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Audit of the Food Safety Enhancement Program (FSEP)

Audit Report

Conducted By: Internal Audit Directorate

Report approved: November 7, 2007
Management Action Plan approved: June 27, 2008


Table of Contents


Executive Summary

The CFIA's risk-based, consultative audit planning exercise undertaken in 2006 cited the need to audit the Food Safety Enhancement Program (FSEP).  The plan, approved by the Sub-Committee on Audit and Risk Management (SCARM), confirmed that an audit of FSEP would be undertaken and that its focus would be the use of a risk-based approach.  The audit would also provide assurance on the adequacy and effectiveness of the management control framework, and assess the level of compliance with FSEP's own procedures.  The audit took place between January and June 2007 and was carried out by Centre for Public Management Inc. in partnership with AERO Branch's Internal Audit Directorate.  An evaluation of the CFIA's Hazard Analysis Critical Control Point (HACCP) strategy was undertaken concurrently by AERO's Evaluation Directorate with the intent that the projects would be complementary.

The audit was organized along the following lines of inquiry:

  • Compliance with relevant regulation,
  • The extent to which the concept of risk is used in the program,
  • Adherence to the CFIA's management control framework; and,
  • FSEP's effectiveness in meeting its program objectives.

In following these lines of enquiry, we noted that the guidance used by industry and the FSEP auditors (the FSEP Manual) contained all relevant regulations and legislation.  We also found that the concept of risk is employed in the day-to-day operation of the program, both in the number of audits planned for an establishment each year as well as the classification and follow up of any deviations.

There are mixed results with respect to adherence to the management control framework. While roles and responsibilities are well communicated and understood, and management has a strong awareness of the operation, there are inconsistencies in the way FSEP is delivered across the country.  While in the Ontario Area FSEP is delivered through dedicated FSEP auditors, in the other Areas (the Atlantic, Québec and the West) it is delivered by inspection staff with support from Area Coordinators.  Inspectors are not accountable to these Coordinators, but report through Operations branch.  The audit observed that for those Areas using inspection staff for FSEP, the result was less consistency in audit files, but better audit coverage.  In Ontario, however, files are more consistent, but the dedicated FSEP team is less able to perform the required numbers of audits.  A new approach to performing audits (the Compliance Verification System or CVS) is being piloted on meat in Ontario, which may result in the incorporation of the benefits of both approaches.

Finally, with regard to the program's effectiveness in meeting its objectives, the audit concludes that the objectives of the program are stated at such a high level that measurement is a challenge thereby having an impact on planning of program resources and effectiveness.

Recommendations

Roles and Responsibilities

Accountabilities should be examined in order to balance the responsibilities of the FSEP Area Coordinator with the resources and organizational structure at their disposal. We recognize that the Ontario model may not be feasible for other Areas due to resource constraints, and indeed that this model is undergoing changes with the implementation of the Compliance Verification System (CVS).  However, there must be more accountability between FSEP and the resulting field audits.

Consistency and File Quality

There are a number of recommendations designed to address the weaknesses in file management noted during the audit.

Quality Review

All files should be subject to a quality review on an annual basis to ensure, at a minimum, that all required documents are in the file and are complete, and the most current versions of forms and checklists are used.

Corrective Action Requests (CARs)

CARs, currently managed on a file-by-file basis, should be tracked at a national level.  This will help ensure that consistent procedures are in place for tracking these important documents and which allow for the identification of trends that could provide useful program management information.  In addition, we recommend that CAR extensions, which currently can be issued verbally, be issued in writing for greater accountability.

Document Management

The program faces significant challenges in managing its files, as evidenced by the varying approaches taken by the Areas.  We feel that the CVS database system, which is planned for rollout in April 2008, represents the best approach for addressing the concerns raised in our file reviews.  We recommend that this project, which will initially be piloted for mandatory commodities only, be quickly evaluated upon roll-out and a timetable be developed for its extension to other commodities.

Clear and Measurable Program Objective

The program objective should be refined to better reflect the activities of the program, in a manner that can be clearly measured.  Although the program performs work that contributes to improved food safety, the current objectives and approach to performance measurement do not capture this to the greatest possible extent.

Introduction

AERO branch initiated the survey phase of the FSEP Audit in November 2006 to gain sufficient knowledge of the program in order to develop an examination plan that would provide the basis for the orderly, efficient and cost-effective conduct of the audit. As auditors from the Centre for Public Management (CPM) of Ottawa, we were engaged in partnership with CFIA Internal Audit staff to conduct the planning, execution and reporting of the audit.

