Follow-up Audit of Emergency Preparedness and Response

March 2013

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Final Audit Report - Follow-up Audit of Emergency Preparedness and Response (PDF document - 124 KB- 22 pages)


Executive summary

The follow-up audit of recommendations from the 2010 Audit of Emergency Preparedness and Response was carried out as part of the Public Health Agency of Canada's (the Agency's) Risk-Based Audit Plan for 2012-13. The objective of the follow-up audit was to determine whether the implementation of the management action plan has been effective in addressing the recommendations made in the 2010 audit report.

An assessment to conclude on the progress to date of actions taken by management was performed to address the recommendations outlined in the 2010 audit report. The follow-up audit was conducted from October 2012 to January 2013.

One of the Agency's key roles is to provide a clear focal point for federal leadership and accountability in managing public health emergencies. The Centre for Emergency Preparedness and Response (CEPR) is clearly identified as the focal point for dealing with emergency preparedness and response. The 2010 audit concluded that while the Agency was able to respond to emergencies, the operating effectiveness of the management control framework could be strengthened to continue to ensure that the Agency could fully meet its mandate of protecting and promoting the health of Canadians.

Since the time of the audit, a business transformation agenda resulting from the federal Budget 2012 has been implemented which has streamlined and consolidated the emergency management function of the Health Portfolio within the Agency. It is anticipated that the consolidation of the Health Canada staff within the Agency will improve its ability to coordinate emergency preparedness and response activities and provide stakeholders with a single point of contact in the event of a health emergency. As such, CEPR remains Canada's central coordinating point for public health security issues.

The follow-up audit concludes that the implementation of the management action plan has been effective in addressing most of the recommendations made in the 2010 Audit of Emergency Preparedness and Response. Of the fourteen recommendations, 2 are in the preparation for implementation stage, 3 are substantially implemented and 9 have been fully implemented.

Improvements have been noted in the mandate description regarding the Agency's roles and responsibilities in emergency preparedness and response. There has also been considerable work done in the development of key initiatives, such as a long term threat and risk assessment, training, exercise and succession plans. Progress continues in the renewal of the National Emergency Stockpile System (NESS) Program. Lastly, further progress is required in the implementation of a surge capacity model and standardized Health Portfolio Operations Centre (HPOC) software.

A. Introduction

1. Background

As part of the Public Health Agency of Canada's (the Agency's) Risk-Based Audit Plan for 2012-13, the Portfolio Audit and Accountability Bureau undertook the follow-up audit of the management action plan commitments as outlined in the 2010 Audit of Emergency Preparedness and Response.

One of the Agency's key roles is to provide a clear focal point for federal leadership and accountability in managing public health emergencies. On behalf of the Health Portfolio, the Agency acts as the principal public health advisor to the Minister. The Agency's Centre for Emergency Preparedness and Response (CEPR) is Canada's central coordinating point for public health security issues and is clearly identified as the focal point for dealing with emergency preparedness and response.

The 2010 audit concluded that while the Agency was able to respond to emergencies, there were concerns that some areas needed to be addressed to ensure that the Agency could fully meet its mandate of protecting and promoting the health of Canadians. The audit contained fourteen recommendations to strengthen areas relating to:

  • mandate, governance and strategic directions;
  • planning and preparedness;
  • response activities;
  • recovery; and
  • support functions.

As part of the business transformation agenda resulting from the federal Budget 2012, the emergency management function was streamlined and consolidated within the Agency. It is anticipated that consolidation of the Health Canada staff within the Agency will improve its ability to coordinate emergency preparedness and response activities and to provide stakeholders with a single point of contact in the event of a health emergency. The CEPR remains Canada's central coordinating point for public health security issues. The Health Portfolio Emergency Preparedness Committee (HP EPC – formerly the Joint Emergency Preparedness Committee) will continue to oversee the coordination and integration of joint emergency management activities for both organizations reporting to the newly formed Health Portfolio Partnership Executive Committee.

2. Audit objective

The objective of the follow-up audit was to determine whether the implementation of the management action plan has been effective in addressing the recommendations made in the 2010 Audit of Emergency Preparedness and Response tabled in June 2010.

3. Audit scope

The follow-up audit focused on management action plan commitments contained in the 2010 Audit of Emergency Preparedness and Response.

4. Audit approach

For each recommendation, the progress achieved against the action plan commitments was assessed. The follow-up methodology included interviews and the analysis of supporting documentation.  The follow-up audit was conducted from October 2012 to January 2013.

