QUARANTINE, MIGRATION AND TRAVEL HEALTH AND INTERNATIONAL HEALTH REGULATIONS. Audit Services Division. January 2010

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1 AUDIT REPORT QUARANTINE, MIGRATION AND TRAVEL HEALTH AND INTERNATIONAL HEALTH REGULATIONS Audit Services Division Approved by Chief Public Health Officer on February 18, 2010

2 Table of Contents Executive Summary...2 Background...4 Audit Objectives...5 Scope of Audit...5 Approach and Methodology...6 Audit Findings and Recommendations...7 Part I - Quarantine Program...7 Strategic Direction and Governance... 7 Risk Management Quarantine Services Delivery Model Performance Measurement Processes and Support Tools Organization and Human Resources Administration and Enforcement of the Quarantine Act Part II - Migration and travel Health Program...21 Management Framework Travel Health Website Part III - International Health Regulations...26 Overall Conclusion...30 Acknowledgments...30 Appendix A: Audit Criteria...31 Appendix B: Management Action Plan...34 Appendix C: Service Delivery Model Options...42 Appendix D: List of Acronyms...50 HP5-92/2010E-PDF Audit Services Division Public Health Agency of Canada 1

3 Executive Summary 1. The overall objectives of this audit were to assess whether the Public Health Agency of Canada (PHAC or the Agency) has adequate controls in place to ensure that the Quarantine, Migration and Travel Health Programs and related activities are managed with due regard to economy, efficiency and effectiveness; and determine if the Agency has put in place appropriate mechanisms to administer and enforce the Quarantine Act, and assess PHAC's compliance with the International Health Regulations; 2. The audit was conducted from March 2009 to, and included interviews with PHAC and service delivery partners and stakeholders officials. The audit included site visits to Halifax, Montreal, Ottawa and Toronto Airports and Regional Offices. 3. The audit identified a number of areas that need to be addressed. Primary observations are presented below. Quarantine Program 4. The audit revealed that Quarantine Officers (QOs) respect the powers conferred to them as part of the Quarantine Act and Regulations and we did not find any significant cases where the Act was not administered and enforced adequately. However, PHAC has not yet finalized a strategy to administer the obligation under the Act for departing travellers. 5. The Agency has not yet articulated a clear mandate for the Quarantine Program. Consequently, strategic and operational objectives and plans for the Office of Quarantine Services lack clarity. 6. Quarantine Program Management does not have reliable information to demonstrate the Program s performance and effectiveness nor risk management mechanisms to identify, assess, monitor, mitigate and report on risks. The result is that basic program performance information is not available to support management decision-making. Similarly, PHAC and the Office of Quarantine Services lack basic workload and performance information at a quarantine station level in order to assess and optimize the alignment of operational resources to workloads. 7. Without a solid foundation, the Agency is not well positioned to identify and implement an efficient service delivery model to administer the Quarantine Program. 8. Optimizing the service delivery model will require the Agency to reassess the risk profile of international travellers which includes emerging disease risks, demographic risks, and the evolving frequency and nature of international travel. 9. Beyond the Office of Quarantine Services, there is a lack of clarity in the roles and responsibilities of the various service delivery partners involved in delivering the Audit Services Division Public Health Agency of Canada 2

4 Program. Migration and Travel Health Program 10. The Migration and Travel Health (MTH) Program lacks a clear mandate, objectives or a stable funding source. While progress has been made in defining and approving a vision for the Program, efforts to execute against the vision have stalled. 11. MTH provides travel health information and advisories to travellers and medical practitioners via a website. However, there is no readily available evaluation mechanism in place to systematically assess if the information presented on the website is relevant, timely and useful. 12. PHAC is encouraged to continue efforts with the Provinces and Territories to modernize the process and improve the efficiency of the designation of Vaccination Centres in Canada to ensure that vaccines for travellers conform to the provisions of the International Health Regulations. International Health Regulations 13. The Agency has established a governance structure to guide the implementation of the International Health Regulations. The Agency complies with IHR minimum requirements that were expected by June 2009; however, some areas require attention to reach full compliance by June Conclusion 14. Many issues identified in this report need to be addressed to ensure that the health of Canadians continues to be protected at the Canadian border in a cost effective manner. Management attention is required: to ensure that the Quarantine Program mandate, strategies and operational goals are clearly articulated and communicated, and the service delivery model is optimized; to develop relevant strategic and operational plans and establish a stable funding base for the Migration and Travel Health Program; to ensure that PHAC continues to progress towards full IHR compliance by Audit Services Division Public Health Agency of Canada 3

