ARCHIVED - Appendix C: Management Response and Action Plan

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Project Title: Audit of the Management Process for Corrective Action Requests (CARs)

Management Response: Operations Branch agrees with these findings and recommendations. The Branch is re-engineering the CAR process related to meat, feed and rendering as a result of this audit. Findings of this audit will inform a number of changes that can be implemented over the next several months that will address the issues raised in this audit including improving the accessibility of information, monitoring, oversight and documentation. CFIA will also be enhancing the transparency related to CARs. Specifically, the CAR process will be modified to enhance the uniformity and consistency for documentation of non-compliance. Further enhancements to improve the accessibility of compliance information are also planned under the new food inspection model including the development and implementation of a new IM/IT system (2016) which will provide access to comprehensive and historical compliance information for all food commodities.

Management Action Plan

Recommendation (1): It is recommended that the Agency identify essential information that would constitute a complete compliance history and ensure this information is readily accessible to individuals making compliance and enforcement decisions.

Proposed Management Actions Responsible Official(s) Completion Date

All information pertaining to the compliance history of a registered establishment is currently captured – however it is captured in different places. Therefore, in order for an Inspection Manager (IM)/EG-05 to have a complete picture of the compliance history, they must access information that is scattered throughout the Agency.

Leads:

Karen McIntyre,
Executive Director, Operations Strategy and Delivery Directorate

and

Luc Lafrance Executive Director,
Business Information Management Centre

Develop approach and costing by April 30, 2013

In order to make available the complete compliance history at a given establishment OSD will work with IT developers in the Business Information Management Centre to link existing CAR related databases for registered meat and feed establishments. This information will be readily accessible by all individuals making enforcement decisions i.e. IMs and EG-05s.

Leads:

Karen McIntyre,
Executive Director, Operations Strategy and Delivery Directorate

and

Luc Lafrance Executive Director,
Business Information Management Centre

Implementation by September 30, 2013

Recommendation (2): A risk-based approach to monitoring and oversight should be developed outlining specific roles and responsibilities to ensure CARs are being effectively managed.

Proposed Management Actions Responsible Official(s) Completion Date
There is variance between the areas in the procedures currently in place to monitor and oversee that CARs are closed in a timely manner which has resulted in some CARs being open for long periods of time. This will be improved through the use of a common, risk based approach to monitoring. Similarly, written roles and responsibilities for oversight will be clarified. CFIA's Internal Review Team will provide additional oversight related to closing CARs. Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate September 30, 2013

OSD will implement a new risk- based approach that will triage non-compliance for meat, feed and rendering commodities inspected using the Compliance Verification System. This will be distributed to Regional Directors (RDs), IMs and EG-05s.

Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate April 30, 2013
In order to ensure effective monitoring of CARs, OSD will provide weekly reports to Regional Directors (RDs) for distribution to responsible managers i.e. Regional Veterinary Officers (RVOs) and IMs Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate March 31, 2013

Chapter 14 and 18 of the Meat Hygiene Manual of Procedures (MOP) and appropriate sections of the Feeds and Rendering MOP will be revised to clarify roles and responsibilities for IMs and EG-05s for monitoring and oversight.

Area Executive Director's accountability for overseeing that CARs are closed in a timely manner is explicit in 2013-14 Performance Agreements.

Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate April 2013

Recommendation (3): It is recommended that timely information be disseminated to the appropriate levels of management to support effective decision making.

Proposed Management Actions Responsible Official(s) Completion Date

This action is linked to the need for clarification of roles and responsibilities and making sure that timely information is in the hands of appropriate levels of management. It is recognized that a structured and consistent approach to information distribution is needed.

To ensure that RDs are aware of their role with respect to distribution and monitoring of compliance data on an on-going basis, OSD will update current procedures (noted in the previous recommendation) and provide training at an upcoming RD face to face meeting.

Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate April 19, 2013

Recommendation (4): It is recommended that policy guidance be developed to specify the required CAR documentation necessary to complete an inspection file to support compliance and enforcement decisions.

Proposed Management Actions Responsible Official(s) Completion Date

The audit found that the level and quality of supporting documentation contained in inspection files did not always support compliance or enforcement decisions. Actions will be taken to strengthen documentation, (including training) and performance will be monitored on an ongoing basis to ensure that documentation is robust.

OSD is leading a uniformity initiative in the meat program to evaluate the quality and uniformity of selected CVS inspection activities. One aspect of the review is CAR documentation. A draft report with recommendations will inform revisions to MOPs and other relevant operational policy as necessary.

Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate May 31, 2013
Quality Management System (QMS) performance measures will be built in to measure the successful implementation of the new enforcement approach and ensure consistency of data collection and file maintenance. Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate May 31, 2013
Training of inspection staff and others involved in enforcement decisions will take place in preparation for full implementation with the new system. Karen McIntyre Executive Director, Operations Strategy and Delivery Directorate September 30, 2013
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