5. Statement of assurance

In the professional judgment of the Chief Audit Executive, sufficient and appropriate procedures were performed and evidence gathered to support the accuracy of the follow-up audit conclusion. The follow-up audit findings and conclusion are based on a comparison of the conditions that existed as of the date of the audit, against established criteria that were agreed upon with management. Further, the evidence was gathered in accordance with the Internal Auditing Standards for the Government of Canada and the International Standards for the Professional Practice of Internal Auditing.

B. Findings, recommendations and management responses

1. Follow-up on the 2010 audit recommendations

1.1. Progress made on 2010 audit recommendations

Audit criterion: Management's actions have been effective in addressing the recommendations identified in the audit tabled in 2010.

The follow-up audit concludes that the implementation of the management action plan has been effective in addressing most of the recommendations made in the 2010 Audit of Emergency Preparedness and Response. Improvements have been noted in the development of a clear mandate regarding the Agency's roles and responsibilities in regards to emergency preparedness and response. There has also been considerable work done in the development of key initiatives, such as a long term threat and risk assessment, exercise, training and succession plans.

Progress has been made in regards to the health emergency response team's mandate and its operational concept as well as strengthening the coordination and integration of the National Emergency Stockpile System and human resources. Progress continues in the renewal of the National Emergency Stockpile System Program; however, an optimization plan still needs to be developed and implemented. The Program is modernizing its stockpile management practices using a risk-based approach to determine future needs. As well, progress continues in relation to the implementation of a surge capacity model and standardized Health Portfolio Operations Centre software.

Recommendation implementation progress
Implementation rating level Number of recommendations Percentage
No progress - insignificant progress 0 0%
Planning stage 0 0%
Preparation for implementation 2 14%
Substantial implementation 3 22%
Full implementation 9 64%
Total
14

Please refer to Appendix A for the assessment rating guide and to Appendix B for the detailed assessments.

Scorecard

The table below summarizes the status of each audit recommendation.

Recommendations Rating Conclusion Current
Target Date
Full implementation
Substantial implementation
Preparation for implementation
Planning stage
No progress
Obsolete
Governance
1 - Re-examine the emergency preparedness and response mandate and supporting roles and responsibilities. FI The Public Health Agency of Canada’s (the Agency’s) mandate and supporting roles have been clarified through the Public Safety’s Federal Emergency Response Plan, the Health Portfolio Strategic Emergency Management Plan (HP SEMP), the Agency’s Policy on the Global Health Framework and the Policy on International Donations and Mobilization.  
Risk
2 - Develop a long term comprehensive threat and risk assessment process and an “all hazards” risk management plan to support emergency preparedness and response efforts. FI The HP SEMP includes a Health Portfolio all-hazards risk assessment.  
Internal Controls
3- Revise the Health Portfolio Emergency Preparedness Policy FI The HP SEMP replaced the Health Portfolio Emergency Preparedness Policy.  
4 - Develop and implement public health exercises to test newly developed plans and arrangements, and develop and implement comprehensive multi-year work plans for training and exercises. FI The HP SEMP 2012-13 and the Health Portfolio Emergency Training Plan 2010-15 have been completed.  
5 - Continue the development of Agency surge capacity models; make a decision on the usage of a common software; and provide mandatory emergency management training. SI The HP Emergency Management Exercise Plan 2012-15 has been developed and approved.

The Human Resources Emergency Preparedness and Response Framework needs to be finalized and approved.

An interdepartmental Operations Centres Interconnectivity Portal has been implemented until a HP incident management software solution is deployed through the HP Shared Services corporate approach.
Oct 2013
6 - Conduct an evaluation of National Emergency Stockpile System (NESS); articulate a clear mandate, followed by the development of updated Memoranda of Understanding formalizing the NESS and provincial and territorial roles and responsibilities. SI An evaluation was completed. The mandate for the NESS Program has been approved by the Agency’s senior management.

Memoranda of Understanding (MoUs) to be developed with key stakeholders to reflect the mandate, roles and responsibilities as they relate to the NESS.

March 2014 for signatures on five MoUs
7 - Initiate the development and ongoing maintenance of a NESS strategic plan and operational business plan.. PI The policy framework needs to be approved.