5 Management Response 15. The Agency s management agrees with the findings and recommendations and a management action plan is presented in Appendix B. Background 16. The emergence of Severe Acute Respiratory Syndrome (SARS) in 2003 demonstrated the need for Canada to have a national point of focus for public health issues. In response, the Public Health Agency of Canada (PHAC or the Agency) was established on September 24, The emergence of new pathogens and the re-emergence of known disease threats in new formats have been increasing globally. This trend is driven by a variety of factors such as increased movement of populations to urban environments, global warming, and the encroachment of human populations into close contact with wildlife in previously uninhabited areas. 18. Changing patterns of global migration, whether through war, civil unrest, economic opportunity or tourism, have fundamentally changed the mix of country of origin of migrants entering Canada. During the 1990 s, Canada admitted over 2.2 million immigrants, the largest influx per decade in the last 100 years. The 2001 census recorded over 200 ethnic groups, with 18.4 percent of the population reporting that they were born outside of the country 1. In 2008 alone, Canada accepted 10,800 refugees for resettlement from United Nations High Commissioner for Refugees referrals and over 72,000 travellers asked for refugee status A rapidly expanding global network of air travel routes has linked over 3,500 international departure cities carrying over two billion travellers per year to every corner of the globe. Although almost 60 percent of more than 15 million air travellers entering Canada come from airports in the United States of America (USA) and the United Kingdom (UK), there is a growing volume of traffic from developing countries. Travellers from China entering Canada (780,000) now rank third, followed by Mexico (655,219). In addition, there are growing numbers of travellers coming from India (331,678), South Korea (219,331) and the Philippines (155,461) The coupling of the trends of increasing pathogen availability, migration and efficient, cheap air travel in a globalized economy has fundamentally reset the travel risk paradigm globally and for Canada. As demonstrated by the current pandemic influenza A (H1N1), it is now possible for disease outbreaks to spread rapidly and become global in a matter of a few days, thereby greatly shortening the time for detection and response. 1 Statistics Canada, 2009, Canada s ethnocultural portrait. www12.statcan.ca 2 World Refugee Survey The Bio.DIASPORA Project, 2009,Kahn et al. Audit Services Division Public Health Agency of Canada 4

6 21. In recognition of these trends, the World Health Organization (WHO) member countries decided to move to a more active approach to better mitigate the risks and impacts of the international spread of infectious diseases. A key element of this strategy was the revision in 2005 of the International Health Regulations (IHR) to better manage collective defences to detect disease events and to respond to public health risks and emergencies. Canada has endorsed and committed to the full implementation of the IHR by June In addition, the Government of Canada has reinforced the Quarantine Act in December 2006, and passed a Human Pathogens and Toxins Act to enhance control of Human Pathogens in The complexity and global nature of these threats has prompted the need for better integration and coordination of public health operations and outreach, both within Canada and with international partners. The need is based on the recognition that travel and migration is a series of connected activities (a continuum) through all phases: pre-departure, in transit and after return to Canada. These major shifts have had a direct impact on the Agency s activities relating to the changing dynamics and impacts of population mobility on public health. 23. In addition to these forces of change, we noted that the current Quarantine Program was quickly launched in response to SARS in 2003, without the benefit of an approved mandate or formalized funding and resource structure (i.e. TB submission). This gap has not yet been addressed by the Agency. It is in this context that the Audit Service Division examined the Quarantine, Migration and Travel Health Programs as well as the International Health Regulations related activities. Audit Objectives 24. The objectives of this audit are to: assess whether PHAC has adequate controls in place to ensure that the Quarantine, Migration and Travel Health Programs and related activities are managed with due regard to economy, efficiency and effectiveness; determine if the Agency has put in place appropriate mechanisms to administer and enforce the Quarantine Act, and assess PHAC's compliance with the International Health Regulations; assess the Quarantine Services delivery model; and identify relevant opportunities for improvement. Scope of Audit 25. The audit of the Quarantine, Migration and Travel Health Programs and Audit Services Division Public Health Agency of Canada 5

7 International Health Regulations is a component of the Risk-Based Audit Plan for The scope of the audit included examination of: all activities related to Quarantine, Migration and Travel Health Programs and the IHR. These included the design, development and operation of the Programs and related governance structures to determine if the Agency appropriately administers and enforces the Quarantine Act; key management considerations, including: o o o o o the management control framework; organization roles, responsibilities and accountabilities; corporate, team and regional service delivery processes; reporting and information management practices; and risk management strategies and practices. PHAC s compliance with the capacity assessment phase of the International Health Regulations. The areas of work focused on articles related to Points of Entry (Part IV) and Health Documents (Part VI). 27. The audit scope excluded complementary migration health activities conducted in other branches of the Agency (e.g. Health Promotion, Control and Disease Program Branch). Approach and Methodology 28. The audit was conducted in accordance with the Treasury Board of Canada Secretariat s (TBS) Policy on Internal Audit and the Institute of Internal Auditor s (IIA) International Standards for the Professional Practice of Internal Auditing, except that no external assessment was performed to demonstrate that PHAC s internal audit function was in compliance with the IIA Standards and Code of Ethics. The audit was performed between March 2009 and. 29. Audit criteria and sub-criteria (Appendix A) were derived from applicable legislation, Treasury Board (TB) policies, generally accepted management practices and the Office of the Comptroller General s Core Management Controls and were used to develop an audit program. Audit methods included documentation review, detailed files review, and interviews with managers, program specialists, and representatives of program partners. Site visits were conducted at National Headquarters (NHQ) and the Halifax, Montreal, Ottawa, Toronto Airports and Regional Offices. Audit Services Division Public Health Agency of Canada 6

