Audit of Policy Management– Phase Two

Final Report

October 2020

Table of contents

• Acronyms and abbreviations
• Executive summary
• Management's response to the audit
• 1. Background
• 2. Objective, scope and methodology
  • 2.1 Objective
  • 2.2 Scope
  • 2.3 Methodology
  • 2.4 Statement of conformance
• 3. Audit findings
  • 3.1 Policy development
  • 3.2 Policy publication
  • 3.3 Monitoring and oversight
• 4. Conclusion
• 5. Recommendations
• Appendix A – Audit objective and criteria
• Appendix B – Management action plan
• Footnotes

Acronyms and abbreviations

AM

Administration Manual

C&IP

Contract and Indigenous Policing

CIO

Chief Information Officer

CROPS

Criminal Operations

FP

Federal Policing

GBA+

Gender-Based Analysis Plus

HR

Human Resources

IAER

Internal Audit, Evaluation and Review

NRS

National Review Services

OM

Operational Manual

OP&C

Operational Policy and Compliance

PPS

Policy and Publications Section

RCMP

Royal Canadian Mounted Police

SEC

Senior Executive Committee

SME

Subject Matter Expert

SMT

Senior Management Team

SPS

Specialized Policing Services

ULQA

Unit Level Quality Assurance

Executive summary

The management of operational and administrative policy is an important function within the Royal Canadian Mounted Police (RCMP) to support effective decision-making, operational performance and officer safety. Accordingly, the Commissioner approved the Audit of Policy Management - Phase Two in the 2018-2023 Risk-based Audit, Evaluation and Data Analytics Plan. The Audit of Policy Management - Phase One was completed in 2018, focussing on strategic policy and planning.

The objective of the audit was to assess whether the processes and practices in place to manage operational and administrative policies are effective and consistent across the RCMP. The scope of the audit focussed on the policy development process in place and examined policies which had been developed or updated by Business Lines between January 2017 to January 2019.

The RCMP Administration Manual, Operational Manual and subsidiary manuals (collectively referred to as the "Manuals") are the official policies that govern and guide the actions of all employees. The audit found that an operational and administrative policy development process was not consistently carried out across the Force, although key elements of a policy development process were carried out to various extents by Business Lines. National training and tools were not available to assist employees responsible for policy development, with the exception of a publication guideline. Policies were not regularly updated by Business Lines and publishing delays were experienced resulting in a publication backlog.

The audit also found that Business Lines had not developed monitoring mechanisms to assess compliance with policies and to mitigate risks. The Unit Level Quality Assurance monitoring tool existed but no unit in the RCMP was assigned responsibility for the management of this tool. In addition, oversight of the Manuals was not assigned to ensure that all Business Lines were using a consistent format and updating policies regularly.

Opportunities exist to strengthen the operational and administrative policy development process and to assign oversight for the Manuals. Policy development would benefit from developing national training and guidance tools, establishing service standards for publishing national policy, updating policies in the Manuals on a periodic basis, and developing monitoring mechanisms to assess compliance with policy.

The RCMP Policy Renewal initiative for the Manuals has the potential to play a significant role in the RCMP's modernization efforts. The assignment of formal accountability for this initiative will help ensure that all policy centres participate fully in the modernization of the Manuals.

The management response and action plan developed in response to this report demonstrate the commitment from senior management to address the audit findings and recommendations. The RCMP Internal Audit will monitor the implementation of the management action plan and undertake a follow-up audit if warranted.

Management's response to the audit

Federal Policing

Overall, Federal Policing agrees with the findings and recommendations in the Audit of Policy Management Phase Two report and support the areas identified for improvement. A detailed action plan which addresses the report recommendations, including specific timelines and milestones, will be developed for review by the Departmental Audit Committee prior to the next Committee meeting.

Deputy Commissioner Michael Duheme, Federal Policing

Specialized Policing Services

Overall, SPS agrees with the findings and recommendations in the Audit of Policy Management Phase Two report. While acknowledging differing resources available within SPS Programs dedicated to policy update and maintenance, the audit provides a generalized overview of the work needed to improve operational policy management across the organization.

A detailed action plan which addresses the report recommendations, including specific timelines and milestones, will be developed for review by the Departmental Audit Committee prior to the next Committee meeting.

Deputy Commissioner Stephen White, Specialized Policing Services

Contract and Indigenous Policing

Overall, C&IP agrees with the findings and recommendations of the audit. C&IP is committed to the Commissioner's long term vision for modernizing the RCMP, and delivering quality police services at the highest standards.

The September 2019, Audit of Policy Management – Phase Two is a timely, valuable, and instructive resource on how C&IP maintains operational policy.

