Internal audit of the health screening process

Internal Audit & Accountability Branch
25 October 2018

Table of Contents

• I. Background
• II. Audit objective, criteria, scope and methodology
• III. Audit findings and recommendations
• IV. Conclusion
• Appendix A – Management response

I. Background

Introduction

1. The Audit of the Health Screening Process was included in the Department’s 2018-2020 Risk-Based Audit Plan, which was reviewed by the Departmental Audit Committee at its February 2018 meeting and subsequently approved by the Deputy Minister.

The health screening process

2. The health screening process is administered by the Migration Health Branch (MHB) within Immigration, Refugees and Citizenship Canada’s (IRCC’s) Operations Sector. The health screening process is used to manage health risks related to permanent and temporary residence applications according to the three grounds for medical inadmissibility under the Immigration and Refugee Protection Act (2001), which are:
   • danger to public health,
   • danger to public safety, and
   • excessive demand on health or social services.
3. Health screening requires the collection and management of applicant health information. The process of collecting this medical information begins with the Immigration Medical Examination (IME). IMEs include tests for certain health conditions identified as necessary by IRCC officials and are performed by IRCC designated independent medical professionals around the world, referred to as Panel Members. This group of approximately 2,000 Panel Members is referred to as the Panel Network and is composed of physicians and radiologists. Panel Members are responsible for providing IME results to IRCC, primarily through the eMedical web portal.

Diagram 1. Immigration medical examinations conducted between 2015 and 2017

Text version: Diagram 1. Immigration medical examinations conducted between 2015 and 2017

Year	Permanent Resident	Temporary Resident	Unlinked Up-front Medicals	Total
2015	340,289	168,806	42,291	551,386
2016	357,096	216,254	275,264	632,250
2017	365,095	58,900	365,096	688,880

4. Panel Members do not have the authority to assess or determine the admissibility of applicants. The process of recommending whether a visa applicant should be deemed inadmissible on health grounds is conducted by IRCC officials through an Immigration Medical Assessment (IMA), based on the results of IMEs conducted by Panel Members. Depending on the severity and complexity of IME results, IMAs may be completed individually by IRCC medical officials for higher risk cases or automatically through the Global Case Management System for low risk cases through a process called “auto-clearance”.
5. When the result of an applicant’s IME indicates there is no danger to public health or public safety, and there are no conditions likely to place excessive demand on health or social services, the Immigration Medical Assessment is automatically cleared in the Global Case Management System. This indicates that the applicant did not have a medical condition that would require a manual review by IRCC’s medical officers. After the assessment of medical results has been completed, this health information is one of the key admissibility elements considered by visa officers in their final visa decisions.

eMedical implementation

6. IRCC’s eMedical system, launched in November 2012, replaced the previous paper-based processing model. Prior to 2012, all IMEs were completed and submitted to IRCC via paper-based applications. IRCC’s Regional Medical Officers would receive these applications by regular mail from Panel Members, manually enter the application information into GCMS (or into the system that pre-dated GCMS), and then perform IMAs based on this information. eMedical is a web-based health information processing system developed by Australia’s Department of Immigration and Border Protection (DIBP) for the electronic submission and processing of IMEs. As of December 2017, four of the Migration 5 ^{Footnote 1} countries are using the eMedical system.
7. Panel Members directly input finalized medical data from the IMEs into the eMedical portal. The data is then automatically uploaded to the Global Case Management System. If there are no significant medical concerns, the IMEs are automatically cleared within 24 hours. More than 80 percent of the IMEs are auto-cleared. The remaining IMEs are triaged by the Regional Medical Offices for manual assessment.
8. IRCC’s Regional Medical Offices are located in Manila, Philippines; New Delhi, India; London, United Kingdom; and Ottawa, Canada. The Regional Medical Offices are responsible for:
   • the management of the Panel Members,
   • communicating with visa offices and investigating applicant and visa office complaints or issues as they relate to medical admissibility,
   • assessing IMEs,
   • liaising with local and regional stakeholders, and
   • monitoring local operations statistics and workflows for IMEs and IMAs.
9. Subsequent to the implementation of eMedical, the Migration Health Branch assessed and identified risks which required mitigation related to the collection and management of health screening information. For example, the Branch developed a process flow chart regarding its core health screening processes, risks and mitigation strategies and developed a Program Integrity Framework which included quality assurance activities as key controls to mitigate the risks.