The NESS Optimization Plan needs to be developed and implemented.
Oct 2013
8 - Develop a policy and related procedures in order to properly record and report on NESS assets in accordance with the Treasury Board Accounting Policy. SI NESS management and staff are testing an SAP inventory management module. The module is being updated with current NESS asset inventories.

A specific NESS asset policy is to be finalized in August 2013.
Aug 2013
9 - Confirm or revisit the Health Emergency Response Teams (HERT) mandate and its operational concept; and ensure good coordination and integration of NESS and human resource deployments in operational settings. PI The final Pan-Canadian Operational Framework for Mutual Aid Surge Requests for Health Care Professionals During Public Health Emergencies is to be presented at the Public Health Network Council in August 2013.

The Health Portfolio Emergency Response Plan which addresses the coordination across the Agency and develops standard operating procedures is currently being revised/updated and is expected to be completed in August 2013.
Aug 2013
10 - Initiate the development and roll-out of a standard methodology encompassing lessons learned exercises; the development of related action plans; and an evaluation of the effectiveness of actions taken. FI The interim After Incident Report (AIR) Process has been updated and approved. The Centre has a standard methodology and governance to implement the lessons learned and the evaluation activities included in the lessons learned process.  
11 - Consider the establishment of a supporting forum (for example, sub-committee) to oversee the approval and compliance of lessons learned deliverables. FI A sub-committee to oversee the implementation of findings of post-event reviews is in place. Records of decisions indicate the approval of the terms of reference and governance structure for the Sub-Committee.  
12 - Develop, implement and monitor staffing and succession plans for key positions. FI The Vacancy Management Template outlines the Emergency Management and Regulatory Affairs Branch (EMRAB) staffing and succession plan. This plan outlines priority levels for each position that requires staffing as well as the mechanism on how the staffing shall occur.  
13 - Once the mandates of the emergency preparedness and response activities have been clarified, secure the required funding. FI The NESS has been included in the investment plan (August 2011). HERT funding has been addressed during the transition to the new surge capacity model (Health Emergency Surge Capacity Unit). The new model, including the financial analysis, has been presented to and approved.  
14 - Continue to develop the Agency contingency plan to deal with significant service interruptions. FI Completed Business Impact Analysis including monitoring of critical services and contingency plans to address any service interruption.  

Appendix A - Lines of enquiry and audit criteria

Follow-up of the Audit of Emergency Preparedness and Response
Criteria Title Audit Criteria
Line of Enquiry 1: Progress made on the 2010 Audit Recommendations
1.1 Progress made on 2010 recommendations Management’s actions have been effective in addressing the recommendations identified in the audit tabled in 2010.

1. No progress or insignificant progress
No action taken by management or insignificant progress. Actions such as striking a new committee, having meetings and generating informal plans are insignificant progress.

2. Planning stage
Formal plans for organizational changes have been created and approved by the appropriate level of management (at a sufficiently senior level, usually at the Executive Committee level or equivalent) with appropriate resources and a reasonable timetable.

3. Preparation for implementation
The entity has begun necessary preparation for implementation, such as hiring or training staff, or developing or acquiring the necessary resources to implement the recommendation.

4. Substantial implementation
Structures and processes are in place and integrated in some parts of the organization, and some achieved results have been identified. The entity has a short-term plan and timetable for full implementation.

5. Full implementation
Structures and processes are operating as intended and are implemented fully in all intended areas of the organization.

6. Obsolete
Audit recommendations that are deemed to be obsolete or have been superseded by another recommendation.

Appendix B – Assessment of recommendation implementation

Recommendation 1 (63)

The Assistant Deputy Minister, Emergency Preparedness and Response and Corporate Affairs in cooperation with key partners and stakeholders should re-examine the emergency preparedness and response mandate and supporting roles and responsibilities in order to appropriately address the Public Health Agency of Canada’s (the Agency’s):

  • role in relation to international emergencies;
  • role in support of Federal health partners;
  • role in support of Canada’s Territories; and
  • expectations of regional offices vs. available resources.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The Assistant Deputy Minister, Emergency Preparedness and Response and Corporate Affairs (ADM, EPRCA) will put in place a project team to respond to Agency-wide issues related to emergency preparedness and response, including the mandate and roles and responsibilities.

September 2010

A project team was put in place to address issues related to emergency preparedness and response, including the mandate, roles and responsibilities.

Full Implementation

A2. The ADM, EPRCA will clarify the emergency preparedness and response mandate, and roles and responsibilities. The ADM, EPRCA will work with the project team and horizontally with internal and external partners and stakeholders and seek Executive Committee (EC) approval.

