Internal Audit Report
Audit of CFIA External Stakeholder Complaints Process

Table of Contents

1.0 Executive Summary

The Complaints and Appeals Office (CAO, the Office) is designed to provide consumers, producers and industry stakeholders in Canada's agriculture and agri-food industry with a transparent and accessible way to register complaints about CFIA's services, administrative errors and regulatory decisions.

The CAO is responsible for leading the management of all complaints received by the Office, and responding to the complainant with an outcome of the review. The Office tracks complaints, compliments and comments, collects metrics and analyzes the data captured. The data analysis is used to identify repetitive issues within CFIA with the intent that this information can be used by CFIA to develop and enhance work plans for improving programs and policies, tool development and service delivery.

The CAO has been operational since April 1, 2012. During fiscal years 2014-15 and 2015-16, the Office received a total of 168 complaints: 90 regulatory complaints and 78 related to CFIA service.

Service excellence is a key Agency priority. Providing external stakeholders with a straight-forward, transparent and fair mechanism to submit and have their complaints heard will assist the Agency in meeting this priority.

Audit Objective

The objective of the audit was to assess the efficiency and effectiveness of the management of the external complaints processes and key controls that have been established by the CAO to support its mandate.

Key Audit Findings

Complaints Handling Processes and Controls

The CAO has established complaint handling processes which incorporate controls to help ensure due diligence and a timely response. These processes were well-designed and generally found to be free of redundancies and excessive controls with one exception: the CAO's information management practices included the maintenance of both a paper and electronic file. CAO standard operating procedures were generally followed and files were well-organized and structured in a logical manner; however, some opportunities for improvements related to information management were noted: retain consistent file documentation and ensure all documents/files include information security markings.

Communication and Awareness

To support the effectiveness of the CAO, both internal and external stakeholders need to be made aware of the Office's mandate and processes. The CFIA's external website and intranet provide sufficient information and tools. Nevertheless, the audit found that a more formal or systematic approach to outreach, especially in Areas and regions, is needed.

Performance Measures and Service Standards

The CAO implemented a performance measurement strategy framework in fiscal year 2015-16. The Framework identifies performance measures and service standards that are measurable and directly linked to planned results. Performance against service standards was calculated and reported at year-end. A review of the performance measurement strategy framework has not yet been undertaken, including a review of performance measures and targets.

Continuous Improvement

CFIA branch management is provided with information on the types of issues/complaints received by the CAO; however, branch responses to annual reporting of themes and systemic issues were not consistently provided by the responsible branch.

Accountabilities, along with roles and responsibilities pertaining to the tracking or follow-up of management actions to address observations have not been established. Furthermore, there is no formal mechanism in place to inform senior management across the Agency of themes and systemic issues identified through stakeholder complaints.

Conclusion

The management of the external complaints processes and key controls were found to be well-designed and generally efficient. Performance measures and services standards are in place, standard operations procedures were being adhered to and the processes were generally free of redundancies, excessive controls and duplication of effort.

Nevertheless enhancements were identified that could further support and demonstrate the effectiveness of the CAO program. Most importantly, a formal approach to engaging senior management as well as oversight protocols with respect to identified opportunities for improvement would better position the Agency to demonstrate service excellence. A more systematic approach to stakeholder outreach activities would also enhance awareness of the CAO.

2.0 Introduction

2.1 Background

The Canadian Food Inspection Agency (CFIA, the Agency) is a regulatory agency responsible for administrating and enforcing 13 federal statutes and 38 sets of regulations, for supporting a sustainable plant and animal resource base and regulating the safety and quality of food sold in Canada. New legislation was passed in November 2012, the Safe Food for Canadians Act, and once fully in force, will bring into effect new regulations and provide the necessary legal framework for a more consistent approach to strengthening food inspection in Canada.

CFIA has approximately 6,750 employees stationed in field offices, laboratories and food processing facilities across the country. The CFIA's activities include verifying the compliance of imported products; registering and inspecting establishments; testing food as well as plants and animals along with their related products; and approving the use of many agricultural inputs.