II. Audit objective, criteria, scope and methodology

Audit objective, criteria, and scope

10. The audit objective was to determine if key controls are in place to effectively mitigate the identified risks associated with the collection and management of health screening information.
11. Criteria were selected to evaluate the extent to which the Department has met the audit objective. Two criteria were used to evaluate the audit objective:
    • Key controls are in place to manage identified risks associated with the collection of health screening information through the Immigration Medical Examination process conducted by Panel Members; and
    • Key controls are in place to mitigate the risks associated with the management of the Immigration Medical Assessment process.
12. The audit scope covered the time period from 1 January 2015 to 31 March 2018. The audit did not assess the Migration Health Branch’s Centralized Medical Admissibility, Medical Surveillance and Notification, or the Interim Federal Health Program.

Methodology

13. The following audit procedures were performed:
    • Reviews of key supporting documents and relevant background documentation such as program policies, procedures, guidance, and manuals, including the Program Integrity Framework and the Panel Members’ Handbook;
    • Interviews with key personnel within the Migration Health Branch in Ottawa;
    • Site visits to selected IRCC Regional Medical Offices abroad (Manila and New Delhi);
    • Audit testing of a selected sample of quality assurance reports to examine the implementation of the quality assurance activities; and
    • Reviews of the ongoing monitoring process for selected corrective actions resulting from Quality Assurance activities.
14. The audit observations, conclusions, and recommendations are based on the analysis of the information and evidence collected above.

Statement of Conformance

15. This audit was planned and conducted in conformance with the Institute of Internal Auditors International Professional Practices Framework, as supported by the results of IAAB's quality assurance and improvement program.

III. Audit findings and recommendations

Risk management and program integrity framework

16. The Treasury Board Framework for the Management of Risk (2010) indicates that effective risk management in the federal government should support decision-making and priorities, and be tailored and responsive to the organization’s context. The need for the Migration Health Branch to create and consistently follow a robust quality assurance framework in relation to the medical examination system was highlighted in previous assurance reviews.
17. To manage program risk, the Migration Health Branch developed a Program Integrity Framework (the Framework) in 2016. The purpose of the Framework is to assess the quality and consistency of the Immigration Medical Examinations and Assessments. As part of this process, the Migration Health Branch defined the core Immigration Medical Examination and Assessment processes, identified the associated risks, and set out controls to mitigate these risks. The mitigating controls for each core process are further supported through quality assurance activities.
18. Following the first year of implementation, the Migration Health Branch developed the Program Integrity Framework Expansion Plan to continue to respond to the new gaps it had identified within the Framework. The Framework, as of the end of the audit scope period, had 45 quality assurance activities to monitor identified risks within the Health Screening Process.