8 Audit Findings and Recommendations PART I - QUARANTINE PROGRAM 30. The Quarantine Program enforces the Quarantine Act and Regulations. The Program plays an essential role in protecting public health in Canada. Responsible for monitoring international entry and departure points in Canada, the Quarantine Program provides urgent assessment, management, and follow-up of suspected cases of communicable diseases among air, land, and sea travellers. The Quarantine Program also plays a vital role in pandemic preparedness and response to emergency situations that would pose a threat to Canadians, such as an outbreak or pandemic. 4 The Program also requires a close working relationship with key partners at Points of Entry (PoE) such as Health Canada (HC), Royal Canadian Mounted Police (RCMP), Canada Border Services Agency (CBSA), Citizenship and Immigration Canada (CIC), Transport Canada, Airports, Ports and Local Health Authorities. 31. As of June 2009, there were approximately 35 employees within the Office of Quarantine Services (the Office); most of them are Quarantine Officers (QOs). Expenditures for the fiscal years and were of $2.82 million and $2.52 million respectively. Strategic Direction and Governance 32. We expected that essential elements such as internal coherence, appropriate governance structure, and alignment to outcomes were in place within the Quarantine Program in order to provide effective strategic direction. 33. Quarantine Program Strategy. We noted that the operational mandate and objectives of the Quarantine Program have not yet been clearly articulated. In April 2009, Program Management, in cooperation with key quarantine staff, prepared an Office of Quarantine Services Position Paper which articulates the Program s objectives and deliverables. This document attempts to rationalize the current operating model of maintaining quarantine stations in six Canadian airports, and defines specific initiatives to be undertaken by the organization. The Position Paper has not formally been discussed or approved by senior management and leaves significant questions unanswered regarding the mandate and operational objectives of the Program, including: the expectations for the quarantine response role (e.g. responding to quarantine calls) versus expectations for the proactive role of promoting, 4 Audit Services Division Public Health Agency of Canada 7

9 planning and implementing public health education programs for service delivery partners, stakeholders and the travelling public; the existent strategy for addressing quarantine issues at land crossings, marine ports and international airports not currently staffed with QOs; the current strategy for dealing with complex, high profile or high risk quarantine events (e.g. multiple ill travellers, or travellers arriving at remote locations that demand a flexible and responsive surge capacity); and a number of new initiatives lack priority and clarity with expected timeframes. 34. Quarantine Program Roles. The key responsibilities of PHAC and partners under the Quarantine Act are as follows: Quarantine Officers employed by the Agency are responsible to assess ill travellers arriving in or departing from Canada, who are suspected of having or being in contact with a communicable disease; to arrange for the transfer of ill travellers who are suspected of having communicable disease to health care facilities; and to develop and maintain relationships with key partners at point of entry; Border Services Officers (Customs Officials) employed by CBSA are responsible for screening travellers and conveyances arriving in Canada, and referring travellers, who are suspected of having a communicable disease, to a Quarantine Officer; Environmental Health Officers employed by Health Canada have the power to inspect conveyances arriving in Canada or are in the process of departing from the country to determine if the conveyance is the source of a communicable disease; and Peace Officers employed by the Law Enforcement Authorities may be asked to assist officers when travellers fail to comply with orders and may arrest those who are in contravention. 35. While these roles are clearly defined, we noted a lack of clarity in the definition of the governance responsibilities of participating organizations. Specifically, it is not clear whether PHAC assumes a leadership role, a collaborative role or a support role with respect to the administration of the Quarantine Act. In response, the Office of Quarantine Services has attempted to refine the definition of service partner roles and responsibilities by developing a number of Memorandum of Understandings (MOU) and framework documents. However, the only signed agreement with a partner under the Quarantine Act that exists today is with the Transport Canada Civil Aviation (TCCA) which establishes roles related to the diversion of aircraft. 36. Four years after the introduction of the new Quarantine Act, there remain a number of risks related to roles and responsibilities that need to be addressed. Audit Services Division Public Health Agency of Canada 8

