HomeMy WebLinkAboutFCS-18-021 - 1st Quarter Audit Status ReportREPORT TO: Audit Committee
DATE OF MEETING: March 19, 2018
SUBMITTED BY: Corina Tasker, Internal Auditor, 519-741-2200 ext. 7361
PREPARED BY: Corina Tasker, Internal Auditor, 519-741-2200 ext. 7361
WARD(S) INVOLVED: All
DATE OF REPORT: March 12, 2018
REPORT NO.: FCS-18-021
SUBJECT:1st Quarter Audit Status Report
___________________________________________________________________________
RECOMMENDATION:
No recommendation required. The following information is being provided as an
update and assurance on internal audit matters, in accordance with the Audit
Committee Terms of Reference.
BACKGROUND:
The following report provides a summary of the Internal Audit activities completed
during the period of December 2017 to February 2018. The chart below shows the
audits contained in this report.
Division / Topic Scope
Fire Administration Process / capacity review
By-law Enforcement, Property Standards Process / capacity review
SAP User Access Separation of duties
Kitchener Utilities Risk assessment
The following items are currently in progress and will be brought forward at a future
audit committee meeting:
Winter Maintenance, comprehensive audit
Use of Consultants / Professional Services, value for money audit
*** This information is available in accessible formats upon request. ***
Please call 519-741-2345 or TTY 1-866-969-9994 for assistance.
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REPORT:
1. Fire Administration, Process / Capacity Review
Status: Complete, January 31, 2018
Background Information:
The Fire Administration division supports the administrative needs of the Kitchener Fire
Department. It consists of five full time staff. They provide a range of services including
general administrative support for management, payroll and financial transactions,
meeting coordination, program specific support for Direct Detect, training, and fire
prevention, and a variety of other tasks.
Objectives:
Workload has been an ongoing issue in the division. Conducting a workload analysis of
the Administration division is 1 of 35 strategic and operational actions in the Fire Master
Plan and the catalyst for this Lean process review. The goal of this review was to
determine if improvements could be made to streamline processes and increase
capacity. A secondary objective was to look at the distribution of tasks between the five
administrative roles to ensure the most effective groupings of like tasks and to smooth
workload pressures between all staff.
Methodology and Scope
This review incorporated the following elements:
Literature review of current job descriptions
Consultation with staff and internal stakeholders (including Fire management,
platoon chiefs and assistant platoon chiefs)
Workload / capacity assessment with a focus on distribution of tasks across roles
Lean process review for seventeen (17) selected administrative processes, which
included:
o Current state value stream mapping to identify sources of waste, problem
statements and root causes
o Future state value stream mapping to identify and quantify potential
solutions
o Implementation planning
o Three rapid improvement events to implement identified solutions related
to three different processes
This project excluded:
Lean process reviews for all administrative processes (32 processes were not
reviewed due to time constraints)
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Lean Process Review Outcomes:
The goal of a Lean process review is to eliminate or reduce non-value-add process
steps. A non-value-add process step is any step in the process that the customer
(internal or external) does not receive value from, is not done right the first time, and / or
does not transform the product or service in some way. Through the course of the
current state mapping of the 17 selected processes, staff identified 49 problem
statements or non-value-add process steps.
All of the problem statements were further analyzed to determine root cause and to
brainstorm possible solutions and improvements. A total of 139 different solutions were
generated and the qualitative and quantitative impacts of each solution were estimated.
All potential solutions were then prioritized based on ease of implementation and total
impact (qualitative and quantitative) and input to an implementation plan.
Three of the processes and associated problem statements and actions were chosen to
be implemented immediately during three rapid improvement events. Management is
responsible for taking the lead on facilitating additional rapid improvement events to
ensure the remaining actions are implemented in a timely fashion, as per the agreed
upon implementation plan.
One of the main issues that were solved through this process was a lack of clarity
around customer expectations. At the outset of the Lean review key stakeholders /
customers were interviewed to gain a better understanding of their administrative needs
and what service attributes they value. This helped to identify which process steps were
not adding value to these internal customers. Also, by having Fire management
participate in the rapid improvement events it allowed staff and management to openly
discuss service requirements and brainstorm solutions together.
