Audit of the Implementation of Jordan’s Principle

Context

Jordan's Principle began in 2007 as a parliamentary response to the death of Jordan River Anderson. Jordan passed away before being released from the hospital due to jurisdictional disputes within and between the federal and provincial governments over who would pay the costs for his in-home care. The Principle is a legal requirement; it is not a policy or program. It is a child-first initiative that calls for services to be delivered to First Nations children in their home communities and for government of first contact to ensure First Nations children can have equitable access to publicly funded services.

In 2016, the Canadian Human Rights Tribunal (CHRT) determined that Canada's approach to services for First Nations children was still discriminatory because it resulted in service gaps, service delays and service denials to First Nations children when accessing the support and services needed to achieve a normative standard of care and substantive equality with non-First Nations children. Achieving substantive equality for First Nations children is more than just providing equal access to health, education, and social supports and services; it's about providing the services required to support equal outcomes. The Government of Canada was ordered to immediately implement the full meaning and scope of Jordan's Principle.

The total approved budget for Jordan's Principle was $679.9M from 2016-2017 to 2018-2019. Budget 2019 proposed an investment of $1.2 billion in Jordan's Principle over the next three years to continue helping First Nations children obtain government products and services to address unmet needs. Approximately 90% of the Service Access Resolution Fund is being delivered through Contribution Agreements (CAs).

Why this is important

The implementation of Jordan's Principle is essential to ensuring that the Government of Canada meets the educational, social and health needs of First Nations children. The services and products provided by Jordan's Principle offers First Nations children the opportunity to achieve similar health, education, and social outcomes as other Canadian children.

Audit Objective and Scope

The Audit of the Implementation of Jordan's Principle used a two-phase approach. The two phases of the audit had different but complementary objectives and scopes, which were aimed at first assessing the initial risk related to the implementation of the Principle and then assessing the sustainability of the Principle by looking at key short-term and long-term practices needed to effectively implement the Principle. The following table outlines the objective and scope of each phase.

Statement of Conformance

The audit was conducted in conformance with the International Standards for the Professional Practice of Internal Auditing as supported by the results of the quality assurance and improvement program.

Conclusion

A unique challenge with Jordan's Principle has been the need to develop business processes while managing and delivering the Principle under tight deadlines and high pressure. Jordan's Principle is a unique initiative; therefore, a pre-existing model for its implementation is not available. In addition, a traditional period of design for the initiative is not available due to high demand and time constraints which resulted from implementation of the CHRT orders. Due to the changing landscape under which the Principle operates, the business processes and the definition and scope of what is required under Jordan's Principle have been continuously adapted to the CHRT orders.

In phase 1, the audit found that the Department has positioned itself to fully manage some of its risks related to the availability of information, communications with First Nations as well as financial practices including delegation of authority, Financial Administration Act (FAA) Section 34 and 33, and quality assurance reviews for payments. The employees and the follow-up they perform have helped the Department partially mitigate some of its information and knowledge risks.

In phase 2, the audit found that the Department had positioned itself to partially mitigate some of its risks related to the coordination and collaboration between all sectors involved in Jordan's Principle, identifying opportunities to address commonly occurring needs of First Nations children, ensuring that employees are equipped to respond to the variation and volume of Jordan's Principle requests, real and perceived conflicts of interest and building awareness of the importance of Jordan's Principle to all Canadians. The Department has not fully implemented the mitigation measures that they identified to oversee the monitoring and reporting requirements in the contribution agreements.

The audit team identified recommendations to address the remaining risks to the Department.