The examination phase of the audit commenced in January 2007 and was completed in June 2007.  Our work in this area consisted of field visits, interviews, observation and file reviews.

Background of FSEP

In its 1988 report on the Food Production and Inspection Branch of Agriculture Canada, the Office of the Auditor General made specific recommendations concerning inspection and food safety. The following are excerpts from the audit report:

  • The [Inspection Branch] shares responsibility with industry and with provincial and other federal departments for the safety, health and wholesomeness of agricultural food products. It conducts a wide range of activities to protect the health and safety of Canadians and the viability of large sectors of Canada's food, plant, and animal industries. Work remains to be done to fully determine which risks are most serious, so resources can be better concentrated where risk is greatest.
  • The branch needs to strengthen several key inspection practices to provide reasonable assurance that human health and safety threats posed by chemical and bacterial hazards associated with food and agricultural products are prevented and removed. Although it does extensive sensory inspections, it needs to use additional laboratory testing, generally the only way of detecting these hazards. 

In the following year, Agriculture Canada's Agricultural Policy Review confirmed that food safety was ranked as very important in the minds of consumers and the following conclusions were made:

  • Responsibility for food safety must be shared by all participants in the food chain, including processors and consumers.
  • Canada's food inspection system should adopt an open model, enabling consumers and industry to become directly involved.
  • To maintain consumer confidence, Canada should adopt internationally recognized food safety standards focussing on food safety risk assessment.

The following initiatives resulted from the review:

  • Agriculture Canada developed FSEP which incorporated Hazard Analysis and Critical Control Point (HACCP) principles. HACCP is an internationally recognized science-based food safety system;
  • Fisheries and Oceans Canada developed the Quality Management Program (QMP) based on HACCP principles for fish and seafood products; and
  • Federal departments developed a common approach for inspection activities in both registered and non-registered establishments. These principles were incorporated into FSEP.

Upon its inception in 1997 the responsibility of implementing FSEP and QMP was transferred to the Canadian Food Inspection Agency (CFIA).

The objective of FSEP is to ensure that the ingredients used to manufacture food products and the conditions in which these products are processed lead to the production of safe food. FSEP applies to the following commodity sectors: meat and poultry, dairy, processed fruit and vegetables, eggs, honey and maple products.

Under FSEP, members of the food processing industry are responsible for designing and implementing their HACCP systems. The role of the CFIA is to define the requirements of these systems in consultation with the food industry and to verify the effectiveness and adherence to the HACCP system in each federally-registered food processing establishment.

The industry is responsible for:

  • Providing a corporate commitment to HACCP;
  • Developing and implementing prerequisite programs, HACCP plans, and HACCP system reassessment procedures;
  • Maintaining necessary records;
  • Ensuring that the appropriate staff are trained in their areas of responsibility;
  • Submitting any revisions to HACCP plans to the CFIA for review; and
  • Providing the necessary assistance to CFIA staff during the recognition process and during subsequent system audit activities.

The CFIA is responsible for:

  • Recognizing establishments' HACCP plans;
  • Auditing establishment records;
  • Assessing corrective actions taken by establishments;
  • Observing on-site monitoring and verification activities;
  • Ensuring that establishments continue to maintain their HACCP systems; and,
  • Ensuring that establishments comply with all federal acts, regulations and program requirements.

In order to achieve its objectives and meet its responsibilities, FSEP is organized as follows:

  • For each of the four Areas (West, Ontario, Québec and the Atlantic) there are FSEP-trained inspection staff  overseen by FSEP Area Coordinators;
  • The Area FSEP Coordinators are part of the FSEP National Implementation Team (NIT), which is responsible for the direction of program design and implementation;
  • The NIT has a direct linkage with the National Training and Development Team, which designs the training material delivered by the FSEP units; and
  • FSEP falls under the authority of the Director of Program Delivery and Enforcement, who is part of the Operations branch.

It is important to note that FSEP is but one element of the food safety system in Canada.  Meat and poultry also benefit from the daily presence of CFIA inspectors, which goes beyond the requirements of FSEP.  Some of these programs are identified in the next section, within the context of the audit scope.  Any potential impact on food safety arising from the type of issues observed in this report is mitigated by the daily presence of CFIA inspectors at meat and poultry establishments.

While a HACCP approach under FSEP is mandatory for meat and fish establishments, adoption of a HACCP approach for non-mandatory commodities has been a challenge, with an average 10% adoption rate.

