina DeViet (2025 Committee Chair Appoint)
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, Executive Assistant to the 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
Dr. Janice Mok, Medical Resident

At 6:01 p.m., Secretary and Treasurer Emily Williams called the meeting to order.

Meeting Procedures

Election of 2025 Quality and Governance Committee Chair

Secretary and Treasurer Emily Williams opened the floor to nominations for Chair of the Quality and Governance Committee for 2025.

It was moved by M. Smibert, seconded by M. Steele, that Aina DeViet be nominated for Chair of the Quality and Governance Committee for 2025.
Carried
Aina DeViet accepted the nomination.

E. Williams called three times for further nominations. None were forthcoming.

It was moved by M. Smibert, seconded by M. Steele, that Aina DeViet be acclaimed as Chair of the Quality and Governance Committee for 2025.
Carried

Disclosure of Pecuniary Interest

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

Approval of Agenda

It was moved by M. Steele, seconded by M. Smibert, that the AGENDA for the February 20, 2025 Quality and Governance Committee meeting be approved.
Carried

New Business

2025 Quality and Governance Committee Terms of Reference (Report No. 01-25QGC)

Emily Williams, Secretary of the Board of Health introduced the draft 2025 Quality and Governance Committee Terms of Reference.

E. Williams explained that the new Quality and Governance Committee will conduct work that includes policy review and reviewing quality-related reporting such as strategic planning, organizational performance, privacy statistics and risk management. Meetings will be quarterly at 6 p.m. before the regularly scheduled Board of Health meeting.

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. 01-25QGC re: “2025 Quality and Governance Committee Terms of Reference” for information; and
2) Approve the 2025 Quality and Governance Committee Terms of Reference.
Carried

2023-25 Provisional Plan 2024 Q4 Status Update (Report No. 02-25QGC)

Sarah Maaten, Director, Public Health Foundations presented the 2024 Q4 Status Update of the Middlesex-London Health Unit’s Provisional Strategic Plan.

S. Maaten noted that progress has been made on many of the Provisional Plan strategic initiatives within Q4 of 2024 with some initiatives being delayed and paused following a reprioritization process in Q3. The initiative to develop an organizational emergency response plan (ERP) and continuity of business operation plan (COOP) has been completed. This is the first provisional plan initiative to be completed and will be presented to the Board of Health at the regular Board of Health meeting later in the evening (February 20 at 7 p.m.). Three types of risks were identified within the tactics in Q3 2024: (1) Operational / Service Delivery, (2) People / Human Resources, and (3) Financial.

S. Maaten noted that the following initiatives have experienced delays or pauses:
• The Partnership Engagement Framework and Partnership Inventory initiatives were placed on hold at the beginning of Q3 resulting in no activities being completed during Q4. This initiative is planned to resume in Q1 2025 with a trial of the draft inventory.
• The Intervention Description and Indicator Development initiative was paused towards the end of Q3 and during Q4. Timelines have been extended to respond to competing priorities. This initiative is planned to resume in Q1 2025.
• The sociodemographic and race-based data collection project experienced a decline in staff participation due to several operational and service delivery factors. A few strategies are planned for Q1 2025 to further understand the challenges in data collection from early adopter teams and explore technical solutions.
• Some activities associated with the Job Description Review experienced delays in Q4 due to limited staff capacity to review position descriptions.
• Some activities associated with Document and Refine Budgeting Processes were delayed due to turnover in the Finance team.

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 receive Report No. 02-25QGC re: “2023-25 Provisional Plan 2024 Q4 Status Update” for information.
Carried

Privacy Program Report – IPC Statistical Reports for 2024 (Report No. 03-25QGC)

Ryan Fawcett, Associate Director, Operations/Privacy Officer presented the 2024 privacy statistics for the Middlesex-London Health Unit.

R. Fawcett noted that reporting to the Information and Privacy Commissioner of Ontario for local boards and municipalities is due March 1 each year. Required reports include confirmed privacy breaches, access and correction requests under the Personal Health Information Protection Act, O. Reg 329/04 (PHIPA) and access and correction requests under and the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Reporting was completed on February 10, 2025.

