Internal audit report outlining results of the Review of the Implementation at Transport Canada of the Policy on COVID-19 Vaccination.
On this page
- Background
- Context
- Review criteria
- Methodology
- Categories of key observations
- Conclusions
- Annex A
- Annex B
Background
The Policy on COVID-19 Vaccination for the Core Public Administration Including the Royal Canadian Mounted Police (the Policy) took effect on October 6, 2021. The main objective of this Policy was to take every precaution reasonable, in the circumstances, for the protection of the health and safety of employees through vaccination.
Employees were required to attest to their vaccination status in the Government of Canada's Vaccine Attestation Tracking System (GC-VATS). Those who attested that they were not vaccinated could request an accommodation.
At Transport Canada (TC), a Review Committee (the Committee) was formed to review accommodation requests and provide recommendations to the managers responsible for employees requesting accommodation.
Audit and Evaluation assisted the Department in designing an appropriate monitoring framework to verify the proof of employees’ vaccination status and HR implemented a random sampling approach in March 2022. In this verification exercise, 427 out of 472 employees selected were successfully verified; the remaining 45 employees had verifiable and appropriate reasons for not having attested in GC-VATS. No anomalies were found, and no further testing was required.
Effective June 20, 2022, the vaccination requirement for the Core Public Administration, including the RCMP, was suspended. As of that date, employees were no longer required to be vaccinated as a condition of employment.
October 6, 2021 – Effective date of the Policy on Vaccination.
October 6 to 29, 2021 – Attestation period.
October 29 until November 14, 2021 – Employees attend training if not attested. Managers send reminder to complete attestation.
November 15, 2021 – Full implementation date of the Policy on Vaccination, or two weeks following the “Attestation Deadline”.
Context
While the Policy is suspended, it is important to recognize the impact it has had on government departments and the importance of learning lessons from its implementation to help prepare for similar future events (e.g., where decisions have to be made quickly in a rapidly evolving environment).
The Review of the Implementation at Transport Canada of the Policy on COVID-19 Vaccination was included in the Department’s Risk-Based Audit and Evaluation Plan.
The Review’s objectives were to:
- assess the effectiveness of the controls designed and implemented to support TC’s implementation of the Policy; and
- identify lessons learned that could be applied to similar situations in the future.
By examining the Department’s implementation of the Policy, the Review highlights areas of success and areas for improvement to consider in preparation for similar events in the future.
Review criteria
The following criteria were used to review how TC implemented the Policy:
- Governance – Governance structure is well defined covering decision-making and provision of advice regarding the Policy.
- Governance – Clear roles and responsibilities supporting the governance structure are communicated within the Department.
- Guidance – Sufficient resources (financial and people) and guidance are in place to support the implementation of the Policy.
- Monitoring and reporting – The information reported is relevant, accurate, and complete to facilitate the necessary monitoring and reporting of activities.
- Information management – Processes are in place to properly safeguard the personal information that is collected, shared, and stored.
Methodology
Interviews
- Conducted a series of interviews with key Human Resource personnel and Committee members to understand their practices in implementing the Policy and the support they provided to managers and employees. Also interviewed some Access to Information and Privacy (ATIP) personnel, and a sample of managers involved in making accommodation request decisions.
Document reviews
- Reviewed various Office of the Chief Human Resources Officer (OCHRO) and TC documents to learn more about the Policy requirements, central agency and departmental guidance, as well as the support provided to TC managers.
OGD comparison
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Collected information from a few Other Government Departments (OGDs*) that reviewed the implementation of the Policy to highlight what they have learned and identify some good practices for TC’s consideration.
* Treasury Board of Canada Secretariat (TBS), Environment and Climate Change Canada (ECCC) and Public Services and Procurement Canada (PSPC)
Data analysis
- Analyzed data provided by key HR stakeholders to understand how vaccination-related data was collected, tracked, reported, and used to inform management decisions.
Categories of key observations
The key observations have been categorized into five areas based on the review criteria.
The following sections include the context, observations, the OGD comparisons when applicable, and considerations.
- Governance structure
- Governance: roles and responsibilities
- Guidance
- Monitoring and reporting
- Information management
1. Governance structure
Context:
With limited guidance from OCHRO, TC and other departments had to mobilize quickly. TC decided to establish a senior-level Review Committee (the Committee) to review the accommodation requests from the employees who attested that they were unable to be vaccinated “based on a certified medical contraindication, religion, or another prohibited grounds of discrimination as defined under the Canadian Human Rights Act”. The Committee made recommendations to managers who were ultimately responsible for granting or denying their employee’s request.
Observation:
The Committee comprised senior-level managers. There was no documented Terms of Reference (ToR) that clearly defined the Committee’s mandate, scope, objectives, and the roles and responsibilities of its members. The Committee proactively established criteria to assess accommodation requests in a consistent manner and formulate recommendations to support managers’ decisions. The time it took for the Committee to develop criteria did however slow the initial communications with managers.
OGD comparison:
TBS: Set up a committee with a documented ToR.
ECCC: Established a Human Resources Expert Review Committee comprised of HR management without a formally documented ToR; however, a guide was developed by HR outlining the responsibilities and operation of this committee.
PSPC: Its audit did not review the senior-level committee and only reviewed the vaccination verification process.
Consideration:
In the future, when establishing a committee, develop a ToR that sets out the mandate, objectives and members’ specific roles and responsibilities, including communication protocols and standards to support the committee’s effective and efficient operations and help manage employees’ and managers’ expectations.
2. Governance: roles and responsibilities
Context:
The OCHRO guidance did not provide guidance on whether a committee should be put in place to support reviewing accommodation requests. TC, like some other departments, decided to establish a senior-level committee to ensure consistent review of accommodation requests and to assist managers in making decisions.