The Agency developed a Statement of Rights and Service for Producers, Consumers and Other Stakeholders (the Statement) and guides with the objective of offering stakeholders and CFIA staff a clear, plain language explanation of the CFIA's commitment to:

  • transparent decision making;
  • accessible and timely information;
  • fair, respectful and unbiased interactions with stakeholders; and
  • responsiveness and continuous improvement.

Based on the Statement, and in order to undertake a more comprehensive approach to transparency and service delivery, CFIA implemented a more effective, visible and accessible process for stakeholders to provide feedback and register complaints within the Agency.

CFIA Complaints and Appeals Office

The Complaints and Appeals Office (CAO) of CFIA resides within the Integrity and Redress Secretariat and has been operational since April 1, 2012.

The CAO is designed to provide consumers, producers and industry stakeholders in Canada's agriculture and agri-food industry with a transparent and accessible way to register complaints. The CAO reviews complaints related to the quality of CFIA's services, administrative errors and regulatory decisions. The CAO also welcomes and registers all compliments and comments.

The CAO is responsible for giving direction and advice on managing complaints, encouraging CFIA to respect the CAO's policy and processes, leading the management of all complaints received by the office and responding to the complainant with an outcome of the review. Finally, it is responsible for tracking all complaints, compliments and comments, collecting metrics and analyzing the data captured. As outlined in the Complaints and Appeals Administrative Policy, the data analysis is used to identify repetitive issues within CFIA and opportunities for improvement, shared with senior management and used by CFIA to develop and enhance work plans for improving programs and policies, tool development and service delivery.

Complainants are encouraged to resolve complaints through an incremental, three-step process:

  1. Speak with the CFIA employee involved in the complaint.
  2. If this does not resolve the matter, speak with the employee's supervisor, manager or director.
  3. If this does not resolve the matter, submit a formal complaint with the CAO by completing a Complaints, Comments and Compliments form.

However, if a complainant does not feel comfortable discussing the issue directly with the employee or manager, the CAO will accept the complaint without the complainant having followed the incremental steps.

As defined in the CAO's Complaints and Appeals Administrative Policy, a complaint is a concern brought forward by an external stakeholder related to the delivery of activities or programs mandated by CFIA. Complaints are categorized as either regulatory or service. During the last two fiscal years (2014-15 and 2015-16), the CAO received a total of 168 complaints (90 regulatory and 78 service-related complaints). Since the implementation of CFIA's Complaints and Appeals Office in 2012, the number of complaints year-over-year have increased 1% to 2% per year.

Based on information gathered during a complaint review, the CAO determines whether the available facts support the complaint as founded, unfounded or inconclusive. In some cases, there is no review of the complaint or it is withdrawn such as when a complaint does not fall within the scope of CAO, or when the complainant withdraws or abandons their submission at some point during the course of a complaint review.

The CAO does not review legal disputes, internal disclosures, cases where redress is not being sought, or where there is already an existing appeal or review process. The CAO will refer complaints related to these matters to the existing mechanism within CFIA for resolution.

2.2 Significance

CFIA's 2016-2017 Report on Plans and Priorities identified a "Focus on Service Excellence" as a priority. The CFIA strives for continuous improvement in dealings with external stakeholders and is committed to providing quality service that is consistent, professional, timely and fair. A core component to meeting this objective is to provide external stakeholders with a formal channel to communicate compliments and complaints. It is important to ensure that the Agency has established key processes and controls to handle complaints in order to support this priority.

With the implementation of the Safe Food for Canadians Act, CFIA regulations will likely change, resulting in greater flexibility for inspectors to adapt to different situations and select appropriate responses. As well, these changes will likely result in an increased number of regulated parties. The Agency is also implementing a new inspection model that sets out a standardized and consistent process to deliver systems-based inspections across business lines and commodities. This will change the way CFIA inspectors approach their work, the tasks they perform, and how they capture and report the inspections they carry out. An increase in the number of regulated parties may result in an increase in the volume of complaints.

The handling of external complaints was deemed a high priority through the 2016/17 to 2018/19 risk-based audit planning process. This is the Agency's first audit of processes and controls related to external complaints, as the CAO was formed in 2012.

2.3 Objective

The objective of the audit was to assess the efficiency and effectiveness of the management of the external complaints processes and key controls that have been established by the Complaints and Appeals Office to support its mandate.