10 While a draft MOU has been developed between PHAC and CBSA, this agreement has not yet been finalized or signed. Given the critical role that CBSA resources play in screening international travellers and the competing priorities of CBSA (i.e. administration of about 90 different Acts, including the Quarantine Act), it is imperative that the expectations and responsibilities of each of these organizations be clearly articulated. There are various other organizations that play an unrecognized role (under the Quarantine Act) in screening ill travellers. As an example, when an airline employee recognizes an ill passenger on board, they may only contact the Airport Operations Centre (and not quarantine stations). In these cases, the Airport duty manager is making a de facto screening decision as to whether the Quarantine Officer will be involved in the response to the ill traveller. Given this role, it is imperative that the expectations and responsibilities of Airport Authorities be clearly articulated in regards to the administration of the Quarantine Act. The Office of Quarantine Services led the drafting of framework documents outlining the general roles and responsibilities of PHAC, the Provinces and Territories (P/Ts), Local Health Authorities (LHA) and Airports Authorities. However, these documents have not yet been formally adopted by PHAC and limited consultation has taken place with P/Ts and stakeholders. Furthermore, given the varied nature of provincial and territorial health care delivery models, it is imperative that the Office works towards the definition and finalization of agreements with each jurisdiction level to ensure that expectations of all parties are clearly understood. Health Canada is responsible for the administration of the Quarantine Act with respect to conveyances (watercraft, aircraft, train, motor vehicle, trailer or other means of transportation, including a cargo container that arrives in Canada or is in the process of departing from Canada). Health Canada also has nurses that work in other areas such as occupational health and safety. These resources represent potential capacity to respond to significant quarantine events; however no formalized arrangements to support this flexibility exist today. Regional Coordinators for Emergency Preparedness (RCEPs) have a mandate to coordinate the federal health response with stakeholders for plans, policies, procedures and training for emergency preparedness. These coordinators are part of the National Joint Committee for Emergency Preparedness and Response, which includes all health portfolio partners and stakeholders. Their role is to ensure that provincial and local health authorities have consistent data on health issues. The relationship between the Office of Quarantine Services and the RCEPs is not formalized and therefore subject to varied interpretation. 37. Quarantine Program Governance. A comprehensive program governance structure for administering the Quarantine Act has not yet been implemented. The Office of Quarantine Services has taken steps to establish and execute a cross- Audit Services Division Public Health Agency of Canada 9

11 organization governance structure for the administration of the Quarantine Act through the establishment, in 2008, of the Quarantine Act Operations Committee. 38. Establishment of this forum is an effective means of further refining roles and responsibilities and addressing implementation issues as they arise. To date, the official membership of this Committee is limited to PHAC and Health Canada representatives. Based on our observations related to the implementation of issues and limitations encountered between PHAC and CBSA, we believe extension of this membership to include CBSA, a critical delivery partner, would greatly assist the delivery partners in clarifying roles and responsibilities and addressing Quarantine Act implementation issues. Conclusion 39. The Quarantine Program mandate and strategy have not been formally established. A comprehensive program governance structure for administering the Quarantine Act has not yet been implemented. In addition, management attention is required to clarify and formalize the various service delivery roles and responsibilities of key partners and stakeholders. Recommendations 40. The Agency senior management should clarify the mandate of the Quarantine Program. Once the mandate of the Quarantine Program has been clarified, Quarantine Program Management should: 41. Develop a strategic plan and operational business plan to guide program activities; and; 42. Develop and formalize Memoranda of Understandings with key service delivery partners. Risk Management 43. We expected that risk management mechanisms exist to support the identification, assessment, monitoring, mitigation and reporting of strategic and operational risks. 44. Organizational and Strategic Risks. Program Management has not yet developed a robust risk management process for addressing strategic and operational risks. The absence of a proactive risk management and measurement approach makes it difficult to assess whether the Quarantine Services approach for administering the Quarantine Act has had any degree of impact on reducing the risk of the spread of communicable disease via international traveller arrivals at Canada s border Points Audit Services Division Public Health Agency of Canada 10

12 of Entry. This statement is made in the context of significant risk factors such as increased global travel impacting the nature of and potential for communicable disease spread, and inherent limitations that exist in the administration of the Quarantine Act which include the need to not unduly impede the movement of travellers arriving at Canada s border PoE and the role of CBSA screening resources to identify potential high risk of communicable disease travellers. 45. In addition to identifying and mitigating day-to-day risks, there is a need to develop a strategy and plan for dealing with complex, high profile or high risk quarantine events as this is not documented today within the Quarantine Program. Conclusion 46. The Program has not yet developed a robust risk identification, mitigation and management approach and has no contingency plan to deal with major quarantine events. Recommendations Once the mandate of the Quarantine Program has been clarified, Quarantine Program Management should: 47. Conduct a comprehensive risk assessment and develop a risk management plan; and 48. Develop a strategy and a plan to deal with complex, high profile or high risk quarantine events. Quarantine Services Delivery Model 49. We expected that PHAC has implemented a service delivery model to support execution of responsibilities under the Quarantine Act and provide appropriate capacity and flexibility to deliver services and meet service levels as defined in the Act. In addition, we expect that PHAC exercises active leadership in raising awareness on the part of service partners and the international travelling public on communicable disease and public health risks. 50. Rationale for Quarantine Station Locations. The current Quarantine Services delivery model was established in response to SARS in The rationale supporting this model was based on a preliminary risk assessment that concluded: international airports represented the highest risk Points of Entry; and stationing Quarantine Officers at Canada s seven highest international traveller volume airports (Toronto, Vancouver, Montreal, Calgary, Ottawa, Halifax and Audit Services Division Public Health Agency of Canada 11

