Report to: General Committee Date Report Authored: December 1, 2010
SUBJECT: 2010 Quality Management System Management Review Outcomes
PREPARED BY: Eddy Wu, P.Eng. ext. 2737
Waterworks Quality Management System Controller
RECOMMENDATION:
1) That the report entitled “2010 Quality Management System Management Review Outcomes” be received;
2) That Council, as the Owner of the Town’s drinking water system, acknowledge and support the outcomes and action items identified from the 2010 Management Review;
3) That Council, as the Owner of the Town’s drinking water system, acknowledge and endorse the revisions make to the Town’s QMS documentation as the result of the annual document review as outlined in Attachments “C” & “D”;
4) And further that Staff be authorized and directed to do all things necessary to give effect to this resolution
EXECUTIVE SUMMARY:
Not applicable
The purpose of this report is to:
1. Update the Owner on the status of all outstanding Management Review action items;
2. Communicate outcomes from the 2010 Management Review to the Owner;
3. Request the Owner to endorse the revised two (2) System Level Documents
With the introduction of the new Municipal Drinking Water License Program from the Ministry of the Environment in 2007, one of the requirements for each Operating Authority of a drinking water system is to implement a Quality Management System (QMS) that complies with the Drinking Water Quality Management Standard (DWQMS). There are 21 elements in the DWQMS, and the Operating Authority must undergo the accreditation process in order to obtain the QMS accreditation. The accreditation process consists of a desk top audit and an on-site audit performed by the accreditation body. These audits are performed in order to evaluate if the implemented QMS complies with all 21 elements and if they are functioning properly.
Element 20 of the Drinking Water Quality Management Standard (DWQMS) requires a Management Review to be conducted at least once every twelve (12) months. It is required by DWQMS that the outcomes from each Management Review is reported to the Owner. The report brought forward to the Owner’s attention is summarizing the outcomes from the Management Review, together with action items identified within the meeting. The update of each previously identified action item is also reported to the Owner so that the Owner is fully aware of the status of each action item.
DWQMS Element 20 states that the Management Review is to evaluate the continuing suitability, adequacy and effectiveness of the QMS and that includes consideration of:
a. incidents of regulatory non-compliance,
b. incidents of adverse drinking-water tests,
c. deviations from critical control point limits and response actions,
d. the efficacy of the risk assessment process,
e. internal and third-party audit results,
f. results of emergency response testing,
g. operational performance,
h. raw water supply and drinking water quality trends,
i. follow-up on action items from previous management reviews,
j. the status of management action items identified between reviews,
k. changes that could affect the QMS,
l. consumer feedback,
m. the resources needed to maintain the QMS,
n. the results of the infrastructure review,
o. Operational Plan currency, content and updates, and
p. staff suggestions
The Management Review inputs are structured to include all the above required items as per DWQMS. These inputs are maintained by the Waterworks QMS Controller (Eddy Wu) for recording purposes and as objective evidence to prove that the Town is in compliance to DWQMS Element 20.
Council, as the Owner of the Town’s drinking water system, has the overall responsibility and authority to ensure that the Town meets all legislation and regulatory requirements. The Owner also has the responsibility and authority to provide infrastructure and Quality Management System (QMS) resources as required and agreed upon with the designated Top Management Therefore, it is very important for the Owner to be aware of the Management Review outcomes.
This is the fourth Management Review the Town had since the implementation of QMS. The first one was held in November 2008, with the second one held in September 2009. In 2010, the frequency of the Management Review has been changed to bi-annual instead of annually. An interim Management Review has been held in April 2010, and this is the second Management Review of this year. All Management Reviews were held with an identical agenda, with the same attendees invited to the meetings which consisted of the Corporate Top Management (Chief Administrative Officer, Commissioner of Community and Fire Services, Director of Operations and Waterworks General Manager) and the Operational Top Management (Waterworks General Manager, Manager of Information Management System, Manager of Infrastructure, Manager of Operations & Maintenance, Manager of System Engineering, QMS Controller and Training Coordinator).