2.4 Scope

The scope of the audit focused on the management of external complaints by the Complaints and Appeals Office consisting of, but not limited to:

  • Extent to which performance measures and service standards are in place to help ensure strategic objectives of the Complaints and Appeals Office are met;
  • External and internal communication and outreach initiatives to inform stakeholders of the complaints process;
  • Mechanisms in place to help establish continuous improvement within the Agency as a result of information received through the complaints process;
  • Effectiveness and efficiency of processes and controls related to complaints handling;
  • The manner in which sensitive information is controlled and secured; and,
  • Training initiatives and tools made available to Complaints and Appeals Office analysts.

The audit covered the period between April 1, 2014 and March 31, 2016. The audit was conducted between April and August 2016.

The audit did not review complaints that are handled and closed at the district, regional and area levels or the CAO's Alternate Dispute Resolution process. Similarly, the audit did not review complaints that the CAO does not have authority to receive, such as those covered by various acts and regulations administered by CFIA that contain existing mechanisms for recourse such as appeal of compensation decisions under the Health of Animals Regulations, request for re-inspection under the Fish Inspection Act and appeal of decisions made under the Administrative Monetary Penalties Act.

The scope of the audit excluded appeals as necessary regulations to host appeals are currently on hold. Appeals will be considered in future risk-based audit plans once this process is implemented.

2.5 Approach

The following procedures were performed in the audit:

  • Reviewed documentation and CFIA websites (internal and external) relating to the processing of complaints; performance information; CAO communications activities;
  • Reviewed documentation relating to tracking, monitoring and reporting of complaints; CAO Analyst training plans and materials, and accountabilities for continuous improvement;
  • Assessed historical performance data relating to established service standards;
  • Interviewed CAO personnel and a limited selection of branch management;
  • Conducted limited enquiry of the complaints process at other federal government organizations; and
  • Tested a sample of external complaints that were initiated and closed during the scope period to determine if documented processes and controls were operating as intended.

2.6 Statement of Conformance

The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the CFIA's internal audit quality assurance and improvement program. Sufficient and appropriate auditing procedures were performed and evidence gathered in accordance with Institute of Internal Auditor's International Standards for the Professional Practice of Internal Auditing and to provide a high level of assurance over the findings and conclusion in this report. The findings and conclusions expressed in this report are based on conditions as they existed at the time of the audit, and apply only to the entity examined.

3.0 Findings and Recommendations

3.1 Complaints Handling Processes and Controls

Complaints handling processes and controls were efficient with the exception of maintaining both paper and electronic complaint files.

The CAO has established complaint handling processes which incorporate controls to help ensure due diligence and a timely response. Key interactions with the complainant and branch representatives are made throughout the complaint process. In addition, the branch, CAO Director and Chief Redress Officer are engaged prior to the final outcome being made to help ensure technical accuracy and objectivity.

Process and control efficiency was assessed through a review of the standard operating procedures and information management practices, and a mapping of processes and controls. The audit found that complaint handling processes were free of unnecessary redundancies and excessive controls. Although the processes and controls were found to be generally efficient, the CAO's information management practices include the maintenance of both paper and electronic files. This practice represents a process inefficiency that could impact workload and records management within the CAO.

Policies and Procedures

Complaints handling processes and controls are operating in accordance with CAO standard operating procedures; however complaint file documentation was not consistently maintained.

The Complaints and Appeals Administrative Policy captures the roles and responsibilities of the CFIA branches, the CAO, and the Chief Redress Officer. The branch heads and their management teams are responsible for reviewing and gathering information on complaints referred to them by the CAO. The CAO requests that each branch identifies a contact (branch representative) responsible for sending feedback and information to the CAO. The CAO's established "single-window" communication approach is an effective practice given that it encourages responses in a timely and streamlined manner.

The Standard Operating Procedure (SOP) for Complaints and Appeals processed by the Complaints and Appeals Office (December 2015), provides guidance regarding the implementation of the Complaints and Appeals Administrative Policy. The SOP details the inputting of complaints into a database, triaging, reviewing complaints, roles and responsibilities, communications, service standards, and the process for closing complaint files and reporting.