Voluntary Hazard Analysis Critical Control Point / Food Safety Enhancement Program Adoption Levels
Voluntary Hazard Analysis Critical Control Point / Food Safety Enhancement Program Adoption Levels

There are many factors which contribute to this low adoption rate, discussion of which is outside the scope of this report however, is addressed in the evaluation of the Agency's HAACP strategy conducted concurrently with this audit.

Audit Scope

It is important to clarify the relationship between FSEP and HACCP.  While FSEP utilizes HACCP, there are other inspection initiatives that also make use of HACCP and HACCP concepts.  As demonstrated by the following diagram, only FSEP is included in the scope of the audit:

Image - Audit Universe
Image - Audit Universe

The Quality Management Program (QMP) has been scoped out of this audit for four principal reasons:

  • The two programs, although similar in some respects, had different genesis, are operated independently and represent two different audit entities,
  • QMP receives foreign country reviews on a regular basis,
  • QMP is fully implemented; and
  • QMP is included in the scope of AERO's evaluation of HACCP.

Audit Objectives

The objectives of this audit are as follows:

  • Assess the extent to which FSEP is effective in meeting its objectives; and
  • Provide assurance as to the effectiveness of the management control framework.

Audit Approach

We have summarized the audit approach to meet the two audit objectives in the following diagram: 

Image - audit approach to meet the two audit objectives
Image - audit approach to meet the two audit objectives

As noted in the diagram, we assessed the following activities:

  • whether the policies and procedures outlined in the FSEP manual were compliant with legislative requirements through a review of relevant legislation.
  • the extent to which risk assessment techniques were employed in the implementation of the program.  This included both the impact of risk on the determination of mandatory commodities as well as the extent to which risk was employed in the development of the FSEP manual
  • the extent to which the management control framework has been deployed to ensure the program meets its objectives.  The specific areas of the MCF from which we drew our criteria include:
    • Accountability framework
    • Policy framework
    • Operational controls
    • Managerial oversight
    • Values and Ethics
  • the extent to which the program has been effective in identifying its objectives and measuring its performance.  This is not specifically addressed by the management control framework, and as such requires additional criteria.
  • the extent to which the policies and procedures outlined in the FSEP manual have been implemented in the field.

Findings

Regulation

Criterion

Regulatory and legislative policy requirements are clearly outlined and the FSEP manual contains all mandatory policies and procedures.

Audit procedures

We reviewed the relevant legislation and regulations to identify components that referenced FSEP and which we would expect to find reflected in the FSEP manual.  We verified that these items are indeed reflected in the FSEP manual.  This approach allowed us to base our subsequent audit work on the FSEP manual as a benchmark.

Findings

All relevant legislative and regulatory requirements are reflected in the FSEP manual.

Impact

If the FSEP manual is appropriately applied in the execution of FSEP, we can be assured that all relevant regulations are being followed.

Risk

Criterion

The concept of risk is employed within FSEP in the operation of the program.

Audit Procedures

We performed interviews and reviewed the FSEP manual for specific guidance on the operation of the program.  In addition, we reviewed other FSEP-related documents and publicly available information for indications on the role played by risk within the program.

Findings

We noted that risk concepts are employed in the day-to-day operation of FSEP. Establishments are classified according to risk and this classification determines the frequency by which they are audited.  In addition, the risk posed by non-conformities with the FSEP requirements (identified as corrective action requests or CARs) identified during the FSEP audit process is taken into consideration via the classification of the non-conformity.

Impact

The fact that the concept of risk is employed in the day to day operation of FSEP contributes to the Agency meeting its overall objectives and is consistent with Treasury Board guidance.

Management Control Framework

Criteria

We expected that:

  • Roles and responsibilities of the process' various stakeholders are clearly communicated and understood;
  • Management has a strong awareness of the operation;
  • Changes to FSEP policies and procedures are communicated effectively; and
  • There is clear accountability for the success of the program, with results tracked and communicated.

Audit Procedures

This objective was addressed through interviews of senior management and those in the field, a review of FSEP documentation, and attendance at a national FSEP conference.

Findings

Roles and responsibilities are clearly communicated and understood and management has a strong awareness of FSEP.  We observed that although the program changes rapidly, those in the field felt they receive adequate guidance on these changes.  The national conference provided a good opportunity to observe the knowledge dissemination process in action, with a varied agenda which covered current procedures as well as upcoming changes.

