September 15, 2016
Report To: Executive Committee, Board of Health
Submitted by: Dr. Nicola Mercer, Medical Officer of Health & CEO
Subject: GOVERANCE FRAMEWORK POLICIES & PROCEDURES
Recommendations
(a) That the Executive Committee makes recommendation to the Board of Health to accept the Policy Strategic Plan CA.45.01.100, attached Appendix 1.
(b) That the Executive Committee makes recommendation to the Board of Health to accept the Policy Medical Officer of Health/CEO Job Description CA.45.01.201, attached Appendix 2.
(c) That the Executive Committee makes recommendation to the Board of Health to accept the Policy Stewardship of Management Operations CA.45.01.400, attached Appendix 3.
(d) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Capital Funding Plan CA.45.02.401, attached Appendix 4.
(e) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Communications Strategy CA.45.02.402, attached Appendix 5.
(f) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Educational Requirements for Public Health Professionals CA.45.02.403, attached Appendix 6.
(g) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Financial Policies and Procedures CA.45.02.404, attached Appendix 7.
(h) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Financial Records CA.45.02.405, attached Appendix 8.
|(i) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Human Resources Strategy CA.45.02.406, attached Appendix 9.
(j) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Information Management CA.45.02.407, attached Appendix 10. Executive Committee Report BH.09.SEP1516.R01 Page 2 of 25
(k) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Medical Officer of Health Direction to Staff CA.45.02.408, attached Appendix 11.
(l) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Operational Plan CA.45.02.409, attached Appendix 12.
(m)That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Procurement CA.45.02.410, attached Appendix 13.
(n) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Professional Practice Support CA.45.02.411, attached Appendix 14.
(o) That the Executive Committee makes recommendation to the Board of Health to accept the Procedure Stewardship of Management Operations – Research Ethics CA.45.02.412, attached Appendix 15.
(p) That the Executive Committee makes recommendation to the Board of Health to accept the Policy Governance Framework CA.45.01.500, attached Appendix 16.
(q) That the Executive Committee makes recommendation to the Board of Health to accept the Policy Board of Health Purchase of Services CA.45.01.510, attached Appendix 17.
Background
The Ontario Public Health Organizational Standards (OPHOS) specifies the requirements that all boards of heath are obligated to implement. The WDGPH Board of Health is accountable for compliance with these standards and achievement of the Ontario Public Health Standards (OPHS). The attached policies and procedures outline the reporting expectations and requirements of the organization through the Senior Staff for the provision of adequate information to the board, enabling it to confirm WDGPH organizational compliance to the OPHS & OPHOS.
Public Health and/or Financial Implications
Failure to achieve requirements of OPHS may result in a reduction of the health and wellness of the overall population served by WDGPH and a reduction or loss of public confidence. Failure to achieve the requirements of the OPHOS may result in reduced funding, ministry review and/or oversight.
Appendices
APPENDIX 1
POLICY CATEGORY: Board of Health NUMBER: CA.45.01.100
SUBJECT: Strategic Plan
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
POLICY STATEMENT:
The Board of Health (BOH) for Wellington-Dufferin-Guelph Public Health (WDGPH) shall ensure the development, implementation and monitoring of a strategic plan for the Agency which:
- Articulates the vision, mandate, mission and values of WDGPH;
- Identifies strategic priorities, goals and objectives;
- Addresses local contexts and reflects the needs of the community;
- Integrates BOH, staff and community partner input;
- Links to and informs organizational and operational planning;
- Is regularly reviewed (at least annually) and revised, as appropriate; and
- Is communicated to the BOH, staff and community partners.
The strategic plan will be developed for a specific time frame, no less than five years. Development, implementation and monitoring of the strategic plan will be the responsibility of the Medical Officer of Health/CEO.
