Performance Assurance

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AUDIT OF ASSISTANCE TO EMPLOYEES

Internal Audit Branch
378-1-235
Approved by Audit Committee
January 31, 2008

PDF 468kb

TABLE OF CONTENTS

Annex A - Audit Objectives and Criteria

Annex B - Location of Site Visits

Annex C - Management Action Plan

EXECUTIVE SUMMARY

As in all organizations, the employees of the Correctional Service of Canada (CSC) are subject to stressors associated with the work environment and their personal lives. As noted in the CSC Strategic Plan for Human Resource Management, however, there exists an inherent stress associated with working in a correctional environment which has resulted in CSC employees experiencing a higher level of stress on the Business Health Culture Index scale than other public servants1.

The CSC currently employs approximately 14,500 staff2. Two occupational groups represent over half of all staff employed in operational units. The correctional officer/primary worker group (CX) comprises 41% of staff, while another 13% of staff are employed in the group that includes parole and program officers (WP) working in the institutions and in the community. In an effort to create a work environment that is healthy and safe for its employees, CSC has implemented three programs to help employees deal with stress and to aid in their return to work following an extended period of absence: the Employee Assistance Program (EAP), the Critical Incident Stress Management (CISM) program and the Return to Work (RTW) program. Use of these three programs can be seen across the Service. In 2004-05, 18% of employees used EAP for the first time and peer helpers held 202 CISM debriefing sessions with 1714 employees3. In 2006-2007, CSC managed 800 RTW cases across the country4.

The objectives established for this audit were as follows:

  • To assess the extent to which a management framework for EAP, CISM and RTW is in place and meets CSC’s needs;
  • To assess the extent to which the EAP and CISM activities and practices comply with policy requirements; and
  • To assess the extent to which RTW activities and practices comply with policy requirements.

In order to conclude on these objectives, we reviewed the overall framework for EAP, CISM and RTW. We reviewed key documentation, examined processes, procedures and databases and carried out visual inspections. In addition, a total of 256 interviews were conducted with national, regional and local coordinators for the three programs, EAP referral agents, CISM peer helpers, advisory committee members (management and union) and a selection of managers.

Overall Conclusion

The results of the audit indicate that key elements of a management framework are in place for EAP and CISM, and CSC is in compliance with the legislative and policy requirements for both programs. We found a high level of support and awareness for the two programs, due in large part to the efforts of dedicated employees who, for the most part, contribute to the programs on their own time. While there is room for improvement in some areas, policies are in place, roles and responsibilities are clearly defined and understood, resources are in place at the local, regional and national levels, training is being provided, the programs are being actively promoted and some monitoring and reporting activities are in place.

CSC’s Corporate Risk Profile has identified a risk of CSC not being able to improve the health of its workplace and that the implementation of a revised EAP framework would be an important mitigation factor. As such, in the Strategic Plan for Human Resource Management 2007-2008 to 2009-2010, the HRM Sector committed to updating the EAP Management Framework as well as establishing indicators to better meet the needs of employees. This audit showed that, in undertaking this work, continued attention is needed in the following areas:

  • Policies and guidelines require updating to reflect recent changes and current initiatives;
  • Role and mandate of EAP/CISM advisory committees at all levels needs to be reviewed and clarified;
  • Interaction between National EAP/CISM advisory committee and senior management should be greater and communications more frequent;
  • Recruitment of agents and helpers in community offices and at the managerial level needs to be improved;
  • Course curriculum and training materials for referral agents and peer helpers are required to ensure consistent training;
  • Training needs to be developed and implemented for coordinators and advisory committee members; and
  • Program monitoring needs to be strengthened to ensure that the current needs of employees are being met.

Action on the results of the audit should contribute to the realization of the objectives of the Strategic Plan for Human Resource Management.

With respect to the RTW program, we found the current management framework to be inadequate. Policies and guidelines are outdated and/or incomplete, roles and responsibilities are not clear, proper standard training is lacking and performance monitoring is weak. In the Strategic Plan for Human Resource Management, 2007-2008 to 2009-2010, CSC made a commitment to a more proactive approach to the RTW program, allowing for greater accessibility to the program as well as relevant placements within and outside the department. This audit showed that in order to support this proactive approach, the following areas require significant improvement:

  • The policy and guidelines need to be updated and clarified, and need to include the roles and responsibilities that are currently missing from the guidelines;
  • Roles and responsibilities for the Advisory Committees at all levels need to be clarified;
  • Training should be developed and provided to local and regional coordinators, and consideration should be given to the provision of training/awareness for new RTW committee members; and
  • Performance monitoring needs to be strengthened.
  • Guidance should be provided on the need to collect and maintain necessary information on all RTW files.

In addition, the audit found that there are currently no national guidelines, tools or procedures to ensure that consistent information is gathered, documented and maintained on RTW files. More guidance is required relating to the need to collect and maintain necessary information for all RTW cases. In the absence of clear direction, many files reviewed were missing sufficient documentation to establish basic information about the case, to follow its progress, or to assess compliance. Nonetheless, our interviews with managers and coordinators showed that both groups understood the importance of and the process that must be followed in the RTW program. However, we could find little evidence to support that RTW cases are being managed in compliance with CSC policy.

Recommendations have been made in the report to address these areas for improvement. Management has reviewed and agrees with the findings contained in this report and a Management Action Plan has been developed to address the recommendations (see Annex C).

1.0 INTRODUCTION

As in all organizations, the employees of the Correctional Service of Canada (CSC) are subject to stressors associated with the work environment and their personal lives. As noted in the CSC Strategic Plan for Human Resource Management, there exists an inherent stress associated with working in a correctional environment which has resulted in CSC employees experiencing a higher level of stress on the Business Health Culture Index scale than other public servants5.

The CSC currently employs approximately 14,500 staff6. Two occupational groups represent over half of all staff employed in operational units. The correctional officer/primary worker group (CX) comprises 41% of staff, while another 13% of staff are employed in the group that includes parole and program officers (WP) working in the institutions and in the community. In an effort to create a work environment that is healthy and safe for its employees, CSC has implemented three programs to help employees deal with stress and to aid in their return to work following an extended period of absence, namely the Employee Assistance Program (EAP), the Critical Incident Stress Management (CISM) program and the Return to Work (RTW) program.

All three programs have permanent positions staffed at the national and regional levels to oversee activities. At the local level, the EAP and CISM programs are based on a peer referral model that relies on employees who volunteer to take on the role of referral agent and/or peer helper in addition to their regular duties. With respect to RTW, at the local level one person coordinates RTW cases7 and this individual normally manages other program responsibilities associated with HRM.

The following is a synopsis of the three programs:

1.1 Employee Assistance Program (EAP)

On May 29, 1995 the Treasury Board Secretariat of Canada (TBS) issued the EAP policy. The objective of the policy is to “foster and maintain the well-being and productivity of employees by providing confidential assistance or short-term counselling to those who are experiencing personal or work-related problems”8. CSC has supplemented the TBS policy with Commissioner’s Directive (CD) 253, Employee Assistance Program and Guidelines 253-1, Employee Assistance Program. These policies further encourage employees to voluntarily seek assistance through EAP referral agents who are located in the workplace. Referral agents at each site provide employees with confidential referrals to a wide variety of professionals, services, or agencies in the community. Through EAP, employees can receive help on numerous topics including, but not limited to: gambling addiction, alcohol and drug addiction, financial issues and marital/family issues.

Organizationally, EAP falls under the responsibility of the HRM Sector within CSC. There are six dedicated full-time employees assigned to EAP, including a national coordinator along with five regional coordinators.

A fundamental tenet of the EAP involves employee confidentiality. Referral agents must keep referrals strictly confidential in order to protect the integrity of the program. For this reason, CSC only gathers generic statistical information for program reporting purposes. These statistics are reported to TBS once every two years, with the most recent report covering the period of 2003-2004 and 2004-20059. For 2004-2005, CSC reported that 2863 employees used the EAP for the first time. This represented a small increase from 2003-2004, when 2804 employees accessed the service for the first time.