13 Edmonton (the Edmonton quarantine station has since been shut down) would provide coverage to 94 percent of incoming international air travellers. 51. The current service delivery model classifies the quarantine stations into major airports (Toronto, Montreal and Vancouver) and minor airports (Ottawa, Halifax, and Calgary). Major airports are typically staffed for up to 17 hours per day, seven days per week, while minor airports are typically staffed for eight hours per day, five days per week. All airports have responsibility for quarantine calls originating from the international airports, marine ports and land crossings within their geographic region. Major airports also assume responsibility for quarantine calls to minor airports during off hours. 52. Based on international arrival experience, 91 percent of arriving international air travellers entered Canada via one the six international airports with quarantine stations, with 79 percent of these travellers arriving at the three major airports of Toronto, Vancouver or Montreal. 53. This current profile raises questions as to the value of maintaining in-person quarantine response capacity at the three minor airports, based on the application of the risk criterion that were used in establishing the service delivery model in These questions are further highlighted by the current manner by which quarantine calls and incidents are handled. 54. Based on our review of traveller health assessments, 46 percent were conducted remotely, without a Quarantine Officer being in the physical presence of the ill traveller. 55. Based on the current international traveller volume profile and the high incidence, and apparent acceptability of remote traveller health assessments, the rationale for maintaining Quarantine Officers at airports beyond the major airports (Toronto, Montreal and Vancouver) requires clearer justification. 56. Quarantine Officer Utilization and Workloads. We noted that the capacity of the existing complement of Quarantine Officers is not being deployed in an effective manner. The current focus of Quarantine Officers is on responding to quarantine event calls initiated by service partners (e.g. CBSA, Airlines, Airport and Port Authorities, etc.). Upon being contacted, the Quarantine Officer will typically conduct a health assessment, which is documented via a Traveller Health Report (THR). This wait for the phone to ring approach typically results in Quarantine Officers being subjected to long periods of inactivity in their work days. In , Quarantine Officers, on average, each responded to less than 2 quarantine calls per month. 57. Quarantine Officers interviewed indicated that their capacity could be much better utilized by adopting a more proactive approach in administering the Quarantine Act, but that they did not have clear management direction to undertake additional activities. Examples of proactive activities mentioned included: Audit Services Division Public Health Agency of Canada 12

14 actively driving public health education activities for service delivery partners and stakeholder s employees and the international travelling public; and actively engaging service delivery partners at points of entry beyond Canada s major international airports, in order to ensure effective understanding and administration of the Quarantine Act. 58. Program Management has recognized this issue and has proposed, via the Office of Quarantine Services Position Paper a series of improvement initiatives. Teams composed of Quarantine Officers from across Canada have been assigned the responsibility for a specific improvement initiative. This latter initiative is seen as one means of better engaging Quarantine Officers. As these initiatives have not yet fully commenced, it is too early to assess their impact. 59. Points of Entry Quarantine Screening. While air travel has been identified as the mode of highest risk, in terms of spread of serious communicable disease, we noted that there are a disproportionately low volume of quarantine calls originating from PoE that do not have quarantine stations. Based on traveller health assessment files reviewed: 92 percent of health assessments originated from ill travellers arriving at one of the six international airports that have quarantine stations, while travellers arriving to Canada through these PoE, represented only 24 percent of total international arrivals to Canada; Not one health assessment originated from any of the other Canadian international airports (2 percent of total international arrivals to Canada). These airports do not have quarantine stations; and Only 3 percent of health assessments originated from land crossings (no quarantine stations), while land travellers represented 73 percent of all international travellers. 60. As evidenced above, the current low number of health assessments arising from PoE that do not have quarantine stations raises questions as to the extent of traveller screening that is being undertaken at these PoE. 61. Quarantine Program Awareness Building. Quarantine Services efforts to educate and build awareness among key partners (e.g. CBSA officers at PoE not staffed with QOs) to date have been undertaken in an ad hoc and inconsistent manner and may be one reason for the disproportionately low volume of quarantine calls and issues arising from Points of Entry that are not staffed with Quarantine Officers. 62. Similarly, there have been limited efforts undertaken by the Agency to date to educate and build awareness among the international travelling public, who are a key target audience in the Quarantine Services approach towards minimizing the risk of the introduction of communicable disease via one of Canada border ports. Audit Services Division Public Health Agency of Canada 13