SCOPE:
This policy applies all members of the BOH.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Procedure:
N/A CA.45.01.302 Compliance Monitoring and Improvement
Contact for inquiries: Office of the Medical Officer of Health/CEO
Original document signed by: Chair of the Board of Health ______________________________
APPENDIX 2
POLICY CATEGORY: Board of Health
NUMBER: CA.45.01.201
SUBJECT: Medical Officer of Health/CEO Job Description
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1 REPLACES: N/A
POLICY STATEMENT:
The Board of Health (BOH) for Wellington-Dufferin-Guelph Public Health (WDGPH) will ensure the Medical Officer of Health/CEO (MOH) will have an up to date job description. The BOH will ensure the details of the MOH job description are aligned with the requirements of the Health Protection and Promotion Act and any other relevant legislation. General Principles Job descriptions provide a summary of the position’s duties, principal responsibilities, education and experience requirements, and an overview of other generally expected responsibilities placed upon the MOH. Job descriptions become the basis for the assessment of the MOH work performance. Process The Executive Committee of the BOH will informally review the MOH job description annually as part of the performance management process. The Executive Committee of the BOH will ensure revisions and updates are made as required by legislative changes or business requirement needs. The MOH job description will be formally reviewed, revised and approved by the BOH at least every three years. The Director, Administrative Services will support the Executive Committee in the revision process as required.
SCOPE:
This policy applies to all members the BOH.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Procedure: N/A
Contact for inquiries: Chair of the Board of Health
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 3
POLICY CATEGORY: Board of Health
NUMBER: CA.45.01.400
|SUBJECT: Stewardship of Management Operations
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 2
REPLACES: N/A
POLICY STATEMENT:
The Board of Health (BOH) for Wellington-Dufferin-Guelph Public Health (WDGPH) is committed to confirming the highest standards of administration, ensuring Senior Management use a proactive, problem solving approach to establish its operational directions, organizational priorities and objectives and through its actions, ensure the Agency delivers effective programs, and functions in an efficient and effective manner.
- Specifically, the BOH will ensure compliance with the Ontario Public Health Organizational Standards (OPHOS) providing stewardship to ensure the following areas are effectively managed:
- Capital Funding Plan;
- Communications Strategy;
- Educational Requirement for Public Health Professionals at WDGPH;
- Financial Policies and Procedures;
- Financial Record Management;
- Human Resources Strategy;
- Information Management and Security Policies and Procedures;
- Medical Officer of Health Direction to Staff;
- Operational Plan;
- Procurement Policies and Procedures;
- Professional Practice Support;
- Research Ethics;
- Risk Management;
- Service Level Agreements;
- and Staff Development and Training.
SCOPE:
This policy applies to all WDGPH employees responsible for program and services development and delivery and the reporting of service outcomes.
RESPONSIBILITY:
BOH Members will:
• Request and review information regarding the administration of programs and services that provide them confidence that effective programs and functions are compliant and meeting the OPHOS.
MOH/CEO and Senior Management will:
- Provide reports to the BOH as outlined in policy and/or procedure to enable the BOH to fulfill its stewardship function; and
- Modify programs and services accordingly based on feedback from the BOH to enhance effectiveness and/or efficiency.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
|
Corresponding Procedures:
CA.45.02.401 Stewardship of Management Operations – Capital Funding Plan
CA.45.02.402 Stewardship of Management Operations – Communications Strategy
CA.45.02.403 Stewardship of Management Operations – Educational Requirements for Public Health Professionals
CA.45.02.404 Stewardship of Management Operations – Financial Policies and Procedures
CA.45.02.405 Stewardship of Management Operations – Financial Records
CA.45.02.406 Stewardship of Management Operations – Human Resources Strategy
CA.45.02.407 Stewardship of Management Operations – Information Management
CA.45.02.408 Stewardship of Management Operations – Medical Officer of Health Direction to Staff
CA.45.02.409 Stewardship of Management Operations – Operational Plan
CA.45.02.410 Stewardship of Management Operations – Procurement
CA.45.02.411 Stewardship of Management Operations – Professional Practice Support
CA.45.02.412 Stewardship of Management Operations – Research Ethics
Contact for inquiries: Chair of the Board of Health
Original document signed by: Chair of the Board of Health _______
APPENDIX 4
PROCEDURE CATEGORY: Board of Health
NUMBER: CA.45.02.401
SUBJECT: Stewardship of Management Operations – Capital Funding Plan
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1:
- Capital funding plan (section 6.9).