The first bi-annual (interim) Management Review was held on April 22, 2010 with selected agenda items deferred to the final Management Review which was held on November 30, 2010 where all agenda items were covered. The meeting information package is maintained by the QMS Controller as part of the controlled records for the Management Review and is readily available upon request.
Below are the key highlights from this Management Review:
1.
Action Items review
There were eighteen (18) outstanding action items from the previous Management Review meetings. Eight (8) of these action items were deemed completed before this meeting. The status of the remaining ten (10) incomplete action items were reviewed and updated during this Management Review. From the review, three (3) more action items were deemed completed and the remaining seven (7) were either not due for completion yet, or received later completion dates. Detail of each action item from previous meetings is shown in Attachment “A”.
From this Management Review, six (6) new action items were identified. Detail of each new action item identified is shown in Attachment “B”.
2.
System Performance Summary
In previous meetings, Waterworks established the period of August 1 to July 31 as the annual period to review and compare water quality data. In the 2009-2010 period a total of eight (8) adverse water quality incidents (AWQI) with microbiological tests (decreased from fourteen (14) in 2009) and one (1) with chlorine test (same in 2009) were discovered. No AWQI incident was found in both 2009 and 2010 period for other chemical parameters. Also in the 2009-2010 period there was one (1) incident (comparing to three (3) in the 2008-2009 period) of regulatory non-compliance. Overall, with close to 3600 water quality tests performed in both periods, improvements have been shown by the reduction in AWQI incidents and regulatory non-compliance.
Waterworks IMS Manager briefly reviewed the new dashboards his group designed. These dashboards would allow management to have real time access for service level and performance data for all work critical activities, and customer service requests once fully developed. This would allow management to have better view of how staff performs in each task for evaluation purpose.
3.
Risk Assessment Review
Outcomes
A team of Waterworks staff completed the annual review of the Risk Assessment Outcomes in May 2010. With improved monitoring processes and better communication with other parties involved, the team has reduced the total risk score for three (3) risk events. These changes are:
·
Risk #1 - Air Valves: Negative
pressure in system causing the introduction of contaminated water via submerged
air valves. New preventive maintenance program for air valves was introduced in
2010 resulting in regular inspection. As a result, the Detectability Score has
been dropped from 4 to 3, with total Risk Score being dropped from 9 to 8
·
Risk #16 - Design issue in New
Development Infrastructure: Infrastructure incorrectly sized. With the
implementation of a new Drinking Water works Permit approval process,
Waterworks has been able to identify any design issue with new development
infrastructure more effectively. This allows the Detectability Score to drop
from 4 to 2, with total Risk Score being dropped from 10 to 8
·
Risk #6 - Hydrant Usage: Fire
Department causing sustained negative pressure at high points in the system
when using hydrants at lower elevation, or causing a high flow in a small
diameter watermain. Waterworks and Fire Department met and agreed on the impact
on the water system. An interim measure involving education of Fire Department
staff is in place as described in Attachment “B” item #6. As a result, the Likelihood
Score has been dropped from 3 to 2, Detectability Score has been dropped from 4
to 2, with total Risk Score being dropped from 10 to 7
These changes result in a Document Change Request for the System Level Document 8a Risk Assessment Table. The revised document is shown in Attachment “C” and re-endorsement of this document from the Owner is required.
4.
Overview of Operational Plan
The annual review of the QMS Operational Plan
and the seventeen (17) System Level Documents (SLDs) were completed in the summer
2010. No major changes are deemed necessary as most of these controlled
documents reflect the current practices with the exception of two SLDs:
·
SLD 8a
Risk Assessment Table needs to be revised to reflect the changes made at the annual
risk assessment review (as noted above).
·
SLD 18
Emergency Management needs to be revised as a result of the outcomes from the
annual mock emergency exercise. Changes are required to clarify certain areas
in the procedure to reflect the current practice in place. The revised SLD 18
is shown in Attachment “D” and re-endorsement of this document from the Owner
is also required.