It provides great focus on the role and importance of policy, and the significance of maintaining well-informed policies to guide the effective actions of employees and front-line police personnel.

C&IP managers and their functional specialists will benefit from the content, structure, principles, findings and keen insights provided at this stage of the Audit. While some successes have been noted, it is acknowledged that there are areas that C&IP can improve upon. C&IP's Operational Policy & Compliance (OP&C) unit will be reviewing and discussing details of this Audit Report over the next four weekly unit meetings.

In addition, C&IP initiated the development of an Operational Policy Compliance Framework, earlier in 2019. While the full details of this initiative are still being defined, virtually all of the intended activities identified thus far will address observations noted in this Audit Report on the subject of policy monitoring and compliance. The narrative from the Audit Report can be used in advancing the compliance agenda, and the strategy will be revised to incorporate aspects of the audit.

C&IP is also in the process of re-aligning resources to improve policy management capacity and oversight, establishing key performance indicators and compliance monitoring processes for operational policies in higher risk activities such as prisoner handling, missing persons, and crimes against persons.

Deputy Commissioner Brian Brennan, Contract and Indigenous Policing

Human Resources

Overall, HR agrees with the findings and recommendations included in the report and supports the three key areas identified for improvement. A national policy framework should include the development and periodic updating of policies, timely publishing and communication as well as mechanisms to support the ongoing monitoring, oversight and adherence to policy.

Chief Human Resources Officer, Gail Johnson

1. Background

The management of operational and administrative policy is an important function within the Royal Canadian Mounted Police (RCMP) to support effective decision-making, operational performance and officer safety.

The RCMP Administration Manual (AM), Operational Manual (OM) and subsidiary manuals (collectively referred to as the "Manuals") contain policies that govern the RCMP's programs and policing services and constitute advance official approval of the actions that employees are to take under stated circumstances.^{Footnote 1} Operational policies provide support for the RCMP to judiciously exercise lawful authorities in managing and fulfilling its priorities.^{Footnote 2} Administrative policies ensure departmental accountability for RCMP allocated resources. Policies are used to achieve the guidance standards, principles of policing, and priorities of the organization.^{Footnote 3}

Policy development includes developing new operational and administrative policy, as well as updating existing policy to ensure they remain current over time. The policy development process refers to a continuum in which management sets policy direction; staff develop policies through the conduct of research, analysis, consultation and policy options; policies are then approved and implemented; and periodically monitored for compliance to assess if intended results are being achieved.

The RCMP employs a decentralized policy model, where operational policy functions are performed by all Business Lines and Divisions. Business Lines serve as the national policy centre for their respective areas of responsibility and address policy issues that fall within their mandate. Divisions perform operational policy development functions to address unique divisional differences as a result of inquiries, jurisprudence or provincial legislation. The Policy and Publications Section (PPS) within Specialized Policing Services (SPS) is responsible to review, edit and publish all national policy for the Manuals. Divisional Supplements are published by the Division's Forms and Directives unit.

Internal Audit, Evaluation and Review (IAER) conducted an Audit of Policy Management - Phase One in 2018. This audit focused on the strategic policy and planning capacity within the RCMP. Upon completion of the Phase One audit, the Audit of Policy Management - Phase Two was initiated with a focus on operational and administrative policy in the RCMP.

The 2018-2023 Risk-based Audit, Evaluation and Data Analytics Plan approved by the Commissioner included the Audit of Policy Management - Phase Two.

2. Objective, scope and methodology

2.1 Objective

The objective of the audit was to assess whether the processes and practices in place to manage operational and administrative policies are effective and consistent across the RCMP.

2.2 Scope

The scope of the audit included all RCMP policies in the Administration and Operational Manuals.

The audit focused on the process and mechanisms in place for operational policy development, approval, publication, and monitoring at the national and divisional levels.

Audit testing included a sample of policies developed or updated between January 2017 and January 2019 within the responsibility of SPS, Contract & Indigenous Policing (C&IP), Federal Policing (FP) and Human Resources (HR).

2.3 Methodology

Planning for the audit was completed in April 2019. In this phase, the audit team conducted interviews, process walkthroughs and examined relevant policies, procedures and results of previous audit work performed.

The examination phase, which concluded in August 2019, employed various auditing techniques including interviews, documentation reviews and data analysis.

A file review was conducted on a sample of policies to test whether various key steps in the policy development process had been carried out. In order to capture a variety of policies across SPS, C&IP, FP and HR, the audit team selected 25 national policies out of a population of 183 policies that had been updated between January 2017 and January 2019.