CAO policies and procedures were found to be well-designed and complete to support the office and the discharge of staff responsibilities.

File Documentation

The audit reviewed a sample of 20 files to determine if processes and controls were operating in accordance with CAO standard operating procedures. The results of the sample testing found that standard operating procedures and controls were being followed, specifically in the areas of: soliciting input from branches, approvals from the CAO Director and Chief Redress Officer and informing the branch of the final outcome.

Files were well-organized and structured in a logical manner; however, not all documentation was consistently retained in the complaint files. This included evidence of initial telephone conversations with the complainant and, where applicable, evidence of technical review by the applicable branch. Although CAO paper files contain a checklist of analyst procedures, it did not contain a list of what final complaint review documents should be retained in the master file (paper or electronic).

Recommendation 1.0:

The Chief Redress Officer should clarify file documentation requirements and ensure all files adhere to these requirements.

Training and Development

CAO Analysts are supported with training and development, guidance and tools to support their work.

Training and development is fundamental to establishing and maintaining capacity to deliver programs.

Upon hire, CAO Analysts are provided with the CAO Process Binder, which contains information on policies and procedures, applicable regulations, tools and templates. The CAO Analysts review this binder and familiarize themselves with their responsibilities. Following the review of this information, new CAO Analysts will "job shadow" existing Analysts in order to fully understand the complaints process from beginning to end.

Regarding ongoing training, CAO Analysts develop annual training plans. The annual training plans reviewed included courses pertaining to business writing, dealing with clients, and negotiations.

Information Security

Complaint files are physically secured and safeguarded except that Protected A files did not have the required information security markings.

The audit expected to find that the CAO files were appropriately labelled, stored and secured throughout the complaints handling process.

The Complaints and Appeals Office is located in a restricted area requiring authorized access to enter. Within the CAO offices, there are RCMP-approved security containers with an integral combination lock which store the hard copy of the complaints files.

Complaint files are classified as either Protected A or Protected B. The default classification for complaint files is Protected A (defined as unauthorized release could cause injury to an individual, an organization or the Government). A complaint file is classified Protected B if sensitive information on an employee is mentioned (unauthorized release could cause serious injury to an individual, an organization or the Government). Protected A or B files should be marked on the top right corner of the file folder containing hard copy complaint information.

Of the 20 files sampled, two had employee information that escalated the file to Protected B status. These two files were labelled Protected B, but the remaining 18 files that should have been labelled Protected A were not.

At the end of every complaint process the CAO Analyst writes a final report that summarizes the complaint, the process followed, and the result of the review. The names and contact information of the complainants must not be included in the final report. In the 20 files reviewed, all final reports excluded complainant names and contact information in accordance with the Privacy Act.

Information regarding the complaint is also stored electronically within an electronic database called ccmMercury/TRECS. A user access listing was reviewed to verify that only authorized users within the CAO had access to the database. The audit found one exception, for which management has taken immediate action to remove access.

Recommendation 2.0:

The Chief Redress Officer should ensure all complaint files meet the requirements of the CFIA Security Management Policy with respect to the security marking of files. Additionally, the Chief Redress Officer should periodically review system access to the CAO's electronic database.

3.2 Communication and Awareness

The CAO is responsible for delivering information sessions on complaints processes with internal and external stakeholders in order to raise awareness of the CAO's mandate and processes.

A primary benefit of the communication of the complaints process is that the CAO has the opportunity to increase the visibility of stakeholder complaints and help find solutions. Internally, educating CFIA employees about the CAO allows them to appropriately refer stakeholders with issues to the CAO. Educating external CFIA stakeholders about the complaints process enables them to bring their concerns forward to CFIA which can help improve CFIA's service delivery, enhance regulatory oversight and contribute to a stronger relationship between CFIA and its stakeholders.

The CAO engages both internal and external stakeholders through various types of outreach activities. These outreach activities include attending conferences where external stakeholders will be present, giving presentations to both internal and external stakeholders, publishing and distributing the CAO's annual report, and posting information regarding the CAO and its processes on CFIA's internal and external websites. The audit found that the CAO complaints review process, service standards and applicable forms were made available on both the external website and the intranet (Merlin) as a reference tool for stakeholders and CFIA employees.

