March 2021 Board of Health Meeting - Risk Management Information Report

Meeting Date
March 2021 Board of Health Meeting
Meeting Document Type
Information Report
Risk Management

SUBMITTED BY

Marc Frey, Manager, Planning and Strategic Initiatives Department

DATE

March 18, 2021

SUBJECT

Risk Management

BACKGROUND

The Windsor-Essex County Health Unit (WECHU) maintains a corporate risk registry. The Ministry of Health (MOH) requires yearly reporting on the ten (maximum) highest residual risks to the organization and the related operations. Residual risks are defined as the assessed risk level after consideration of associated mitigation strategies. The MOH requires the use of a specific template and consistent language to harmonize efforts in tracking risks across the province.

CURRENT INITIATIVES:

The WECHU enterprise risk registry monitors 29 risks across 14 risk categories. Based on the categorization and reporting requirements by the MOH, 8 of these risks were identified as being high residual risks. The high risks reported to the MOH are related to: funding, health system transformation, disasters/hazards, planning information and evaluation, work stoppage, privacy breaches, and local health disparities.

Each identified high risk includes documentation of current and future mitigation approaches. Some of the mitigation approaches are anticipated to be delayed due to the impact of the ongoing COVID-19 pandemic. The WECHU enterprise risk registry will be updated in the current year, based on the reported risk information to the MOH, with adjustments to the current status of risks and mitigation strategies.

RISK REPORTING

1: Funding

Description

CAUSE: Funding uncertainties.

EVENT: Hampered financial planning, monitoring, and decision making processes. Recent exogenesis factors, including the COVID-19 pandemic and the municipal cost-sharing changes have exacerbated funding uncertainties.

CONSEQUENCES:

  1. Inability to satisfy the WECHU's objectives (Strategic and Operational)
  2. Inability to meet the requirements of the Ontario Public Health Standards
  3. Cost reduction measures (i.e. headcount reductions; prioritization of expenditures) and resulting impact on staff morale
  4. If late approval or approval in excess of budget, lost opportunities if the WECHU is unable to act on plans
  5. Organization’s reputation is at risk
  • CATEGORY: Financial
  • IMPACT: 4
  • LIKELIHOOD: 5
  • OVERALL RATING: 20 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Quarterly variance analysis comparing budget to actual financial results reviewed by Leadership Team and Board of Health (BOH) with forecast (Q3 and or Q4 only).
  2. Responsible budget process that balances finite resources with program/departmental priorities
  3. Identification of priorities (i.e. contract positions, operating expenditures) to be strategic with budget/planning reallocation when positive budget variances are realized
  4. Forecasting of expenditures on a quarterly basis

ACTION REQUIRED:

  1. Evaluation of budget (process and quality)

2: Health System Transformation

Description

CAUSE: Ministry mandated public health system changes.

EVENT: The WECHU may be at risk of significant disruptions and high opportunity costs related to health system transformation including the possibility of regionalization.

CONSEQUENCES:

  1. Inability to meet the requirements of the Ontario Public Health Standards
  2. Hampered ability to effectively respond to COVID-19 requirements/expectations
  3. Confusion of purpose
  4. Confusion within partnerships and working relationships
  5. The organization’s reputation is at risk
  • CATEGORY: Governance / Organizational
  • IMPACT: 5
  • LIKELIHOOD: 4
  • OVERALL RATING: 20 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Working with regional leadership groups to identify local priorities
  2. Engaging with regional leadership groups to establish working relationships for priority areas

ACTION REQUIRED:

  1. Monitoring public health modernization developments
  2. Engagement in public health modernization efforts
  3. Change management planning based on public health modernization information

3: Disasters/Hazards

Description

CAUSE: Epidemiological, natural, and anthropogenic disasters or hazards. This current risk assessment incorporates consideration of the ongoing COVID-19 pandemic, as well as other potential disasters/hazards.

EVENT: The WECHU may be at risk of disrupted service delivery, modified program/service priorities, and/or novel requirements due to a disaster/hazard occurrence.