Prior to June 2007, the only funding allocated to EAP/CISM was for one national and five regional program coordinator positions. In 2007, the program has received $1.3 million to fund contracting for external counselling services, program awareness and promotion. These resources are to be divided among the regions on a per capita basis. To ensure that the new funding is appropriately allocated, CSC plans to develop monitoring and reporting mechanisms during 2007-2008 to track and analyze program performance.

1.2 Critical Incident Stress Management (CISM)

CISM provides services to employees who have been involved in critical incidents due to the nature of their work. CISM also provides education and awareness sessions to help employees prepare to deal with the potential hazards of being exposed to stressful events.

Central agency direction regarding CISM is found in the TBS Employee Assistance Program policy, which requires that “where employees are likely to be involved in critical incidents because of the nature of their work, a procedure is established to provide an initial stress debriefing session as soon as possible after such an incident and EAP follow-up if required”10.

CSC’s policy framework for CISM is found in CD 253, Employee Assistance Program, and Guideline 253-2, Critical Incident Stress Management. Following a critical incident in the workplace, a team of CISM peer helpers and, depending upon the severity of the incident, mental health professionals, gather to offer services to employees who may have been affected by the incident. Sessions are provided either individually or in a group setting. It is important to note that CISM does not offer specific mental health counselling of any kind. During the CISM intervention, the CISM team gives the affected employee(s) information about the incident, the different physical and mental reactions that can be expected following a critical incident and a reminder that EAP is available if needed.

Organizationally, CISM falls under the responsibility of the HRM Sector within CSC. The six EAP coordinators discussed in the previous section are also responsible for managing the CISM program. Regional and local management teams are responsible for ensuring that employees involved in critical incidents are quickly identified, informed about services available and offered prompt access to program services to help prevent or reduce harmful stress or reactions. There are also volunteer peer helpers in all sites across CSC.

As with EAP, a fundamental tenet of CISM involves employee confidentiality. For that reason, CSC only gathers generic statistical information for program monitoring purposes. As in the case of EAP, TBS policy requires departments to report on a bi-annual basis, and CSC’s most recent report covers the period of 2003-2004 to 2004-2005.

For 2004-2005, CSC reported to TBS that it had conducted 113 Critical Incident Stress awareness sessions that included 719 participants; an increase from 2003-2004 when 65 Critical Incident Stress awareness sessions were conducted that included 679 participants. In addition, 202 post critical incident debriefing sessions were held in 2004-2005 that involved 1714 employees; an increase from 90 post critical incident debriefing sessions involving 1460 employees in 2003-2004.

There is no specific budget allocated to CISM activities or for promotion of the program. Funding for the CISM program is included in the budget for EAP or, in some cases, is supplemented by additional local resources. As there is a National Training Standard associated with CISM, training costs are covered by the operational units.

1.3 Return to Work (RTW)

Another significant CSC policy designed to promote the health and well-being of employees is CD 254, Occupational Safety and Health and Return to Work Programs and Guideline 254-2, Return to Work Program. This guideline gives direction regarding CSC’s requirement to provide employees who have incurred injury or illness with assistance and support in their return to work.

There is no specific central agency policy that addresses Return to Work; however, TBS does have a policy on the Duty to Accommodate Persons with Disabilities which may apply in some cases. Other relevant authorities include the Workers’ Compensation Boards (WCBs) which are provincial organizations that provide compensation to employees who sustain injuries or illness while on the job. There are also disability insurance companies which provide support to employees who become ill or injured while away from the workplace.

The RTW program falls under the responsibility of the Labour Relations Branch of the HRM Sector at National Headquarters (NHQ). The guidelines outline the responsibilities of the Assistant Commissioner Human Resource Management (ACHRM), Regional Deputy Commissioners (RDC), Regional RTW Advisors, managers, supervisors, unions, the injured or ill employee, treating practitioners and the WCBs. Additionally, there is a provision about the role of disability insurance companies, specifically Sun Life and National Life.

For fiscal year 2006-2007, there were over 800 active RTW cases11. For the same year, CSC was invoiced all inclusive fees of $8.6 million by WCBs12, against a forecast of $10.1 million13. The forecast for WCB costs in 2007-08 is $11.3 million, an increase in forecast of $1.2 million from the previous year. In fact, WCB costs are forecasted to increase steadily into the foreseeable future. This projected trend is due to factors such as increasing number of cases, increasing health care costs as well as an aging workforce.

In June 2006, the Union of Canadian Correctional Officers (UCCO) signed the Global Agreement with the CSC. The agreement is specific to the CX group (which represents 41% of CSC’s workforce) and addresses how injury on duty and health and safety are to be managed as well as the requirements for reporting accidents, logging leave usage and WCB reporting requirements. As a result of the new agreement, the HRM Sector is currently revising the RTW policy and guidelines. At the time of the audit, an expected publication date for any revisions was not available.

2.0 AUDIT OBJECTIVES AND SCOPE

2.1 Audit Objectives

The audit objectives were:

  • To assess the extent to which a management framework for EAP, CISM and RTW is in place and meets CSC’s needs;
  • To assess the extent to which the EAP and CISM activities and practices comply with policy requirements; and
  • To assess the extent to which RTW activities and practices comply with policy requirements.

Specific criteria related to each of the objectives are included in Annex A.

2.2 Audit Scope

The audit was national in scope and included an examination of the EAP, CISM and RTW services provided to CSC employees. The audit involved visits to: NHQ; the five Regional Headquarters (RHQ); institutions at the maximum, medium and minimum security levels; and district and area parole offices. Site visits also included the Special Handling Unit (SHU) as well as a number of regional psychiatric/treatment centers. The period of coverage for the audit included activities and services relating to the EAP, CISM and RTW programs between April 1, 2006 and March 31, 2007.

It should be noted that work conducted at NHQ looked at the functional leadership provided by the Human Resource Management Sector (NHQ) as well as at a regional level (NCR). In those areas throughout the report that refer to six regions, the NCR represents the sixth.

Excluded from the audit were the following:

  • EAP services provided to the families of CSC employees, as well as CISM services offered to offenders and the families of offenders (given that the purpose of the audit was Assistance to Employees); and
  • A review of Occupational Health and Safety, including investigation, recording and tracking of employee accidents, as this was included as part of the audit of Occupational Safety and Health conducted in 2005-200614.

2 Ibid.

3 Public Service Employee Assistance Program Activities, CSC’s Report to TBS, 2004-2005

4 National RTW Roll-up, April 2006-March 2007. Human Resource Management Sector, Working Document

6 Ibid.

7 The exception to this structure is found in the Atlantic Region where the Regional Coordinator handles all cases for the region.

9 At the time of the audit, the TBS report for 2005-2006 and 2006-2007 had not yet been completed. It is expected to be submitted prior to the end of fiscal year 2007-2008.

11 National RTW Roll-up, April 2006-March 2007. Human Resource Management Sector, Working Document

12 WCB Costs 2006-2007, All Four Quarters by Institution. Human Resource Management Sector, Woking Document

13 WCB Report by Years with Forecasts to 2011-2012, Human Resource Management Sector Woking Document

 

3.0 AUDIT APPROACH AND METHODOLOGY

Audit work included a review of the overall framework for EAP, CISM and RTW. We reviewed key documentation, examined processes, procedures and databases and carried out visual inspections. In addition, a total of 256 interviews were conducted with national, regional and local coordinators for the three programs, EAP referral agents, CISM peer helpers, advisory committee members (management and union) and a selection of managers.

Table 1 identifies the number of interviews conducted by program type and by region:

Table 1 - Number of Interviews Conducted Regionally by Program Type
Region EAP/CISM RTW All 3 Programs (Selected Managers) Total
NHQ/NCR 7 4 3 14
Atlantic 27 5 8 40
Québec 17 13 7 37
Ontario 34 15 13 62
Prairies 32 12 15 59
Pacific 26 10 8 44
Total 143 59 54 256

In addition, the audit team conducted brief interviews with 99 randomly selected employees from various occupational groups (correctional officers, other operations, administration, management, etc.) in order to assess their level of awareness of EAP and CISM and the willingness of employees to contact EAP referral agents if the need arose.