The solutions are expected to save approximately 135 hours per year of administrative
staff time and they will provide better customer service to Fire staff and management.
Staff and management are supportive of this process and are enthusiastic about
implementing the improvements.
Recommendations:
In order for the continuous improvement momentum to be sustained within the Fire
Administration division, it is recommended that:
•Management regularly monitor the status of the Lean implementation plan and
hold themselves and staff accountable for actions assigned to them.
•Management communicate with staff regarding progress on the Lean
implementation, involve staff in carrying out the plan, assist staff in making time
to work on these actions, and explain any barriers to implementation.
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• Once the Lean implementation is complete, begin a Lean review on the
remaining processes to look for new problems, root causes and solutions to
implement.
• Recognize staff that embrace the Lean method and encourage a continuous
improvement culture.
• Share Lean and continuous improvement success stories within the division and
with the corporation.
Capacity Analysis:
One of the deliverables in this review was to analyze the current capacity in the division
to determine if changes are required to the distribution of work between the five roles.
This included looking at current workload, proposed time savings from the Lean
improvements, and actual staff available hours.
Data were gathered for the average amount of time required to complete each of the 49
administrative processes and the frequency that each is performed. The total time
required was then compared to the time available for each person. This incorporated
their regular working hours, statutory holidays and floaters, actual vacation entitlement,
and an estimate for sick days. Staff was also asked if they regularly worked overtime
to complete their tasks. This provided a picture of current capacity.
The estimated savings from the Lean review were then factored in to determine what
impact these changes would have on the overall picture.
The initial calculations show that overall the section of five full time staff are currently
over capacity by 705 hours per year or roughly 0.5 full time equivalents (FTE). This
deficit of hours is concentrated mainly in two positions. The staff work, on average, 409
hours of paid overtime per year which equates to $12,800 of extra costs. They also
regularly do not take breaks or full lunches in order to accomplish their workload. This is
unpaid overtime that equates to 487 hours or $14,900.
While the Lean process review did reveal many improvements that could be made to
processes to improve customer satisfaction, the 135 hours per year in time savings for
administration staff is not adequate to completely address this deficit. Having to
regularly work overtime or not take breaks is stressful for staff and affects work/life
balance and morale. This is not sustainable in the long term.
In addition, the Emergency Management and Public Education programs do not
currently have any administrative support. As these programs expand, it is anticipated
that at least 260 hours per year of administrative services will be required.
There were however, two existing processes which will cease to exist or will require less
time in the future.
The current capacity less the Lean improvement savings, less the tasks that have been
eliminated, plus the additional time required to support Emergency Management and
Public Education will put the division in a deficit position of 602.5 hours per year or
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roughly 0.4 FTE (assuming no paid or unpaid overtime worked by staff). This equates
to a part time position that would work 14 hours per week. Not factored into this
calculation are the potential Lean improvement savings for the remaining 32 processes
and expected efficiencies from the installation of a new records management system.
As mentioned previously, a goal of this review was to smooth out workload between
staff. Staff and management worked with the project team to rearrange the distribution
of tasks such that the workload is more evenly distributed and tasks are logically
grouped together. While this exercise was successful in grouping like tasks and
spreading some of the workload to those positions with surplus capacity, it does not
erase the fact that there is more work than there are hours to complete it.
Recommendations:
Although it was not a goal at the outset of this review to recommend more staffing, the
current deficit is not sustainable and is affecting staff morale. However, the impacts of
the Lean improvements have not been realized yet nor have all processes been
reviewed yet. It is therefore recommended that a temporary part time staff be hired for
an 18-month period to help alleviate workload, overtime and reduce stress levels in staff
in the short term. This resource will also allow staff to continue implementing the Lean
improvements and begin work reviewing the remaining 32 processes.
Having additional resources will also allow service requirements for Emergency
Management and Public Education to be better defined through experience and
experimentation. Throughout this time a new records management system will be
installed which may lead to additional time savings.
During the temporary contract management should not approve any overtime and
should also ensure that staff are taking all lunches and breaks. At the end of the
temporary contract it is anticipated that this additional resource will no longer be needed
as the efficiencies from process improvements, system installations and removal of
tasks will make the workload manageable within the existing complement.