April 2011

Several documents that show a clear mandate, roles and responsibilities surrounding emergency preparedness and response were reviewed. Key amongst them is Public Safety’s Federal Emergency Response Plan designed to harmonize emergency response efforts by federal and provincial/territorial governments, non-governmental organizations and the private sector. An annex to the Plan - Emergency Support Function #5, clearly states the Agency’s role in public health and essential human services emergency response. The Health Portfolio Strategic Emergency Management Plan (HP SEMP) also clarifies governance and roles and responsibilities for emergency management. The Agency has developed the Policy on the Global Health Framework for International Activities as well as the its Policy on International Donations and a Mobilizations to also define the its roles in international events.

Full Implementation

Recommendation 2 (88)
The Director General, Centre for Emergency Preparedness and Response, should develop a long term comprehensive threat and risk assessment process, and an “all hazards” risk management plan to support emergency preparedness and response efforts.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The Director General, Centre for Emergency Preparedness and Response (DG, CEPR) will develop a formal Agency public health threat and risk assessment process.

The DG, CEPR will engage the intelligence community and the Health Portfolio. This assessment will inform the development of CEPR's All-Hazards Risk Management Plan and will be integrated into the Agency's overall risk management framework.


April 2011

The HP SEMP, which includes the Health Portfolio’s All-Hazards Risk Assessment, was approved by the Agency’s Chief Public Health Officer and Health Canada’s Deputy Minister. The Plan was developed in accordance with the framework outlined in Public Safety’s Emergency Management Planning Guide
(2010-11). One of the stated objectives of the Plan is to use risk assessments to inform strategic emergency management planning.

Public Safety assessed the HP SEMP and gave the full ranking points (8/8) for risk management.

The Health Portfolio - Public Health Threat and Risk Assessment reflects internal emergency preparedness and response risks and complements the overall corporate risk management framework.

Full Implementation

Recommendation 3 (97)
In cooperation with Health Canada, the Director General, Centre for Emergency Preparedness and Response should revise the current version (2007) of the Health Portfolio Emergency Preparedness Policy, particularly in view of the Agency’s experience in responding to major incidents/events in the 2008-10 time frames such as H1N1.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. In cooperation with Health Canada, the DG, CEPR will revise the Health Portfolio Emergency Preparedness Policy as part of the Joint Emergency Preparedness Committee work plan for 2010-12.

Dec 2011

The Health Portfolio Emergency Preparedness Policy was replaced with the HP SEMP (see recommendation 2). The Plan was developed in accordance with the framework outlined in Public Safety’s - Emergency Management Planning Guide (2010-11).

The Health Portfolio Emergency Preparedness Committee - Operations Sub-Committee recently approved the lessons learned process. This process is the mechanism to incorporate observations and recommendations from exercises. Further, the After Incident Report/After Action Report (AIR/AAR) has been developed to improve emergency management preparedness and response.

Full Implementation

Recommendation 4 (111)
In cooperation with key partners and stakeholders, the Director General, Centre for Emergency Preparedness and Response should:
  • develop and implement public health exercises to test newly developed plans and arrangements such as the Federal Emergency Response Plan, the Agency emergency support function, the Health Portfolio Emergency Response Plan and the Health Portfolio Emergency Preparedness Policy ;
  • develop and implement comprehensive multi-year training and exercise plans; and
  • secure training and exercise funding requirements.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR is in the process of developing a comprehensive multi-year work plan for training and exercises which will inform funding requirements to support program priorities. This will be based on an assessment of client/stakeholder needs both within the Health Portfolio and externally (for example, provinces and territories).

June 2011

The 2012-15 Health Portfolio Emergency Management Exercise Plan was developed with stakeholder involvement and was approved.  The Plan includes exercise priorities and identifies suggested areas for funding priorities.

Likewise, the 2010-15 Health Portfolio Emergency Management Training Plan was developed and approved. Its main goal “is to ensure that employees are provided with emergency management training to successfully perform their duties and responsibilities during an emergency event” and provides detailed information on the core curriculum for the target audience within the Health Portfolio.

In April 2013, the Office of Emergency Response Services’ Training Unit and the Operations Sub-Committee are expected to table the 2011-12 Annual Report on Training.