Recommendations

1. Going forward, the Senior Assistant Deputy Minister (ADM) of FNIHB should ensure that information stored in multiple locations is consolidated into the request file. This will allow information to be found more easily in the future.
2. While there is a strong sense of urgency to make a decision within the timelines mandated by the CHRT, the timelines stop once the decision is communicated. The Senior ADM of FNIHB should ensure that a post-decision review of file completeness is performed to ensure that information required by management in the Standard Operating Procedures is present and accessible for future reference.
3. The Senior ADM of FNIHB , with support from the CFRDO, should implement a monitoring process to ensure that FAA Section 32 commitments are being input into System Application Products after the decision has been communicated and that unused funds are released after final payment. The results of the monitoring should be addressed through corrective action as required.
4. The Senior ADM of FNIHB in consultation with ESDPP, CFRDO, CFSR and RO should formally define and communicate roles, responsibilities and accountabilities for all sectors involved to ensure efficient coordination of their approach to implementing Jordan's Principle.
5. The Senior ADM of FNIHB should leverage data trends to proactively identify alternative ways to provide commonly requested products and services through existing or new programs.
6. The Senior ADM of FNIHB should adopt a risk-based approach to the oversight of reporting and monitoring the external use of funds through Jordan's Principle.
7. The Senior ADM of FNIHB , in consultation with all involved sectors, should provide additional assistance to employees to better equip them to respond to the increase in volume and variation in Jordan's Principle requests by finalizing and implementing the Wellness Plan and by providing global feedback and lessons learned throughout the adjudication process.
8. The Senior ADM of FNIHB should formalize the existing internal conflict of interest practices specific to Jordan's Principle's operational context.
9. The Senior ADM of FNIHB , in consultation with Communications, should work towards developing and implementing a communication strategy to directly target the wider population to build awareness of the importance of Jordan's Principle.

Management Response

2.1 Key Orders and Requirement

Jordan's Principle is a legal requirement resulting from the 2016 CHRT decision. Since the initial CHRT decision, several subsequent CHRT orders regarding how Jordan's Principle should be defined and implemented were issued. In its May 26, 2017 ruling (amended November 2017), the CHRT provided additional clarity vis-à-vis Jordan's Principle. It outlined that Jordan's Principle:

• Applies to all First Nations children, no matter where they live;
• Ensures there are no gaps in publicly funded services for First Nations children;
• Does not require the presence of a jurisdictional dispute to be applied; and,
• Requires that Canada consider funding services and supports not available to other children if those services/supports would enable substantive equality, be culturally appropriate and/or in the best interest of the child.

In February 2019, the CHRT issued an interim relief order for Jordan's Principle stating that in urgent and/or life-threatening situations, non-status First Nations children who live off-reserve (but are recognized by their First Nation) will be covered based on the child's best interests. This interim relief order will be in effect until the issues regarding the definition of a First Nations child and the impact of status on eligibility are adjudicated at a full hearing. Canada has asked the Panel to dismiss the motion and the Interim Order. Canada is still waiting for the results from these hearings.

The CHRT mandated specific timeframes for the Department to address Jordan's Principle requests. The timeframes begin once all the information required to make a decision has been received. The timeframes outlined in the CHRT orders are different based on the urgency of the request and if the request is for an individual or for a group. The timeframes are:

• 12 hours for urgent individual requests;
• 48 hours for non-urgent individual requests and urgent group requests;
• 7 calendar days for non-urgent group requests; and,
• Immediate referral to emergency authorities for cases where the denial or delay of a service could reasonably result in significant and/or irremediable harm to a child who is the subject of the request. This applies to individual and group service requests.

2.2 Jordan's Principle Implementation

Multiple sectors work together to deliver Jordan's Principle within ISC. They include First Nations and Inuit Health Branch (FNIHB), FNIHB -Regional Operations (RO), Education and Social Development Programs and Partnerships (ESDPP), RO, Child and Family Services (CFSR) and Chief Finances, Results and Delivery Officer (CFRDO).

Within the FNIHB regional offices and RO (British Columbia (BC) region), there are focal points that are responsible for receiving requests, reviewing the information, and making a decision within the mandated CHRT timelines. If the request cannot be approved or requires additional clinical consultation, the request must be escalated to FNIHB Headquarters where a decision will be made by the Assistant Deputy Minister (ADM) of FNIHB -RO.

As of April 1, 2019, the majority of the responsibility for adjudicating Jordan's Principle request was transferred to FNIHB regional offices.