It is important for the Owner to understand any
major change to the QMS Operational Plan and System Level Documents. Any
changes must be re-endorsed by the Owner accordingly, as this is a requirement
under DWQMS. The original vision and any previous revisions of all controlled documents
have all been previously endorsed by the Owner.
As a summary, currently in the QMS there are four
hundred and fifty six (456) controlled documents as of October 31, 2010.
5.
Internal or Third Party
Audit Results
Waterworks schedules internal audits on a
continuously basis to ensure all of the DWQMS 21 elements are internally
audited at the minimum of once every twelve (12) months. This action is
required in order to be in compliance to DWQMS element 19 Internal Audits.
Periodically, Waterworks invites a guest external auditor from other
municipalities to complete a full QMS audit in order to increase the awareness
level.
All 2010 scheduled internal audits have been completed.
Non-conformances and Opportunities for
Improvements are identified by the audit team to ensure continuous improvement.
There was no on-site external audit in
2010, as the external audit is on a three-year cycle. Waterworks expects the
accreditation body Canadian General Standards Board (CGSB) to conduct a review
in 2012. CGSB expects annually to receive a list of documentations and records
which is required in order for the Town to demonstrate the QMS is functioning
properly.
For the Owner’s information, as of the end of
September 2010 CGSB has completed one hundred fourth six (146) accreditation
audits in Ontario. Only twenty one (21)
of these audits are for Full Scope DWQMS accreditation, and the Town was one of
the first five systems in Ontario to achieve such accreditation in 2009.
6.
Resources Need
Waterworks has been addressing any resources requirements through the
capital and operating budgets requests which are currently ongoing. The
Corporate Top Management held a separate Staffing Meeting outside the
Management Review to discuss specifically the Waterworks resource requirements
including personnel and non-personnel requests. These requests would fit into
one of the four drivers affecting Waterworks business:
a.
Fiscal
b.
Environmental
c.
Growth
d.
Business –
Continuous Improvement
New staffing requests are required to be first
evaluated by the Chief Administrative Office and
Commissioners Committee (CCC). Any CCC approved requests are then further
evaluated and to be approved by the Budget Committee. Finally, the request will then be reviewed and
approved by the Council (Owner).
The interim Management Review information package and meeting minutes are maintained by the Waterworks QMS Controller as part of the records as required by DWQMS. These records are available upon request if needed but are not submitted as part of this report.
Not applicable
Business Case for each new staffing request has been prepared as part of the 2011 Capital Budget request. These business cases have been forwarded to CCC for approvals.
Municipal Services – The accredited QMS is a requirement for the Town to retain the Municipal Drinking Water License. Without the accreditation, the Town cannot become the Operating Authority in order to continue operating the Town’s drinking water system. Performing the Management Review and communicating the outcomes from the Management Review to the Owner is required in order for the Town to remain in compliance to DWQMS. This is crucial in order for the Town to be able to continue providing the same high level of drinking water to the Town’s consumers.
Not applicable
The undersigned represent the Corporate Top Management of Town of Markham’s Drinking Water Distribution System. By signing below the Corporate Top Management of the Operating Authority has reviewed the two revised System Level Documents, the outcomes and action items identified from the 2010 Management Review dated November 30, 2010, and hereby recommend these outcomes and action items to be brought forward to the Owner’s attention.
RECOMMENDED
BY: ________________________
Jerry Klaus
General Manager, Waterworks
________________________
Peter Loukes, P.Eng.
Director, Operations
________________________
Brenda Librecz
Commissioner, Community and Fire Services
________________________
John Livey
Chief Administrative Officer
Attachment “A” – Outstanding Management Review Action Items Summary from Previous meetings dated September 21, 2009 & April 22, 2010
Attachment “B” – New Action Items Summary from 2010 Fall Management Review dated November 30, 2010
Attachment “C” – System Level Document 8a Risk Assessment Table Revision 3.0
Attachment “D” – System Level Document 18 Emergency Management Revision 3.0
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Outcomes.docx