Evaluation of the IRB Process for making a complaint about a member - Management response and action plan

​​​​​​​​​​​​​​​ThemeRecommendationResponseManagement action planArea responsibleExpected deliverables per actionExpected completion date
There are 8 recommendations in this MAP:
  • 5 are related to implementation;
  • 3 relate to effectiveness and efficiency
The IRB has accepted all of the recomme-ndationsWhile there are 31 action items listed in this MRAP, consultation and engagement with external stakeholders and internal personnel will occur simultaneously for recommendations, resulting in 23 distinct action items.The Ombudsperson’s Office is responsible for all action itemsWhile there are 31 deliverables listed in this MRAP, several occur simultaneously or satisfy multiple action items, resulting in 21 distinct deliverables.All items will be completed by end of Q4 2021-22
Implementation: accessibility and use
1. Promote understanding of the complaints process with outreach activities for both internal and external stakeholdersAccept

The IRB has taken recent steps to increase awareness and understanding of the complaints process by improving communications with parties involved in the complaints process. 

In addition, the Ombudsperson’s Office which is responsible for managing the complaints process, is currently engaged in internal outreach regarding the roles and responsibilities of the Office. This includes providing information on the complaints process to new and existing members.

The IRB will seek further opportunities for outreach with stakeholders:

1.1 Developing guidance materials for the complaints process - for example, clarify the scope within which a complaint can be submitted and the process through which the complaint is addressed.

1.2 Publish guidance materials on the IRB website and intranet.

1.3 Consult with external stakeholders to identify other potential means of increasing awareness and understanding.

1.4 Implement identified options where feasible.

Ombudsperson Office

1.1 New guidance documentation

1.2 Link to new guidance on IRB website and intranet

1.3 Consultation documents

 1.4 Listing and supporting documentation of further outreach actions.

1.1 Q3, 2021-22

1.2 Q3, 2021-22

1.3 Q3, 2021-22

1.4 Q4, 2021-22 and ongoing

2. Consider methods to limit sharing the identity of complainants until it is determined that a complaint is within scope and will be investigated.Accept

The IRB recognizes that complainants may have concerns around confidentiality particularly if they appear before the IRB and potentially the same member multiple times.

The IRB will:

2.1 identify options to limit sharing the identify of complainants without jeopardizing procedural fairness for members.

2.2 Consult with stakeholders on options identified (Dependent on delivery of 3.2 and occurs concurrently with 3.3 of this MAP).

2.3 Revise procedures (Occurs concurrently with 3.1 and 3.5 of this MAP).

2.4 Promote awareness of procedures (Occurs concurrently with 3.6 and 3.7 of this MAP)

Ombudsperson Office

2.1 Options identified

2.2 Record of consultation with internal and external stakeholders

2.3 Revised Complaints Procedure document

2.4 Documentation supporting awareness of revised procedures

2.1 Q2, 2021-22

2.2 Q3, 2021-22

2.3 Q4, 2021-22

2.4 Q4, 2021-22 and ongoing

Implementation: clarity and coherence
3. Review the Code of Conduct and its intersection with the 2017 Procedures to clarify the scope of the complaints process in consultation with stakeholders.Accept

The IRB is committed to continuous improvement of the complaints process and has already taken steps to improve communications with parties by providing more details about decisions regarding whether a complaint will be investigated.  

In addition, the IRB will:

3.1 ​Draft revised Procedures based on intersection with the Code of Conduct to clarify scope of the complaints process. This will include minor adjustments to the Code of Conduct, as appropriate.

3.2 Prepare consultation documentation identifying proposed changes to the Procedures (also factoring in other revisions to the Procedures identified in this MAP).

3.3 Engage external stakeholders to discuss proposed revisions to the Procedures. (Occurs concurrently with 2.2)

3.4 Engage internal stakeholders via email/focus discussions regarding proposed revisions to the Procedures.

3.5 Finalize the revised Procedures following consultations. (Occurs concurrently with 2.3 of this MAP)

3.6 Publish the revised Procedures on the IRB website and intranet.

3.7 Promote awareness through outreach and communications products such as updated guidance materials on the IRB website/intranet, revised training materials sessions for members and information sessions with external stakeholders.