15 63. Quarantine Surge Capacity. The Office of Quarantine Services has not yet established a flexible and responsive surge capacity. We found that similar to the awareness building role, there is a lack of clarity in the Quarantine Services mandate related to the development and maintenance of capacity to address complex or high risk quarantine incidents. 64. We recognize that PHAC s surge capacity, including quarantine surge capacity, is a broader issue that is currently being examined and evaluated across various PHAC operational areas. Conclusion 65. There is an opportunity to align the Quarantine Services delivery model to better address the risks associated with the international travelling public. In addition, there is an opportunity to improve alignment of service delivery resources to current workloads and to better support the needs of service partners at all Canadian PoE. Recommendation 66. Once the mandate of the Quarantine program has been clarified, Quarantine Program Management should undertake an analysis of an alternative service delivery model in order to identify and implement a more responsive approach to minimizing the risk of spread of communicable disease at Canadian border (PoE). As input to this analysis, we have defined a number of alternative approaches (Appendix C) for Quarantine Program Management consideration. Strategic and Operational Human Resources potential impacts should also be addressed. Performance Measurement 67. A Performance Measurement Framework that includes relevant information on results, outputs, indicators and targets is necessary to support organizational decision-making on programs and key activities, and to effectively monitor and manage operations. We therefore expect Quarantine Program Management to have reliable information to demonstrate the Program s performance and to support operational decisions. 68. Performance Measurement and Reporting. The Quarantine Program has not yet developed meaningful performance measures or performance information. Gaps identified include: the primary activity for quarantine stations is to conduct traveller health assessments. The numbers and results of the traveller health assessments, a key indicator of work volumes, are not maintained on any regular basis. As a result, basic program performance information is not available to support management decision-making; and Audit Services Division Public Health Agency of Canada 14

16 similarly, PHAC and the Office of Quarantine Services lack basic workload and performance information at a quarantine station level in order to assess and optimize the alignment of operational resources to workloads. 69. Analysis of Existing Performance Information. As part of the audit, we analyzed all available traveller health assessment files submitted by Quarantine Officers for fiscal year from all quarantine stations. This analysis identified the following: more than 46 percent of traveller health assessments were completed remotely (via phone versus in person ), leading us to the following questions: o o o is this response rate acceptable? if so, what is the value in having in person staff at minor airports? is there appropriate alignment between the hours of operation at minor quarantine stations and the frequency of quarantine events? while 73 percent of international travellers entered Canada via land crossings (vs. 24 percent air and 3 percent marine) in , approximately 3 percent of quarantine calls originated from these same land crossings, leading to the following question that needs to be addressed by Quarantine Program Management: o does this profile make sense from a risk perspective or is this an indication of a gap in the extent to which screening resources are supported at land crossings and marine Points of Entry? Quarantine Program Management would be better positioned to further define and execute its service delivery strategy by additional analysis of existing performance information. 70. Broader Benefits of Performance Measurement. The Office of Quarantine Services is uniquely positioned to provide higher value insight into the public health risks associated with international travellers. It potentially communicates with all service delivery partners on specific quarantine cases. Depending on the specifics of a quarantine case, the communication might involve PHAC generating information from any or all of the following key players: conveyance operators (e.g. airlines); airport authorities; CBSA; emergency services; and local health authorities. Audit Services Division Public Health Agency of Canada 15

17 71. Conducting traveller health assessments provides an opportunity for the Quarantine Services to gather and generate highly meaningful data, information and insight into specific public health risks including, for example: the incidence of specific communicable diseases and symptoms; the incidence of communicable diseases and symptoms by international source of traveller; the travel patterns of those identified with communicable diseases or symptoms; and the seasonal patterns associated with communicable diseases and symptoms. 72. This type of data could be utilized to greatly improve the risk profiling necessary for the Quarantine Services to better align its response capabilities to those areas of highest risk. In addition, this insight would be of benefit for broader public health purposes. Conclusion 73. Program Management has not yet developed methods and tools to support the Program performance measurement and reporting requirements. Recommendation 74. Quarantine Program Management should develop and implement a performance measurement framework which include key performance indicators and associated management reporting on: progress against strategic/operational goals; progress against financial goals; business process performance; employee performance; and stakeholders and partners performance. Processes and Support Tools 75. We expect that the Quarantine Program has documented responsive processes and effective support tools which contribute to the Quarantine Program s ability to meet its objectives and priorities in an effective and efficient manner. 76. Quarantine Program Process Documentation. While procedures and process documentation have been developed, we noted discrepancies in their implementation. For example, documented operating procedures do not differentiate among Points of Entry (i.e. land crossings, airports and ports) to address the unique characteristics and the organization of Quarantine Services at Audit Services Division Public Health Agency of Canada 16