While the file testing did not include divisional policies, divisional Criminal Operations (CROPS) officers were consulted in all divisions, with the exception of National Division and Depot, on their respective policy development processes and challenges.

Upon completion of the examination phase, the audit team held meetings to validate findings with personnel and debriefed senior management on the relevant findings.

The audit's findings are based on the review of operational and administrative policies during the two-year audit scope period ending in January 2019. However, the audit team is aware that during the scope of the audit, efforts to change the structure and format of the RCMP Manuals were underway with PPS leading the RCMP Policy Renewal initiative. A working group entitled the "RCMP Policy Working Group" was established in December 2017, with policy representatives from various policy centres within the Business Lines and Divisions to work on a collaborative basis to renew the Manuals. PPS has estimated that the policy renewal initiative to modernize the Manuals will be completed in 2023. As the initiative is in progress, it was not subject to the audit. However, the audit team has identified impacts to findings when relevant.

2.4 Statement of conformance

The audit engagement conforms to the Institute of Internal Auditor's International Professional Practices Framework and the Treasury Board of Canada Directive on Internal Audit, as supported by the results of the quality assurance and improvement program.

3. Audit findings

A sound operational and administrative policy framework, that includes the development and periodic updating of policies, timely publishing, communication of changes to employees, and ongoing monitoring and oversight, is critical to ensure that policy is adhered to and guides the actions of employees to achieve organizational objectives.

Accordingly, in regards to the operational and administrative policy development process, we expected to find:

• a well-established and consistent policy development and approval process across the Force
• policies and amendments published in a timely manner and well-communicated across the Force
• policy monitoring mechanisms in place to support compliance and oversight of the Manuals to ensure that a cohesive operational policy framework is maintained

3.1 Policy development

Policy development and approval

The development of operational and administrative policy is an important function within the RCMP to provide the standards of conduct, regulatory requirements, and expectations under stated circumstances to support operational performance and officer safety. Key elements of the policy development process include: developing and approving policy in a structured manner; providing policy direction; conducting research and consultations with key stakeholders; considering Gender-Based Analysis Plus (GBA+) principles; and aligning national policy and divisional supplements. A policy development process for operational and administrative policy was not documented for the RCMP.

The audit found that each Business Line had a distinct approach to developing operational and administrative policy. As identified and reported in the Audit of Policy Management - Phase One, we found that the RCMP employed a decentralized policy development model to manage operational and administrative policy, with reliance on subject matter experts (SMEs) who have the operational expertise to contribute to policy development. Each Business Line had a different approach for the Manuals policy development process.

Within C&IP, the Operational Policy and Compliance (OP&C) Unit within the National Criminal Operations initiates, co-ordinates and is responsible for operational policy that directly impacts police operations. The OP&C unit formalized the policy development process and created a checklist of key activities to be completed. The OP&C acts as a resource for other policy centres within the Business Line.

Within FP, the Operational Policy Unit within the FP Strategic Direction is responsible for coordinating the operational policy development process through to publication, including editing policy. Upon request, the Unit provides guidance to policy centre SMEs within the Business Line who are required to write policy. Within SPS, each policy centre is responsible to develop their own approach for policy development. Program areas included in the audit generally had dedicated policy specialists to assist with operational policy development and alignment of content to publishing standards. The program area policy resources engaged SME's as needed to develop operational policy.

Within HR, each policy centre is responsible to develop their own approach for operational and administrative policy development, with most relying on SMEs to develop their policies.

While no evidence of a formalized policy development process was identified across Business Lines, all Business Lines were found to follow the same process for approval of national policy. The AM ch.III.4 states that approvals for routine administrative or operational program changes should be approved by the Assistant Commissioner, Director General or Director responsible for the respective program or service. Audit testing was conducted to assess if policies complied with the approval requirement.

File testing identified that 21 out of 25 files included evidence of approvals compliant with the AM requirement. The remaining four files did not retain any documentation related to the policy development process. While no documentation was available for these files, the responsible policy centres noted during interviews that approval had been obtained. As the policy publication process for the national Manuals includes confirmation of approval by PPS prior to publication, the audit team believes there is limited risk that a policy would not be approved in compliance with the AM. Results of the audit testing by Business Line are in the table below.

At the divisional level, the CROPS office is generally responsible for policy development for their Division, and policy supplements are approved by the Division's Commanding Officer or their delegate. SMEs within the Division contribute their operational knowledge and expertise to support the policy function.

The audit did not find evidence of a formalized policy development process that was consistently applied across the Divisions. Only two Divisions provided evidence of a formal policy development process as noted in the table below. As the audit's scope did not include testing of divisional policy supplements, the approval of divisional files was not assessed.