Fourteen institutions and district offices were selected based on having the highest proportion of return to work cases. These 14 sites formed the initial basis for our site visits for all three programs (EAP, CISM and RTW). During our risk assessment process, interviews with Regional EAP/CISM coordinators identified the SHU as well as each of the regional psychiatric/treatment centres as institutions where there may be an increased need for EAP and CISM due to the operational environment. As a result, the SHU and four regional psychiatric/treatment centres were added to the site selection. Finally, the audit team conducted audit work at each of the five RHQs and NHQ. A full list of the sites visited in each region can be found in Annex B.

Table 2 - Number of RTW Files Reviewed
Region # of Files Reviewed
NHQ 7
Atlantic 12
Québec 25
Ontario 35
Prairies 38
Pacific 20
TOTAL 137

At each of the sites visited, a sample of return to work files was examined.  Table 2 identifies the total number of files reviewed by region. We reviewed 17% (137 files) of the approximate 800 RTW cases being managed in 2006-2007.

Upon completing the site visits, the team held regional exit meetings to debrief senior management on relevant findings. In addition, a debriefing was held at NHQ with the ACHRM.

 

4.0 AUDIT FINDINGS AND RECOMMENDATIONS

Employee Assistance Program and Critical Incident Stress Management

4.1 Management Framework for EAP and CISM

We assessed the extent to which an appropriate management framework for EAP and CISM is in place. This included a review of directives and guidelines, organizational structure, roles and responsibilities and training statistics, curriculum and course material. We also reviewed the promotional activities taking place for EAP and CISM, as well as the reporting and monitoring mechanisms for both programs.

4.1.1 Policy Framework

We expected to find that CSC’s directives and guidelines are up-to-date with respect to EAP and CISM. We also expected that the EAP and CISM policies and guidelines are consistent with relevant TBS policies and other governing authorities such as the Privacy Act and Official Languages Act.

CSC’s current policies and guidelines for EAP and CISM are consistent with relevant TBS policy and other governing authorities; however, they require updating.

Our comparison of CSC’s relevant CDs and guidelines with the TBS policy, Employee Assistance Program, did not find any inconsistencies. CSC’s policies are also consistent with the requirements contained in the Privacy Act and the Official Languages Act.

The EAP and CISM policy and guidelines, dated 2002-05-13, contain key program information. However, they require updating to reflect changes in the programs since 2002. For example, the recent increase that CSC made in the number of short-term counselling sessions available to all CSC employees is not reflected in the guidelines for EAP. Also, with respect to the CISM guidelines, in May 2006 a Board of Investigation report recommended that NHQ review the CISM guidelines to more accurately reflect the true need for the program in community operations. NHQ accepted this recommendation (and issued interim guidance to the regions via email), but the CISM guidelines have not yet been updated in this regard.

For CISM, the definition of a “critical incident” needs to be clarified.

The audit identified an issue with respect to the definition of a “critical incident”. Though we found that the CISM guidelines contain a comprehensive list of circumstances where CISM is to be invoked, the paragraph leaves room for interpretation. In 24% (19/80) of interviews with staff who play a role in the CISM program, interviewees noted that what may be perceived as a “critical incident” by some may not be seen as meriting a CISM intervention by others. For example, different experiences of staff members and different operational settings may influence whether a supervisor or manager calls for CISM, or whether EAP services are used. Some staff believe that an over-reliance is being placed on addressing stressful incidents through CISM when the promotion of EAP may be a more appropriate response.

4.1.2 Organizational Structure and Roles and Responsibilities

We expected to find that CSC’s organizational structure as well as roles and responsibilities for EAP and CISM are clearly defined, documented and understood.

With the exception of the advisory committees, the organizational structure and roles and responsibilities for EAP and CISM are defined, documented and understood by employees.

A review of EAP and CISM policy documents shows that the organizational structures for the two programs have been defined and documented. According to the guidelines, the EAP and CISM programs are required to have national and regional coordinators and EAP referral agents and CISM peer helpers at each site. Additionally, national, regional and local advisory committees must be established, which include representation from both management and the unions. The guidelines also outline roles and responsibilities for each of the key program participants. Interviews with the program participants indicate that they understand the organizational structure and their roles and responsiblities related to EAP and CISM, with the exception of the advisory committees as noted below.

There is limited evidence of action taken to resolve issues raised during National EAP/CISM Advisory Committee meetings.

According to the CD on EAP, a National EAP/CISM Advisory Committee is in place to oversee the departmental programs and provide advice and guidance to the CSC Executive Committee (EXCOM) regarding the national management of the EAP and CISM programs. Given this requirement, we reviewed meeting minutes of the National EAP/CISM Advisory Committee dating back to 2005 to find evidence of program oversight. We noted that the committee meets once each fiscal year. At each meeting, the main issues discussed included the development of a Terms of Reference for the committee itself, the budget for EAP/CISM and the need to update the policy guidelines for the programs. The minutes also reflect discussion surrounding the need to develop resource indicators for the program to ensure consistent application in the level of service to employees across the country. Our interview with the National Coordinator confirms that currently the budget issues have been resolved, and all other issues remain outstanding.

Limited advice and guidance on the EAP/CISM programs has been provided to senior management committees.

We also examined the EXCOM minutes for the past two years, expecting to see that the Advisory Committee has provided some advice and guidance on the EAP/CISM programs. At no time did the EXCOM minutes reviewed note that there had been a presentation on, or discussion surrounding, the programs. We do note that compliance with CISM policy is discussed at EXCOM in the context of investigations; however this does not address the management of the program, and does not constitute advice or guidance from the National EAP/CISM Advisory Committee. During our interview with the National EAP/CISM Coordinator, we also noted that the results of investigations are not shared with the National Coordinator, and therefore cannot be taken into account by the Advisory Committee.

We further reviewed the minutes for the National Human Resources Management Committee (NHRMC). Though this subcommittee of EXCOM had not been created when the EAP and CISM policies were last promulgated, we reviewed the past two years of minutes, again looking for advice and guidance received from the National EAP/CISM Advisory Committee. We found two references made to EAP in the meeting minutes for 2007. Discussions focused on the additional funding being allocated to the EAP/CISM program, as well as the need to develop program indicators to ensure consistent application of the programs across the country. We could find no further evidence of presentations being made to the senior management committees regarding the EAP and CISM programs.

Senior management committees have paid little attention to the management of the EAP and CISM programs.

CSC’s Corporate Risk Profile has identified that there is a risk that: “CSC will not be able to improve the health of its workplace”15. Specifically, the Risk Profile notes as a source of risk that the: “EAP Management framework is not responsive to the inherent and elevated stress in most CSC environments”16. One of the mitigation factors recommended is to “implement a revised EAP framework”. Given the above, the fact that EXCOM recognizes the risk and that the CD specifies that the Committee is to provide advice and guidance to EXCOM, we expected our review of minutes from the senior management committees to show discussions surrounding possible solutions to alleviate this risk. As indicated above, our review has found some discussions surrounding budget, but no other aspect of the management framework has been reviewed by the senior management committees. Finally, as we will discuss in section 4.1.5, there is little performance information available, with the result that this type of information cannot be discussed at the senior management committee level.

With the exception of Ontario, all regions have an active EAP/CISM Advisory Committee in place.

Five of the six regions (Atlantic, Québec, Prairies, Pacific and the NCR) have an active regional EAP/CISM advisory committee that provides direction and support. Minutes are recorded and are made available throughout the region. The issues usually discussed at these meetings include the budget for the program, training for referral agents and peer helpers and promotional activities to take place in the region during the year. We could find no evidence in any of the minutes we reviewed that the committee in the NCR discussed CISM issues, though it is noted that CISM is rarely invoked at the national level. We note too that while the Ontario region had a regional EAP/CISM committee, it has been inactive since 2005.

In half of the local sites visited, there were no Advisory Committees established.

Table 3 - EAP and CISM Advisory Committees by Region
Region Total Local Facilities Visited # with EAP Committee # with CISM Committee
Atlantic 3 3 1
Québec 3 0 0
Ontario 5 2 1
Prairies 3 2 1
Pacific 3 1 1
Total 17 8 4

Policy further requires that each site must have a local EAP and CISM advisory committee. As noted in Table 3, less than half of the sites visited had an active EAP committee in place and less than a quarter of them had an active CISM committee. Where they exist, these committees support and promote the program, primarily through staff awareness initiatives. Interviews revealed, however, that many committee members were not clear about their roles and responsibilities or the purpose of the committees. Rather than having a formal committee structure in place, a few sites were conducting regular team meetings composed of all referral agents and/or peer helpers. Some sites without an active committee did not see the added value of having one. Given the number of sites without Committees, there is a need to assess the Committee structure and what role they play at the institutional level.