There are differences in the way the program is executed in Ontario when compared to the other Areas.  While Ontario has a dedicated team of FSEP auditors, the other Areas are served by inspectors, and the work is coordinated by an FSEP Area Coordinator.  The Area Coordinator acts as an FSEP “coach” to the inspectors, but there is no direct accountability through the FSEP Area Coordinator to the program itself.  We found the Area Coordinators to be dedicated and hardworking representatives of FSEP, but they face significant challenges due to this lack of accountability and the vast geographic area they must cover.

Based upon the results of our file review, we noted that the Ontario approach of a dedicated FSEP team yielded the fewest deviations in the supporting documentation (i.e. file completeness), but also the highest percentage of establishments which did not receive the required number of Regulatory System Audits (RSA).  This finding indicates possible resource constraints: One would expect better adherence to the policies and procedures with a dedicated FSEP team, however, without the ability to leverage the inspection staff to perform the FSEP audits, Ontario's performance against the required number of audits would be constrained by resources.  This may be mitigated as Ontario moves forward with the Compliant Verification System (CVS) approach to FSEP.  This new approach, currently in the pilot phase for meat and poultry, delegates selected FSEP tasks to the inspectors who already have a daily presence in the plant.

Impact

The different organizational structures between Ontario and the other Areas, along with the lack of direct accountability between those performing FSEP tasks and the FSEP Area Coordinators outside of Ontario, increases the risk of non-conformity and lack of consistency in application of the program.

Based on the above, it is Internal Audit's intention to seeks a mandate from the Audit Committee to undertake further audit work on the CVS.  This model has been running as a pilot in Ontario, and there should be sufficient experience to evaluate the impact it will have on overall program adherence to the Management Control Framework and other findings of this report. We believe that the best time to perform this work is prior to full implementation, allowing any recommendations to be taken into consideration.

Recommendation

We recommend that accountabilities be examined in order to balance the responsibilities of the FSEP Area coordinator with the resources and organizational structure at their disposal.  We recognize that the Ontario model may not be feasible for other Areas due to resource constraints, and indeed that this model is undergoing changes with the implementation of the Compliance Verification System (CVS).  However, there has to be more accountability between FSEP and the resulting field audits.

Management Control Framework:  Field audit

Criteria

We expected that:

  • Establishments are classified according to risk, and that the number of inspections dictated by this risk classification are carried out; and
  • For the inspections themselves, a common approach following the FSEP manual is used in all Areas and that the files are complete.  When corrective action requests (CARs) are issued, they are tracked and followed up on a timely basis.

Audit Procedures

Auditors representing CFIA's AERO branch and the Centre for Public Management visited a number of establishments across the country, either observing an audit in progress or obtaining a walkthrough of the establishment's HACCP program in order to obtain a greater understanding of the FSEP field audit process.  These seven establishments included two in the Atlantic, one in Québec, two in Ontario and two in the West, and comprised both establishments processing commodities for which FSEP is mandatory and those for which it is non-mandatory.  This gave us context for our file reviews, for which we selected a sample of establishment files from the year 2006/07: 19 representing acknowledgement under the FSEP program, and 18 representing the audits that were undertaken during the year.  The sample size and the file selection were performed judgmentally to obtain a broad representation of establishments, areas and inspectors and provide a good working knowledge of the program.  All files were selected from establishments that fell under the mandatory FSEP program, as this represented the area of highest risk.

For the acknowledgement files, we tested:

  • The presence of either a mandatory FSEP/HACCP checklist or Appendix VIII checklist (FSEP/HACCP Checklist for Establishment requesting a license) was verified. Only one of these two checklists needed to be present in the file;
  • The presence of Appendix IV (FSEP/HACCP Plan Review and HACCP System Reassessment Checklist) was verified;
  • The presence of the official acknowledgement was verified;
  • The formal date of acknowledgement noted in the acknowledgement letter was recorded; and
  • The formal date of acknowledgement obtained from the acknowledgement letter was compared to the formal acknowledgement date mentioned in the Tracking Sheet. In situations where two dates were significantly different, the differences were recorded.

Audit procedures for Regulatory System Audit (RSA) files:

  • Based on the risk category assigned to the establishment, the required number of RSAs that should have been performed was calculated and recorded;
  • For each audit that was carried out at the establishment, the presence of the following documents was verified and recorded:
    • FSEP Audit Scope Worksheet;
    • FSEP Audit Worksheet; and
    • FSEP Audit Report.
  • For each audit carried out at the establishment, it was verified whether or not the items listed in the Audit Scope Worksheet were examined during the course of the RSA,
  • For each audit carried out at the establishment, it was verified whether or not Corrective Action Requests (CARs) had been issued. In situations where CARs had been issued, the presence of the following documents was verified and recorded:
    • CAR report for each CAR that was issued,
    • The corrective action plan for each CAR that was issued; and
    • The CAR Tracking table.
  • In situations where CARs had been issued, it was verified whether or not the CARs were closed.