Monitoring of panel members

19. To mitigate the identified risks associated with the collection of immigration medical information by Panel Members, the Migration Health Branch has developed a number of controls, which include monitoring activities. The outcomes of these monitoring activities, including the Program Integrity Framework quality assurance activities, are presented to the Migration Health Branch Executive Committee on a quarterly basis.
20. In 2011, site visits by Regional Medical Officers were implemented to provide monitoring of the Panel Members and their offices. Site visits are comprehensive reviews that include the verification of credentials, and adequacy of facilities and resources. The site visits take place at the offices where the Immigration Medical Examinations are conducted. Panel Members are located in over 170 countries.
21. As per the guidance on conducting site visits, the Regional Medical Officers are required to submit a trip overview report as well as Panel Member review forms following the visits. If trip reports are not completed, there is a risk that pertinent information or issues identified during the visit are not documented and maintained for future reference and action when required. A review of the trip reports indicated that over 90 percent had been completed.
22. In March 2017, the Migration Health Branch implemented a tool to determine each country’s risk level to inform the planning of site visits. The level of risk is based on four criteria: tuberculosis rates, volume of Immigration Medical Examinations, tuberculosis rate in Immigration Medical Examinations, and observations from pervious site visits. Based on the risk rating, site visits would be prioritized so that high risk countries would require a full site visit conducted by the Regional Medical Officer.
23. For medium and low risk countries, the Department is working to implement a format to carry out a review, which will be intended to check on service and management without including medical content. The approach has not yet been formally designed or implemented.
24. Prior to March 2017, there was no formal mechanism in place to determine which sites to visit. These decisions were made by the Regional Medical Officers based on professional judgement and operational considerations. It was determined that 29 percent of the countries that the risk tool identified as high risk, had undergone a Medical Officer site visit between January 2015 and March 2018.
25. As part of the Framework, the Migration Health Branch has developed quality assurance activities used to monitor and mitigate risks associated with the Immigration Medical Assessment process. During the assessment process, files with no medical concerns or requiring medical surveillance are auto-cleared through the Global Case Management System. Files that are not auto-cleared are transferred to the appropriate level of delegated authority for manual assessment, based on the medical condition identified. A review of the monitoring activities associated with the auto-clearance process and monitoring of the non-autocleared files identified that the quality assurance activities, such as verifying that the same standards and coding practices are being applied by all IRCC staff, were consistently completed as required.
26. Based on the monitoring activities, corrective actions were identified following Program Integrity Framework activities. A review of the monitoring reports as well as validation with the Regional Medical Offices identified that corrective actions were managed independently by each Regional Medical Office. As such, the Migration Health Branch does not have the ability to aggregate the corrective actions across all four regions to identify trends and inform additional guidance that may be required to improve controls and mitigate the risk of recurring errors.
27. Recommendation 1. The Assistant Deputy Minister, Operations Sector should review and strengthen the monitoring of Panel Members by establishing:
    • procedures to determine the requirements for implementing the duty travel tool for site visits for high, medium, and low-risk sites; and
    • a process to monitor corrective actions resulting from the monitoring activities across all four Regional Medical Offices to ensure that recommended actions have been addressed and global trends can be identified.

Panel member designation

28. All applicants for Permanent Resident and some Temporary Resident visa programs are required to complete an Immigration Medical Examination as part of the visa application process. Applicants are required to have the examination completed by an IRCC designated Panel Member. To be designated as a Panel Member, the physician or radiologist must complete IRCC’s formal designation process.
29. The process includes providing a copy of the candidate’s medical degree and professional licence. Applicants are also required to complete IRCC forms, including the Consent to Share Information form as well as the Acceptance of Designation form, which includes an attestation that the Panel Member has read and understood the Panel Members’ Handbook. IRCC’s medical officers are expected to review this evidence and, if satisfactory, will issue the designation. There is an operational guideline to support the designation process. As of March 2018, IRCC has 1,117 designated Panel Physicians and 1,027 designated Panel Radiologists around the world.
30. For a new Panel Member designation, a quality assurance activity was added to the Framework to ensure that new Panel Member designation documents are accurate and complete. Quarterly and annual reports were published to track the credentials of new Panel Members.
31. In May 2016, the Migration Health Branch started a Special Designation Project to improve the management of Panel Member designation documents. The Special Designation Project was completed for Panel Physicians in May 2017 and found a number of inconsistencies, particularly in the tracking and maintenance of expired licences of Panel Physician. The Special Designation Project for Panel Radiologists is ongoing. The Migration Health Branch has not followed up on the expired medical licences identified during the Special Designation Project, as well as licenses that have subsequently expired.

Panel member training

32. The Panel Members’ Handbook was implemented in 2013. It provides instruction, information and reference materials related to the work of Panel Members and to the IME process. However, the Department has identified that some of the guidance is out of date, as processes and procedures have changed. Reading and understanding the Handbook is IRCC’s only mandatory training tool for Panel Members. During the empanelment process, Panel Members must sign the Acceptance Designation form, which acknowledges that they have read and understood the Handbook. There is no other requirement for Panel Members such as requiring Panel Members to review the Handbook and periodically re-sign the form to attest that they have maintained their knowledge of the Handbook requirements.
33. A review of a sample of 30 active Panel Physicians (as of March 2018) indicated that 97 percent had signed the Acceptance of Designation form, which attests that the physicians read the Handbook. The one Panel Physician who had not signed the Acceptance of Designation form has since been removed from the Panel Member Network in May 2018 for other reasons.
34. Regional Medical Officers provide eMedical training to Panel Members on an as-needed basis. The eMedical training is offered by webinar, and training material for the webinar includes eMedical user and quick reference guides, screencasts, tip sheets and a PowerPoint presentation. Other ad-hoc training is provided such as how to identify fraudulent identification documents and guidance on furtherance. Records of the ad-hoc training provided to Panel Members, such as the eMedical training, are not maintained.
35. The Department has not determined if the current approach to training Panel Members (for example, the use of the Handbook and the eMedical training) is effective in helping Panel Members to administer the Immigration Medical Examinations and recording the information in the eMedical system. An outdated training manual such as the Handbook, and a lack of tracking of training may lead to inconsistent practices and issues of non-compliance with the IME process.
36. Recommendation 2. The Assistant Deputy Minister, Operations Sector should assess and update the designation monitoring process and the training program for the Panel Members so that:
    • IRCC has complete, accurate, and up-to-date designation documents on file for all Panel Members; and
    • the training program includes the development and implementation of a control to record training and track progress to provide assurance that Panel Members have sufficient tools and guidance.