Director of Administrative Services will:
- Ensure compliance with Board of Health (BOH) By-Law No. 3, being a by-law relating to the property of the BOH for Wellington-Dufferin-Guelph Public Health;
- Provide to the BOH annually for information, a report on the contributions to, disbursements from, and income generated by Facilities Reserve Funds established under BOH By-Law No. 3, section 1.4: Care and Maintenance of Property; and
- Provide to the BOH annually for information, a report on the status of Facilities Reserve Funds established under BOH By-Law No. 3, section 1.4: Care and Maintenance of Property, in relation to the BOH’s Reserve Fund Plan.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Oversight of Management Operations
Board of Health (BOH) By-Law No. 3 1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 5
PROCEDURE CATEGORY: Board of Health
NUMBER: CA.45.02.402
SUBJECT: Stewardship of Management Operations – Communications Strategy
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Communications Strategy (section 6.11).
The Board of Health (BOH) is committed to ensuring a Communications Strategy for Wellington-Dufferin-Guelph Public Health is developed and that focuses on public health services, advocacy and health promotion while building a general understanding of the public health mandate. A comprehensive Communications Strategy will provide:
- Guidelines for sharing information with community partners and staff;
- A plan to ensure consistency in messaging at all levels, to all audiences, ensuring accessibility;
- Consistency of messaging across multiple media platforms to ensure integrated communications;
- Dissemination plans of relevant research findings for each approved research project;
- Guidelines for use of relationships with media channels to share health information;
- Strategies for educating community partners and the public about key public health issues; and
- Methods for issues management and support of key spokespeople.
In the first quarter of each year the BOH will receive a summary of Communications activities including how the Communications Strategy objectives have been met throughout the previous year.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 6
PROCEDURE CATEGORY: Board of Health
NUMBER: CA.45.02.403
SUBJECT: Stewardship of Management Operations – Educational Requirements for Public Health Professionals
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 :
Educational Requirements for Public Health Professionals (section 6.5). A report will be provided to the Board of Health each year. The report will provide confirmation that the recruitment of staff in the roles identified in the Health Promotion and Protection Act (HPPA) meet the standards as outlined:
- Business Administrator;
- Public Health Dentist;
- Dental Hygienist;
- Public Health Inspector;
- Public Health Nurse; and
- Public Health Nutritionist (HPPA, Reg.566)2
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations Health Promotion and Protection Act
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
2 Qualifications of Boards of Health Staff, R.R.O. 1990, Reg. 566. Available at: http://www.e-laws.gov.on.ca/ html/regs/9nglish/elaws_regs_900566_e.htm.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 7
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.404
SUBJECT: Stewardship of Management Operations – Financial Policies and Procedures
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Financial policies and procedures (section 6.7).
Director of Administrative Services will:
- Provide to the Board of Health annually, a report on Wellington-Dufferin-Guelph Public Health’s policies and procedures in place to ensure compliance with the requirements listed in section 6.7 of the OPHOS;
- Provide a list of Agency operational policies and procedures reviewed during the year; and
- Provide an overview of updates and changes made to Agency policies and procedures throughout the year.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 8
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.405 SUBJECT: Stewardship of Management Operations – Financial Records
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 :
- Financial records (section 6.6).
Director of Administrative Services will:
- Provide to the Board of Health (BOH) quarterly for information, reports on the status of income and expenditures for the year to date, which will be prepared based on the books and records of the financial affairs of Wellington-Dufferin-Guelph Public Health (WDGPH).