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Conclusion:
This review looked critically at a variety of Fire Administration processes, and the
resulting recommendations are focused on enhancing effectiveness and efficiency,
reducing waste and increasing capacity. Only a portion of the administrative processes
were reviewed and therefore there may be even greater unrealized improvements
waiting to be discovered in the future. Staff should embrace the culture of continuous
improvement and use the skills learned through this process to continue to improve their
processes.
2. By-law Enforcement, Property Standards, Process / Capacity
Review
Status: Complete, January 31, 2018
Background:
The Property Standards team in the By-Law Enforcement division is responsible for
inspecting sites, investigating situations and gathering evidence concerning the
maintenance and occupancy of lands and buildings within the city, including complaints
about the following topics:
Property standards
Zoning
Snow / ice
Lot maintenance / grass / weeds
Signs / graffiti
Sight obstructions
Fences
Vacant buildings
Animals
Lack of heat
Their service is mostly reactive in response to citizen complaints, although there are a
few areas in the City that receive proactive monitoring.
Earlier in 2016 Council had taken an interest in exploring the idea of proactive
enforcement and had requested a service review be conducted. Prior to starting this
review staff had engaged with residents to obtain their feedback on the issue. In report
CSD-17-060 staff concluded that additional resident education and changes to the
property standards by-law could help better serve citizens and proactive enforcement
was not required at this time.
Objective:
The primary focus of this property standards section review was to conduct a Lean
process review to determine existing capacity and calculate the estimated impact on
staffing if a more proactive approach was taken. Included in the Lean review was the
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goal of identifying and implementing any process improvements which could provide
better customer service and / or reduce non-value added tasks, and thereby increase
capacity.
Methodology and Scope:
This project included the following components:
Literature review of relevant documents, e.g., job descriptions, standard
operating procedures
Consultation with By-law Enforcement property standards staff and Council
Workload / capacity assessment
Lean review including
o Current state value stream mapping to identify sources of waste, problem
statements and root causes
o Future state value stream mapping to identify and quantify potential
solutions
o Implementation planning
This project excluded:
All other By-law Enforcement units (noise, trails/school zones, parking)
Findings:
An important part of this review was to interview members of Council to clarify what was
meant by proactive enforcement in order to be able to quantify the resource
requirements to implement such an approach.
It was found that Council felt By-Law Property Standard Officers were doing a great job
enforcing the current property standards by-laws andseven of the eleven councillors
feel that the city currently provides the right amount of by-law service. When asked
whether they would support a more proactive approach to enforcement, six councillors
did not support it, three did, and two only supported it for specific areas such as
Downtown or Conestoga College. It can be concluded there is no new work or service
level required at this time as Council as a whole is not supportive of investing resources
in a proactive approach.
Although the majority of Council did not support a patrol based proactive approach to
by-law enforcement, many had suggestions of other actions that could be taken to
improve the process and service level to citizens. Staff has indicated that they currently
are performing these actions in some form or another as listed in the chart below:
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Proactive Approach Idea Response
1 Targeted patrol based
Already do this in Downtown and Conestoga
approach to designated areas
College areas
like Downtown and Conestoga
Already observe adjacent houses in all areas to
College
see if there are obvious problems
Each area has its own ‘neighbourhood watch
dogs’ to report activities
Staff don’t feel additional patrols are required
unless there is an additional problem area that
Council would like patrolled
2
More follow-up (weekly basis)
Staff do follow-up with repeat offenders,
with repeat offenders to
however this is not done weekly
ensure continued compliance
If this was moved to weekly follow-up, it takes
time from other files, staff incur extra mileage
costs, and there is no time for the offender to
bring it into compliance
Each of seven officers typically has four or five
repeat offenders
3 More education / public
Already do this, e.g., Neighbours Day at
outreach regarding seasonal
community centres, fire station open house,
topics such as grass / snow /
police week open house, Conestoga College
fences etc.
