Report to: General Committee Report
Date:
SUBJECT: Quality Management System Management Review Outcomes
PREPARED BY: Eddy Wu, P.Eng. Ext. 2737
Waterworks Quality Management System Controller
RECOMMENDATION:
That the report “Quality Management System Management Review Outcomes” be received;
And That Council, as the Owner of the Town’s Drinking Water System acknowledges and supports the outcomes identified from this Management Review;
And That Council,
as the Owner of the Town’s Drinking Water System directs staff to apply for Full
Scope accreditation when submitting for the Town’s Drinking Water Works Permit,
Municipal Drinking Water License and the Town of
And That Staff be authorized and directed to do all things necessary to give effect to this resolution.
EXECUTIVE SUMMARY:
Not applicable
1. Purpose 2. Background 3. Discussion 4. Financial 5. Others (Strategic, Affected Units) 6. Attachment(s)
PURPOSE:
The purposes of this report are:
· To communicate outcomes from the Management Review to Council, as the Owner of the Town’s Drinking Water System (a requirement under the Safe Drinking Water Quality Management System Act), and
· To request permission from the Owner of the Town’s Drinking Water System to apply for Full Scope accreditation.
BACKGROUND:
The main purposes of the Management Review are:
1. Inform designated Top Management (consists of the Waterworks General Manager, the Director of Operations, the Commissioner of Community and Fire Services and the Chief Administrative Officer) and the Owner on the water system operation and performance,
2. Provide confidence to Top Management (T.M.) and the Owner that the subject system is properly operated and maintained to retain the accreditation, and
3. To fulfill Drinking Water Quality Management Standard (DWQMS) Element 20 – Management Review, where the designated Top Management shall:
a. ensure a Management Review is conducted at least once every twelve months,
b. consider results of the Management Review and identify deficiencies and action items to address the deficiencies,
c. provide a record of any decisions and action items related to the management review including personnel responsible for delivering the action items and the proposed timelines for their implementation, and
d. report the results of the Management Review, the identified deficiencies, decisions and action items to the Owner.
The Owner 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.
Waterworks started
the implementation of the QMS in early 2007 with the target of a full
implementation of all twenty one DWQMS elements by early 2009. After completing
the first QMS internal audit in September 2008, a Management Review was the
final step to complete prior to the application of the system license. This
Management Review was set to review the overall QMS implementation status, performance,
and readiness in order to determine if the Town is ready to engage the
accreditation process. The Town must engage the accreditation process by
submitting the application to the Ministry of Environment on or before
Waterworks conducted the Management Review on November 20, 2008 & November 28, 2008 in order to accommodate the schedule of the designated Top Management (T.M.) The reviewers of this first Management Review consisted of the Operational T.M. (the Waterworks Management Team) and the Corporate T.M. (the Waterworks General Manager, the Director of Operations, the Commissioner of Community and Fire Services and the Chief Administrative Officer). All members of the Operational T.M. and the Corporate T.M. were present at this first Management Review.
OPTIONS/ DISCUSSION:
Management Review Results
The Drinking Water Quality Management System (DWQMS) has two elements related to the ‘check’ component of the QMS cycle which are Element 19 (Internal Audits) and Element 20 (Management Review.)These two elements are in place to review the effectiveness of the QMS and its implementation by conducting internal audits and Management Reviews. These elements provide feedback on the working of the QMS by identifying deficiencies, and to ensure actions are in place in order to rectify these identified deficiencies.
In order to be in compliance, the meeting must be conducted in accordance to DWQMS Element 20 guidelines. The QMS shall be reviewed to see if it has been implemented in line with DWQMS. The QMS and the subject system’s operation processes are being reviewed together with the data generated from these processes. This review is to ensure the QMS when implemented meets the needs of the subject system. In addition to the required items as stated in DWQMS, Waterworks has included an introduction to Waterworks structure and activities. This provided the T.M. and the Owner with the knowledge and clarity on expectations from Waterworks with regard to Waterworks’ responsibilities, operations and relationship to the DWQMS. Designated Top Management would be responsible for reviewing these results, identifying deficiencies and action items to address the deficiencies in the QMS. All of this information must be communicated to the Owner in order to complete the implementation of Element 20.