- Provide to the BOH annually, the financial statements of WDGPH as prepared by management in accordance with Public Sector Accounting Standards, including, at a minimum:
-An annual statement of income and expenses (Statement of Operations); and
-An annual statement of assets and liabilities (Statement of Financial Position).
- Provide to the BOH annually, the auditor’s report on management’s financial statements, with an audit scope that includes, but is not limited to:
-Assessment of the risks of material misstatement in the financial statements, whether due to fraud or error;
-Evaluating the appropriateness of accounting policies used and the reasonableness of accounting estimates made by management; and
-Evaluating the overall presentation of the financial statements.
- Provide to the BOH annually, for information and approval, a budget for WDGPH which outlines management’s estimates of the revenue and expenditures of the BOH for the following year.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.100 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by:
Chair of the Board of Health _____________________________________________
APPENDIX 9
PROCEDURE CATEGORY: Board of Health
NUMBER: CA.45.02.406
SUBJECT: Stewardship of Management Operations – Human Resources Strategy
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Human Resources Strategy (section 6.14) 1.
Senior Management shall ensure the establishment of a human resources strategy, based on a workforce assessment which considers the competencies, composition and size of the workforce, as well as community composition, and includes initiatives for the recruitment, retention, professional development and leadership development of the Wellington-Dufferin-Guelph Public Health workforce.
Senior Management shall establish and implement written human resource policies and procedures which are made available to staff, students, and volunteers. A report will be provided to the Board of Health (BOH) each year. The report will provide an overview of the work completed to meet the requirements of section 6.14 requirements of the OPHOS, and confirmation that policies and procedures shall be maintained concerning but not limited to:
- The availability of position descriptions for staff;
- A process to ensure that staff meet qualifications for their positions, job classifications and licensure (as required);
- Confidential personnel files shall be maintained for each staff member;
- Occupational health and safety policies;
- Recruitment and retention strategies, including workplace health practices;
- A code of conduct;
- Compensation policy;
- Discipline and labour relation policies;
- Staff performance evaluation processes; and
- Succession planning.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 10
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.407
SUBJECT: Stewardship of Management Operations – Information Management
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Information Management (section 6.12).
The Medical Officer of Health/CEO shall establish, maintain and implement policies and procedures related to data collection and records management, which ensure:
- Compliance with all applicable legislation, regulations and policies, including the Health Protection and Promotion Act, Municipal Freedom of Information and Protection of Privacy Act2 , and Personal Health Information Protection Act3 to the management of all personal information and personal health information;
- Data quality in the creation and collection of data;
- Confidentiality in how records are used and accessed;
- Use of current and appropriate security features, including strong encryption of personal health information;
- A records maintenance process that includes remediation of errors;
- Appropriate records retention process that varies by type of record;
- Secure disposal of records; and
- That the purposes and appropriate uses of data being created are communicated to and respected by staff and management who collect, enter, store, analyze, use and/or destroy the data.
A report will be provided to the Board of Health each year. The report will provide an overview of WellingtonDufferin-Guelph Public Health’s programs and standards to achieve the requirements as outlined in section 6.12 of the OPHOS.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011. 2 Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56. Available from: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90m56_e…. 3 Personal Health Information Protection Act, S.O. 2004, c. 3, Sch. A. Available from: http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_04p03_e.htm.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 11
PROCEDURE CATEGORY: Board of Health
NUMBER: CA.45.02.408
SUBJECT: Stewardship of Management Operations – Medical Officer of Health Direction to Staff
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Medical Officer of Health/CEO (MOH) provides direction to staff (section 6.3).