house-by-house campaign, booths at big box
stores (for fences / decks)
New “thank you” campaign through social
media to thank people for not parking on the
streets
Neighbourhood guide
Media campaign (radio, print) – sidewalks,
parking
Pool safety package given with pool permits
Radio / news shows on hot topics
Walk-abouts with information on rats in problem
areas
Want to go to more big box stores, but these
are done on weekends and require overtime
4 Divert resources from parking
Takes away parking revenue
to property standards by
Increase in parking complaints
splitting one parking position
Tried before when there was a lull in lot
to be focused 50% on parking
maintenance work and it did not work (not
and 50% on property
enough time each day to do both)
standards
No lull in lot maintenance work anymore
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Lean Process Review Outcomes:
Staff and management participated in a Lean review of the investigations process which
consumes most of the officers’ time. This process is highly regulated and only 4 non-
value-add process steps were found. Process improvements were minimal and did not
save any time.
Since a proactive approach is not recommended, no additional work was required to
map out the future state of what that approach would look like.
Staff discussed the lack of coverage for absences (i.e. when an officer is off for
vacation, training, or sick leave their files or geographic territory are not actioned by
other officers in their absence unless it is an emergency). In order to ensure consistent
and continual service to citizens staff will be developing an absence coverage model.
Capacity Analysis:
One of the deliverables in this review was to analyze the current capacity to determine if
resources are sufficient to support current and future demand for the next five years. In
addition, if any service level enhancements or process improvements were
recommended, the associated capacity implications would be calculated. Capacity is a
function of service levels, demand for service, and available staff hours.
Staff indicated that they try to acknowledge each complaint within 24 – 48 hours. They
also try to complete the initial inspection within 24 – 48 hours; however, this may take
longer during peak periods. Work is divided between staff based on geography and type
of complaint. Therefore, when staff is absent (for vacation, sick time, or other
absences) their case load and new calls are on hold until their return.
As mentioned previously, service is primarily complaint based with proactive monitoring
within two problem areas of Downtown and Conestoga College. There are no
recommendations in this report to increase this service level or approach. However,
implementing absence coverage will help avoid gaps in service and improve response
time.
Demand for by-law services has many drivers (such as weather, police presence, by-
law education etc.) based on the type of infraction. Many types of violations are driven
at least partially by population. As the population grows there will be more citizens who
could commit by-law infractions, driving demand for by-law services up over time.
Population growth was extrapolated to provide a prediction of future population levels.
The total number of complaints was then correlated to population during that same
period to show the expected growth in demand. This in turn was used in the future
capacity calculations to indicate resources required.
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YearPopulationComplaints
2012225,3742,238
2013240,4572,382
2014261,1242,259
2015275,9212,290
2016294,5362,482
2017311,6192,446
2018328,9982,484
2019346,3762,523
2020363,7542,561
2021381,1322,600
FuturePredictions
500,0002,700
2,600
400,000
2,500
300,000
2,400
Population
2,300
200,000
2,200
Population Complaints
Complaints
100,000
2,100
2,000
20122014201620182020
In addition to population growth, the increase in communication channels that citizens
can use to make complaints to the city (such as the new online portal) will further
increase demand for by-law services.
Information provided by human resources shows that headcount in this section has only
grown by one part-time position over the past five years (6% growth), while population
has grown by 38% and number of by-law complaints has grown by 9% during that same
period. Population is expected to grow by 22% over the next 5 years and by-law
complaints should grow by 6%.
A high-level assessment of workload and capacity was undertaken by the project team
to provide a baseline estimate of capacity across the section. Data was gathered during
the value stream mapping regarding the typical amount of time required to complete
each type of by-law complaint from start to finish. Note that every complaint is different
and could take more or less than the typical time.
Each complaint can take one of four paths, each with a different total time to complete:
1. Complaint is investigated but there is no violation
2. Violation and the citizen complies within the deadline
3. Violation and the citizen appeals (for property standards complaints only)
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4. Violation and the citizen does not comply, and the City proceeds with clean-up
The time-per-complaint estimate was then multiplied by the total number of complaints
or violations as appropriate for each type and each path.
The total time required to meet demand was then compared to the time available based
on eight staff members in the section. This incorporated their regular working hours,
statutory holidays and floaters, actual vacation entitlement, and an estimate for sick
days.