The CAO undertook communication activities that informed both internal and external stakeholders about the complaints process, however, a more systematic approach to outreach would enhance awareness and ensure coverage based on priority.

While the communication and awareness function of the CAO is a requirement as outlined in the Complaints and Appeals Administrative Policy, the audit found that the CAO did not have a communications strategy in place for fiscal years 2014-15 and 2015-16. The lack of a communication strategy could result in stakeholders not being targeted by outreach activities, or outreach activities that are misaligned with CAO's mandate. Although the CAO complaints process is outlined on the external website, there is an opportunity to further enhance awareness and provide a more strategic distribution of outreach activities. Through discussion with the CAO, there was no documented communications strategy to determine and prioritize outreach objectives including targeted stakeholders.

Nevertheless, the outreach activities that have taken place are captured using a tracking tool that outlines the type of outreach activity, the stakeholder name and the date on which the outreach activity occurred. The outreach tracker indicated that a large majority of internal outreach activities occurred in the NCR and that no external outreach activities occurred during fiscal year 2015-16. CAO management indicated that the concentration of outreach activities within the NCR was due to a limited travel budget.

Recommendation 3.0:

The Chief Redress Officer should develop and implement a communications strategy to help better align communication activities with identified priorities.

3.3 Performance Measures and Service Standards

The CAO has developed a performance measurement strategy framework and performance reporting has begun.

Performance Measures

A performance measure is a qualitative or quantitative means of measuring an output or outcome with the intention of gauging the performance of a program. As part of its Results and Delivery agenda, the Government of Canada has made performance measurement a top priority and is critical to the success of any organization. The audit found that the CAO has a well-defined performance measurement strategy framework in place that can facilitate evaluation of the complaints process.

To develop the CAO's performance measurement strategy framework, management first developed a logic model which is a visual expression of the rationale behind a program and serves as the program's road map. It outlines the intended results (i.e. outcomes) of the program, the activities the program will undertake and the outputs it intends to produce in achieving the expected outcomes. It is also expected that targets are established for each performance measure to help evaluate the complaints process.

The CAO identified 19 performance measures that were directly linked to the planned results. Performance measures were found to be measurable as a numerical value was associated with each measure. Performance against targets was calculated and reported at year-end.

As per Treasury Board's Guide to Developing Performance Measurement Strategies, following the first year of program implementation, a review of the performance measurement strategy framework should be undertaken to ensure that the appropriate information is being collected and captured to meet both program management and evaluation needs. The CAO first implemented their performance measurement strategy framework in fiscal year 2015-16. To-date, the CAO has not undertaken a review of its strategy, including performance measures and targets.

Service Standards

The Treasury Board of Canada Secretariat defines a service standard to be a public commitment to a measurable level of performance that clients can expect under normal circumstances. Service standards serve two key purposes: to provide staff with performance targets and to inform clients what to expect. They help clarify expectations for clients and employees, drive service improvement, and contribute to results-based management.

The CAO has established service standards for the acknowledgement of receipt of all complaints, comments and compliments as well as for the amount of time needed to review a complaint. These service standards are communicated to the general public and employees through the CFIA external and internal websites.

Measuring these services to ensure a timely and appropriate delivery is an important element of ensuring CAO's service management excellence. The service standards were found to be measureable as they are based on the number of business days outstanding from receipt of the complaint to the final closing letter. They also align with the overall objectives allowing for an efficient, accessible and timely system for processing of complaints.

CAO has established a performance target of 90% for both service standards. It was reported in the draft Complaints and Appeals Office 2014-2016 Biennial Report that the CAO met the service standard of acknowledging receipt of the complaint within two days 99% of the time; however, the service standard related to the 30 business days to complete a review of a complaint did not meet the established target. The CAO has not yet formally analyzed the root cause of the service standard not being met in order to identify opportunities for continuous improvement.

Recommendation 4.0:

The Chief Redress Officer should undertake a review of the CAO's performance measurement strategy framework to ensure that objectives and performance expectations are appropriate and being met.

3.4 Continuous Improvement

Branch management is provided with information on the types of issues/complaints received by the CAO; however actions in support of continuous improvement could not always be determined.