Text alternative for Figure 1 - Process for making a decision on product or service requests

Figure 1 illustrates the adjudication process for making a decision on goods or services requests under Jordan’s Principle. The figure differentiates between individual and group requests. Individual requests are requests submitted by individuals or by groups not under CAs. Group Requests are requests that are managed through CAs. The adjudication process is divided in six steps. Step one is described as the request for services being made by the requester to the Focal Point. Step two is described as the intake form or proposal being and the documentation being gathered. Step three is described as the assessment made by the Focal Point. For individual requests, step four is described as the decision being communicated to the requester by the Focal Point. For group requests, step four is described as contribution agreement being amended to include Jordan’s Principle funding. For individual requests, step five is described as goods and services being acquired by the requester if the request is approved. For group requests, step five is described as funding being provided to the recipient. For individual requests, step six is described as invoices being submitted to the Department by the requester for reimbursement. For group requests, step six is the interim and annual reports. The adjudication process ends when the invoices are reimbursed to the requester.

2.3 Tools in Place for Jordan's Principle

The Jordan's Principle Division of FNIHB has developed Standard Operating Procedures (SOP) which are contained in an evergreen document that summarizes the steps to process requests for products and services for eligible First Nations children. The SOP has also evolved to reflect the current business practices required by the changing operational context.

A Management Control Framework (MCF) for Jordan's Principle is near completion, with action plans that evolve to align with the ongoing changes to the set of priorities and CHRT orders. The MCF will help to achieve the Principle's strategic, operational, reporting, and financial objectives. The MCF action plan focuses on key areas such as:

• Governance;
• Metrics and Expected Results;
• Data Collection and Monitoring;
• People Management; and,
• Operational and Financial Control Processes.

Furthermore, Synergy in Action, the business intelligence group within FNIHB , has been mandated to modernize the processes and systems used in the delivery of Jordan's Principle. As of June 2019, the mapping of Jordan's Principle decision-making process for every region, in addition to Headquarters, has been completed. This was part of a table top exercise in order to present and validate future proposed processes and systems basic capabilities.

3.1 Objective and Scope

3.2 Audit Approach and Methodology

The audit team obtained and analyzed sufficient information and evidence to provide assurance in support of the audit conclusion. Additional information on the audit coverage is provided in the Appendix A: Audit Criteria.

The audit methodology included:

• Review of documentation related to the management of Jordan's Principle;
• Interviews with key employees in Headquarters and the Ontario, Northern and Manitoba regional offices ;
• Walkthroughs with key employees in Headquarters and the Ontario, Northern and Manitoba regional offices; and,
• Testing of a sample of Jordan's Principle files in Headquarters and the Ontario, Northern and Manitoba regional offices.

A judgmental sample of 310 Jordan's Principle files was tested in phase 1. The sample included approved, denied, and escalated files for both individual and group requests. The sample covered the 2017-2018 and 2018-2019 fiscal years up to September 30, 2018. The purpose of the file testing was to generate illustrative and practical evidence of the types of issues/challenges encountered in delivering Jordan's Principle within the regions.

4.1 Information Available for Future Reference

To respect the timelines mandated by the CHRT, the Principle has been managed and delivered at the same time as the appropriate business processes were being developed. To put the needs of First Nations children first, the early business processes focussed primarily on decision-making and less on the administrative aspects of the Principle.

As the delivery of the Principle matured, management developed the SOP. Requests under Jordan's Principle are to include sufficient information for the regional Focal Points to consider a request as complete and to make a decision.

The request file should include details of the individuals involved, the products or services requested, complete costing information and the reason for the request. Additional information may include letters of support from professionals, a professional assessment or diagnosis, and details on the child's eligibility for product and services under Jordan's Principle.

4.2 Defending Decision Made

External parties that are not familiar with Jordan's Principle might find it difficult to understand the exact nature of the services and support provided to First Nations children. Management's SOP requires that the decision made for the request and the rationale to support that decision are included in the file.

4.3 Timely Communication with First Nations

There is a strong sense of urgency in the Department to ensure that requests are processed and decisions are made within the mandated timelines. Despite the urgency, service delivery to First Nations is a key element of ISC's mandate that needs to remain a priority.