18 these locations. We understand that the Operations Manual, currently under revision, will provide additional guidance on how health assessments can be conducted remotely for land crossings PoE. 77. We also noted that the Office of Quarantine Services does not review partners procedures to ensure consistency of instructions to officers (e.g. Screening Officers, Peace Officers). If procedures are not systematically reviewed and endorsed by the Office of Quarantine Services, PHAC cannot be assured that these officers will act appropriately when potential cases of communicable disease are suspected. 78. Health Assessment Process Consistency. Based on our review of traveller health assessment files, we noted that documented operating processes are not consistently applied. We found that while the Office of Quarantine Services is responsible for reviewing completed Travel Health Reports, the quality assurance process undertaken is informal and results are not consistently documented. Examples of inconsistencies in the preparation of health assessments include: documenting traveller health assessment via Officer Notes instead of a Travel Health Report; not completing all sections of the Travel Health Report; inconsistencies in creating Case Identification Numbers where it is unclear if the designated PoE code used on the THR is the one where the traveller is located or where the Quarantine Officer is located; multiple Case Identification Numbers created for the same case; and no evidence of follow-up and confirmation that the traveller has reported to the Local Public Health Authority, if required. 79. Process Support Tools. We noted that the Office of Quarantine Services have developed a Travel Health Assessment Database (THAD) that will be implemented upon completion of a privacy impact assessment. While this tool is expected to be implemented shortly, we were not able to establish whether this tool addresses any documented program management objectives or information needs. 80. Quarantine Officer Training. We noted that a training program has been defined and implemented for Quarantine Officers, however, we have identified a number of improvement opportunities related to training program delivery: the content of the training material focuses on the powers, duties and obligations of the Quarantine Officers, however, there is very little information provided with respect to the specific communicable diseases covered under the Quarantine Act; and Quarantine Officers observed that their training would be more effective if the training documentation provided was supplemented with real life exercises. Audit Services Division Public Health Agency of Canada 17

19 We were informed that the recent pandemic influenza A (H1N1) triggered changes in the training delivery approach but this was temporary. 81. Service Delivery Partner Training. Service Delivery Partners have not received systematic training to adequately exercise their roles under the Quarantine Act. The training of Screening Officers (there are approximately 6,000 Border Services Officers) and Peace Officers of various local law enforcement agencies remains a challenge. Service Delivery Partner representatives interviewed during this audit noted that they lack training on their roles under the Quarantine Act. Formal training often consists of receiving a brief overview of the Quarantine Act, which they consider insufficient to be able to exercise their roles appropriately. 82. Service Delivery Partner employees, working at airports where a quarantine station is located, noted that they receive informal training through presentations offered by Quarantine Officers or through networking. However, this additional informal training is only available to a very small population of Service Delivery Partners, those working in airports, and excludes other border PoE. 83. In addition, we observed that information pertaining to communicable disease that has historically appeared on the travellers Declaration Card for travellers arriving in Canada, has recently been removed with the introduction of a new card. Removal of this information increases the risk that ill travellers do not self-identify to screening officers. Given that PHAC is ultimately responsible for the administration and enforcement of the Quarantine Act with the exception of conveyances, there is an opportunity for PHAC to take a leadership position to address this challenge. Conclusion 84. There are opportunities to improve the breadth and consistency of process documentation to address operational requirements (e.g. air, marine and land border PoE). In addition, there are opportunities to improve operational support tools (e.g. THAD) and the Program s training approach. Recommendations Quarantine Program Management should: 85. Broaden its process documentation to address the unique attributes of implementing the Quarantine Act at land crossings, airports and marine ports; 86. Implement a quality control process for traveler health assessments and related documentation to ensure that this process is completed in a consistent manner and complies with the Quarantine Act; 87. Formalize and broaden the training delivery mechanism for Quarantine Officers to provide them with the necessary knowledge, skill sets, tools, resources and Audit Services Division Public Health Agency of Canada 18