Recruitment of Referral Agents and Peer Helpers

CSC is experiencing challenges in recruiting referral agents and peers helpers at the community level and at the managerial level.

At the local levels, both the EAP and CISM programs are based upon a voluntary peer referral model. Ensuring that there are sufficient trained and accessible referral agents and peer helpers available to assist in a timely manner is essential to the success of the two programs. We confirmed that efforts are made to recruit, train and retain a cross section of employees representing large organizational groups such as Correctional Officers (CX), Parole Officers (WP) and Administrative or Clerical Services (AS and CR). However, we identified some limitations, including:

Good Practice

In the Prairie region, the Regional EAP/CISM coordinator holds ceremonies where she presents awards, such as certificates, to referral agents and peer helpers who have worked with the program for a certain amount of time to acknowledge their contribution to the wellbeing of their colleagues’.

  • Two of the four community offices included in the audit indicated that they have experienced difficulty recruiting referral agents and/or peer helpers as employees feel that they have no time to take on the additional responsibilities. In the institutions, this concern about workload was also prevalent among people in positions such as Parole Officers and administrative staff, whose workload remains the same regardless of EAP/CISM duties;
  • Interviewees in four of the six regions indicated that there is a need to recruit referral agents and peer helpers at the supervisor/manager level. Though these interviewees believed that managers would not feel comfortable going to a subordinate with EAP related issues, few of the sites visited had managers/supervisors included in their list of referral agents and peer helpers. As such, the programs may not be meeting the needs of managers; and
  • The issue of “compassion fatigue” or “burnout” was also raised as a concern at the local, regional and national levels in regard to having a sufficient number of referral agents and peer helpers. At some facilities (such as the SHU and RPCs), referral agents and peer helpers are called upon more frequently to assume additional duties above and beyond their substantive positions.
4.1.3 Training

We expected to find that training is being provided in accordance with the National Training Standard and is sufficient to allow key program staff to understand and fulfill their roles and responsibilities.

The majority of EAP referral agents and CISM peer helpers are receiving initial and annual refresher training. However, training provided is not consistent across regions and training material is outdated.

We reviewed the Human Resource Management System (HRMS) training records for 76 of the EAP referral agents and CISM peer helpers interviewed and found that 83% (35/42) of referral agents and 97% (33/34) of peer helpers had participated in the required initial training. In the eight cases where there was no initial training record found in HRMS, our interview notes indicate that all but one of those employees had been volunteers for more than eleven years and had received initial training prior to 1996. Training records were not captured in HRMS until after 1996.

A further review of training records for 2006-2007 shows that 62% (26/42) of referral agents and 68% (23/34) of peer helpers interviewed received refresher training in 2006-200717. Further verification showed that approximately 50% of referral agents (8/16) and peer helpers (5/11) who did not receive refresher training in 2006-2007 received it within the first three months of the new fiscal year.

Though training is being provided, there is no corporately-developed course curriculum for the initial training of referral agents or peer helpers. The few national training materials that do exist (e.g., Referral Agent Basic Course Pre-Reading Material, Trainers Notes for EAP Advanced Course for Referral Agents and CISM Manual for the Trainer) date back to the early 1990s. According to interviews with the regional coordinators, they have not been given any guidance regarding what must be included in initial training. This may have resulted in inconsistent training being delivered across the country and also poses the risk that inaccurate or irrelevant information may be being taught to new referral agents and peer helpers.

There is also no curriculum for refresher training. However, interviewees felt that this posed less of a risk to the EAP and CISM programs. Regional coordinators believe that they are able to identify trends, issues and concerns applicable to their region and in turn can best determine a training agenda that will benefit their referral agents and peer helpers.

It is noted that NHQ is currently examining the possibility of adapting a training package that has been developed by the Québec region and would be distributed nationally. Promulgation of consistent training material would assist the national and regional coordinators in effective delivery of these national programs.

There are no training requirements for EAP/CISM coordinators and advisory committee members.

Currently, the National Training Standards require that only EAP referral agents and CISM peer helpers take initial training prior to commencing their duties, with an annual refresher course thereafter. There is no National Training Standard or any other CSC training requirement for other key program participants such as the national, regional, or local EAP/CISM coordinators. As well, there are no training or orientation requirements for advisory committee members. Without national training expectations for key program participants, there is a risk that the program is being inconsistently or even incorrectly administered within CSC.

4.1.4 Program Promotion and Awareness

Without sufficient promotion and awareness of the EAP and CISM programs, employees may be unfamiliar with their existence and the scope of the services available. As a result, employees may not use the programs in times of need. We expected to find that, consistent with CSC’s policies, the EAP and CISM programs are being promoted at all levels of the organization in order to ensure employee awareness of how to access the programs and services available to them. This includes information to new employees as well as ongoing promotional activities.

The EAP and CISM programs are being promoted at the majority of sites visited. The additional funding allocated to each region earlier this year should further facilitate the promotion of these programs at all sites.

Throughout all regions, our interviews showed that the intent and context for the programs are generally well understood. There is overall acceptance of the programs by employees, management and unions.

With the exception of the sites visited in the Ontario region and the Montréal-Métro District Office, we found that the EAP and CISM programs were being promoted at all sites visited. The Atlantic, Prairie and Pacific regions conduct annual “EAP/CISM Weeks” to promote the programs and raise employee awareness. The Québec region sponsors a “Wellness Week”, which includes elements of EAP and CISM. Promotional activities include activities such as: information sessions, promotional material, guest speakers, employee breakfasts and barbeques; all of which are designed to raise employee support and awareness.

In interviews with the regional and local EAP/CISM coordinators throughout the Ontario region, we found that promotional activities have not been conducted due to the lack of dedicated funding allocated to the program. As of August 2007, a portion of the $1.3 million ($10.00 per employee or approximately $150,000 in total) in new funding has been allocated to the regions to cover promotional activities. The coordinators in the Ontario region stated that promotional activities will commence once these newly committed funds have been received. The Montreal District Office indicated that promotional activities have been restricted due to the geography of the region, the absence of a local coordinator and lack of sufficient team members to carry out activities.

Good Practice

Some institutions have dedicated space at their front entrance to display key information about the EAP and CISM programs, including the names and, in some cases, photos of referral agents and peer helpers.

We also walked around each of the sites visited and observed that each site had some type of mechanism in place to communicate the names and phone numbers of EAP referral agents and CISM peer helpers. In addition, all sites visited, except one, have the names and telephone numbers of referral agents and peer helpers listed on their regional and local websites. Additionally, the regional websites in the Atlantic, Québec, Prairies and Pacific regions contain information relating to the health and wellness of employees.

We interviewed randomly selected employees from various administrative and operational categories. Of the 99 employees interviewed, 94% (93/99) were aware of the EAP program and 75% (74/99) were aware of the CISM program. Of those employees who were unaware of the CISM program, 44 % (11/25) work at either RHQ or NHQ and are rarely exposed to incidents that require CISM intervention. Of those interviewed, 72% (71/99) indicated that they would feel comfortable contacting a referral agent in a time of need, which is a positive association for the program.  In terms of promotional activities, 65% (64/99) stated that they could remember recent EAP promotional activities. Although this number was significantly lower for CISM, we found that promotion of the CISM program is normally incorporated into EAP or health and wellness activities.

Another component of awareness examined included a review of the type of awareness or orientation that new staff receive regarding EAP/CISM. An examination of corporate documentation revealed that new correctional officers are required to take the Correctional Training Program (CTP) and all other new employees are required to take the New Employee Orientation Program (NEOP). For both of these courses, EAP and CISM are addressed in computer-based learning modules. Some sites have also developed new employee checklists that ensure sharing of information regarding the EAP and CISM programs. However, our interviews with employees showed that only 39% (23/59) who had been hired in the last 1-2 years stated that they remember being informed of the programs when they arrived.