Observation:
The roles and responsibilities of Committee members were not documented to clarify the role of advisors versus decision-makers. It is a good governance practice to define and document roles and responsibilities.
OGD comparison:
TBS: Roles and responsibilities for employees, managers, Labour Relations and review committee members involved in the process were defined, documented, and communicated.
ECCC: Roles and responsibilities were defined, documented, and communicated. The procedures developed by HR to guide the management of accommodation requests outlined the responsibilities and operation of the committee. A lawyer from the Centre of Expertise for Labour and Employment Law at Justice Canada was part of the committee to provide legal advice.
PSPC: Its audit did not review the committee.
Consideration:
In the future, defining members’ roles and responsibilities would help clarify accountabilities (decision-making) versus advisory responsibilities.
3. Guidance
Context:
OCHRO developed a manager's toolkit to assist departments with employee vaccination requirements. The Policy “Reference” section includes other legislation, related policy instruments, and other information (e.g., Directive on the Duty to Accommodate and Framework for implementation of the Policy). OCHRO did not provide specific advice or guidance on whether departments should form “Review Committees” to assist managers in making accommodation request decisions and it was left to departments to establish criteria for assessing accommodation requests.
Observation:
TC’s HR developed and communicated additional guidance to assist management in implementing the Policy, including letter templates for managers to communicate the Committee’s recommendations on the accommodation requests. TC’s HR supported managers with presentations to educate them on their roles and responsibilities regarding employees requesting accommodations. TC also contributed to the larger government exercise by proactively sharing their internal tool sets, for example, the FlexiDesk work app which was then rolled out to various other departments.
OGD comparison:
TBS: The information and activity requirements to support the request for accommodation process were defined and communicated.
ECCC: Their review found that the procedures for administering the accommodation requests, according to the Policy requirements, were appropriately developed and communicated. HR developed additional internal procedures and template letters to assist managers in communicating the accommodation decision. A list of established criteria for the different types of accommodation requests was developed.
PSPC: Operational processes and procedures for vaccination attestations, the duty to accommodate, leave without pay, and return to work from leave were appropriately designed, documented, reviewed, and approved by branch senior management.
Consideration:
In the future, when faced with similar quickly evolving situations, the Department should keep in mind that it might have to operate in the absence of central agency direction, and it should remain prepared to develop processes and take actions to address the situation. The risks of taking actions that are not aligned with eventual central agency direction must also continue to be considered.
4. Monitoring and reporting
Context:
Various HR teams worked together to extract data from GC-VATS and integrate it with other HR systems / tools to monitor and report vaccination status, accommodation requests, and data related to leave without pay (LWOP). HR manually entered vaccination-related information into Excel tracking sheets. Employees were assigned a case number to protect their privacy.
Observation:
Vaccination status tracking and reporting: Information on employee vaccination status and accommodation requests was extracted from GC-VATS. A daily report was sent to the HR Director General and a weekly report was sent to senior management.
Accommodation request tracking: HR used an Excel spreadsheet to manually track requests for accommodation and the recommendation status after the review of the Committee; however, the document reviewed by the Internal Audit team contained incomplete entries and was not up to date, making it difficult to see the entire history of a case from beginning to end.
LWOP tracking: HR used Excel to manually track employees placed on LWOP and when they were reinstated. The document reviewed by the Internal Audit team was not complete and up to date.
OGD comparison:
TBS: A tracker was developed by HR to track accommodation requests.
ECCC: The HR Branch developed, maintained and updated a tracker for all duty to accommodate requests. All accommodation requests had complete files for committee review, but only 39% had the full documents for communicating the results of committee recommendations (emails, letters, etc.).
PSPC: The Phase 1 Report reviewed did not cover monitoring and reporting.
Consideration:
Implement a systematic and well-documented approach for creating and maintaining records, such as standard operating procedures or guidance, to help ensure that information and documents are complete, accurate and up to date, and that they are retained as required.
5. Information management
Context:
TC HR implemented several information management practices to protect the personal and sensitive information related to the Policy implementation of persons on LWOP and persons seeking accommodations.
Observation:
HR assigned case numbers instead of employee names for accommodation requests and utilized a secure inbox for communication.
The TC Access to Information team modified its process for handling requests during the COVID-19 pandemic to digitize part of the ATIP process ‒‒ in response to a request, Offices of Primary Interest sent documents to the ATIP office by email instead of sending hard copies by internal mail. The COVID-19 related information was processed in the same manner as other equivalently classified departmental information.
OGD comparison:
TBS: Assigned numbers to cases. Records supporting accommodation requests activities were kept in a personal email account (only transferred to GCdocs following its audit team’s request for access to the information).
ECCC: Case numbers were used for reporting.
Consideration:
The Department should continue to adhere to established information management protocols when it faces similar situations in the future (versus creating different processes, for example).
Conclusions
Overall, the Department quickly mobilized to implement the Policy and had to act sometimes in the absence of central agency direction. Some of the key processes put in place were:
- A monitoring framework to verify the proof of employees’ vaccination attestations.
- A senior-level committee and criteria to review accommodation requests to help ensure fair and consistent treatment and support managers’ decision-making.
The Review also identified some lessons the Department should apply in preparation for future similar events:
- When forming a review or other committee, create formal Terms of Reference with well-defined roles and responsibilities, including communication protocols.
- Implement a systematic approach to the collection and management of data to help ensure accurate and comprehensive monitoring and reporting.
Annex A – Treasury Board policy suite
Annex B – Other government departments / agencies related work
Treasury Board of Canada Secretariat (TBS) ‒ Audit of Duty to Accommodate for COVID-19 Vaccination
Note: Phase 1 was to address documentation and communication, and Phase 2 will address the implementation of the Policy. At the time of this Review, the team had not seen the publication of Phase 2.