Management Response and Action Plan – Audit of Health Facilities Program at Health Canada, March 2017

March 21, 2017

Recommendation Management Response and Planned Management Action Deliverables Expected Completion Date Responsibility

Recommendation 1

It is recommended that the Senior Assistant Deputy Minister and the Assistant Deputy Minister, Regional Operations, First Nations and Inuit Health Branch, enhance the effectiveness of the committee structures by updating and adhering to the terms of reference for national and regional capital review committees.

Management agrees with this recommendation.

At the national level, FNIHB will update and distribute the Capital Program Review Committee terms of reference (ToR) to all committee participants and ensure the ToR is followed. FNIHB will also communicate to the regions the expected outcomes of their regional capital committees and ensure that regions update the terms of reference for their committees to reflect the expected outcomes.  Going forward, regions will attest annually that regional committees are following their ToR as part of their annual attestation questionnaire that they are required to complete.    

1.1 Updated and Senior Management approved terms of reference for the Capital Program Review Committee.

March 31, 2017

FNIHB- CIAD- Director

1.2 Updated and Regional Executive approved terms of reference for regional capital review committees (or equivalent).

April 30, 2017

FNIHB-ADM-RO

1.3 The updated annual regional attestation questionnaire that includes a component on governance.

Sept  30, 2017

FNIHB- CIAD- Director

Recommendation 2

It is recommended that the Senior Assistant Deputy Minister and the Assistant Deputy Minister, Regional Operations, First Nations and Inuit Health Branch, ensure that:

  • A systematic process to collect and analyze current data related to facility O&M requirements is implemented and that O&M funding provided to recipients is consistently and accurately recorded to support decision making; and,
  • A resource review is undertaken in collaboration with the Assistant Deputy Minister, Corporate Services Branch, to ensure that regional operational plans for the HFP are developed that optimally reflect the best alignment and allocation of human resources to adequately support program delivery activities.

Management agrees with this recommendation.

FNIHB will use 2016-17 GCIMS data along with data from SAP to determine O&M allocations and conduct a quantitative analysis. The analysis will include identification of miscoded transactions and recommendations for correction, and will be used to plan for the implementation of O&M planning and reporting.

2.1 Recommendations for coding transactions to be presented to the Capital Program Review Committee based on the analysis of the 2016-17 O&M allocations.

July 31, 2017

FNIHB – CIAD- Director

FNIHB will implement an O&M planning, analysis, and reporting component into the long term capital planning process.  The template for data collection and input will be developed and implemented to coincide with the next LTCP planning cycle in the fall of 2017. 

2.2 Updated LTCP template, including O&M planning, and reporting component.

September 30, 2017

FNIHB – CIAD- Director

FNIHB, in collaboration with CSB, will develop an MOU including the expected level of service to be delivered and based upon an analysis of the regional supports to ensure proper alignment.

2.3 Signed MOU

September 30, 2017

FNIHB – CIAD- Director 

Recommendation 3

It is recommended that the Senior Assistant Deputy Minister and Assistant Deputy Minister, Regional Operations, First Nations and Inuit Health Branch, ensure that:

Policy, guidance documents and directives for project implementation and monitoring are updated and communicated, and that applicable roles and responsibilities are clarified.

Management agrees with this recommendation.

Clear and up-to-date documentation is critical for the sound operation of a program such as HFP.  In 2015-16, FNIHB updated the FNIHB Framework for Planning and Managing Capital Contributions and the FNIHB Health Infrastructure and Capital Protocol. 

FNIHB will review and update, including strengthening roles and responsibilities, all key documents (as outlined below) related to the delivery of the Health Facilities Program.  This will include updating the Framework and Protocol documents, and completing a draft Project Brief document that was developed in 2016-17, and as well as a project Business Case document.  Finally, FNIHB will revise the Property Planning and Management Manual (PPMM) to reflect policy changes.

3.1 Interim program delivery roles and responsibilities document

March 15, 2017

FNIHB – CIAD- Director

3.2 Interim documentation review and action plan with detailed updates for each individual item.

March 31, 2017

FNIHB – CIAD- Director

3.3 Review, update, and approve: The Project Brief; Business Case; Framework for Planning and Managing Capital Contributions and the Health Infrastructure and Capital Protocol by CPRC and Senior Management Committee and communicated

July 31, 2017

FNIHB – CIAD- Director

3.4 The PPMM reviewed, updated, approved by CPRC and Senior Management Committee and communicated.

December 31, 2017

FNIHB – CIAD- Director

Recommendation 4

It is recommended that the Senior Assistant Deputy Minister and Assistant Deputy Minister, Regional Operations, First Nations and Inuit Health Branch, ensure that:

  • A system to replace the current legacy real property management information system is obtained; and,
  • In the absence of a fully functional real property management information system, an interim mitigation strategy is put in place to capture business information by region.

Management agrees with this recommendation.

FNIHB recognizes the need to have a fully functional real property management information system and work has been underway to advance a solution, while also recognizing the need to work within the Health Canada – Shared Services Canada priority list (as of March 2016, the project was ranked 42 out of 59 on the priority list).

FNIHB will continue to work through the departmental Investment Planning process for an appropriate replacement system for the existing Real Property Management Information System (RPMIS).  Efforts will focus on developing options and a Business Case that will reflect a project scope which has evolved to include different types of assets from different program areas [e.g. Aboriginal Head Start On Reserve, National Native Alcohol & Drug Abuse Program]. This will require a consistent reporting approach across different programs and regions.  The Government of Canada IT funding requirements have changed since the project was originally started, which will have implications on the steps and timing required to complete the project depending on the option chosen. 

In the interim, FNIHB will continue to implement mitigation measures to ensure business processes can be followed and information of value is collected.  A formal strategy will be developed to consider 1) using appropriate components of the existing system to the extent possible, including the following applications: main building information database, FCES, and asset management; and, 2) implement regionally consistent processes and templates, related to: Project Brief, Long Term Capital Plan (LTCP) and audit and inspection follow-up. Work around solutions mainly include the use of excel spreadsheets (e.g. LTCP) and Word templates (e.g. Project Brief).

Please note: While no new development can occur on RPMIS (development platform is no longer supported), the System will be supported and remain active until a replacement solution is implemented.

4.1 Develop a business case to replace the legacy RPMIS.

4.2 Real property information management system mitigation strategy in place.

March 31, 2019

July 31, 2017

FNIHB – CIAD- Director

FNIHB – CIAD- Director and FNIHB-Regional Executives

Recommendation 5

The Senior Assistant Deputy Minister and the Assistant Deputy Minister, Regional Operations, First Nations and Inuit Health Branch should ensure that a national quality assurance function is established to monitor regional capital facility funding and monitoring activities, including project risk management, to support consistent and equitable regional practices and to enable effective and timely adjustments to program policies when required.  

Management agrees with this recommendation.

FNIHB will incorporate a year-end follow-up process for the long term capital plan, including a direct review of project files (random sample of five minor and two major capital files for every region that has this volume of projects), and develop a capital project checklist to better support file management and decrease  risks to the Program.

5.1 National and regional LTCP year-end review procedure.

May 31, 2017

FNIHB – CIAD- Director and
FNIHB-Regional Executives

5.2 Develop a capital project checklist and share with regions

June 30, 2017

FNIHB – CIAD- Director

5.3 Random sample of 5 minor and 2 major capital closed project files per region for Fiscal Year 2017-18.

June 30, 2018

FNIHB – CIAD- Director, FNIHB-Regional Executives

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