Staff was also asked if they regularly worked overtime to complete their tasks. Staff
typically work between 96 – 225 hours of overtime per year. However, this is largely to
respond to after-hours emergencies. The time is banked and taken off at another time,
rather than being paid. Some staff claim paid overtime occasionally to catch up on
paperwork after absences. This amount is less than $2,000 per year.
Capacity Projections:
Year 20172018201920202021
Currentavailablestaffhours11,97011,97011,97011,97011,970
Projected#ofcomplaints24462484252325612600
Estimatedtotalhoursrequired18,80319,09519,38619,67719,969
CapacityDeficit6,8337,1257,4167,7077,999
FullTimeEquivalents(FTE's)3.753.914.074.234.40
The analysis shows there is a lack of capacity to complete all required work. This
conclusion is further supported by the response time of 24-48 hours. The estimate for
2017 shows a total capacity deficit of 6,833 hours or roughly 3.75 FTEs. This figure
grows to 4.4 FTEs by 2021. Given that some of the time estimates may be high since
some cases may take less time than the typical amounts used, it is estimated that at
least two FTEs are required over the next 5 years in order to maintain current service
levels.
An analysis of the number of violations by type by year indicates that snow and ice
complaints consistently make up 35% or more of all violations. The next largest
categories are grass, weeds and lot maintenance at 31%.
However, an analysis of the time required to action these calls by type reveals that
property standards and zoning complaints consume the most resources, at 28% and
20% respectively.
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Category%oftotalhours%oftotalviolations
Propertystandards28%12%
Zoning20%9%
Snow/Ice14%35%
Lotmaintenance/grass/weeds10%31%
Signs/Graffiti7%9%
Sightobstruction6%2%
Fence2%1%
Vacantbuilding1%1%
Animal1%0%
Heat1%0%
Initialinvestigationtime10%
Total100%100%
If staff wish to decrease the number of calls and demand for service, they should focus
their education efforts in those four areas.
Recommendations:
In order to maintain current service levels in light of population growth it is
recommended that:
By-law enforcement management team should request an additional two FTEs,
phased in over the next 5 years. This allows staff to keep pace with demand.
This will also provide staff more time to follow up with repeat offenders and pro-
actively patrol problem areas as desired by Council. If staffing is not increased,
their response time will increase to greater than 48 hours.
By-law enforcement management team should focus education efforts in the
areas that show a high volume of calls and high time spent handling specific
types of calls.
Conclusion:
In conclusion, it was found that minimal improvements can be made to the by-law
enforcement investigations process and no time savings have been found. It is not
recommended to change the approach or service levels at this time. It is also
recommended that additional FTEs be requested to support existing and future demand
for services.
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3. SAP User Access, Separation of Duties
Status: Complete, February 23, 2018
Background:
It was noted during the comprehensive review of the Accounting division that several
SAP users have full access to all functions within the system. This is a separation of
duties conflict and presents the opportunity for fraud or unintended consequences. It
was recommended at that time that Internal Audit and the SAP Business Solutions
Business Analyst (Finance) work together on a separation of duties analysis of all SAP
users, with an initial focus on the users which currently have “ALL” access to determine
whether they have a business need to access all SAP functions.
Objective:
The objective of this audit was to determine the high risk SAP separation of duties
scenarios and determine if any users have access that permits these conflicts. Users
and their supervisors were then contacted to determine if the access can be removed or
whether the corporation will accept the risk and try to mitigate it in some way.
High risk is defined as the ability for an individual to use their SAP access to create
transactions which would:
Allow them to steal funds from the corporation, either individually or in collusion
with vendors / suppliers / customers
Allow them to misrepresent the corporation’s financial situation
Methodology and Scope:
A list of high risk scenarios was developed based on the SAP separation of duties
matrix, online research related to top SAP separation of duties risks, and prior controls
audits in Supply Services, Accounting and Revenue. SAP Business Solutions staff then
reviewed all active SAP user ID’s to determine if conflicts exist.
The list of conflicts was reviewed with Internal Audit, and users and their supervisors
were contacted to determine if access is required in order to do their jobs. Accounting
and Supply Services management was consulted regarding existing controls to mitigate
any unavoidable scenarios.