The lack of a documented process across all Business Lines and Divisions increases the risk that policy will be developed without appropriate consideration of key elements in the policy development process. This could result in inconsistent policies across the organization, which can impact operational performance, acceptable standards of conduct, and exposure to liability.

Policy direction

As the organization's strategic direction and priorities change, it is important that the organization's policies align with these changes. In addition, external factors such as changes to legislation and regulations can give rise to the need to modify policy.

Interviews with policy centres in each of the Business Lines identified that policy direction was provided by RCMP management. Changes to policy may result from feedback from policy users, as well as changes to legislation, court decisions, or technical and scientific standards.

Policy direction can also arise based on changes to departmental strategy and priorities from senior management. Where a policy centre determines that an operational or administrative policy is of national significance they may seek senior management approval. For example, during the audit scope period the Senior Executive Committee (SEC) reviewed draft policy amendments to provide direction on the Investigation and Resolution of Harassment Complaints (AM ch.XII.8) and the RCMP Member Long Service Awards (AM ch.22.4).

Interviewees in all Business Lines stated that policy direction had been provided when developing operational or administrative policy. Testing found evidence of policy direction provided in 19 of 25 files examined. Documentation was not maintained for the remaining 6 policy files. Results of the audit testing by Business Line are in the table below.

Overall, policy direction was provided based on requirements and priorities within the organization, however, documented evidence of policy direction was not consistently retained. Policy direction serves to ensure that policy appropriately addresses the needs and emerging issues of the RCMP.

Research and consultation

Research and consultation with stakeholders are important steps in the policy development process to ensure policy issues are fully understood and buy-in is obtained.

Interviewees in all Business Lines stated that they conducted research and consulted stakeholders when developing operational or administrative policy. The audit found evidence that research was conducted in 17 of 25 policy files examined and consultations were conducted in 20 of 25 files. Research was not documented in 8 policy files and consultation was not documented in 5 files. Results of the audit testing by Business Line are in the table below.

Although research and consultation are important steps in the policy development process, the audit recognized that the extent to which they should be conducted varies depending on the policy. For example, policy development associated with the legalization of Cannabis included substantial research and horizontal consultation across Business Lines and also included consultation with other police forces. In contrast, policy development for the National Economic Profiling Service (OM ch.3.10) included minor changes to the policy and required minimal research and consultation.

As operational and administrative policy is intended to be followed by all employees of the RCMP, we expected that divisional consultation would be conducted to obtain input and assess any operational impacts. We found that divisional consultation was left to the discretion of the policy centre within a Business Line. Only C&IP included a requirement in their policy checklist to conduct divisional consultation.

Of the 25 files tested, 6 of 7 C&IP and 1 of 5 HR policy files included evidence of divisional consultation. The remaining files tested did not have evidence of divisional consultation and the files did not contain sufficient documentation to assess whether divisional consultation would have been necessary.

In addition, the audit team contacted Divisions to determine whether they were consulted by national policy centres during the policy development process. The table on the following page indicates which Divisions stated that they were generally consulted during the national policy development process.^{Footnote 4}

As research and consultations were not consistently documented for operational and administrative policy development, relevant stakeholders may have been omitted from the policy development process. This risk is increased for policy issues of a horizontal nature. Maintaining the results of research and consultations is essential as research supports evidence-based decision making and consultation validates that relevant stakeholder views were considered during policy development.

Alignment of National Policy and Divisional Supplements

According to the AM ch.III.4, Divisions can develop supplemental operational and administrative policies when a directive applies only to their particular area, and when the information is not contained in any national policy. Supplements should not repeat national policy and only local practices unique to a province should be included in divisional supplements. Divisional supplements must be consistent with and aligned to the RCMP national policy.

Divisions can create policy supplements without the involvement of national policy centres. The audit team found examples where divisional supplements did not reference the national policy. For example, seven Divisions (B, D, E, F, H, K, and M) had divisional supplements on Diving Operations but two divisional supplements (K and F) did not reference the national policy (OM ch.52.5). As a result, there is a risk that employees may not be aware that a national policy exists on this topic.

Due to the Force's decentralized model, there is an enhanced risk that policies developed separately at the Business Line and Division level may not be in alignment. The development of divisional supplements without the involvement of national policy centres increases the risk of policy duplication, inconsistencies and negative impacts to officer safety. Alignment between national policy and divisional supplements is key to avoid confusion for employees and to ensure that the Force responds to circumstances in a consistent and appropriate fashion.