4.4 Financial Practices

Jordan's Principle funding is to be managed and delivered consistently with the Financial Administrative Act (FAA) and the Treasury Board Policy on Financial Management which provides key responsibilities for Deputy Ministers, Chief Financial Officers, and Senior Departmental Managers to ensure that decisions are made by employees with proper delegated authority.

5.1 Objective and Scope

5.2 Audit Approach and Methodology

The audit team obtained and analyzed sufficient information and evidence to provide assurance in support of the audit conclusion. Additional information on the audit coverage is provided in the Appendix A: Audit Criteria.

The audit methodology included:

• Review of documentation related to the management of Jordan's Principle;
• Interviews with key employees working in sectors included in the scope of the audit in Headquarters and regional offices (CAs Ontario, Manitoba and Saskatchewan);
• Testing of a sample of Jordan's Principle request files managed under CAs (CAs Ontario, Manitoba and Saskatchewan).

In phase 2, a judgmental sample of 81 Jordan's Principle requests were tested to determine if reporting and monitoring was completed as defined by CAs requirements, how management is obtaining reports from recipients and how this information is being used for performance management, risk management and decision-making. The audit sample covered the 2017-2018 and 2018-2019 fiscal years and included approved request files managed under CAs.

6.1 Sustainability of Jordan's Principle

Coordination and Collaboration

In August 2017, there was a dissolution of Indigenous and Northern Affairs Canada (INAC) which resulted in the formation of two new Departments, Indigenous Services Canada and Crown-Indigenous Relations and Northern Affairs Canada. As part of the Government of Canada transformation, FNIHB was transferred from Health Canada to the new Department of ISC.

For the first two years of the implementation of Jordan's Principle, and prior to FNIHB 's move to ISC, each Department (CAs Health Canada and the former INAC) had dedicated teams sharing the responsibilities of administering and delivering Jordan's Principle. The adjudication of Jordan's Principle requests took place at the regional offices of both FNIHB and RO. FNIHB 's responsibilities focused on requests related to health, and RO Sector of the former INAC was responsible for requests related to the social and educational needs of First Nations children.

As of April 1, 2019, the majority of the responsibility for adjudicating Jordan's Principle requests was transferred to FNIHB regional offices. Due to the change in responsibility, FNIHB and RO have been working together to support the transfer of existing files and RO is referring new requests received pertaining to social and education programs to the FNIHB regional offices.

While FNIHB is taking the lead responsibility for adjudicating Jordan's Principle requests and ultimately will be accountable for decisions made on these requests, other sectors and/or programs (e.g. ESDPP, CFSR, RO, CFRDO) are involved in the delivery of Jordan's Principle. Figure 2 illustrates the sectors involved in delivering Jordan's Principle and their respective roles.

Text alternative for Figure 2: Coordination and Collaboration

Figure 2 illustrates the coordination and collaboration between Sectors involved with Jordan’s Principle Requests which is key to manage requests. FNIHB is located in the center as this sector is taking the lead responsibility for adjudicating Jordan's Principle requests. They adjudicate requests and coordinate with other sectors on a case-by-case basis. Firstly, The Education and Social Development Programs and Partnerships (ESDPP) is consulted when required on requests for Education or Social related services. Secondly, the Child and Family Services Reform (CFSR) are consulted when required on requests for Child and Family related Services. Thirdly, Regional Operations (RO) used to be involved in social and education requests, but that responsibility is being transferred to FNIHB , except for the British Columbia region. Lastly, Chief Finances, Results and Delivery Officer (CFRDO) are responsible for processing payment claims and performing quality assurance payment claims review.

 

Risk

Given the number of sectors involved in Jordan's Principle and the prominent role of FNIHB , there is risk that the health perspective may take priority over social and educational perspectives in decision-making and in the strategic direction of the Principle.

Findings

The audit team was informed by regional employees that efforts are being made to support coordination and collaboration at the regional operational level between FNIHB , FNIHB -RO, RO, ESDPP, CFSR and CFRDO. FNIHB employees working on Jordan's Principle requests are reaching out to their colleagues in other relevant sectors to obtain advice on an ad-hoc basis to support service delivery. For example, FNIHB employees will reach out to verify with a program if funding is available under their authority to support a request. FNIHB 's Jordan's Principle employees indicated that they face certain challenges in receiving timely responses from other sectors when requesting information. This is driven by the fact that other sectors may not see the same timeframes outlined in the CHRT orders, as applicable to them for adjudicating Jordan's Principle requests, and moreover, other sectors may have their own workloads which may hinder their ability to provide a timely response.