Full Implementation

Recommendation 5 (123)
The Director General, Centre for Emergency Preparedness and Response should continue the development of Agency surge capacity models; make a decision on the usage of common software; and provide mandatory emergency management training to Emergency Operations Centre employees and to surge personnel to ensure that they are fully trained and qualified to respond to emergencies or significant events.
Overall Assessment Substantial implementation
Planned Actions Target Date Progress to date Status of action item

A1. The Agency’s Human Resources Directorate is leading the development of an Agency-wide surge capacity model and will also prepare a human resources emergency/events framework to deal with the various human resources issues identified in this report.

June 2011

The draft Human Resources Emergency Preparedness and Response (HR EPR) Framework has been developed and consultations with stakeholders are underway.

Work on the development of an Agency surge capacity model is on-going. It will be tabled in spring 2013 at the Health Portfolio Emergency Preparedness Committee.

Revised date : October 2013

Preparation for Implementation

A2. The DG, CEPR will complete a needs analysis, develop an action plan and seek EC approval on the implementation of a standardized Emergency Operations Centre software and provide adequate training on its use.

February 2011

The Health Portfolio Operations Centre is currently implementing Public Safety's Operations Centres Interconnectivity Portal (OCIP); an operational capability to enable the immediate sharing and accessing of incident data and information between Federal Emergency Operations Centres in order to improve situational awareness.  The OCIP includes the same platform and infrastructure that the HP will use for their incident management software solution once it's deployed through the HP Shared Services corporate approach.  Until approval is sought from Shared Services, HPOC will continue to leverage OCIP for internal needs.

Revised date : October 2013

Substantial Implementation

A3. The DG-CEPR is currently working to identify emergency preparedness and response capacity gaps and to develop a long-term plan to build a response capacity that is appropriately trained and qualified. To this end, staff will be trained to pre-determined levels in the following sequence:

-Dedicated Health Portfolio Emergency Operations Centre – Staff
-Wider CEPR Staff
-Health Portfolio Surge Capacity

A training plan will be presented to the Joint Emergency Preparedness Committee (JEPC) for review and approval annually.

March 2011

The 2012-15 Health Portfolio Emergency Management Exercise Plan has been developed and approved (see recommendation 4). It includes, as a priority, the Public Health Surge Capacity to test and validate the roles and responsibilities within its emergency response plans.  The 2010-15 Health Portfolio Emergency Management Training Plan, includes training for employees who may be required during an event and considers the need for surge capacity training.

Full Implementation

Recommendation 6 (173)
The Assistant Deputy Minister, Emergency Preparedness and Response and Corporate Affairs, in collaboration with the Director, Evaluation Services Division, should initiate a formal evaluation to assess the relevance of the National Emergency Stockpile System Program. If after conducting the evaluation, the Agency chooses to maintain part or the entire Program, the Director General, Centre for Emergency Preparedness and Response, in cooperation with key partners and stakeholders should articulate a clear National Emergency Stockpile System mandate and obtain Agency senior management approval. This would be followed by the development of updated Memoranda of Understanding formalizing the National Emergency Stockpile System and provincial and territorial roles and responsibilities.
Overall Assessment Substantial implementation
Planned Actions Target Date Progress to date Status of action item

A1. The Director, Evaluation Services Division, in collaboration with the DG, CEPR will conduct an evaluation of the National Emergency Stockpile System (NESS) Program to assess its relevance.

Dec 2010

The evaluation report was completed and approved in February 2012 with the Management Response and Action Plan.

Full  implementation

A2. The DG, CEPR will articulate a clear National Emergency Stockpile System (NESS) mandate in cooperation with key partners and stakeholders and present to EC for approval.

April 2011

A mandate was proposed and approved by the Agency’s EC in December 2011.

Full implementation

A3. In cooperation with key partners and stakeholders, the DG, CEPR will develop updated Memoranda of Understanding formalizing NESS and provincial/territorial roles and responsibilities.

March 2012

Memorandums of Agreements are to be updated/developed with provinces and territories.

The Centre for Emergency Preparedness and Response does have a draft Engagement Strategy for consultations with other government departments, non-governmental organizations and provinces and territories.