Employees are subject to the direction of and are responsible to the MOH if their duties relate to the delivery of public health programs or services under this or any other Act. (HPPA, s.67)2
The MOH will provide guidance and direction to staff in work of public health and the fulfillment of its requirements and objectives.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
2 Health Protection and Promotion Act, R.S.O. 1990, c.H.7. Available from: http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 12
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.409
SUBJECT: Stewardship of Management Operations – Operational Plan
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Operational Plan (section 6.1). Senior Management will ensure that the establishment an operational plan for the organization which includes but is not limited to:
- The composition, responsibilities and key function of Wellington-Dufferin-Guelph Public Health (WDGPH);
- The internal processes for managing day-to-day operations of programs and services to achieve the required outcomes;
- Demonstrates that the operational activities of the WDGPH are aligned with the Strategic Plan;
- Includes key objectives, timeframes, responsibilities, and intended results, including planned activities based on an assessment of its communities’ needs;
- Demonstrates efforts to minimize barriers to access;
- Describes the monitoring of key performance indicators and evidence-informed public health practice;
- Involve staff at all levels of the organization and include input from community partners and shall be reviewed and updated at least annually; and
- Achievement of the operational plan shall be monitored and reported in status reports on a quarterly basis to board members and staff as outlined in section 6.1 of the OPHOS.
A report will be provided to the Board of Health each year. The report will provide confirmation that the establishment an operational plan for the organization which includes but is not limited to the requirements outlined in section 6.1 of the OPHOS.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 13
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.410
SUBJECT: Stewardship of Management Operations – Procurement
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1 (OPHOS):
- Procurement (section 6.8).
Director of Administrative Services will:
- Provide a report on the aspects of Wellington-Dufferin-Guelph Public Health’s policy CA.51.01.112 and procedure CA.51.02.112 Procurement as listed in section 6.8 of the OPHOS.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations CA.51.01.112 and CA.51.02.112 Procurement 1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 14
PROCEDURE
CATEGORY: Board of Health
NUMBER: CA.45.02.411
SUBJECT: Stewardship of Management Operations – Professional Practice Support
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1:
- Professional Practice Support (section 6.16).
The Medical Officer of Health/CEO shall insure a management person is designated Chief Nursing Officer (CNO) to be responsible for nursing quality assurance and nursing practice leadership. Annually, the CNO will report to the Board of Health, a summary of the functions of the Nursing Council for the preceding year. This report will include reports on Nursing Practice Issue Resolutions, if any, policy and protocol development that directly relates to nursing practice and leadership development at Wellington-Dufferin-Guelph Public Health.
The Senior Management shall support a culture of excellence in professional practice for all regulated and unregulated health professions that ensures inter-professional collaboration and learning, and that staff are able to comply with professional regulatory body requirements where applicable.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 15
PROCEDURE
CATEGORY: Board of Health NUMBER: CA.45.02.412
SUBJECT: Stewardship of Management Operations – Research Ethics
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
PROCEDURE:
This procedure will address the following goals/objectives in the Ontario Public Health Organizational Standards1:
- Research Ethics (section 6.13).
Senior Management shall establish, maintain and implement policies and procedures related to research ethics that reflect accepted standards of practice.
A report will be provided to the Board of Health each year. The report will describe the activities of the Research Ethics Committee in the previous year. It will also include information about the research ethics reviews that occurred:
- The number of research ethics reviews that occurred within the previous year;
- The number of reviewed projects that were approved with no amendments;
- The number of reviewed projects that were approved with minimal amendments; and
- The number of reviewed projects that were not approved.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Policy: CA.45.01.400 Stewardship of Management Operations
1 Ministry of Health and Long-Term Care and Ministry of Health Promotion and Sport. (February 2011). Ontario Public Health Organizational Standards (Revised Catalogue No. 015523 ISBN 978-1-4435-5469-5 (PDF)). Ontario. Queen’s Printer for Ontario 2011.