The roles, responsibilities and accountabilities of all departmental sectors involved in supporting the delivery of Jordan's Principle have not been clearly defined, formalized and/or communicated in the formal documents supporting Jordan's Principle (CAs, MCF and SOP). The SOP for Jordan's Principle does not set clear expectations related to the roles, responsibilities, and authorities of the sectors involved. The MCF action plan includes an expectation that "roles, responsibilities and accountabilities of key players and organizations are appropriately aligned with one another and cover all key functions" but roles and responsibilities have not been defined. Defined roles and responsibilities reduce inefficiencies in resource utilization and overlaps and/or duplication of funding provided by existing ISC programs for the same services and/or products, which helps to ensure the sustainability of Jordan's Principle.

The Department has established several working groups and committees (e.g. Jordan's Principle Oversight Committee, MCF Advisory Committee, bi-weekly Focal Point meetings, etc.) that include representatives from various ISC sectors that support the governance and direction of Jordan's Principle. While several ISC sectors are invited to participate at these committees, participation is inconsistent.

Recommendation

4. The Senior ADM of FNIHB in consultation with ESDPP, CFRDO, CFSR and RO should formally define and communicate roles, responsibilities and accountabilities for all sectors involved to ensure efficient coordination of their approach to implementing Jordan's Principle.

6.2 Employees Involved with Jordan's Principle

Variation and Volume

Since the 2016 implementation of the Government's approach to Jordan's Principle, the Jordan's Principle team has been managing service delivery while developing business processes, protocols and controls to support the administration and delivery of Jordan's Principle. The implementation of Jordan's Principle is still relatively recent and is continuing to evolve with the development of guidance documents such as the SOP and MCF action plan.

The operational environment for Jordan's Principle is driven by a sense of urgency to ensure that requests are processed and decisions are made within the CHRT mandated timelines. The volume and variation of requests have generally increased the workload for regional Jordan's Principle teams and requires a breadth of knowledge as requests can be for health, social and educational needs.

The commitment and dedication of the employees involved in Jordan's Principle to ensure that service delivery to First Nations children remains a priority has been an asset and important to the Department's implementation of the Principle. Based on their experience, they have a significant amount of corporate knowledge related to the Principle's history as well as the request files. Figure 3 provides a snapshot of the operating environment for regional Jordan's Principle teams.

Text alternative for Figure 3: Variation and Volume

Figure 3 illustrates the complexity and volume increase for Jordan’s Principle requests. It shows the volume increase between 2017-18 and 2018-19. During this period, there was an increase of 59,962 in the total number of approved individual and group requests under Jordan’s Principle. For 2017-18 the average number of requests per Full Time Equivalents (FTEs) was 1590 requests. For 2018-19 the average number of requests per FTEs was 1973 requests. These numbers represent a 24% increase in the average number per FTEs of approved individual and group requests under Jordan’s Principle. That is an average of 383 additional requests per FTEs. The increase in complexity and volume of requests under Jordan’s Principle has multiple impacts: Work pressures, stress and burn out; Overtime and limited time for oversight; Challenges with work-life balance; and, Employee turnover and loss of corporate knowledge.

Given the challenges and pressures in the operational environment, the audit expected to see that Jordan's Principle employees are provided with the tools and support necessary to fulfill their roles, responsibilities and accountabilities.

Risks

The tight timelines to make decisions, the variation of the requests, and the volume of the requests increase the emotional stress and demands on employees, which may result in employee turnover and loss of corporate knowledge. Additionally, due to the volume and tight timelines under which requests are processed, there is limited time for oversight of the review and approval process for Jordan's Principle requests.