Historically, EAP and CISM promotion and awareness initiatives have not been nationally funded. However, most regions and facilities have made some effort to promote the programs from within their own resource bases. The new funds that were recently committed to each region for the promotion of the EAP and CISM programs should result in all sites being able to promote these programs.

15 CSC Corporate Risk Profile Initial Risk List, November 2007

16 CSC Corporate Risk Profile Initial Risk List, November 2007

17 It should be noted that training activities were restricted from December 2006 to March 2007 due to Temporary Expenditure Reduction Measures across CSC.

 

4.1.5 Reporting and Monitoring

The EAP and CISM guidelines contain general statements about monitoring and reporting requirements. We expected to find monitoring and reporting mechanisms in place at the local, regional and national levels for both programs. As well, we expected that the information gathered is accurate and reliable. Finally, we expected to find that the corporate information can be used to support and improve program delivery.

Monitoring and reporting mechanisms are not sufficient and performance information from which to monitor EAP and CISM is very limited.

TBS policy on EAP and CISM requires that government departments report statistical information on a bi-annual basis. The EAP information reported to TBS includes information such as: the number of EAP personnel; the cost of external EAP services as well as the number of EAP information, education and supervisor training sessions conducted; the method and number of union and management consultations relating to EAP; advisory activities; and a summary of assessments, short-term counselling, referrals and follow-up services for clients. For CISM, TBS requires that CSC report on the number of Critical Incident Stress awareness sessions that take place and the number of post critical incident debriefing sessions.

The last bi-annual report on Public Service Employee Assistance Program Activities was presented to TBS for fiscal years 2003-2004 and 2004-2005. At the time of the audit, the report for 2005-2006 and 2006-2007 had not yet been completed. CSC is currently waiting for TBS direction as to when the next program performance report is due.

We noted that there is no established template and there are no clear definitions available for the regions to gather and report upon EAP and CISM program performance. Five of the six regions reported that they have developed their own templates to gather statistical data. The national and regional coordinators have expressed concern about the reliability of the information provided by the institutions/communities. The establishment of a national template, with clear definitions, would help ensure that consistent and comparable information is gathered and reported to TBS and NHQ by the regions. A consistent method of reporting would expedite the retrieval of information, clarify procedures used and address concerns about the reliability of the information collected.

We also found that not all of the referral agents maintain reliable statistics as required in Guidelines 253-1. Of the 49 referral agents interviewed, 22% (11) expressed concern about collection and submission of statistics. The reasons are varied, but are primarily related to the concern that keeping and reporting statistics would put the confidentiality of the programs at risk by identifying the reason for a consultation (family problems, addiction, etc.). Due to this resistance, some data are based on estimates (e.g., number and nature of contacts received).

Regional EAP coordinators indicated that the data collected are used at the regional level to determine topics for annual refresher training for EAP referral agents and CISM peer helpers. However, it is noted that the information submitted for the national roll-up to TBS is not used for any other monitoring, reporting, analysis, or tracking of trends at the national level. Furthermore, there is little information available on costs for these programs. As discussed under the section regarding Advisory Committees, we found little evidence of performance information being discussed at the National EAP/CISM Committee, and we found no evidence of performance information being presented or discussed in another National Committee setting. As there is no discussion surrounding the results, there is a missed opportunity to analyze trends and identify services required to ensure that the programs meet the needs of employees.

Conclusion:

CSC has established EAP and CISM programs that rely on a pool of active and committed employees who serve as peer helpers, referral agents and local coordinators on a volunteer basis. Furthermore, these employees often give their own time in order to meet with employees outside of the workplace when required (e.g., to ensure confidentiality or accommodate schedules). We found a high level of commitment to the programs by management and staff as well as a high level of awareness of the existence of the programs among staff. Employees in need of counseling have access to community resources in all regions.

The key elements of a management framework are in place for EAP and CISM. While there is room for improvement in some areas, policies are in place, roles and responsibilities are clearly defined and understood, resources are in place at the local, regional and national levels, most training is being provided, the programs are being actively promoted and some reporting activities are in place.

In the Strategic Plan for Human Resource Management 2007-2008 to 2009-2010, the HRM Sector committed to updating the EAP Management Framework as well as establishing indicators to better meet the needs of employees. Our audit showed that in undertaking this work, continued attention is needed in the following areas:

  • Policies and guidelines require updating to reflect recent changes and current initiatives;
  • Role and mandate of EAP/CISM advisory committees at all levels needs to be reviewed and clarified;
  • Interaction between National EAP/CISM advisory committee and senior management should be greater and communications more frequent;
  • Recruitment of agents and helpers in community offices and at the managerial level needs to be improved;
  • Course curriculum and training materials for referral agents and peer helpers are required to ensure consistent training;
  • Training needs to be developed and implemented for coordinators and advisory committee members; and
  • Program monitoring needs to be strengthened to ensure that the current needs of employees are being met.

Recommendation no 1: The Assistant Commissioner, Human Resources Management should strengthen the management framework for EAP and CISM, including:

  • Update the current policies on EAP and CISM to reflect recent changes and clarify the definition of a critical incident;
  • Clarify the policy as it relates to the role and mandate of advisory committees at all levels;
  • Improve interaction and communication between National EAP/CISM advisory committee and senior management;
  • Strengthen CSC’s ability to recruit referral agents and peer helpers in community offices and at the managerial level;
  • Implement a training curriculum for referral agents and peer helpers;
  • Develop and implement training requirements for coordinators and advisory committee members; and
  • Enhance the processes and procedures for monitoring and reporting the performance of the programs.

 

4.2 Compliance with Policy Requirements for EAP and CISM

We examined the extent to which the EAP and CISM activities and practices comply with TBS and CSC policy requirements. As previously noted, a major component of the EAP and CISM programs is confidentiality. In order to maintain confidentiality, no files are maintained on specific EAP or CISM cases. As such, the evidence in the following two sections relies on our interviews with staff and, with respect to CISM, a review of investigation reports.

4.2.1 EAP Compliance

We expected to find that EAP services are being provided in accordance with the requirements outlined in the TBS and CSC policies, in particular:

  • A response to a request for service occurs as soon as possible, preferably within one working day;
  • The first counseling session occurs within two weeks unless unforeseen circumstances arise;
  • The program normally offers up to three sessions for each new case;
  • Follow-up is conducted as an integral part of the EAP service;
  • EAP services are available in both official languages; and
  • Confidentiality and privacy of EAP information is maintained.

EAP services are being provided in accordance with TBS and CSC policies.

Based on interviews with 49 referral agents and EAP coordinators, we identified no significant issues with respect to employees being able to meet with referral agents within one working day or having access to their first counseling session within two weeks of being referred. The element of confidentiality is well understood and respected and bilingual referral agents are available where required.

Although not all contacts with referral agents result in a referral to external counseling services, this is a key component of the program in some cases. According to TBS policy, the EAP program normally offers up to three paid sessions for each new case. At the time of the site visits, the number of paid counseling sessions for each new case varied between regions, ranging from one to eight. Following consultation with Health Canada, the HRM sector indicated that the community standard now offers between 5 and 12 sessions per case. As such, in August of 2007 NHQ allocated a portion of the $1.3 million of additional funding to each region and established direction regarding the number of paid sessions to allow employees to access up to 8 sessions, with more being available on a case-by-case basis.

With respect to follow-up and support, in all but a few cases, referral agents interviewed indicate that they conduct follow up with employees who are receptive to having the agent approach them following their initial contact. In addition, some employees who have sought EAP services take the initiative to follow-up with the referral agent themselves.

4.2.2 CISM Compliance

We expected to find that CISM services are provided in accordance with TBS and CSC policies. Following a critical incident, each site must be equipped to offer CISM services to the employees who were affected by the incident. This response must follow specific requirements outlined in Guideline 253-2. In particular:

  • Employees involved in critical incidents are quickly identified, informed of available services and offered prompt access to these services;
  • The need for CISM intervention is promptly identified and supported;
  • The impartiality of peer helpers providing CISM services is ensured; and
  • Confidentiality of information is maintained.

CISM services are being provided in accordance with TBS and CSC policies.