CONSEQUENCES:
1. Inability to meet the requirements of the Ontario Public Health Standards
2. Inability to satisfy the WECHU's objectives (strategic and operational)
3. Increased capital and human resource requirements, beyond budgeted allocations
4. Capacity constraints based on current assets and required actions
5. The organization’s reputation is at risk

  • CATEGORY: Environment
  • IMPACT: 5
  • LIKELIHOOD: 4
  • OVERALL RATING: 20 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. The WECHU works closely with community partners and the Ministry of Health (Emergency Management Branch) for any emergency notification and response
  2. A Continuity of Operations Plan (COOP), a Hazard Identification Risk Assessment (HIRA), and an Emergency Response Plan (ERP) have been developed
  3. N-95 Respiratory fit-testing occurs on regular intervals

ACTION REQUIRED:

  1. Long-term COVID-19 response plan development
  2. Increased resource allocation to address protracted COVID-19 response
  3. Forecasting for resource expectations for future disaster/hazard scenarios

4: Planning Information and Evaluation

Description

CAUSE: Capacity constraints and/or inability to access/collect information/data resources to inform program planning/operations.

EVENT: The inability to collect local data/information resources due to competing priorities (e.g., COVID-19 pandemic response) and the inability to access federal data resources (e.g., CCHS dataset access) affect organizational capacity to make evidence-based regarding program and service plans. Decreased capacity to plan and evaluate program/service operations to inform decision-making.

CONSEQUENCES:

  1. Programs and services that do not align with the needs of the community
  2. Inability to meet the requirements of the Ontario Public Health Standards
  3. Inability to address local emerging public health concerns (e.g., secondary impacts of COVID-19 on local health outcomes)
  4. Increased health disparity/inequity in Windsor-Essex health outcomes
  5. The organization’s reputation is at risk
  • CATEGORY: Information/Knowledge
  • IMPACT: 4
  • LIKELIHOOD: 5
  • OVERALL RATING: 20 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Annual Service Plan development and submission to the Ministry of Health
  2. Program review based on COVID-19 requirements/expectations in 2021
  3. Existing data resources (e.g., the Windsor-Essex County Health Unity Community Needs Assessment 2019 Update)

ACTION REQUIRED:

  1. Development of standard program effectiveness measures to ensure fidelity of implementation with program plans/operations
  2. Program review and prioritization of interventions/services during the COVID-19 pandemic
  3. Ongoing collection and review of program effectiveness data to adjust program/service delivery based on community needs

5: Work Stoppage

Description

CAUSE: The WECHU and internal labour groups are unable to reach collective bargaining agreements.

EVENT: An extended work stoppage involving internal labour groups.

CONSEQUENCES:

  1. Service delivery to residents of Windsor-Essex County is negatively impacted
  2. Delivery of goods and services is impeded
  3. The organization’s reputation is at risk
  • CATEGORY: People/Human resources
  • IMPACT: 4
  • LIKELIHOOD: 3
  • OVERALL RATING: 12 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Routine review of contingency plans to align with the expiration of labour agreements
  2. Routine review of plans with external stakeholders for outside services (e.g., deliveries)
  3. Established plans for work stoppage response (e.g., communication with WECHU staff, communication with vendors, and arrangements for service requirements)

ACTION REQUIRED:

  1. Review and update existing contingency plans
  2. Review and update work stoppage response plans

6: Strategic Priorities

Description

CAUSE: External pressures and resource uncertainty.

EVENT: The WECHU may be at risk of not accomplishing its strategic priorities.

CONSEQUENCES:

  1. The organization’s reputation is at risk
  2. Service delivery to residents of Windsor - Essex County is negatively impacted
  3. Inability to meet the requirements of the Ontario Public Health Standards (2018)
  • CATEGORY: Strategic/Policy
  • IMPACT: 3
  • LIKELIHOOD: 5
  • OVERALL RATING: 15 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Implementation of 2017-2021 Strategic Plan and quarterly progress reporting (NB. These actions have been deferred throughout the COVID-19 pandemic)
  2. Completion and reporting on the Annual Service Plan (NB. Some of these actions have been deferred throughout the COVID-19 pandemic)
  3. Monitoring and review of changes to legislation, protocols, and guidelines
  4. Annual review and update of key policies and procedures

ACTION REQUIRED:

  1. Annual review of strategic plan and implementation of its objectives
  2. Prioritization of strategic plan efforts based on organizational capacity
  3. Review the impact of the COVID-19 pandemic on strategic priorities and directions

7: Privacy Breach

Description

CAUSE: Lack of knowledge, experience, and accountability related to personal information or personal health information of clients.