Findings

Tracking Sheet errors

FSEP uses tracking sheets in each Area to track the number of establishments, their risk level, the number of audits performed, and any CARs that are issued.  These Area tracking sheets are rolled up to the national level for performance measurement tracking.  Since the tracking sheets are the main repository of FSEP audit activities, we tested the internal integrity of the sheets and compared the results of our file reviews to the information contained in the spreadsheets.  The review of the 38 files selected and 5 tracking sheets (4 Area sheets and 1 national), identified:

  • 9 cases where incorrect information was contained in the spreadsheet (e.g. incorrect dates, number of audits performed);
  • 2 cases where information was missing in the spreadsheet (e.g. an audit was performed but not recorded, risk categories not recorded); and
  • 4 cases of incorrect formulae calculating the required number of audits on an overall basis for performance reporting purposes.

Impact

The tracking sheets are a key management tool for the program, and as such must be kept current, accurate and error free, otherwise the risk of erroneous decisions increases.

Required number of audits was not carried out

FSEP dictates that a specified number of audits should be carried out each year, as determined by the risk category of the establishment.  These audits are recorded on the Area tracking sheets as they are performed.  In order to perform our tests, we requested the Area tracking sheets for the 2006/07 year, and calculated the required number of audits based upon risk for the meat and poultry categories (the highest-risk commodities).  These were compared to the actual number of audits documented on the spreadsheet to identify shortfalls.  We started this process prior to the completion of 2006/07, so the required number of audits was prorated accordingly.  We found that approximately 50% of the required audits were performed.

Impact

The determination of the required number of audits is risk-based.  If they are not completed as planned, the risk to food safety increases, and it makes it more difficult for the program to meet its objectives.

CARs were not closed

Although the majority of CARs examined during the course of the audit were closed or extended in the required period of time, four instances were identified where CARs should have been closed, extended within 60 days, or escalation procedures undertaken. These four CARs were not related to major non-conformities, and as such were not immediate food safety issues.

Impact

CARs represent non-conformities which have potential food safety implications.  Any process which is not 100% effective in tracking and closing CARs increases the risk to food safety.

Incomplete documents 

The review of FSEP files identified a number of incomplete documents across all Areas.  These instances included primarily cases in which a document was present in the file however a component, such as a signature or date, was missing or incomplete.  A summary of incomplete documents is as follows:

  • Eight CAR reports;
  • One FSEP/HACCP checklist for an Establishment Requesting a License;
  • Two CAR Tracking tables; and
  • Two Audit worksheets.

Impact

In cases where subsequent events cause a file to be examined to build an audit trail, incomplete documents create questions and confusion, and increase risk to the Agency.  In addition, if the incomplete components represent significant food safety-related tasks, food safety risk is increased.

Missing documents

During the course of our audit, we encountered cases of documents missing from the files.  These documents included:

  • Audit worksheets (9 cases),
  • Mandatory FSEP / HACCP checklists (2 cases),
  • Appendix IVs (FSEP/HACCP Plan Review and HACCP System Reassessment Checklist) (2 cases),
  • The Audit Scope Worksheets (3 cases),
  • Audit documents for an audit conducted (1 case),
  • Corrective action plans (1 case); and,
  • CAR tracking tables (4 cases).

Impact

The impact of missing documentation is similar to that of incomplete documents, with the added impact that time will be wasted trying to locate the missing documents, which may or may not exist, should they ever need to be examined.

Inconsistent use of forms

FSEP is a national program, and as such there should be consistency both across and within Areas with respect to the forms that are used.  We found that different Areas used different versions of forms, and in some cases, inspectors use older versions because they are available in electronic format while newer ones are not.  The basic information on the various versions was the same; however for ease of comparison the same forms should be used.  We noted lack of consistency in the use of:

  • Appendix I (FSEP Recognition Tracking Form),
  • Appendix IV,
  • Audit worksheet,
  • Acknowledgement letters; and,
  • Numbering of CARs.

Impact

Lack of consistency increases the difficulty in managing the program.  It impacts training, public perception (a number of establishments are owned by large companies with operations across Areas) and third party reviews.