Findings

Jordan's Principle employees are working overtime in order to meet the mandated timelines and address the high number of requests. This results in stress and has impacted work-life balance as teams continue to provide essential services to First Nations children. At the FNIHB regional level, employees felt supported within their operational teams as regional level management have implemented informal measures such as teleworking, office quiet rooms, social activities and daily stand-up meetings where ideas are shared to help employees deal with the workload and stress.

Although steps have been taken to help employees cope with current stress of the operating environment of Jordan's Principle, in some interviews, employees noted that there were gaps in the support provided to them to help them deal with the increase in the volume and variation of Jordan's Principle requests.

The Department has drafted a Wellness Plan, which includes several initiatives to improve wellness, but has not yet been approved or implemented.

In order to support and streamline the work of employees, the Jordan's Principle team has developed the SOP, which provides policy background and clear direction to process requests for First Nations children under Jordan's Principle. The intended audience for the SOPs is Focal Points, Regional Executives, Regional and National Office Intake Officers, ADMs and any other decision maker in the process to evaluate requests or appeals under Jordan's Principle. Moreover, the Department's in-house Business Intelligence Unit is in the process of developing a case management tool (as part of the Synergy in Action initiative), which aims to reduce the administration burden and reduce employee workload.

Focal point employees used the escalation process if a request is recommended for denial on the basis of a concern with the recommended intervention, or to safeguard the best interest of the child. Employees adjudicating Jordan's Principle requests did not always receive feedback, rationale or lessons learned from Senior Management on their final decision when a request had been escalated for Senior ADM approval. The June 2019 revised SOP stated that regional Jordan's Principle focal point employees (CAs adjudicators) will be able to attend the Senior ADM Escalation Review meetings, which will allow employees to better understand the rationale for certain decisions that are made as part of the escalation process. The involvement will also allow employees to be more engaged to potentially reduce the number of requests that are escalated in the future.

Recommendation

7. The Senior ADM of FNIHB , in consultation with all involved sectors, should provide additional assistance to employees to better equip them to respond to the increase in volume and variation in the Jordan's Principle requests by finalizing and implementing the Wellness Plan and by providing global feedback and lessons learned throughout the adjudication process.

6.3 Raising Awareness with Canadians

Given that the CHRT Orders were released in 2016, the implementation of Jordan's Principle is relatively new for the Department and for Canadians. There may be a perception that Canadians may misunderstand how Jordan's Principle is using  federal funds to support to First Nations children education, social and health needs.

Recommendations

1. Going forward, the ADM of FNIHB should ensure that information stored in multiple locations is consolidated into the request file. This will allow information to be found more easily in the future.
2. While there is a strong sense of urgency to make a decision within the timelines mandated by the CHRT, the timelines stop once the decision is communicated. The Senior ADM of FNIHB should ensure that a post-decision review of file completeness is performed to ensure that information required by management in the Standard Operating Procedures is present and accessible for future reference.
3. The Senior ADM of FNIHB , with support from the CFRDO, should implement a monitoring process to ensure that FAA Section 32 commitments are being input into SAP after the decision has been communicated and that unused funds are released after final payment. The results of the monitoring should be addressed through corrective action as required.
4. The Senior ADM of FNIHB in consultation with ESDPP, CFRDO, CFSR and RO should formally define and communicate roles, responsibilities and accountabilities for all sectors involved to ensure efficient coordination of their approach to implementing Jordan's Principle.
5. The Senior ADM of FNIHB should leverage data trends to proactively identify alternative ways to provide commonly requested products and services through existing or new programs.
6. The Senior ADM of FNIHB should adopt a risk-based approach to the oversight of reporting and monitoring the external use of funds through Jordan's Principle.
7. The Senior ADM of FNIHB , in consultation with all involved sectors, should provide additional assistance to employees to better equip them to respond to the increase in volume and variation in Jordan's Principle requests by finalizing and implementing the Wellness Plan and by providing global feedback and lessons learned throughout the adjudication process.
8. The Senior ADM of FNIHB should formalize the existing internal conflict of interest practices specific to Jordan's Principle's operational context.
9. The Senior ADM of FNIHB , in consultation with Communications, should work towards developing and implementing a communication strategy to directly target the wider population to build awareness of the importance of Jordan's Principle.

Phase 1

Phase 2