A CAO objective is to use the information gathered on complaints to facilitate continuous improvement. The CAO does this primarily in two manners: through "Branch Email Closings" and through "Opportunity for Improvement" management letters.

The Complaints and Appeals Administrative Policy indicates that the identified repetitive issues within CFIA and opportunities for improvement will be shared with senior management and used by the Agency to develop and enhance work plans for improving programs and policies, tool development and service delivery.

Branch Email Closings (BECs) are emails sent by the CAO to the applicable Branch Executive Director at the end of each complaint process. The purpose of the BEC is to inform the Branch that the complaint file has been closed and to provide a final summary of the complaint.

Annually, the CAO provides Opportunity for Improvement (OFI) management letters to a designated representative, at the Executive Director level, in branches that had been involved in complaints that year. The OFI management letters are intended to capture key observations that the CAO made throughout the year. The observations relate to complaints that could have a broader impact on the Agency or complaints that were received multiple times from different stakeholders. These letters contain key information that could be used to improve service delivery, enhance regulatory oversight or contribute to stronger relationships with stakeholders. The process to complete the OFI management letter involves reviewing all the complaint files for the year, identifying common themes and/or systemic issues and categorizing complaints as observations for the applicable branch. The CAO conducted extensive analysis of historical themes and trends which is used as an input to the OFI process. Although the OFI management letters were sent to impacted branches for the 2014-2015 fiscal year, the letters were not issued in a timely manner.

In 2014-2015, OFI management letters were sent to Executive Directors in Operations Branch and Programs and Policy Branch (PPB). One OFI letter identified six areas for improvement; only two areas were responded to, the remaining four areas were left with a nil response. The other OFI letter identified three OFI areas, of which all were responded to. The audit concluded that where OFI responses were not received, branch actions in support of continuous improvement could not always be determined. As at the end of the audit's examination phase (August 2016), the CAO's 2015-2016 OFI management letters had not been sent to applicable branches.

Specific accountabilities, roles and responsibilities pertaining to the tracking or follow-up of management actions to address observations communicated through the OFI management letter have not been established. Furthermore, there is no mechanism in place to inform Agency executives above the Executive Director level, including the President, Branch Vice Presidents and CFIA governance committees, of themes and systemic issues identified as a result of stakeholder complaints. Such a mechanism would facilitate Agency-wide discussions on significant issues.

Recommendation 5.0:

The Chief Redress Officer should implement a strategy and process to broadly inform senior management and CFIA oversight bodies on key themes and systemic issues raised through the complaints process to help promote continuous improvement.

4.0 Appendices

Appendix A: Audit Criteria

The audit criteria were developed from key controls set out in the Treasury Board of Canada Secretariat (TBS) Guideline on Service Standards and the Office of the Comptroller General's Audit Criteria related to the Management Accountability Framework: A Tool for Internal Auditors.

The audit criteria are organized under the lines of enquiry below:

Line of Enquiry 1: Performance Measures and Service Standards

  • 1.1. Management has identified appropriate performance measures linked to planned results. (MAF – RP-2)
  • 1.2. Service standards are relevant, measurable and communicated to external stakeholders and CFIA staff. (TBS Guideline on Service Standards; CFIA Complaints and Appeals Administrative Policy)
  • 1.3. Service standards are met, monitored and accurately reported on to internal and external stakeholders. (TBS Guideline on Service Standards; CFIA Complaints and Appeals Administrative Policy)

Line of Enquiry 2: Communication and Awareness

  • 2.1 CFIA has in place a communications strategy to guide communications and awareness with external stakeholders and Agency employees. (MAF – CFS-5b; TBS Guideline on Service Standards)
  • 2.2 Outreach and communication strategies and activities are implemented to inform external stakeholders and Agency employees on the complaints process. (MAF – CFS-5c; TBS Guideline on Service Standards; CFIA Complaints and Appeals Administrative Policy)
  • 2.3 External stakeholders are able raise a complaint via multiple service delivery channels. (MAF – CFS-5a; TBS Guideline on Service Standards)