Maintaining multiple versions of a document

Different Areas also maintained different document management approaches.  In one, there was only one version of the file, it was maintained only in physical form and kept on-site at the establishment.  In another, the file was maintained in physical form with some components maintained electronically and held centrally at the regional office.  Auditors took the files to the establishment to perform the audit.  In another Area, all documents were scanned and maintained electronically so that the files existed both electronically and physically, with the versions not always in synch.  These different approaches are partially a result of the different environments faced by FSEP in the Areas.  In the West, there is a large geographical area, with many establishments connected only through a telephone line, rendering electronic transfer of documents difficult.  Ontario benefits from a geographically clustered group of establishments, facilitating a centralized approach and electronic transfer of documents.
We identified duplicate documents with different content in:

  • CAR reports (2 cases); and,
  • Audit worksheets (1 case).

Impact

Different versions of the same document raise questions about which document is the most current, as well as general document management practices.  Regardless of the method used to manage documents, the objective should be the same: to be able to locate a required document quickly, with the assurance that it is the most current and correct version.

Recommendations

Incomplete Audits

We recommend that the number of audits required under the FSEP program be examined.  If the required number of audits is deemed excessive, then it should be reduced.  If the number is appropriate, then appropriate changes should be made to allow the required number of audits to be completed as planned.

Quality Review

We recommend all files be subject to a quality review on an annual basis to ensure, at a minimum, that all required documents are in the file and are complete, and the most current versions of forms and checklists are used.

CARs

CARs, currently managed on a file-by-file basis, should be tracked at a national level.  This will help ensure that consistent procedures are in place for tracking these important documents and which allow for the identification of trends which could provide useful program management information.  In addition, we recommend that CAR extensions, which currently can be issued verbally, be issued in writing for greater accountability.

Document Management

The program faces significant challenges in managing its files, as evidenced by the different approaches taken by the Areas.  We feel that the CVS database system, which is planned for rollout in April of 2008, represents the best approach for addressing the concerns raised in our file reviews.  We recommend that this project, which will initially be piloted for mandatory commodities only, be quickly evaluated upon roll-out and a timetable be developed for its extension to other commodities.

Effectiveness

Criteria

We expected that:

  • Program objectives are clearly defined in a manner that facilitates performance measurement; and
  • Performance measures are in place that clearly report against the program objectives, and action plans are in place when these objectives are not met.

Audit Procedures

In order to assess these criteria we conducted interviews, reviewed both public domain and internal FSEP documentation, and reviewed performance measures.

Findings

The stated objective of the program is to “ensure the conditions under which food products are manufactured and the ingredients used in their manufacture lead to the production of safe food”. This objective represents a work in progress, as best practices indicate that an objective should be specific, measurable, achievable, and relevant and have a timeframe for completion.  While this objective is relevant and potentially achievable, it is not very specific or measurable.  In addition, there is no timeframe for completion.

On the performance measurement side, the current performance measures focus on delivery rate (the number of planned vs. completed audits), and the compliance rate of establishments.  Further measures relating specifically to FSEP are not available at this time.  Performance measurement issues of this nature occur across most programs and we were therefore unable to measure effectiveness of FSEP against its current objective.

Impact

Lack of clear and measurable objectives impacts FSEP's ability to identify program successes thereby potentially impacting program resources and effectiveness.

Recommendation

The program objective be refined to better reflect the activities of the program in a manner that can be clearly measured and incorporates the concept of risk.  Although the program performs work that improves food safety, the current objectives and performance measurement approach do not capture this to the greatest possible extent.

Action Plan as at September 2009

Recommendation - Roles and Responsibilities

Accountabilities should be examined in order to balance the responsibilities of the FSEP Area Coordinator with the resources and organizational structure at their disposal.

Management
Response
1. Implementation of QMS criteria to verify consistency in application of the FSEP program in other commodity than meat (non-mandatory FSEP).
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
Quality Verifications are planned and delivered in each area to verify consistency in application of the FSEP program in other commodities than meat.

 

Management
Response
2. An organizational structure is being developed at the AMT level to define the roles, responsibilities and accountability of the Area FSEP Coordinators associated with consistency of application of the FSEP program in non-mandatory FSEP commodities.
Planned
Implementation
Date
December 2009
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Area Operations Coordinators are currently working with the National Operations group on describing the roles and responsibilities of the Area CVS Coordinators. Finalization of the Area CVS responsibilities and a final work description is in progress. Next step is to describe the roles and responsibilities of the FSEP and QMS coordinators.