Revised date : March 2014 for signatures on five MoUs

Preparation for Implementation

Recommendation 7 (174)
Furthermore, the Director General, Centre for Emergency Preparedness and Response should initiate the development and ongoing maintenance of a National Emergency Stockpile System strategic plan and operational business plan, based on a comprehensive risk and needs assessment, to guide program activities. Key components of this plan should include: a stated vision for the program; strategic objectives; operational objectives; an operational plan that includes performance goals; the development of a comprehensive asset maintenance plan; the implementation of a modernized inventory tracking system; the development of an asset disposition policy and supporting processes; a strategy and business plan for addressing asset obsolescence; change initiatives including an assessment of each initiative’s priority and expected deliverables/milestones and timing; innovative opportunities to acquire, store, rotate and deploy assets; core resource requirements; and change initiatives resource requirements.
Overall Assessment Preparation for Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR will develop a vision statement and strategic objectives for NESS that are aligned with the Agency’s priorities and mandate and will seek EC approval.

May 2011

A draft policy framework, which includes a vision statement and strategic objectives, was developed and circulated. It is waiting final approval.

Revised date : October 2013

Substantial implementation

A2. The DG, CEPR will develop a five-year strategic plan for NESS in consultation with key federal, provincial and territorial partners, and will seek endorsement from EC.

August 2011

The draft policy framework addresses the need for a 5-year strategic plan which is currently under development and called an optimization plan. Specifically, the Optimization Plan will include: governance structure; disposal plan; and asset renewal strategy. The Plan is expected to be ready for approval in June 2013.

Revised date : October 2013

Preparation for Implementation

A3. The DG, CEPR will develop and seek EC endorsement of a comprehensive operational plan to support the NESS Strategic Plan. This comprehensive operational plan will detail various initiatives and outline necessary resource investments required to address issues relating to NESS such as those that are outlined in this recommendation.

Nov. 2011

CEPR has produced a work plan which details deliverables and timelines to: have clear roles and responsibilities with partners; confirm governance; finalize the optimization plan, capacity strategy, asset strategy, inventory system and communication strategy. As well, two committees were established - Pharmaceutical and Therapeutic Committee and the Medical Supply Committee to provide technical advice on assets. The committees and the Centre use the Strategic Asset Management Tool (SAM) to quantify the value of stockpiling an asset based on the risk environment.

Revised date : October 2013

Preparation for Implementation

Recommendation 8 (175)
The Chief Financial Officer, in cooperation with the Director General, Centre for Emergency and Preparedness and Response should develop a policy and related procedures in order to properly record and report on National Emergency Stockpile System assets in accordance with the Treasury Board Accounting Policy.
Overall Assessment Substantially Implemented
Planned Actions Target Date Progress to date Status of action item

A1. The Chief Financial Officer (CFO), in cooperation with the DG, CEPR will develop a policy and related procedures in order to properly record and report on NESS in accordance with the Treasury Board Accounting Policy and will be linked to the proposed NESS inventory system.

Dec. 2011

NESS management and staff are testing an SAP inventory management module. The module is being updated with current NESS asset inventories.  A specific NESS asset policy is to be finalized in August 2013.

Evidence exists that steps have been taken to put in use a warehouse management system to better manage the inventory. The draft project charter with information technology includes timelines, objectives and responsibilities. Several briefing notes were reviewed which indicate that progress is being made and that training has occurred.

Revised date : August 2013

Substantially Implemented

Recommendation 9 (193)
The Director General, Centre for Emergency Preparedness and Response, in cooperation with key partners and stakeholders, should: confirm or revisit the Health Emergency Response Teams mandate and its operational concept; and ensure good coordination and integration of National Emergency Stockpile System and human resource deployments in operational settings.
Overall Assessment Preparation for Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR will obtain a clear and formal mandate from EC to transform the health emergency response teams (HERT).

Dec. 2012

On Aug 26, 2010, CEPR obtained a clear and formal mandate from EC to explore the transition of HERT concept to alternate models.

Full Implementation

A2. If supported by EC, the DG, CEPR will seek senior management approval to develop a National Medical Reserve (NMR) focused on deployable, surge medical professionals to replace the original HERT model. This should be more cost effective and consistent with provincial/territorial interests.

Dec. 2012

In September 2012, the Health Emergency Surge Capacity Unit worked with provinces and territories to assess the merits of a reserve/roster model. It was agreed amongst the stakeholders to continue with the Operational Framework for Mutual Aid Surge Requests for Health Care Professionals.
Three validation exercises to be completed by spring 2013.

Revised date : August 2013

Preparation for Implementation

A3. The DG, CEPR will work horizontally to examine the logistical coordination across the Agency and develop a standard operating procedure for NESS and human resource deployments. This SOP will be brought to the Branch Executive Team and then EC.