Consideration of GBA+

GBA+ is an analytical process used to assess how diverse groups of women, men and non-binary people may experience policies, programs and initiatives.^{Footnote 5} GBA+ also considers many other identity factors, such as race, ethnicity, religion, age, and mental or physical disability. Implementing GBA+ is a Government of Canada commitment and as such the Force has a responsibility to determine whether there are potential impacts on diverse groups of employees within proposed policies. Where such impacts are identified, the Force is expected to undertake a thorough and complete GBA+ assessment.^{Footnote 6}

During interviews all Business Lines stated that they review policy to ensure the use of gender neutral language. However, interviewees could not identify any further specific analysis that had been conducted related to GBA+ considerations (such as age, culture, education, ethnicity, race, ability, geography, etc.). Interviewees informed us that they were aware of GBA+ principles and that employees had completed the RCMP mandatory GBA+ training. C&IP updated their policy checklist in 2018 to include a requirement to assess whether there were GBA+ considerations during policy development. Other Business Lines did not have policy checklists or other formal tools to help identify GBA+ considerations.

The audit found evidence of consideration of GBA+ principles when developing policies in only 3 of 25 files examined. The audit recognizes that some policies may have minimal GBA+ considerations. However, testing indicated that most policy files lacked documentation to confirm if any analysis had been conducted to identify whether a policy had the potential to impact diverse groups of people differently. Results of the audit testing by Business Line are in the table below.

Interviews with officials in the GBA+ Unit identified that the Unit is available to provide guidance to employees to assist them in considering GBA+ principles when developing policy, although there is no formal requirement to consult them during the policy development process within the RCMP.

Lack of consideration of GBA+ principles in the policy development process may indicate that the impacts of policy on diverse groups are not consistently examined, increasing the risk that policy may have unintended consequences and impacts on diverse groups of employees.

Training and tools

Business Lines use different approaches to develop operational and administrative policy and rely on SMEs with operational expertise to contribute to policy development. As the development of policy is an infrequent duty for SMEs, it was expected that employees involved in the policy development process would have access to training, tools and guidance necessary to successfully carry out the policy development process.

The audit team found no evidence of national guidance for the policy development process or training available to assist employees to develop operational and administrative policies, with the exception of a publication guideline developed by PPS, a unit within SPS. PPS has a Policy Writing Guide on the RCMP Infoweb that is available to all employees across the RCMP to assist them with preparing a policy for publication. In addition, PPS has developed a checklist for editors to use for their revisions to policy. C&IP has created a checklist of key activities to be completed when developing policy.

In the absence of national tools and training on how to develop operational and administrative policy, two Divisions (E and H) developed a formal policy checklist to support policy development. There is an opportunity to leverage tools created by Business Lines or Divisions to develop national guidance to be used across the Force.

Interviews with policy centres within C&IP, FP, SPS and HR tasked with developing policy identified that training was primarily on-the-job and employees developed expertise through trial and error. In addition, interviewees in all Business Lines identified that it was challenging for SMEs to develop operational and administrative policy without training and guidance to help them through the process.

A lack of tools, training and guidance related to operational and administrative policy development increases the risk that policy centres may not incorporate key elements of the policy development process. This may result in inconsistent policy development or policy which does not effectively support operations. The development of national guidance tools and training would help ensure that all employees have a common understanding of the process.

3.2 Policy publication

Publication timeliness

The AM ch.III.4 states that all RCMP policy must be published in the AM, OM, and their corresponding subsidiary manuals, and policy centres must use the RCMP Manuals to disseminate policy. Failing to publish policies in the Manuals can cause confusion for employees and can result in legal consequences where actions are taken that do not align with published policy.

PPS is the publishing authority within the RCMP and is responsible for the publication of national policies in the Manuals. PPS had developed a process to prioritize the publishing of the operational and administrative policies. PPS, in consultation with the relevant policy centre, assigned a priority level (1=high, 2=medium, 3=low) to policies they received for publication based on operational urgency, departmental priorities and consideration of officer safety. The audit team noted that PPS had not established service level standards with the expected length of time for the publication of operational and administrative polices.

As of January 2019, PPS had a backlog of 41 policies in a queue waiting to be published. Almost half of the policies in the queue were identified as high priority (16 of 41). Policies in the publication queue experienced delays of an average of 167 days (approximately six months). Some of these policies related directly to officer safety, such as Seizure of Drugs (OM ch.6.8), Explosives Disposal (OM ch.33.3), and Immediate Action Rapid Deployment (OM ch.16.10). The Audit of Policy Management - Phase One identified that PPS had a backlog of 135 policies waiting to be published as of April 2018. PPS identified that they experienced resource constraints to maintain all national policies for the RCMP. While improvements had been made to reduce the backlog of policies awaiting publication, the average length of time for publication indicated there were still challenges in publishing policy in a timely fashion. As a result, there is a risk that members will not have access to the policies they need in order to carry out operational policing activities.