Ombudsperson Office

3.1 Revised Complaints Procedures (draft) document

3.2 Documentation outlining proposed changes for consultation including Procedures.

3.3 Record of consultations with external stakeholders (delivered concurrently with 2.2)

3.4 Records of consultation sessions with internal stakeholders

3.5 Revised Complaints Procedures (same deliverable as 2.3)

3.6 Link to IRB website/intranet

3.7 Key documentation such as revised training materials, revised guidance documents and links to IRB website, awareness sessions (same deliverable as 2.4)

3.1 Q2, 2021-22

3.2 Q3, 2021-22

3.3 Q3, 2021-22

3.4 Q3, 2021-22

3.5 Q4, 2021-22

3.6 Q4, 2021-22

3.7 Q4, 2021-22 and ongoing

Implementation: transparency
4. Consider approaches to enhance transparency in terms of improvements in communications with parties, clarification of criteria used at key points in the process, and promotion of annual reporting.Accept

The IRB has taken steps to improve communications with parties such as more frequent communications with complainants when cases are held in abeyance, clearer articulation of key points in the process in correspondence with parties and promoting informal resolution options with parties as well as publication of an annual report on complaints.​

In promoting the annual report on complaints, the IRB communicates with internal and external stakeholders via email and letter from the Chairperson, respectively, that the report has been published. Hyperlinks to the report on the external website are provided. 

4.1 Identify additional options to enhancing transparency in terms of communication.

4.2 Consult with stakeholders. (Occurs concurrently with 2.2 of this MAP)

4.3 Implement further approaches identified.

Ombudsperson Office

4.1 Documentation of additional communication approaches

4.2 Record of consultations (same deliverable as 2.2)

4.3 Documentation of approaches implemented

4.1 Q2, 2021-22

4.2 Q3, 2021-22

4.3 Q4, 2021-22

5. To assist with reporting and ensure all variables of interest are captured, consider improvements to the method used to track data on complaints.Accept

The IRB has made available comprehensive data on the complaints process beginning with the 2019 annual report.  This report was published in April 2020 which was after the period under review for the Evaluation.

The IRB will continue to publish comprehensive data on the complaints process through the annual reporting process.

The IRB will:

5.1 Identify additional variables of interest as part of the planned consultation with stakeholders on the revised Procedures.  (dependent on the delivery of 2.2 of this MAP)

5.2 Modify reporting method as appropriate

Ombudsperson Office

5.1 Supporting documentation and Record of consultations with internal; and external stakeholders (same deliverable as 2.2 and 3.4)

5.2 Revised reporting methodology

5.1 Q3, 2021-22

5.2 Q3, 2021-22

Effectiveness and efficiency: Investigations and outcomes
6. As part of the review of the Code of Conduct and 2017 Procedures, consideration should be given to what remedies and sanctions should be available, the criteria for their use, and what follow-up steps should be in placeAccept

The IRB is committed to a fair and transparent complaints process.  The 2019 Code of Conduct for Members identified corrective and disciplinary measures that may result from a breach of the Code (Sec. 17).

The IRB will:

6.1 Further clarify disciplinary and corrective measures in the revised Procedures and/or related guidance materials regarding the remedies and sanctions, criteria for their use and follow up steps.

6.2 Consult with stakeholders regarding revised procedures (Occurs concurrently with 2.2 of this MAP)

6.3 Publish revised procedures (Same action as 3.6)

6.4 Promote awareness of revised procedures (Same action as 3.7)

Ombudsperson Office

6.1 Draft of revised procedures (same as deliverable 3.1)

6.2 Record of consultation with internal and external stakeholders (same deliverable as 3.3 and 3.4)

6.3 Revised Complaints Procedure document (same as deliverable 2.3)

6.4 Documentation supporting awareness of revised procedures (same deliverable as 2.4 and 3.7)

6.1 Q2, 2021-22

6.2 Q3, 2021-22

6.3 Q3, 2021-22

6.4 Q4, 2021-22 and ongoing

Effectiveness and efficiency: Credibility, impartiality, and procedural fairness
7. Consider methods to further support the credibility of the complaints process, such as the use of external investigators and either sharing OI recommendations and external investigator’s conclusions or indicating whether they were followed.Accept

Stakeholder confidence in the complaint process is critical to having an effective mechanism in place.

The IRB shares recommendations and conclusions in investigators’ reports, including reports of external investigators, with the parties.

The IRB will:

7.1 Identify options and assess methods for further supporting transparency and credibility including the use of external investigators.

7.2 Revise processes as appropriate, following options analysis

Ombudsperson Office

7.1 Options analysis documentation

7.2 ​Document demonstrating revised process as appropriate

7.1 Q2, 2021-22

7.2 Q2, 2021-22

Effectiveness and efficiency: Efficiency
8. Set service standards for timeliness of service.Accept

The IRB Member Complaints Process has operated under the 2017 Procedures for three years and therefore has gathered historical data regarding the key phases of the process.

8.1 Establish and post on website service standards for IRB complaints process.

8.2 Monitor and report on timeliness service standards

Ombudsperson Office

8.1 ​a) Recommended timeline options and approval documentation
b) Link to published service standards on IRB website

8.2 a) Develop data monitoring dashboards for service standards
b) Link to data monitoring dashboard on IRB website

8.1 a) Q1, 2021-22
b) Q2, 2021-22

8.2 a) Q3, 2021-22
b) Q​4, 2021 2022