Interviews with 46 CISM peer helpers and coordinators indicate that there were no significant issues with respect to the prompt identification of need for CISM intervention, the identification of employees involved in a critical incident, and informing them of and offering CISM services. Following an incident, the manager responsible will supply the CISM team members with a list of employees who were on scene at the time of the incident. Other personnel who may have been affected by the incident are identified in a number of ways; for example, through informal enquiries and general communiqués. The CISM team decides on the most appropriate form of intervention (e.g., individual interventions, group debriefings, etc.) at which time employees are informed of the services available.

Good Practice

Pacific Institution /Regional Treatment Centre is in the process of assembling a “Go Kit” that will be used to help comfort those affected by critical incidents.

We also reviewed CSC’s National Investigation summary reports for 2005-2006 and 2006-2007 identifying where CISM compliance had been raised as an issue. We noted that of the 222 incidents investigated, only 11% (24/222) had identified CISM compliance as an issue. Of these, 19 cases related to CISM services not being offered to all employees involved in the incident, 2 instances involved services not offered at all, 2 instances involved CISM being offered in an inappropriate location and in 1 incident it was unclear as to who was responsible for identifying those involved in the incident. We concluded that compliance with processes and procedures is generally good.

When responding to an incident it is important that CISM team members do not have a conflict of interest in terms of providing CISM services to close family members or friends and that they themselves were not part of the incident. During our interviews with peer helpers, we found no issue with respect to team members maintaining their impartiality. In terms of confidentiality, we confirmed that CISM team leaders and peer helpers do not keep personal information regarding interventions conducted with employees who have accepted CISM services. The only information maintained includes the number of employees who were offered CISM services and the number of employees who attended the debriefing. The names of employees who use the CISM services are not kept at any time.

Conclusion:

EAP and CISM practices are in compliance with TBS and CSC requirements.

  • Employees have access to referral agents and counselling services;
  • Employees are offered CISM services promptly following a critical incident; and
  • Both EAP and CISM services are offered in a confidential manner and bilingual services are available when required.

Return to Work

4.3 Management Framework for the RTW Program

4.3.1 Policy Framework

We expected to find that CD 254, Occupational Safety and Health and Return to Work Programs and Guidelines 254-2, Return to Work are up-to-date and consistent with other relevant governing authorities such as the Privacy Act and Official Languages Act. We also expected to find that the policy and guidelines provide information on the organizational structure and the roles and responsibilities for the RTW process.

CSC’s RTW policies and guidelines need to be clarified and updated.

Our review of the policy framework showed that greater detail and clarity is required in the RTW guideline. Although the current guideline provides some information on topics such as responsibilities, leave types and the return to work plan, we found the document lacked clarity and completeness in terms of the overall RTW process and procedures.

  • RTW is a complex process involving injured and ill employees, CSC managers and staff and external participants such as insurance companies, provincial Worker’s Compensation Boards and treating practitioners. RTW also comprises many different elements such as claims and reporting, leave types and entitlements, accommodated work and ergonomics, the obligation to re-employ and the return to work process and plan. The current RTW guidelines lack clear direction regarding how the program is to be run at the national, regional, and local levels. For example, though local RTW coordinators exist in all but one region, the guidelines are silent on the scope of the roles and responsibilities of this position18;
  • The roles and responsibilities of the National RTW Coordinator have not been defined;
  • The RTW guideline does not mention the issue of RTW Advisory Committees at the national, regional and local levels. Although draft terms of reference have been issued from NHQ regarding committee structure, roles, responsiblities and mandates, this information needs to be formally incorporated into the RTW guideline in order to ensure that membership, roles and responsibilities are clearly defined and understood;
  • The guidelines contain some procedural and process information about RTW. However, almost all interviewees felt that more step-by-step processes and procedural information would be beneficial to those in the program;
  • The checklist for the return to work plan needs to be reviewed and updated. As will be discussed in section 4.4, because this issue remains outstanding, we have observed a number of compliance issues in the RTW program; and
  • In June 2006, CSC entered into a Global Agreement with UCCO which provides an outline of how injury-on-duty leave is to be managed for the CX group. The signing of the Global agreement has resulted in UCCO-SACC represented employees having entitlements for injury-on-duty leave benefits different from other CSC employees. This situation and other changes resulting from the Global Agreement have not yet been reflected in the CSC policies and guidelines.

Roles and responsibilities for the Advisory Committee are unclear and not well understood.

Though the roles and responsibilities for the positions named above have not been defined, the guidelines do outline responsibilities for the ACHRM, the RDC, regional RTW advisors, managers and supervisors, injured and/or ill employees, the respective unions, the treating practitioner and the respective WCBs. Once again, as stated above, though a draft terms of reference has been issued, our interviews with Advisory Committee members found that they are unclear about their roles and responsibilities with respect to the RTW program. Eleven of the 17 institutions and district offices visited had a RTW committee already in place, even though this is not formally required by policy. Three regions (Québec, Ontario and Prairies) had established regional RTW committees. Many committee members interviewed at both levels were unclear about their roles and responsibilities and whether the committees are intended to be decision-making bodies, or simply provide advice and guidance on RTW cases. Issues of privacy and confidentiality were raised in terms of what should be discussed at the committee meetings and how many people should be involved in the discussions. The issue of confidentiality as it relates to employees signing consent forms prior to their cases being discussed at the RTW Committee continues to be a major issue delaying the implementation of the committees.

As noted previously, in 2006-2007 the CSC had over 800 RTW cases with WCB costs totalling over $8.6 million (which is expected to increase in 2007-2008). A clear set of policies and guidelines for this program is imperative to ensure that employees are returned to work in a safe and timely manner with the least amount of expense to the Service.

4.3.2 Training

In order to run a successful RTW program, it is important that managers and staff responsible for the program have a good knowledge of the program. We expected to find that training is being provided to key staff members, and that the training is sufficient to allow key program staff to understand their roles and responsibilities.

There is no national training for the RTW program.

There are no National Training Standards, corporately-developed course curriculum or training material relating to the RTW program for the national, regional or local coordinators. It is noted that the RTW Guideline identifies the national and regional coordinators as experts responsible for providing advice and guidance to managers, supervisors and employees. In addition, local contacts have taken on the role of “experts” within institutions and community offices and are frequently called upon to provide advice and guidance to middle and senior managers as well as to the injured or ill employee. During interviews with RTW coordinators, the lack of training was consistently identified as an issue.

At this time, no training or awareness has been developed for RTW Advisory Committee members either. If the Committee members are also responsible for providing advice and guidance on the RTW program, it would be expected that awareness or training be offered to these staff members as well.

4.3.3 Monitoring and Reporting

We expected to find monitoring and reporting mechanisms in place at the local, regional and national levels for the RTW program, and that the program information gathered is used to support and improve program delivery.

Although some program performance information is being monitored and reported upon, mechanisms need to be improved.

There is no reporting requirement for RTW outside CSC. Within CSC, the local and regional levels report on the status of RTW cases to NHQ on a quarterly basis. The audit team reviewed the information submitted to the National Coordinator by the regions. We were advised by the Coordinator that this information is used to perform some trend analysis. For example, CSC is tracking the following:

  • quarterly WCB costs;
  • number of claims per year;
  • average number of days between the occurrence of an injury and the report to WCB;
  • types of accidents;
  • costs by type of accident;
  • total accidents by occupational group; and
  • different types of leave (number of employees certified sick leave over 30 days, injury-on-duty leave; sick leave without pay; active cases for return to work; RTW resolution when an employee returns to their substantive position; return to full-time work outside of CSC; and permanent accommodation.)

This information is reported to the National RTW Advisory Committee twice a year, and is used to understand program performance. However, based on our review of committee meeting minutes, it is not reported to EXCOM or the NHRMC.

We found that the monitoring and reporting framework for the RTW program also needs to be strengthened in the following areas:

  • An NHQ template exists which is used to track the number of current WCB, Disability Insurance (DI), long-term sick leave and accommodation cases. However, the template is frequently modified, with the result that consistent and comparable long-term data are limited. We note that in conjunction with the Prairie Region, NHQ is working to develop an automated reporting tool that can be used to gather relevant program data on which trend analysis will be done to allow for a more proactive approach to the RTW program; and
  • Nationally, the most commonly cited financial costs associated with RTW being tracked and reported upon are WCB costs. The audit team was advised that there are other program costs associated with RTW that are not tracked, including: accommodation costs for employees who return to work following an injury or illness (i.e., office equipment); re-training costs for employees who are able to return to work, but not to their substantive position; and backfilling of positions and overtime costs to fill vacancies when injured or ill employees are on sick leave.