Risk of up-front medicals

37. By having a Panel Member conduct the medical examination prior to submitting an application for temporary or permanent residence, the applicant could potentially speed up the process, rather than waiting until the application for visa eligibility has been determined. Up-front medicals are sometimes conducted when an applicant visits a Panel Member before that person submits an application to migrate to Canada. The use of up-front medicals was introduced when the health screening process was much slower, paper based, and required instructions and results to be transferred by mail.
38. [REDACTED]
39. [REDACTED]
40. The Department identified up-front medicals as a risk and, in December 2016, ended their use in applications to migrate to Canada, except through the Express Entry stream and temporary resident programs. The Department has been exploring options to remove up-front medicals for the Express Entry stream and temporary resident programs but has not yet developed a solution given the short processing times for these lines of business. The continued use of up-front medicals exposes the Department to the risk of providing a visa to an applicant who otherwise would be deemed inadmissible for medical reasons.
41. Recommendation 3. The Assistant Deputy Minister, Operations Sector should implement a risk management approach for the use of admitting an applicant through the use of up-front medicals within the health screening process.

IV. Conclusion

42. Key controls are in place to mitigate the identified risks associated with the collection and management of health screening information. The Migration Health Branch has implemented controls such as the Panel Members’ Handbook and site visits to mitigate identified risks associated with the management of health screening information.
43. Opportunities for improvement were identified to strengthen the monitoring process to continuously improve the integrity of the program, particularly with the implementation processes such as Panel Member site visits to high risk countries, and monitoring and follow-up on corrective actions. In addition, opportunities were identified to strengthen the management of risks identified with the management of health screening information by improving the monitoring of Panel Member designation credentials as well as the training program for Panel Members, and by reviewing the use of up-front medicals.

Management has accepted the audit findings and developed an action plan to address the recommendations.

Appendix A – Management response

Recommendation 1

The Assistant Deputy Minister, Operations Sector should review and strengthen the monitoring of Panel Members by establishing:

• procedures to determine the requirements for implementing the duty travel tool for site visits for high, medium, and low-risk countries; and
• a process to monitor corrective actions resulting from the monitoring activities across all four Regional Medical Offices to ensure that recommended actions have been addressed and global trends can be identified.

Management response

Management agrees with the recommendation and will implement actions to strengthen monitoring of Panel Members by June 2019.

Recommendation 2

The Assistant Deputy Minister, Operations Sector should assess and update the designation monitoring process and the training program for the Panel Members so that:

• IRCC has complete, accurate, and up-to-date designation documents on file for all Panel Members; and
• the training program includes the development and implementation of a control to record training and track progress to provide assurance that Panel Members have sufficient tools and guidance.

Management response

Management agrees with the recommendation and will continue its efforts with regard to the rigorous collection of designation documents. Actions to address panel member designation documents and training as it pertains to IRCC’s expectations for conducting the Immigration Medical Exam will be implemented by June 2020.

Recommendation 3

The Assistant Deputy Minister, Operations Sector should implement a risk management approach for the use of admitting an applicant through the use of up-front medicals within the health screening process.

Management response

Management agrees with the recommendation and acknowledges the program integrity risks associated with the practice of up-front medicals and will take action by June 2019, while recognizing that this practice is important for maintaining processing timeline targets for certain immigration application streams.