EVENT: Inappropriate collection, use, or disclosure of personal information or personal health information.

CONSEQUENCES:

  1. Risk of litigation and related financial consequences
  2. The organization’s representation is at risk
  3. Non-compliance with data sharing agreements
  • CATEGORY: Privacy
  • IMPACT: 4
  • LIKELIHOOD: 4
  • OVERALL RATING: 16 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Established protocols for some databases that hold personal health information
  2. Privacy policies and procedures
  3. Annually required privacy training
  4. Privacy Impact Assessment process and documentation
  5. Annual reporting to the Information Privacy Commission

ACTION REQUIRED:

  1. Privacy audits (NB. These actions have been deferred due to COVID-19 pandemic response)
  2. Training/standard operating procedures for newly implemented systems that hold personal health information
  3. Expand auditing procedures to new electronic systems

8: Local Health Disparities

Description

CAUSE: A decreased emphasis on local priority populations in program/service delivery due to operational pressures, capacity, and prioritization because of the COVID-19 pandemic.

EVENT: The WECHU may be at risk that its programs and services do not address the health disparities amongst local priority populations.

CONSEQUENCES:

  1. Inability to meet the requirements of the Ontario Public Health Standards
  2. Increased health disparity among local priority populations
  3. Increased burden of illness and poorer local health outcomes
  4. Decreased credibility/influence with local priority population groups
  5. The organization’s reputation is at risk
  • CATEGORY: Equity
  • IMPACT: 4
  • LIKELIHOOD: 4
  • OVERALL RATING: 16 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Past corporate training/capacity building related to social determinants of health
  2. Health Equity Impact Assessment process for programs and services
  3. Annual Service Plan/operational planning includes identification of local priority populations

ACTION REQUIRED:

  1. Identification of health inequities/disparate health outcomes for local priority populations
  2. Language service provision plans/implementation to serve community language needs
  3. Development of standard priority population engagement approaches
  4. Development of indicators of success related to interventions targeting local priority populations
  5. Local planning for priority populations due to a protracted COVID-19 response

9: Program/Service Implementation

Description

CAUSE: Some programs/services may not occur as anticipated due to operational pressures, capacity, and prioritization of the COVID-19 pandemic response.

EVENT: The WECHU may be at risk that its programs and services do not occur as anticipated based on operational plans and the requirements specified in the Ontario Public Health Standards.

CONSEQUENCES:

  1. Inability to meet the requirements of the Ontario Public Health Standards
  2. Decreased effectiveness of long-term interventions on local health outcomes
  3. Increased burden of illness and poorer local health outcomes
  4. Potential damage to partner relationships related to program/service delivery
  5. Potential opportunity cost related to lack of intervention during periods of time where individuals are seeking public health support (i.e., due to reallocation of resources to support the COVID-19 pandemic response)
  6. The organization’s reputation is at risk
  • CATEGORY: Operational/Service Delivery
  • IMPACT: 4
  • LIKELIHOOD: 4
  • OVERALL RATING: 16 - High

Key Risk Mitigations

CONTROL STRATEGY:

  1. Annual Service Plan development and submission to the Ministry of Health
  2. Program review based on COVID-19 requirements/expectations in 2021
  3. Identification of program/service implementation based on priority areas/legal requirements
  4. Monthly engagement with the Board of Health regarding service expectations during the COVID-19 pandemic

ACTION REQUIRED:

  1. Development of standard program effectiveness measures to ensure fidelity of implementation with program plans/operations
  2. Program review and prioritization of interventions/services during the COVID-19 pandemic
  3. Ongoing collection and review of program effectiveness data to adjust program/service delivery based on community needs

MOH Risk Category:

  • Compliance Legal
  • Environment
  • Equity
  • Financial
  • Governance / Organizational
  • Information / Knowledge
  • Operational / Service Delivery
  • People / Human resources
  • Political
  • Privacy
  • Security
  • Stakeholder / Public Perception
  • Strategic / Policy
  • Technology