The Health Unit had one (1) privacy breach incident in 2024 that met the threshold for notification to the Information and Privacy Commissioner. This privacy breach involved a staff member accessing private health information of a client without authorization. The information was not disclosed to anyone else and the Health Unit worked through the disclosure with the client. The steps that the Health Unit conducted to rectify the situation satisfied the Information and Privacy Commissioner.

In 2024, there were five (5) PHIPA access requests, 2 (two) MFIPPA access requests, and one (1) privacy breach. In 2023, there were 21 PHIPA access requests, 7 (seven) MFIPPA access requests and no privacy breaches.

Committee Member Mike Steele inquired on the reason that freedom of information requests would be lower than previous years. R. Fawcett explained that freedom of information requests vary from year to year. Historically, the Health Unit has had higher personal health information (PHIPA) requests than municipal (MFIPPA). Requests for 2024 are on par with pre-COVID trends.

Chair DeViet noted that municipal clerks are reporting higher volumes in freedom of information requests for 2024.

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. 03-25QGC re: “Privacy Program – Information and Privacy Commissioner (IPC) Statistical Reports for 2024” for information.
Carried

Q4 2024 Risk Registry Update (Report No. 04-25QGC)

R. Fawcett presented the Q4 2024 Risk Registry. There are eight (8) risks identified on the Q4 2024 Risk Register.

Three (3) risks carry significant residual risk within the Financial and People/Human Resources and Legal/Compliance categories. The financial risk is related to sustained financial pressures as the provincial government 1% funding increase is not sufficient to offset actual work and inflation. Due to the election, the 2024 funding package has not been received by the Health Unit. MLHU awaits a response from the Ministry with respect to one-time COVID and outbreak disease funding request. The people-related risk is related to reduced resiliency post restructuring. Senior Leadership continues to support leaders and staff through change, as well as conducting goal and priority setting exercises to focus teams on core deliverables. The legal risk is related to a planned legal matter in Q1 2025.

Three (3) risks carry moderate residual risk within the Political, Technology and Operational/Service Delivery categories. The political risk is related to health unit mergers. Voluntary mergers were approved, merging nine (9) health units into four (4) newly created health units. No new mergers are anticipated at this time. The technology risk is related to token software management, which has been mitigated by the Information Technology team. The operational risk is related to the Health Unit needing a new website provider, which vendor options are being explored.

Two (2) carry minor residual risk related to the technology and legal risk categories, both of which have been mitigated to an acceptable level of risk.

R. Fawcett noted that priorities for 2025 are continued support for staff and leaders, hardening cyber defenses, reducing the financial gap and business continuity planning. A new risk register will be developed in 2025 enhancing how risks are identified and communicated within the Health Unit and to the Board.

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:
a) Receive Report No. 04-25QGC re: “Q4 2024 Risk Registry” for information; and
b) Approve the Q4 Risk Register (Appendix A)
Carried

Q4 2024 Performance Reporting (Report No. 05-25QGC)

Dr. Alexander Summers, Medical Officer of Health introduced the Q4 2024 Performance Reporting. Dr. Summers reminded the Committee that this process was a part of the Management Operating System (MOS) at the Health Unit, providing the Committee and Board of Health with quarterly performance reporting.

Highlights of Q4 2024 include:
• Significant changes to the comprehensive school health interventions;
• Ongoing community mobilization efforts to address the toxic drug crisis and homelessness crisis within Middlesex-London;
• Completion of the Continuity of Operations Plan on an expedited schedule; and
• Continued development and implementation of the Management Operating System, including the re-initiation of the intervention description and indicator development process.

E. Williams noted that key performance indicator (KPI) work was picking up at the Health Unit and that more indicators from Corporate Services would be seen in Q2’s report to the Committee.

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 receive Report No. 05-25QGC re: “Q4 2024 Organizational Performance Reporting” for information.
Carried

Other Business

The next meeting of the Middlesex-London Board of Health is Thursday, May 22, 2025 at 6 p.m.

Adjournment

At 6:16 p.m., it was moved by M. Steele, seconded by M. Newton-Reid, that the meeting be adjourned.
Carried

Aina DeViet
Committee Chair

Emily Williams
Secretary