The audit team reviewed 20 policies in the publication queue that were the most outdated (20/41) to determine the reason for publishing delays. When policies are submitted by a policy centre for publication, PPS reviews the policy to ensure it is correctly formatted and aligns with publication standards for the RCMP Manuals. The length of time to complete this depends on the size and complexity of the policy and availability of resources. The audit found that approximately half of the policies (9 of 20) awaiting publication had not yet been processed by PPS, and 5 of the 9 policies were assigned high priority.

For the remaining half of the policies (11 of 20), PPS was awaiting a response from the policy centre as a result of the PPS review. Five of the 11 policies were assigned high priority. PPS may request that the policy centre revise the policy due to formatting and editing issues or a lack of appropriate approvals, resulting in the file waiting in the queue until the issue is addressed by the policy centre. As such, delays can arise when a policy centre does not respond in a timely manner.

Interviewees from eight policy centres across Business Lines identified that operational priorities limit the time they spend on policy development, particularly when relying on SMEs for the policy revisions. This may impact how quickly a policy centre can address PPS' feedback and resubmit a policy for publication.

Interviewees also informed us that they may informally communicate a revised policy to employees before it has been formally published in the RCMP Manuals if there are delays. The delays in the publication process present a risk to the RCMP if members act on revised policy that is not formally approved and may be in conflict with the formal documented policy, particularly for high-risk programs. This risk was previously mitigated by the publication of bulletins. Bulletins were used to communicate changes to a policy if circumstances prevented timely publication in the Manuals. The bulletins were intended to communicate immediate changes while the policy was in the process of being updated. A bulletin was intended to be retained for a maximum of three months, after which it would be incorporated into the official policy or removed. However, bulletins were discontinued by PPS in spring of 2018 for policies in the Manuals to avoid policy centres issuing bulletins but not incorporating them in their policies in a timely manner. In addition, some bulletins remained active even though a policy had been updated, which led to confusion for employees.

The backlog of policies awaiting publication increases the risk that high priority policies are not being published in a timely manner, which could impact officer safety.

Communication of policy

For policy to effectively assist its end users, new policies and amendments need to be effectively communicated across the organization. The audit found that Business Lines used a variety of methods to communicate national policy amendments depending on the significance and impact on operations. Audit testing of policy files indicated that these methods included emails to divisional CROPS from national policy centres, news broadcasts, internal newsletters, RCMP Infoweb updates, and teleconferences. More than one method may be used, depending on the importance of the policy and audience to be reached.

We found that in Divisions, CROPS communicated divisional supplement updates throughout the divisional chain of command with the use of directives, divisional intranet sites or emails.

The results of the audit file testing for the communication of new policy, or updates, indicated that 25 of 25 of the policies had been communicated by Business Lines to employees as indicated in the table on the following page. The method to communicate the policies was primarily through the RCMP Infoweb.

Availability of historical policy

The RCMP historical collection of operational and administrative policies is maintained by the Historical Directives Unit within PPS. The PPS is responsible for retaining policies and sending holdings to the Library and Archives Canada for proper preservation based on retention schedules. Maintaining an historical archive of previous versions of policy is important for the RCMP to provide evidence of policy decisions where the RCMP is challenged to explain its practices during court proceedings.

Interviews with Historical Directives employees and a walkthrough by the audit team of the process to search and retrieve historical policies indicated that previous versions of policies are stored and are available upon request. However, the audit team noted that the Historical Unit experienced challenges with the system used to store policies. For example, the system did not have a search capability, requiring employees to manually search their records to find policies. This can be time consuming and impact the efficiency of searching for archived policies when needed.

The RCMP Policy Renewal led by PPS proposed to the Senior Management Team (SMT) the development of a web portal to make historical versions available and to facilitate a search capability by policy users in a self-serve format. While this initiative was endorsed by the SMT it is still in its preliminary phase and formal authorities and approvals have not yet been obtained.

3.3 Monitoring and oversight

Oversight

The Commissioner's Foreword in the AM states that the Chief Information Officer (CIO) is responsible for the management of the RCMP Manual System. It was expected that an oversight function would be in place to ensure that policies in the Manuals were consistent in format, clear and concise, complied with a Force-wide policy development framework, and that deficiencies would be addressed in a timely manner.