 

Management
Response
3. Implementation of QMS criteria associated with CVS section 4 tasks.
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The CVS section 4 tasks have been implemented in September 2008 in Meat and Poultry registered establishments. Most areas are still mentoring their staff. The associated QMS criteria are available. Quality Verifications are planned for 2009-2010.

 

Management
Response
4. An organizational structure is being developed at the AMT level to define the roles, responsibilities and accountability of the Area FSEP Coordinators associated with consistency of application of the CVS section 4 tasks.
Planned
Implementation
Date
December 2009
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Area Operations Coordinators are currently working with the National Operations group on describing the roles and responsibilities of the Area CVS Coordinators. Finalization of the Area CVS responsibilities and a final work description is in progress. Development of this work description will help provide a clear understanding of the roles and responsibilities of the FSEP Area Coordinator with respect to CVS. Next step is to describe the roles and responsibilities of the FSEP and QMS coordinators.

Recommendation - Incomplete Audits

It is recommended that the number of audits required under the FSEP program be examined.  If the required number of audits is deemed excessive, then it should be reduced.  If the number is appropriate, then appropriate changes should be made to allow the required number of audits to be completed as planned.

Management
Response
1. Meet with the Program Chiefs to:
  • Review and adjust, if required, the frequency of audits. The frequency will be determined considering:
    • The impact on food safety
    • Historical data on state of compliance of the industry as a whole
    • Export requirements
    • International guidelines
  • Develop a national structure to avoid duplication of inspection activities in FSEP recognized establishments. Resources are sufficient if there is no duplication of food safety inspection activities.
  • Amend the FSEP Manual to reflect the changes
Planned
Implementation
Date
January 2010
Responsible
Managers
  • Director, Programs Division, Policy and Programs Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The FSEP Manual is currently under revision. Finalization of the first draft of the revised FSEP Manual and consultation with Programs and Industry is in progress.

A final new edition of the FSEP Manual is anticipated by January 2010.

 

Management
Response
2. An organizational structure is being developed at the AMT level to define the roles, responsibilities and accountability of the Area FSEP Coordinators associated with consistency of application of the FSEP program in non-mandatory FSEP commodities.
Planned
Implementation
Date
December 2009
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Area Operations Coordinators are currently working with the National Operations group on describing the roles and responsibilities of the Area CVS Coordinators. Finalization of the Area CVS responsibilities and a final work description is in progress. Next step is to describe the roles and responsibilities of the FSEP and QMS coordinators.

 

Management
Response
3. CVS implementation in all federally registered meat establishments.
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update

Action Completed.

 

Management
Response
4. Initiate the review process for all of CFIA's inspection programs bringing them into one common inspection methodology applied through the CVS program. Make a decision on either incorporating HACCP into the CVS (mandatory approach) or take a more HACCP based approach to developing verification tasks without mandating HACCP. The objective of the FSEP Manual would then be restricted to define the design of the Canadian HACCP System. Verification of compliance to regulations and HACCP system design would be covered by the CVS developed in each commodity.
Planned
Implementation
Date
April 2012
Responsible
Managers
  • Director, Programs Division, Policy and Programs Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Inspection Strategies Unit has initiated discussions with Executive Directors and Programs regarding the needs and beneficial effects of having one common inspection system.

 

Management
Response
5. Amend the FSEP Manual to reflect the changes
Planned
Implementation
Date
January 2010
Responsible
Managers
  • Director, Programs Division, Policy and Programs Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update

 

Recommendation - Quality Review

All files should be subject to a quality review on an annual basis to ensure, at a minimum, that all required documents are in the file and are complete, and the most current versions of forms and checklists are used.

Management
Response
1. Implementation of QMS criteria to verify consistency in application of the FSEP program in all commodities other than meat (non-mandatory FSEP).
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
Quality Verifications are planned and delivered in each area to verify consistency in application of the FSEP program in other commodities than meat. Confirmed by each area.

 

Management
Response
2. An organizational structure is being developed at the AMT level to define the roles, responsibilities and accountability of the Area FSEP Coordinators associated with consistency of application of the FSEP program in non-mandatory FSEP commodities.
Planned
Implementation
Date
December 2009
Responsible
Managers
  • Director, Programs Division, Policy and Programs Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Area Operations Coordinators are currently working with the National Operations group on describing the roles and responsibilities of the Area CVS Coordinators. Finalization of the Area CVS responsibilities and a final work description is in progress. Next step is to describe the roles and responsibilities of the FSEP and QMS coordinators.

 

Management
Response
3. Implementation of QMS criteria associated with CVS section 1, 2, 3 and 5 tasks.
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Director, Programs Division, Policy and Programs Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update

Quality Verifications are planned and delivered.