Dec. 2012

The 2009 Health Portfolio Emergency Response Plan addresses the coordination across the Agency and has standard operating procedures. The Plan was approved by the Agency’s Chief Public Health Officer and Health Canada’s Deputy Minister.  The document is currently being updated.

Revised date : August 2013

Preparation for Implementation

Recommendation 10 (212)
The Director General, Centre for Emergency Preparedness and Response, through the Joint Emergency Planning Committee, should initiate the development and roll-out of a standard methodology encompassing the: conduct of lessons learned exercises; development of related action plans; evaluation of the effectiveness of actions taken; and establishment of a repository/ library of lessons learned.
Overall Assessment Full implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR will develop a formalized methodology and governance structure to facilitate the implementation of lessons learned and subsequent evaluation. This methodology will incorporate available public safety guidance as required.

Dec. 2012

Changes in the terminology in the Lessons Learned Process have been made to reflect Public Safety terminology (Comprehensive Lesson Learned Process).

The Interim After Incident Reviews Process has been updated and approved by the Health Portfolio – Emergency Preparedness Committee. CEPR also has a standard methodology and governance to implement lessons learned and evaluation activities included in the Lesson Learned Process. As indicated in the terms of reference, the Lessons Learned Task Group will also develop action plans, evaluate the effectiveness of those plans and establish a repository of lessons learned.

The Comprehensive Lessons Learned Process was approved on December 2012 by the Health Portfolio Emergency Preparedness Committee (HP EPC).

Full implementation

Recommendation 11 (213)
The Director General, Centre for Emergency Preparedness and Response, through the Joint Emergency Planning Committee, should also consider the establishment of a supporting forum (for example, sub-committee) to oversee the approval and compliance of lessons learned deliverables (for example, after action reports, improvement plans and evaluation results).
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR will work with JEPC to develop a sub-committee to oversee the implementation of findings of post-event reviews.

 

The Health Portfolio Emergency Preparedness Committee – Operational Sub-Committee’s terms of reference indicates that one of the roles of this committee is to review, respond and/or make recommendations on lessons learned issues within the Portfolio.

Records of decisions indicate the approval of the terms of reference and governance structure for the Sub-Committee. Evidence exists that the Sub-Committee has been holding meetings through the review of meeting minutes.

Full Implementation

Recommendation 12 (223)
The Director General, Centre for Emergency Preparedness and Response, in cooperation with the Human Resources Directorate should develop, implement and monitor staffing and succession plans for key positions.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, CEPR will develop, in consultation with the Human Resources Division, staffing and succession plans.

Dec. 2012

The Vacancy Management Template outlines the Emergency Management and Regulatory Affairs Branch’sFootnote 1 (EMRAB) staffing and succession plan. This plan outlines priority level for each position that requires staffing as well as the mechanism on how the staffing shall occur. In addition, the record of decision from the October 11th 2012 Workforce Management Committee meeting shows that this template was presented and approved by the Agency’s Workforce Management Committee.

Full Implementation

Recommendation 13 (224)
Once the mandates of the emergency preparedness and response activities including those of Health Emergency Response Teams and the National Emergency Stockpile System have been clarified, the Director General, Centre for Emergency Preparedness and Response should secure the required funding.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. In cooperation with the project team, the DG, CEPR will examine funding issues and propose solutions for EC consideration.

Dec 2012

The NESS has been included in the recently approved Investment Plan.

Funding has been addressed during the transition to the new surge capacity model (Health Emergency Surge Capacity Unit). The new model, including the financial analysis, has been presented to and endorsed. As such, sustainable funding for the Health Emergency Surge Capacity Unit has been secured.

Full Implementation

Recommendation 14 (225)
The Director General, information management and information technology should continue to develop the Agency contingency plan to deal with significant service interruptions.
Overall Assessment Full Implementation
Planned Actions Target Date Progress to date Status of action item

A1. The DG, information management/information technology (IM/IT) has developed a proposal for addressing contingency issues which will be brought forward for funding.

Dec. 2012

A review of the Business Impact Analysis (BIA) noted monitoring of critical services and contingency plans to address any service interruption. To be successful, the Agency’s programs have assessed priority activities for the Chief Information Officer related to continuity of service. This process is managed through both the Branch and IM/IT governance tables, as well as bilaterally with the CIO and DG of programs.

Going forward, Shared Services Canada will be involved in the management service interruptions relating to the Agency’s critical services.

Full Implementation

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