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________________________
APPENDIX 16
POLICY
CATEGORY: Board of Health
NUMBER: CA.45.01.500
SUBJECT: Governance Framework
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 6
REPLACES: N/A
POLICY STATEMENT:
The Board of Health (BOH) for Wellington-Dufferin-Guelph Public Health (WDGPH) is created by statute pursuant to the Health Protection and Promotion Act (HPPA) to superintend, provide or ensure the provision of the health programs and services required by the HPPA and its Regulations to the persons who reside in the County of Wellington, County of Dufferin and the City of Guelph. The BOH shall also perform such other functions as are required by or under the HPPA or any other Legislative Act.
Members of the BOH are appointed under the HPPA either by a Municipal Council or from the Province of Ontario. The City of Guelph shall appoint three members, the County of Wellington shall appoint three members, and the County of Dufferin shall appoint two members. The Province of Ontario may appoint up to seven members to the BOH.
The BOH members are responsible for selecting officers for the BOH. The election of officers is held at the inaugural meeting of the BOH for each calendar year in accordance with By-Law 1 section 5.11. Terms of office run until the next inaugural meeting of the year following the election. The BOH selects three officers, Chair, ViceChair and Secretary-Treasurer.
SCOPE:
This policy applies to all members of the BOH.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Procedure: N/A
CA.45.01.200 Medical Officer of Health/CEO Performance Appraisal
CA.45.01.502 Board of Health Self-Evaluation
Appendix A BOH Chair Role and Responsibilities
Appendix B BOH Vice Chair Role and Responsibilities
Appendix C BOH Secretary/Treasurer Role and Responsibilities
Appendix D BOH Member Role and Responsibilities
Contact for inquiries: Chair of the Board of Health
Original document signed by: Chair of the Board of Health ___________________________________
APPENDIX A – BOH CHAIR ROLE AND RESPONSIBILITY
Accountability
The Chair serves and is accountable to the BOH.
Authority
The Chair has no formal authority to direct the BOH or the affairs of WDGPH. Like other BOH members, the Chair is entitled to make motions and vote on matters before the BOH.
The Chair is included as a member of the BOH in constituting quorum.
The Chair may not, on behalf of WDGPH, enter into contracts without the knowledge and approval of the BOH including the Medical Officer of Health/CEO (MOH).
Responsibility
The Chair is, first and foremost, responsible for the effective functioning of the BOH in its role of governing WDGPH. All other duties are secondary.
Primary Duties
In addition to the duties of every BOH member, the duties of the Chair are described in By-Law No. 1 and include:
- Overseeing the preparation of the BOH meeting agenda in collaboration with the office of the MOH;
- Chairing all meetings of the BOH in accordance with the agenda, the By-Laws and the Rules (Robert’s Rules of Order);
- Reviewing BOH meeting minutes;
- Ensuring compliance with BOH policies and procedures as they apply to the BOH and its individual members;
- Ensuring there is a self-evaluation process to evaluate the effectiveness of the BOH and its annual completion;
- Ensuring there is a formal evaluation of the performance of the MOH and that the Ministry of Health and Long Term Care (MOHLTC) is so informed; Ensuring full and timely communication with all members of the BOH;
- Ensuring the effectiveness of standing committees of the BOH;
- Chairing the Executive Committee of the BOH;
- Signing of behalf of the BOH the annual Program Based Grant Submission and amending documents, the Audited Financial Statements and other financial documents as required by the MOHLTC or other government ministries, and By-Law amendments; and
- The Chair is a signing authority on behalf of WDGPH.
Secondary duties
The Chair may, with greater regularity than other members of the BOH:
- Prepare recommendations for BOH consideration;
- Prepare recommendations to the BOH members for changes to By-Laws;
- Ensure the preparation of, and signs on behalf of, the BOH for all BOH correspondence;
- Be available to the MOH for consultation purposes; and
- Represent the BOH at public or official functions and may speak publicly on behalf of the BOH;
Other duties
Recognizing that the Chair’s role is a voluntary one, the BOH may authorize the Chair to take on additional duties only if they do not interfere with any of the above.
Ex-officio Status
To ensure effective communication, the Chair will be an ex-officio member of all standing committees to which he/she has not been named a member.