20 information on communicable diseases and public health to support the discharge of their responsibilities; and 88. Engage Service Delivery Partners to identify opportunities to extend and enhance the Quarantine Program training. Organization and Human Resources 89. We expect that the organizational structure appropriately supports achievement of the Program objectives and operational requirements and Human Resources are properly planned, managed and supported. 90. Organization Stability. The Office of Quarantine Services is slowly emerging from a period of instability that adversely impacted the Program implementation. Five Directors have managed the Office of Quarantine Services in the past three years. This situation has lead to inconsistencies in the approach and direction taken in establishing the Program priorities, and implementing the Program within the Agency and with partners and stakeholders. 91. Currently, there remain a number of acting positions at the management level of the Office of Quarantine Services and until these acting positions are staffed permanently, the risks associated with management instability remain. In response, the Office is currently implementing staffing actions to stabilize the organization structure. 92. As part of this change, Quarantine Program Management is encouraged to address inconsistencies in the Quarantine Officer (QO) job description versus their day-today work activities. As an example, we noted that there is a QO role related to public health education activities targeted at service delivery partners and the international travelling public that is defined in the job description, however, this activity is not consistently performed. This issue has been addressed in the Position Paper and Working Groups assigned by Program Management to work towards the development of networking sessions. However, at the time of the audit it was not possible to comment on the progress as this plan had only recently established. 93. Human Resources Operating Practices. Human resources planning and operational practices employed at quarantine stations lack consistency. We examined the scheduling and staffing practices at the quarantine stations located in Halifax, Ottawa, Montreal, Toronto, Calgary and Vancouver. In comparing the practices employed at these stations, inconsistencies and misalignments in the organization of working shifts, the hours of operations and the staffing practices were noted, including: number of shifts and number of QOs varied at Montreal and Halifax stations; hours of operations for minor airports are not aligned with international flights and/or sun flights arrivals. Number of hours per shift also varied; Audit Services Division Public Health Agency of Canada 19

21 two out of three major airports have administrative staff; some quarantine stations are staffed with indeterminate part time QOs positions while the majority are staffed with indeterminate full time positions; requisite number of hours that Quarantine Officers must work in a 12 week verification period varied between part and full time QOs; and some QOs occupy French or English unilingual positions in bilingual regions. Conclusion 94. Quarantine Officer roles and responsibilities require clarification; in addition human resources planning and operational practices are not applied consistently. Recommendations Quarantine Program Management should: 95. Clearly articulate and communicate the role of the Quarantine Officer and update the Quarantine Officer job description accordingly; 96. Undertake actions to permanently staff current acting positions; and 97. Identify, document and implement more consistent Human Resources planning and operational practices in quarantine stations. Administration and Enforcement of the Quarantine Act 98. We expected that only authorized and qualified Quarantine Officers (QO) exercised their duties as required by the Quarantine Act and that they respected the powers conferred to them as part of the Act. We also expected that Quarantine Officers adequately administer and enforce the Act. 99. We conducted a review of traveller health assessment files for the period of April, 2008 to June, 2009 to assess how the Agency administers and enforces the Quarantine Act. This review was limited to the most relevant and auditable sections of the Quarantine Act that confer powers or responsibilities to Quarantine Officers This review supports a conclusion that Quarantine Officers have respected the powers conferred to them as part of the Quarantine Act and Regulations. We have not identified any significant cases where the Quarantine Act was not administered and appropriately enforced by Quarantine Officers We found that in all cases requiring a measure or action other than unconditional release of a traveller, a Quarantine Medical Officer (QMO) was engaged and Audit Services Division Public Health Agency of Canada 20

22 consulted to advise the QO. In complex cases, the NHQ quarantine team (Quarantine Program National Coordinator, Quarantine Program Director and other QMOs), were also involved in order to determine the appropriate measures regarding the traveller PHAC has not yet finalized a strategy for departing travellers. The Act states that every person who leaves Canada through a departure point shall, immediately before leaving, present themselves to a Screening Officer or a Quarantine Officer at the departure point. According to section 10 of the Act, the Minister can designate any point of entry in Canada as a departure point. However, no such points have been designated yet. Designating points of departure would mean that arrangements would have to be made to screen departing travellers. This requirement has been partially implemented for cases of tuberculosis, where some jurisdictions maintain a travel restriction list. This Exit Screening gap has been identified by Quarantine Services Management who has defined a planned initiative to develop an Exit Screening guideline, although this effort has only recently commenced. Conclusion 103. Quarantine Officers respect the powers conferred to them as part of the Quarantine Act and Regulations and no significant cases were identified where the Quarantine Act was not administered and enforced adequately by Quarantine Officers. Recommendation 104. Quarantine Program Management should finalize a strategy regarding PHAC obligations under the Act for departing travellers. PART II - MIGRATION AND TRAVEL HEALTH PROGRAM 105. The Migration and Travel Health Program is administered by the Migration and International Health Division (Division) which was created in January The Division comprises seven employees from the Centre for Emergency Preparedness and Response (CEPR) and the Centre for Infectious Disease Prevention and Control (CIDPC). The Division focuses on: providing travel information, travel health notices and guidelines, and the prevention and treatment of travel related illnesses; managing the Yellow Fever Vaccination Program obligations under the IHR; managing collaboration with Citizenship and Immigration Canada on immigrant and refugee health; Audit Services Division Public Health Agency of Canada 21

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