 

Management
Response
4. Implementation of QMS criteria associated with CVS section 4 tasks.
Planned
Implementation
Date
Implemented
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The CVS section 4 tasks have been implemented in September 2008. Most areas are still mentoring their staff. The associated QMS criteria are available. Quality Verifications are planned for 2009-2010.

 

Management
Response
5. An organizational structure is being developed at the AMT level to define the roles, responsibilities and accountability of the Area FSEP Coordinators associated with consistency of application of the CVS section 4 tasks.
Planned
Implementation
Date
December 2009
Responsible
Managers
  • Area EDs, Operations Branch
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The Area Operations Coordinators are currently working with the National Operations group on describing the roles and responsibilities of the Area CVS Coordinators. Finalization of the Area CVS responsibilities and a final work description is in progress. Development of this work description will help provide a clear understanding of the roles and responsibilities of the FSEP Area Coordinator with respect to CVS. Next step is to describe the roles and responsibilities of the FSEP and QMS coordinators.

Recommendation - Corrective Action Requests

CARs, currently managed on a file-by-file basis, should be tracked at a national level.  This will help ensure that consistent procedures are in place for tracking these important documents and which allow for the identification of trends which could provide useful program management information.  In addition, we recommend that CAR extensions, which currently can be issued verbally, be issued in writing for greater accountability.

Management
Response
1. Development of a National database for FSEP audit-related CARs.
Planned
Implementation
Date
January 2010
Responsible
Managers
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
CAR’s are currently tracked by each area. A national database will be developed to track audit/inspection activities associated with the revised FSEP Manual.

 

Management
Response
2. Review of the FSEP Manual.
Planned
Implementation
Date
January 2010
Responsible
Managers
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
The FSEP Manual is currently under revision. Finalization of the first draft of the revised FSEP Manual and consultation with Programs and Industry is in progress.

A final new edition of the FSEP Manual is anticipated by the end of December 2009.

Recommendation - Document Management

The program faces significant challenges in managing its files, as evidenced by the different approaches taken by the Areas.  We feel that the CVS database system, which is planned for rollout in April 2008, represents the best approach for addressing the concerns raised in our file reviews.  We recommend that this project, which will initially be piloted for mandatory commodities only, be quickly evaluated upon roll-out and a timetable be developed for its extension to other commodities.

Management
Response
1. Meeting with the Area FSEP Coordinators to evaluate current FSEP tracking sheets and come up with one National procedure to track FSEP data.
Planned
Implementation
Date
Implemented
Responsible
Managers
  • National FSEP/HACCP Coordinator, Operations Branch
Status
Update
It has been decided that a national database will be developed to track audit/inspection activities associated with the revised FSEP Manual.

Recommendation - Clear and Measurable Program Objective

The program objective be refined to better reflect the activities of the program in a manner that can be clearly measured.  Although the program performs work that improves food safety, the current objectives and performance measurement approach do not capture this to the greatest possible extent.

Management
Response
1. Programs and Operations Branch will undertake a review of the alignment between program activities and FSEP's objectives.  This work will be undertaken under the auspices of the larger context of the Program Activity Architecture and performance measurement which is currently underway.
Planned
Implementation
Date
March 2010
Responsible
Managers
  • Associate Vice President Policy and Programs Branch
Status
Update

The Program Activity Architecture (PAA) and the related Performance Measurement Framework (PMF) define a process for reporting on the overall performance of the CFIA. However, the PAA and PMF do not provide the level of detail and specificity needed to manage and report on performance for activities at the level of FSEP and individual commodities. To provide such detail, the CFIA is in the process of developing and implementing the Enterprise and Operational Reporting (EOR) system. This information management system is dependent on the use of quality, high-level indicators to frame the reports necessary to highlight the performance of programs. EOR is expected to streamline and optimize the production of reports, ensuring reporting efficiency and effectiveness Agency-wide. Performance indicators are being developed for each Agency program and it is expected that these will be finalized by December, 2009 and will be implemented as programs are incorporated into EOR.

EOR is an Agency-wide project and is not limited to FSEP-related commodities. It is being implemented in stages, starting with data collection and storage at the program management level. The first pilot was delivered in the Fish, Seafood & Production Program and it was successfully completed in March 2008. Three other programs have been scheduled for the Phase 2 pilot in 2009 (Feed, Fertilizer and Processed Products). Future plans include adding three additional programs per year, and experience with these pilots will guide future direction for the roll out of this system.