Qualifications
The Chair must have:
- A commitment to, and a clear understanding of the mission, vision and values of WDGPH;
- Knowledge of meeting procedures, BOH policies procedures and By-Laws of WDGPH;
- Knowledge of the HPPA, Ontario Public Health Standards (OPHS) and Ontario Public Health Organizational Standards (OPHOS); and
- Sufficient time to devote to his/her primary duties.
Evaluation
The effectiveness of the Chair shall be evaluated as part of the annual evaluation of the BOH itself.
APPENDIX B – BOH VICE-CHAIR ROLE AND RESPONSIBILITY
Accountability
The Vice-Chair serves and is accountable to the BOH.
Authority
The Vice-Chair has no formal authority to direct the BOH or the affairs of WDGPH. Like other BOH members, the Vice-Chair is entitled to make motions and vote on matters before the BOH. The Vice-Chair is included as a member of the BOH in constituting quorum.
Responsibility
The Vice-Chair has all the powers and shall perform all of the duties of the Chair in the absence or disability of the Chair. This position is typically a successor to the Chair position.
Primary Duties
- Is a member of the Executive Committee of the BOH;
- Chairs the Executive Committee to oversee the annual performance appraisal process of the MOH in accordance with BOH policy CA.45.01.200 MOH/CEO Performance Appraisal; and
- Chairs the Ad-Hoc working group in accordance with the BOH policy CA.45.01.502 Board of Health SelfEvaluation.
Secondary Duties
At the request of the Chair, may be asked to perform the duties of the Chair. Other Duties Recognizing that the Vice-Chair’s role is a voluntary one, the BOH may authorize the Vice-Chair to take on additional duties only if they do not interfere with any of the above.
Qualifications
The Vice-Chair must have:
- A commitment to, and a clear understanding of, the mission, vision and values of WDGPH;
- Knowledge of meeting procedures, BOH policies, procedures and By-Laws of WDGPH;
- Knowledge of the HPPA, OPHS and OPHOS; and
- Sufficient time to devote to his/her primary duties
APPENDIX C – BOH SECRETARY-TREASURER ROLE AND RESPONSIBILITY
Accountability
The Secretary-Treasurer serves and is accountable to the BOH.
Authority
The Secretary-Treasurer has no formal authority to direct the BOH or the affairs of WDGPH. Like other BOH members, the Secretary-Treasurer is entitled to make motions and vote on matters before the BOH. The SecretaryTreasurer is included as a member of the BOH in constituting quorum.
Responsibility
Is responsible for ensuring that the financial position of the BOH is prepared and provided to the BOH in a regularly scheduled manner, and that all written documentation and corporate reporting of the BOH are maintained in accordance with the By-Laws and BOH policies and procedures.
Primary Duty
Is a member of the Executive Committee of the BOH;
Chairs the Finance Committee of the BOH;
The Secretary-Treasurer is a signing authority on behalf of WDGPH;
The Secretary-Treasurer signs on behalf of the BOH, the annual Program Based Grant Submission and amending documents, the Audited Financial Statements and other financial documents as required by the MOHLTC or other government ministries, and By-Law amendments; Other Duties Recognizing that the Secretary-Treasurer’s role is a voluntary one, the BOH may authorize the Secretary-Treasurer to take on additional duties only if they do not interfere with any of the above.
Qualifications
- The Secretary-Treasurer must have:
- A commitment to, and a clear understanding of, the mission, vision and values of WDGPH;
- Knowledge of BOH policies, procedures and By-Laws of WDGPH;
- Knowledge of the HPPA, OPHS and OPHOS; and
- Sufficient time to devote to his/her primary duties.
APPENDIX D - BOH MEMBER ROLE AND RESPONSIBILITY
Accountability
All members of the BOH have a fiduciary duty to the BOH.