In practice, the audit found that the CIO's responsibility extended to publishing national policies on the Infoweb. The audit team did not find evidence of management oversight assigned within the RCMP to provide governance for the entire policy development process for the Manuals. Policy owners within Business Lines and Divisions were responsible to manage and provide management oversight for their respective policies. The decentralization of responsibility has contributed to inconsistent policy formats in the Manuals, resulting in a voluminous policy suite that may be difficult for employees to navigate. Oversight of operational and administrative policy is needed to ensure that the RCMP has a relevant operational policy framework for the Manuals.

The RCMP Policy Renewal initiative has been launched by PPS to address the deficiencies in the Manuals, such as inconsistent formats and policies not being updated in a timely fashion. The audit team was informed that PPS's vision is to become the hub for operational and administrative policy renewal to ensure consistent policy standards, support policy centres, enforce periodic review of policies RCMP-wide, and maintain accountability for the entire policy life cycle for the Manuals framework. However, PPS stated that they did not currently have formal oversight authority to implement their vision.While outside the audit scope period, the audit noted that PPS presented their vision for policy renewal to the National Integrated Operations Council in May 2019, and to the SMT in June 2019 where they received endorsement for the initiative. The RCMP Policy Renewal initiative was also formally supported by Vision 150 under the "Our Stewardship" pillar.

While the RCMP Policy Renewal initiative may play a significant role in the RCMP's policy modernization efforts, formal accountability and oversight have not been assigned to ensure that all policy centres and Divisions comply with the requirements. Modernization of the Manuals will depend on the cooperation and effort of all policy owners within Business Lines and Divisions and their commitment to meet timelines. Without formal assignment of oversight, there is a risk that policy centres may not dedicate the effort needed and PPS may not have the accountability and authority to implement the activities needed and secure appropriate funding for the success of the Renewal initiative. Oversight of the Manuals would also ensure that modernization will provide a coherent policy framework for the Manuals, including consistency in policy format and user accessibility.

Periodic policy updates

As the RCMP operates in an environment of constant change, there are a variety of internal and external factors that result in the need to update policy, including changes in organizational priorities, changes in legislation, and issues identified during daily operations. It was expected that policy centres within all Business Lines would update policy on a periodic basis to assist the RCMP in ensuring that its policies are current and relevant.

The audit team was informed by national policy centres that they updated their policies on an ad hoc basis in response to factors such as a change in legislation, regulatory or legislative changes, results of a court case, or feedback from members.

The audit performed an analysis of the current inventory of RCMP policies within the Manuals as of March 2019. The analysis revealed that 360 of 904 (40%) policies had been updated within the last 5 years. The remaining 60% of the policies had not been updated in more than 5 years. The results of the analysis by Business Line are in the table below.

Policy centre interviewees from all Business Lines informed the audit team that competing operational priorities, reliance on SMEs who have limited availability, and insufficient dedicated policy resources may have prevented the periodic update of policies, resulting in many outdated policies.

Updating policies on an ad hoc basis increases the risk that policies remain outdated for long periods of time. As changes occur in the operational environment or in legislation, current policy may no longer be factually correct and may not be compliant with laws and regulations. Outdated policies also present a risk of increased exposure to member safety if members respond to changes in the environment with actions that may be in conflict with the formal documented policy, particularly for high-risk programs. A systematic process where Business Lines adhered to a schedule to update all policies on a periodic basis would ensure the integrity of the Manuals.

Monitoring for compliance

Policies are an important component of the RCMP as they provide guidance on health and safety, appropriate conduct, and regulatory requirements. As such, it is important to monitor compliance with policy to ensure that members and employees follow guidance and make consistent decisions. It is also essential to monitor policy in order to assess whether changes to policy are required.

Interviewees with all Business Lines informed the audit team that they had not established a monitoring process to ensure that employees complied with policies, but relied on day-to-day management activities as a method to informally assess if policies were being followed. While this information can provide indicators of potential issues with policies, it cannot replace information gathered through a formal process to assess whether policies are being adhered to, particularly for high-risk programs. It was noted that C&IP was in the process of developing a National Operational Policy Compliance Framework which was in draft stage during the audit.

Divisions also relied on day-to-day management activities as a method to informally assess if policies were being followed. Four Divisions identified formal mechanisms to monitor compliance with divisional policy supplements as indicated in the table below, which included Unit Level Quality Assurance (ULQA) tracking and high-risk reviews.