CSC has some capacity to gather and report information relating to RTW cases and some trend analysis is being conducted. However, it is important that it further enhances its ability to monitor the RTW program’s performance.

Conclusion:

The current management framework for the RTW program is inadequate. In the Strategic Plan for Human Resource Management, 2007-2008 to 2009-2010, CSC made a commitment to a more proactive approach to the RTW program, allowing for greater accessibility to the program as well as relevant placements within and outside the department. Our audit showed that in order to support this approach, the program will require significant attention in the following areas:

  • The policy and guidelines need to be updated and clarified, and need to include the roles and responsibilities that are currently missing from the guidelines;
  • Roles and responsibilities for the Advisory Committees at all levels need to be clarified;
  • Training should be developed and provided to local and regional coordinators, and consideration should be given to the provision of training/awareness for new RTW committee members; and
  • Performance monitoring needs to be strengthened.

Strengthening the management framework for RTW will help CSC to better support employees in need of the program and to identify and address issues on a timely basis.

Recommendation no 2: The Assistant Commissioner, Human Resources Management should strengthen the management framework for RTW, including:

  • Update the current policy and guidelines on RTW to reflect recent changes and clarify issues raised in section 4.3.1;
  • Clarify the organizational structure and role and mandate of those involved in the RTW process, including RTW advisory committees;
  • Implement a training program for RTW coordinators and RTW Committee members; and
  • Strengthen program performance monitoring and reporting.

 

4.4 Compliance with Policy Requirements for RTW

We expected that the RTW program was being carried out in compliance with policy requirements. In particular:

  • Cases for UCCO-SACC represented employees are assessed against the criteria established in Bulletin #2006-05 as required;
  • A RTW plan has been established and the RTW file contains evidence of communications between the employee, employer and other parties as applicable;
  • Public Service Commission priority considerations are documented on file when applicable; and
  • Leave entitlements are being managed appropriately.

In order to assess the above criteria, we reviewed 137 RTW files across NHQ and the five regions and conducted interviews with managers and staff responsible for RTW cases.

Files generally lacked complete information, making assessment of compliance difficult.

In 17% (27/137) of the files reviewed we were unable to draw any conclusions regarding the four criteria under this section, as there was a complete lack of documentation on file to support that the case had been properly managed. In many of the remaining files reviewed, there were gaps in the information that made it difficult to follow the RTW process from the beginning through to its current status, making it difficult to assess compliance with some of the criteria under this objective. As indicated in section 4.3, the guidelines are out-of-date, the roles and responsibilities of key stakeholders are either not well defined or are not included in the RTW guidelines and there is no national training standard, course curriculum or training material available for those accountable and responsible for managing the RTW program. Despite the absence of these key program components, interviews with managers and staff revealed that efforts are being made to manage RTW cases effectively.

4.4.1 Application of Bulletin no. 2006-05 - Injury on duty leave

Following the signing of the Global Agreement between CSC and UCCO in June 2006, Bulletin no 2006-05 was issued explaining that the 130 day injury-on-duty leave restriction no longer applies to the CX group. We expected to find that all injury-on-duty cases for CXs had been assessed against the criteria outlined in the Bulletin.

There was a lack of evidence on the RTW files reviewed to demonstrate that the new criteria related to the CX group were being considered.

A total of 54 CX files were reviewed as part of our sample. In 10 of these files we could not determine what type of leave was used. Nineteen of the files were injury-on-duty cases. For these 19 cases, there was no evidence on file of any assessment against the criteria resulting from the Global Agreement. An additional 17 files reviewed did not contain adequate information to determine if the file pertained to a CX.


18 NHQ, Pacific, Prairies, Ontario and Québec have assigned someone on site (i.e., local) to oversee the coordination of RTW cases. In the Atlantic Region, this responsibility is managed from RHQ.

 

4.4.2 RTW Plan and Evidence of Communication

CSC’s RTW guideline requires that a return to work plan be created for each employee following an extended absence. This RTW plan must include:

  • The RTW occupation;
  • The activities to be undertaken to achieve re-employment;
  • Responsibilities of the parties in the return to work processes;
  • Specific time frames;
  • Who will do what and when; and
  • Comments, instructions or extra details.

The RTW plan can also be used to outline necessary steps for a gradual return to the pre-injury/ illness job. All parties involved in the process must sign the RTW plan. In addition, evidence of communication must be ongoing throughout the RTW process between the employee, the RTW coordinator, the manager, the supervisor and the disability insurance company and/or WCB as applicable. There may also be evidence of communication with the treating physician, depending on the circumstances surrounding the case. We expected to find that a RTW file contains the elements described above.

Most files reviewed did not contain completed RTW plans or evidence of adequate and ongoing communication.

Our review of RTW files indicates that the majority did not contain adequate evidence of a RTW plan or ongoing communication between all stakeholders in the RTW process. Less than half of the 137 RTW files contained any element of a RTW plan. In those files where partial RTW plans could be found, they were in the form of e-mails, in-house generated forms, and some used the RTW plans created by WCB. At no time did we find a RTW plan that meets all of the expected requirements as discussed above. With respect to adequate and ongoing communication, we again found less than half of the files contained sufficient documentation to support that communication is ongoing. Further enquiries regarding cases that contained limited documentation revealed that the information is often held in other types of HR and administrative files.

4.4.3 Public Service Commission Priority Considerations

Public Service Commission priority consideration is given in situations where an employee is deemed to be permanently disabled and, though able to return to work, cannot be returned to their substantive position. Employees in this situation may be placed on a priority listing with the Public Service Commission. Once listed, employees are prioritized to be appointed without competition to a position in the Public Service for which they meet the qualifications. In order to qualify for the priority listing, employees must be:

  • Deemed fit to return to work within 5 years of being declared disabled;
  • Unable to return to substantive position; and
  • Not able to be accommodated anywhere within the CSC.

In cases meeting this criterion, we expected evidence of Public Service Commission priority considerations on RTW files.

There was no evidence in the majority of the files reviewed that Public Service Commission priority entitlements are being considered.

Of the 62 cases that could have been applicable, 45% (28/62) contained insufficient information to draw any conclusions regarding a referral to the priority listing. In the 34 cases where we could determine that a referral was required, 62% (21/34) did not contain evidence on file of the priority consideration being made.

4.4.4 Leave Entitlements

When an employee is injured at work, he/she must use sick leave credits until the respective WCB approves the claim. Once the claim has been approved, the sick leave credits are to be reinstated and Injury on Duty Leave is granted. We reviewed both the RTW files and the Human Resources Management System (HRMS) records for all applicable cases to ensure these leave credits were properly recorded, usage tracked and credits granted.

No assurance can be given that leave entitlements are being properly managed.

The audit found that the files reviewed did not contain sufficient information concerning leave credits to determine if they are being properly recorded, usage is being tracked, or credits are reinstated where applicable. To supplement our file review, we conducted additional verifications on a small sample of files where we had evidence that an injury-on-duty had occurred and reviewed the leave records in HRMS. We found that it was still difficult to track whether leave credits were being properly managed. For example:

  • 8/15 leave records were miscoded as being illness/disability rather than injury on duty;
  • 2/15 injury-on-duty leave was granted but there was no record of sick leave being taken or reinstated; and
  • 5/15 cases had HRMS data fields that were not completed and therefore it could not be determined if the proper amount of injury-on-duty leave was credited.

The lack of information available in the HRMS leave module made it difficult to assess whether employee leave is being properly recorded, the usage tracked and necessary credits granted. Therefore no assurance can be given that leave is being properly managed.

Conclusion:

As noted in section 4.3, more guidance and training is required for this program, particularly training and guidance relating to the need to collect and maintain necessary information for all RTW cases. In the absence of clear direction, many files reviewed were missing sufficient documentation to establish basic information about the case, to follow its progress, or to assess compliance. During our interviews with managers and coordinators, we found that both groups understood the importance of and the process that must be followed in the RTW program. However, we could find little evidence to support that RTW cases are being managed in compliance with CSC policy.