Line of Enquiry 3: Continuous Improvement

  • 3.1 Results / outcomes from complaint reviews are formally communicated, considered and used to coordinate and integrate changes to existing CFIA policies and programs. (MAF – PP-2; TBS Guideline on Service Standards)

Line of Enquiry 4: Process and Controls

  • 4.1 Complaints handling processes and controls are efficient and operating in accordance with CAO standard operating procedures. (MAF – ST-16)
  • 4.2 CFIA provides CAO Analysts with the necessary training and tools to support the discharge of their responsibilities. (MAF – PPL-4)
  • 4.3 Records, data and information pertaining to complaints are appropriately secured (MAF – CFS-4c)

Appendix B: Management Response and Action Plan

Audit of CFIA's External Stakeholder Complaints Process

Overall Management Response:

The Chief Redress Officer (CRO) is committed to ensuring the appropriate management response for the recommendations put forward in this audit report. The CRO will track progress on the action plan and provide status reports as required. The Complaints & Appeals Office (CAO) accepts and agrees with the finding of the audit, and will use its recommendations to improve the Office's processes in place so that Canadians can continue to have access to an impartial redress mechanism.

Recommendation 1: The Chief Redress Officer should clarify file documentation requirements and ensure all files adhere to these requirements.

Management Response and Action Plan Implementation Or Completion Date Responsible Lead(s)

The CAO will clearly demonstrate that its transitory documents are for working purposes only and that final files are properly stored electronically for recording purposes.

The CAO will modify its checklist respecting file documentation to include an acknowledgement when a particular step or document is not included in a file, and why.

June 2017 Director, CAO

Recommendation 2: The Chief Redress Officer should ensure all complaint files meet the requirements of the CFIA Security Management Policy with respect to the security marking of files. Additionally, the Chief Redress Officer should periodically review system access to the CAO's electronic database.

Management Response and Action Plan Implementation Or Completion Date Responsible Lead(s)
The CAO will clarify the documentation requirement clearly within its Standard Operating Procedures to include "Protected A" information on all CAO generated documentation as the required information security markings. The CAO will ensure that it continues to protect information as appropriate. June 2017 Director, CAO
The CAO will also review system access to the CAO's electronic database semi-annually (beginning in January 2017) as per its revised policy to ensure its accuracy, and this review will be documented in the CAOs yearly work plan. January 2017 Director, CAO

Recommendation 3: The Chief Redress Officer should develop and implement a communications strategy to help better align communication activities with identified priorities.

Management Response and Action Plan Implementation Or Completion Date Responsible Lead(s)

The CAO will evaluate its communication objectives in order to determine if the current communication activities align with the identified priorities and then will develop a strategy.

If the implementation of the strategy identifies that a communication plan is deemed warranted with specific outreach activities, the CAO will develop a detailed plan.

June 2017 Director, CAO

Recommendation 4: The Chief Redress Officer should undertake a review of the CAO's performance measurement strategy framework to ensure that objectives and performance expectations are appropriate and being met.

Management Response and Action Plan Implementation Or Completion Date Responsible Lead(s)

As described in the report, the CAO first implemented their performance measurement strategy framework in fiscal year 2015-16. As a result, at the time of the audit the CAO had not yet completed a review of its performance measures and service standards.

The CAO will formalize a semi-annual review process of its indicators within its policy to oversee that the office objectives and performance expectations are being met.

January 2017 Director, CAO
The CAO will also review the appropriateness of the performance measurement targets, and use the information collected in the review in order to make informed decision on the targets set out for the Office, and adjust as necessary. After the review in 2017, this review of appropriateness of targets will be done every second year. June 2017 Director, CAO

Recommendation 5: The Chief Redress Officer should implement a strategy and process to broadly inform senior management and CFIA oversight bodies on key themes and systemic issues raised through the complaints process to help promote continuous improvement.

Management Response and Action Plan Implementation Or Completion Date Responsible Lead(s)
The CAO will analyze and develop options for consideration by the CRO, for broadly informing senior management and CFIA oversight bodies with respect to systemic issues that are identified. June 2017 Director, CAO
The CRO will implement a strategy for raising the identified opportunities for improvement to the senior management and oversight bodies at the Agency. December 2017 CRO
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