ULQAs are a tool designed to assess compliance with operational, financial, administrative, and program responsibilities, focusing on high-risk activities. They are used by Detachment and Unit Commanders to assess the level of adherence with specific policies by their employees. ULQAs are incorporated into the Detachment Performance Plan and the Unit Performance Plan as per divisional requirements. Units conduct ULQAs based on their assessment of risk in certain areas, which includes assessing compliance, determining why deficiencies have occurred and noting good practices. When deficiencies are identified, proper corrective action must be taken and monitored.

In 2009, the ULQA Handbook was developed by National Review Services (NRS) to provide information for the implementation and maintenance of the ULQA process. However, the Handbook has not been updated since 2009 and the NRS group was dissolved in 2011 based on a decision by the SEC.

Business Lines and policy owners are responsible for developing, updating and sending ULQAs to the RCMP repository. Currently, IAER holds the repository of ULQAs. However, IAER is not responsible for maintaining the repository, nor managing the implementation of ULQAs as per the 2011 SEC decision.

The audit team conducted an analysis of the frequency of access of the ULQA repository to assess if it was being used for policy compliance. The analysis indicated that ULQAs were requested approximately 208 times from March 2018 to February 2019. However, the analysis could not inform the audit whether the ULQA guides were used to monitor policy or whether they were requested for another reason. The analysis found that one ULQA guide was updated in 2018, two guides were updated in 2017, and there were no updates sent to the repository in 2016 and 2015.

ULQAs could be a useful tool to monitor policy compliance at the organization level if results were aggregated and forwarded to responsible Business Lines for analysis. ULQAs could be used to identify policy issues and changes that may be needed. Monitoring compliance with policy by Business Lines and Divisions would ensure that policies are understood and followed. In order to be effective as a policy monitoring mechanism, the use and maintenance of ULQAs should be reviewed, with the intent to identify an appropriate owner in the organization to maintain the repository and manage the use of ULQAs.

4. Conclusion

The management of operational and administrative policy is an important function within the RCMP to support effective decision-making, operational performance and officer safety. In order to maintain an effective operational and administrative policy Manuals framework, a strong policy development process needs to be in place to ensure that policies provide clear direction to employees across the RCMP.

The audit concluded that the operational and administrative policy development process could be strengthened to ensure that policies are developed in a consistent manner across the Force. This includes conducting key elements of the policy development process, such as evidence-based research, adequate stakeholder consultation, and consideration of GBA+ implications.

Areas for improvement include assigning oversight for the Manuals framework along with clearly establishing policy owner responsibilities, providing national guidance tools and training to employees who are responsible to develop policy, and establishing service level standards for publishing policy. In addition, updating policies on a periodic basis is needed to maintain a relevant operational policy suite, as well as creating policy monitoring mechanisms to ensure compliance with policy. Further improvement opportunities exist to assign responsibility for the management of ULQAs as they may be a useful tool in monitoring policy compliance and mitigating risks.

The RCMP Policy Renewal initiative led by PPS has the potential to play a significant role in the RCMP's operational and administrative policy modernization efforts. However, formal accountability has not been assigned to ensure that all policy centres dedicate resources and participate in this initiative to meet the timeline for modernization of the Manuals.

5. Recommendations

1. The Deputy Commissioner SPS, Deputy Commissioner FP, Deputy Commissioner C&IP, and the Chief Human Resource Officer should identify a central unit that will be responsible to create a centre of policy development expertise for the RCMP Operational and Administration Manuals. The unit should develop:
   1. A policy development process to be used Force-wide‎, which includes consideration of GBA+ principles.
   2. Common policy development, compliance monitoring, and file documentation tools to provide guidance to policy centres and Divisions.
   3. A schedule to update policies in the Manuals on a periodic basis, along with an approval mechanism and annual reporting to ensure policy centres within Business Lines and Divisions adhere to updating the Manuals.
2. The Deputy Commissioner SPS, Deputy Commissioner FP, Deputy Commissioner C&IP, and the Chief Human Resource Officer should assign responsibility for the management of ULQAs to the appropriate unit, including reviewing and updating the ULQA Handbook
3. The Deputy Commissioner SPS, Deputy Commissioner FP, Deputy Commissioner C&IP, and the Chief Human Resource Officer should implement the Force-wide policy development process within their respective Business Line that includes:
   1. Updating policies on a periodic basis in compliance with a central schedule.
   2. Developing monitoring mechanisms for policy compliance to ensure policies are adhered to and risks are mitigated by policy centres. Monitoring should include the analysis of aggregate ULQA results, if relevant, or other tools used for monitoring.
4. The Deputy Commissioner SPS should establish formal service standards for the publication process to ensure policies awaiting publication are managed effectively and timely.

Appendix A – Audit objective and criteria

Appendix B – Management action plan

Footnotes

Date modified:

2021-02-25