Recommendation no 3:

The Assistant Commissioner Human Resource Management should provide clear guidance and tools to ensure that RTW files contain all necessary information to support the management of RTW cases and monitor compliance with CSC policy.

 

Annex A

Audit Objectives and Criteria
Objective Criteria
1. To assess the extent to which a management framework for EAP, CISM and RTW is in place and meets CSC’s needs. 1.1 CSC directives and guidelines are up-to-date, consistent with relevant TBS policies and other governing authorities and ensure that CSC’s responsibilities with respect to EAP, CISM and RTW are being met.
1.2 CSC’s organizational structure, roles and responsibilities are defined, understood and documented.
1.3 Training is provided according to policy and/or National Training Standards.
1.4 The EAP and CISM programs are promoted at all levels of the organization in order to ensure employee awareness.
1.5 Reporting and monitoring mechanisms are in place at the local, regional and national levels.
2. To assess the extent to which the Employee Assistance Program and Critical Incident Stress Management activities and practices comply with policy requirements. 2.1 EAP services are provided in accordance with policy.
2.2 CISM services are provided in accordance with policy.
3. To assess the extent to which RTW activities and practices comply with the policy requirements. 3.1 Cases are assessed against the criteria established in Bulletin #2006-05 (CX group) prior to transferring an employee from Injury-on-Duty Leave Pay to WCB Direct Pay.
3.2. A RTW file contains the RTW plan and evidence of communications between the employee, employer and insurance carrier to demonstrate that an early and safe return to work strategy has been developed and acted upon.
3.3 PSC priority considerations are documented on file where permanent impairment has occurred.
3.4 Leave entitlements are properly recorded, usage is tracked and credits granted when appropriate.

 

Annex B

Location of Site Visits

National Headquarters - Corporate and Region

Atlantic Region
Regional Headquarters
Dorchester Penitentiary/ Shepody Healing Centre - Medium and Multi-Level Security
Nova Institution for Women - Multi-Level Security
Atlantic District Office - Community (New Brunswick/Prince Edward Island Community Corrections)

Québec Region
Regional Headquarters
Regional Reception Centre - Multi-Level Security/ Special Handling Unit - High-Maximum Security
Joliette Institution - Multi-Level Security
Montreal Metro District - Community

Ontario Region
Regional Headquarters
Bath Institution - Medium Security
Kingston Penitentiary - Maximum Security
Regional Treatment Centre - Multi-Level Security
Grand Valley Institution for Women - Multi-Level Security
Greater Ontario and Nunavut District - Community

Prairie Region
Regional Headquarters
Rockwood Institution - Minimum Security
Saskatchewan Penitentiary/ Riverbend Institution - Maximum and Minimum Security
Regional Psychiatric Centre - Multi-Level Security

Pacific Region
Regional Headquarters
Pacific Institution/ Regional Treatment Centre - Multi-Level Security
Mission Institution - Medium Security
Pacific Region Community Corrections - Community

 

Annex C

MANAGEMENT ACTION PLAN

Recommendation Responsibility Action Plan Target completion date
EAP/CISM PROGRAMS
1. The ACHRM should strengthen the management framework for EAP and CISM, including: ACHRM    
a) Update the current policies on EAP and CISM to reflect recent changes and clarify the definition of a critical incident   1.a.1 Finalize CISM and EAP guidelines review. March 2008
b) Clarify the policy as it related to the role and mandate of advisory committees at all levels   1.b.1 Develop, in consultation with regional representatives and NAC members, the Role and Mandate of National Advisory Committee and of the other advisory committees as well as present a proposal to the NHRMC for approval October 2008
1.b.2 Amend Commissioner Directive 253 to reflect the role and mandate of the National Advisory Committee and of the committees December 2008
c) Improve interaction and communication between national EAP/CISM advisory committee and senior management   1.c.1 Role and Mandate of the national EAP/CISM advisory committee to address the interaction and communication. June 2008
d) Strengthen CSC’s ability to recruit referral agents and peer helpers in community offices and at the managerial level   1.d.1 Develop recruitment strategy/model for the referral agents and peer helpers in the community offices in consultation with regional representatives
September 2008
1.d.2 Develop an approach to address the needs at the managerial level September 2008
e) Implement a training curriculum for referral agents and peer helpers   1.e.1 Develop a national training curriculum in consultation with regional representatives and with representatives from Learning and Development September 2008
f) Develop and implement training requirements for coordinators and advisory committee members   1.f.1 Develop a Manual for coordinators March 2008
1.f.2 Develop a Manual for Advisory Committee members (refer to actions section 1b) December 2008
g) Enhance the processes and procedures for monitoring and reporting the performance of the programs   1.g.1 In conjunction with the requirements of the Canada Public Service Agency for EAP/CISM, develop and implement processes and procedures November 2008
RETURN TO WORK
2. The ACHRM should strengthen the management framework for RTW, including: ACHRM    
a) update the current policy and guidelines on RTW to reflect recent changes and clarify issues raised in section 4.3.1;   2a) CD 254, Occupational Safety and Health and Guidelines 254-2 Return to Work to be reviewed and revised as required in consultation with regions and Unions.
The revised Guidelines should include:
  • roles and responsibilities of managers, supervisors, employees and RTW Coordinators at the local, regional and national level; and
June 2008
  • Terms of Reference of the Advisory Committees at all levels which will identify roles and responsibilities of its members and the purpose of the Committees (Annexe).
June 2008
b) clarify the organizational structure and role and mandate of those involved in the RTW process, including RTW advisory committees;   2b) Organizational Structure, Roles and Mandate, RTW Advisory Committees
  • review RTW/OHS coordinator positions and implement standard organizational structure including a support function (note: implementation is dependant on funding)
June 2008


  • ensure clear and consistent roles and responsibilities as well as ensuring a knowledgeable workforce by:
June 2008
  • developing a competency profile for RTW Coordinator positions;
September 2008
  • developing a staffing strategy; and identifying resource indicators.
June 2008
c) implement a training program for RTW coordinators and RTW Committee members; and   2c) Training
  • Explore options to develop training material for regional and local coordinators as well as all advisory committee members through an outside consultant (i.e.: NIDMAR) and in consultation with Learning and Development. Training material should include:
 
  • Orientation program for new Coordinators;
April 2008
  • Refresher training for experienced Coordinators;
November 2008
  • Develop RTW Program awareness sessions for all employees, supervisors and managers. Explore options of delivering such sessions through the following National Training Standards and included within the:
December 2008
  • New employee orientation sessions (NEOP); and
June 2008
  • Middle Managers Training Program.
September 2008
d) Strengthen program performance monitoring and reporting.   2d) Program performance monitoring and reporting:  
  • Develop and implement in consultation with the Human Resource Business Process Reengineering, an automated reporting system to gather relevant RTW data through HRMS;
September 2008
  • Review and implement a Management Control Framework (MCF) in consultation with the Performance Assurance Sector in order to monitor RTW Program effectiveness; and
June 2008
  • Develop and implement a RTW information monitoring framework.
December 2008
3. The ACHRM should: a) provide clear guidance and tools to ensure that RTW files contain all necessary information to support the management of RTW cases and monitor compliance with CSC policy. ACHRM 3a) Guidance and tools:
  • Revise the Return to Work Procedures Manual to provide step-by-step process and procedures in the RTW program. The RTW Procedures Manual will provide information on best practices and include the following tools:
    • RTW file “checklist”;
    • RTW case management “checklist”;
    • RTW plan template:
    • Template letter for PSC Priority entitlement;
    • Template letter for the request of a Health Canada Assessment;


June 2008
  • Update the Injury-on-Duty Leave Bulletin 2006-05 to ensure files are properly assessed against the criteria identified in the Bulletin;
June 2008
  • Explore option to address the situation of employees in need of suitable employment in order to return to the workforce
May 2008
  • In consultation with Compensation and benefits at the local, regional and national levels, monitor RTW leave entitlement standards to ensure leave is recorded and credited as per applicable terms and conditions of employment.
October 2008