Authority
Individual BOH members have no authority to approve actions by WDGPH, to direct staff, or to speak on behalf of WDGPH unless given such authority by the BOH.
Responsibility
BOH members are responsible for acting in the best long-term interests of WDGPH and the community and will regularly attend meetings and actively contribute their knowledge and skills to accomplish the task of; superintending, providing or ensuring the provision of the health programs and services required by the HPPA and its Regulations to the persons who reside in the County of Wellington, County of Dufferin and the City of Guelph.
Primary Duty
Every member of the BOH, including the BOH officers, is expected to do the following:
- Prepare for BOH meetings by reading agendas, minutes, reports and other documentation required to actively participate in the meeting;
- Attend meetings regularly;
- Support governance decisions once made;
- Provide input into the development of a strategic plan when so required;
- Help the BOH to monitor the performance of WDGPH in relation to the strategic plan;
- Abide by the By-Laws, Code of Ethics and Conduct and other policies and procedures that apply to the BOH;
- Participate in the approval of the annual budget and monitor the financial performance of the Agency in relation to it;
- Participate in the hiring of the MOH;
- Participate in the evaluation of the MOH;
- Participate in the evaluation of the BOH itself (annual board self-evaluation);
- Contribute to the work of the BOH as a member of a standing committee;
- Attend and participate in the Annual BOH Retreat; and
- Keep informed about community issues relevant to the mission and objectives of WDGPH.
Secondary Duty
Identify prospective BOH members and possibly help recruit them.
Qualifications
BOH members must have:
- A commitment to the mission, vision and values of WDGPH;
- Knowledge of the community;
- An openness to learning the required material; and
- Sufficient time to devote to his/her primary duties.
Evaluation
The performance of individual members is evaluated annually in the context of the whole BOH as part of the annual evaluation of the BOH itself.
APPENDIX 17
POLICY
CATEGORY: Board of Health
NUMBER: CA.45.01.510
SUBJECT: Board of Health Purchase of Services
EFFECTIVE: October 5, 2016
DIVISION: N/A
PAGE(S): 1 of 1
REPLACES: N/A
POLICY STATEMENT:
The Board of Health (BOH) for Wellington-Dufferin-Guelph Public Health (WDGPH) is responsible for the overall governance of the affairs of WDGPH, subject to the provisions of the Health Protection and Promotion Act, Ontario Public Health Standards, Ontario Public Health Organizational Standards, BOH By-Laws and policies and procedures, as well as all other applicable legislation and memorandums of agreement. The BOH is under a fiduciary duty to carry out their duties honestly and in good faith, in the best interests of WDGPH, and with care and diligence.
Policy:
As the need arises, the BOH shall have the authority to retain professional or consulting services providers in order to properly discharge its duties and responsibilities. Professional and consulting services retained may include, but are not limited to legal advisors, public relations experts, human resources/labour relations consultants, and other professionals whose expertise is provided on a contract or temporary basis. Selection and procurement of professional or consulting services shall be completed in a transparent manner consistent with the organization’s approved procurement policy and procedure. The Chair of the BOH will advise the Medical Officer of Health/CEO of expenditures to be incurred that are not included in the approved budget for the BOH.
SCOPE:
This policy applies to all members of the BOH.
DEFINITIONS:
Consultant – a person or entity that under agreement, other than an employment agreement, provides expert or strategic advice and related services for consideration and decision-making.
Legal Advisor – a person who specializes in offering legal assistance on a variety of matters.
Professional Services – banking, insurance, legal, and accounting services.
REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES:
Corresponding Procedure: N/A
CA.51.01.112 and CA.51.02.112 Procurement
Contact for inquiries: Director, Administrative Services
Original document signed by: Chair of the Board of Health _____________________________
Prepared by: Elizabeth Bowden Interim, Director Administrative Services
Reviewed by: Dr. Nicola Mercer, Medical Officer of Health & CEO
Approved by: Dr. Nicola Mercer, Medical Officer of Health & CEO