Findings:
“ALL” access has been removed from all users except the SAP Business Solutions and
Technology and Innovation staff who need this access in order to be able to trouble
shoot and resolve problems. There are however several user ID’s which still have more
access than they require for their role. While there is no evidence of fraud, the potential
is there if these separation of duty conflicts are not removed or mitigated. In some
cases the City has accepted the risk, given that Kitchener is a mid-sized city and unable
to have complete separation of duties in all staff roles. For all other cases SAP
Business Solutions is working on removing the unneeded access.
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Recommendations:
Remove all unnecessary access (contact users prior to removing access)
Ensure support availability following the removal of the access in case it is found
that it is required for other tasks.
Run a report semi-annually to ensure that no unauthorized transactions or
changes to the system are made
Remind and ensure SAP Business Solutions and Technology and Innovation
staff who post journal entries to have their journal entries approved by
management and file the backup in the Accounting file room
Create a process to review required access when users change positions within
the corporation.
Perform an annual check of system access to ensure no conflicts, or that
conflicts are documented with valid rationale and supporting mitigating controls
4. Kitchener Utilities, Risk Assessment
Status: Complete, February 20, 2018
Background:
Risk is defined as the effect of uncertainty on objectives. The management of risk
involves regularly and proactively scanning the organization and the environment to
identify, assess, and treat potential risks to ensure the achievement of goals or
objectives.
The last risk assessment performed in Kitchener Utilities was done in 2010.
Objective:
To conduct a risk assessment of the Kitchener Utilities division in order to identify and
assess current risks that could affect the achievement of goals. This will provide a
roadmap for new management as to where to place focus, and identify areas for deeper
review.
Methodology:
This assessment followed these steps:
Review of 2010 Kitchener Utilities risk assessment
Interviews with a sample of Kitchener Utilities staff and management
Interviews with a sample of stakeholders including Revenue, Supply Services,
Engineering, GIS, Support Services, and Financial Planning
Workshop to jointly assess the likelihood and impact of each risk identified during
the interviews
Findings:
Staff and stakeholders identified and then assessed several distinct risks. The risks
were then sorted based on total risk score, which is the multiplication of the likelihood
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score by the impact score. The result is a prioritized list of risks which management will
now work to create treatment plans for. Treatment can take the form of avoidance,
reduction, transference or acceptance of risks.
The risks that were identified fall into the seven corporate risk categories, specifically:
Service delivery risk – the risk of not meeting customer expectations
Employee risk – the risk that employees or contractors at the City will be
negatively impacted including physical harm, morale, workload, etc.
Public risk - the risk that there will be a negative impact on the public, including
physical harm, loss of service, financial, etc.
Physical environment risk – the risk that the environment will be damaged
Reputation risk – the risk associated with anything that can damage the
reputation of the City or undermine public confidence in it
Financial risk – the risk related to decisions about assets, liabilities, income,
expenses including asset management, capital and operational funding,
economic development, theft and fraud
Regulatory risk – the risk related to the consequences of non-compliance with
laws, regulations, policies, or other rules
Two of the largest underlying issues that were identified and which lead to numerous
risks or consequences are:
1. Staffing has not kept pace with growth in population and the customer base; and
2. Data that staff relies on to do their work is out of date or incorrect.
The data being out of date is also a consequence of the staffing not keeping pace with
growth, but in and of itself leads to a host of other risks. If the division can resolve these
two issues, a lot of the related risks will diminish in likelihood of happening.
It will be up to management to monitor the risks and ensure timely mitigation of the
highest risks.
ALIGNMENT WITH CITY OF KITCHENER STRATEGIC PLAN:
This report supports the achievement of the city’s strategic vision through the delivery of
core service.
FINANCIAL IMPLICATIONS:
There are no financial implications related to this report.
COMMUNITY ENGAGEMENT:
INFORM – This report has been posted to the City’s website with the agenda in
advance of the council / committee meeting.
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ACKNOWLEDGED BY:Lesley MacDonald, Acting Deputy CAO, Finance and
Corporate Services
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Committee
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