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:
- incidents of regulatory non-compliance,
- incidents of adverse drinking-water tests,
- deviations from critical control point limits and response actions,
- the efficacy of the risk assessment process,
- internal and third-party audit results,
- results of emergency response testing,
- operational performance,
- raw water supply and drinking water quality trends,
- follow-up on action items from previous management reviews,
- the status of management action items identified between reviews,
- changes that could affect the QMS,
- consumer feedback,
- the resources needed to maintain the QMS,
- the results of the infrastructure review,
- Operational Plan currency, content and updates, and
- staff suggestions
The Management Review inputs are structured to include the Waterworks departmental overview and 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.
From the first round of internal audits completed in September 2008, a total of four (4) minor nonconformances and thirty-six (36) opportunities for improvement have been identified. Minor nonconformance is raised as a flag to notify the section lead of a minor system error. Immediate attention is required to rectify the error or else the issue will become a major nonconformance. When the nonconformance becomes major, the Town’s certification will be put on hold and the Operating Authority must rectify the major nonconformance immediately in order to reactivate the certification status. As a result, no major nonconformance should be received if the QMS is implemented properly, and being maintained properly. However, minor nonconformances can be expected, especially in the early stages of QMS implementation and they are also very useful tools in the continuous improvement process.
Other than nonconformance, opportunities for improvement are also identified from the audits. An opportunity for improvement is not a nonconformance, but the opportunity is identified in order to better improve the effectiveness of the QMS. It is the responsibility of the auditor to identify opportunities for improvement during an audit, as no QMS is perfect and there must be something to improve.
Results of the internal audits are included as part of the Management Review inputs. The following table summarized the outcomes from the first round of internal audit performed:
|
Waterworks Section audited |
Number of |
Number of Nonconformance identified |
|
|
Minor |
Major |
||
|
Top Management |
3 |
0 |
0 |
|
Operations & Maintenance |
9 |
1 |
0 |
|
Infrastructure |
4 |
1 |
0 |
|
IMS |
4 |
1 |
0 |
|
System Engineering |
6 |
0 |
0 |
|
Training |
5 |
1 |
0 |
|
QMS |
5 |
0 |
0 |
|
TOTAL |
36 |
4 |
0 |
The corrective actions of all four nonconformances have already been received and implemented. Follow up audits will be performed by the QMS Audit Team in order to ensure the corrective actions implemented are effective. The follow up audits are targeted to be conducted in December 2008/January 2009 prior to engaging the accreditation process. The identified nonconformances from the internal audits are listed in Attachment “A”.
From this first Management Review, a total of sixteen (16) decisions or deficiencies have been identified, each with action items assigned to a champion responsible for carrying out the actions. The Waterworks QMS Controller will ensure all action items identified are properly planned and addressed. Each action item will also be followed up by the Waterworks QMS Controller with the identified champion(s) to assure the action item identified has been acted upon. The overall status of these action items will be reviewed in the future Management Reviews, with the outcomes to be communicated to the Owner. All action items identified from this Management Review are listed in Attachment “B”.
Next Step
Although there are opportunities for improvement identified from the internal audits and the Management Review, Waterworks is confident that all twenty-one DWQMS elements are implemented to meet the standard. It is normal practice to discover areas for improvement from these two Checking elements, as that would lead to the Improve element of the DWQMS – Element 21 Continual Improvement.
The endorsed Operational Plan and the System Level Documents are documented in order to meet the DWQMS requirement. They have been put in practice by all Waterworks Sections and been subject to internal audits. The Management Review is the final step required prior to the application to become the Accredited Operating Authority of the Town’s Drinking Water System.
In conclusion,
Waterworks is recommending that the Town submits the application for Full Scope
accreditation based on the documentation and implementation of all twenty-one
elements of DWQMS on or before
Not applicable
ALIGNMENT WITH STRATEGIC PRIORITIES:
Municipal Services – To continue providing safe drinking water to the Town’s residents, the Town must become an accredited operating authority. Implementing QMS and being audited by the accreditation body is the only way the Town can become accredited in order to continue the provision of safe drinking water.
DEPARTMENTS
CONSULTED AND AFFECTED:
Not applicable
The undersigned represent the Top Management of Town of Markham’s Drinking Water Distribution System and by signing below the Top Management of the Operating Authority has reviewed the deficiencies, decisions and action items identified in the Management Review, and hereby communicating these results to the Owner.
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
ATTACHMENTS:
Attachment “A” – Internal Audit Nonconformance Summary
Attachment “B” – Management Review Action Item List