City of Mount Dora, Florida Fire Department Administrative Performance Audit. Presented to the Mount Dora City Council July 12, 2017.

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1 City of Mount Dora, Florida Fire Department Administrative Performance Audit Presented to the Mount Dora City Council July 12, 2017 Conducted by: James E. White, EFO, CFO, MiFireE Chief of Department Winter Park Fire Rescue Winter Park, Florida FINAL REPORT Executive Summary At the request of the City of Mount Dora (FL) City Manager Robyn Hayes, I was asked to complete an administrative performance audit of the Mount Dora Fire Department. A scope of work was developed and approved which described a two phase process including personnel interviews with fire department personnel, combined with a review of the department s policies and procedures. I was also asked to look at the department s operations and administrative structure and provide direction that would assist the city in making application for accreditation from the Commission on Fire Accreditation International (CFAI). It is understood that my selection to complete this audit was in part based on my experience in the fire service and with the accreditation processes of the CFAI. As a brief summary, I am entering my 35th year as a career firefighter. I came to Winter Park (Florida) as their deputy fire chief in 1992 and was promoted to fire chief in I am a graduate of the National Fire Academy s (NFA) Executive Fire Officer Program and am now an adjunct, on-campus instructor for the (NFA); I am degreed in both Fire Science and Public Administration, and credentialed as a Chief Fire Officer by the Commission on Professional Credentialing. My involvement with CFAI includes leading our agency though four successful accreditation processes as well as authoring the agency s Standard of Cover document. I also serve as an instructor for CFAI as well as a peer assessor where I have completed more than 30 individual agency assessment reviews. I am also proud to say our city is rated by the Insurance Service Office (ISO) as having a public fire protection classification of 1 and we are also accredited through the Commission on the Accreditation of Ambulance Services (CAAS). Myself, nor my employer, were compensated for this audit process. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

2 To initiate the review I conducted a phone interview with acting Fire Chief Timmons Griner. Chief Griner was very helpful and able to share with me the current status of the department and its operations. I explained the process I would be implementing to complete the audit and we agreed on several dates for my interviews with each of the operational shifts, as well as the administrative staff. The structured interview was set around a list of prepared questions. The questions were intended to initiate a conversation with the staff on their impressions of the overall fire department, the workplace environment, and any future goals for themselves. The interview sessions were held in the evenings at the headquarters fire station. Each meeting offered an open environment with the staff being extremely open and helpful with the completion of the process. It was my initial observation that a majority of the firefighters were genuinely interested in the audit process and seeing the fire department improve. Most responses were positive and appreciative of city management for initiating the audit. The firefighters expressed a genuine desire to work with the city to improve the services of the fire department. While some legitimate issues were raised, a majority of the comments were supportive and remained suggestive in nature. Several common themes of concern were found among the operations staff, included the updating of the department s policies and procedures, the continued replacement of emergency apparatus, the need to address the issues related to the facility at fire station 35, the planning for future resources to prepare for the known growth in the area, and the selection of a new fire chief. The second part of the audit process involved a review of the agency s administrative documents, policies, and procedures. It was evident that while the agency remains legally compliant with Florida Statutes for the operation of a fire department providing emergency medical services, most of the documents provided were dated (more than three to five years old) and did not accurately represent some of the current operational practices, while other key documents were not offered for review, assuming they do not exist. While the operational policies and procedures are in need of attention, the most current document presented for review was the agency s Strategic Plan. A review of the planning process showed a welldeveloped, community-driven, assessment which yielded very specific goals and objectives, driven from citizen and firefighter input. I would recommend this document be used to launch the immediate and short-range future efforts of the agency. The goals and objectives from the Strategic Plan should be reviewed to determine acceptance by the agency s new leadership team. It would be a critical failure on the part of the city and the fire department to place this type of effort into gaining citizen opinions, only to Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

3 let them go without being addressed. Most of the remaining documents offered for review were critical to the agency s operations and should be updated as soon as possible. I was also asked to assess the agency s path towards accreditation through a process offered by the Commission on Fire Accreditation International (CFAI). Certainly a community like Mount Dora who supports a fire department serviced by career firefighters could benefit from the CFAI self-assessment and peer review process. To begin to build a path towards accreditation the department should initiate the immediate updating of all agency policies and procedures, the enacting of the identified goals and objectives found in the current strategic plan, and the establishment of policies that would develop a structured community risk assessment and standard of cover. The currency of the department s policies should be addressed as soon as possible. The review will help lead to a successful adoption of the self-assessment process found in the CFAI accreditation model. I am confident with my experiences and exposure to the current fire department personnel, policies, and processes, Mount Dora has the potential to not only build and create a great fire service organization, I feel you have the clear potential to improve your services, become accredited, and improve the work environment for your firefighters. In summary, the administrative audit process resulted in the successful interview of a majority of the Mount Dora Fire Department personnel and the review of the department s operational documents. The personnel were positive and excited about the future of the city and the fire department. A majority of personnel expressed their willingness to exercise patience with future changes and are excited to come to work each day. A large majority of personnel also stated they are not currently seeking employment that would have them leaving Mount Dora for other fire service careers. The employees, as a group, presented a strong, family persona, caring for each other and for the future of the fire department. The department s operational documents are in need of immediate updating to reflect current practices and what are considered as modern firefighting policies. With regards to the community s move towards accreditation, I observed that while much work needs to be accomplished to adopt the CFAI model as the department s business plan, the commitment is there and needs continued support from the top of the organization to be successful. With fulltime effort on the self-assessment process, I would predict a timeframe of months for document completion and subsequent peer review and commission presentation. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

4 Administrative Audit Process The audit process was completed in two phases and included personal interviews with fire department staff as well as a review of the department s documented polices, rules, and procedures. The first part of the audit was initiated with a phone conversation with then acting Fire Chief Timmons Griner. Chief Griner explained how senior leadership had recently changed with the departure of Chief Kirkoff. It was agreed that I would visit individually each crew while on-duty, as well as with the department s administrative staff during their normal working hours. The firefighter interview meetings were scheduled and held on successive evenings in January 2017 (17, 18, and 19). All meetings were conducted at fire department headquarters in the shift kitchen area. I also met with the department s administrative staff on Wednesday, February 8 in their offices at fire headquarters. All attempts were made to see that the environments were open and receptive. During each session I observed a workforce sincerely energetic towards the future of the fire department, and for the vast majority, loved the community and wanted to be part of a positive future in Mount Dora. The majority of the firefighters appeared to be very committed professionals who love their work. They also see Mount Dora as a place they want to pursue, or complete, their careers in the fire service industry. Morale is often described as the confidence of an individual or group, at a particular moment in time, to follow the directions of the organization. More often, morale is what is actually perceived in the mind of the beholder. My overall observations were of a very motivated and positive workforce within the fire department. They are concerned about the immediate future and want to see the Mount Dora Fire Department rise to a level of prominence in the region and state. Moral, when considering the aspect of firefighting and their work is high; meaning they are a motivated and eager group of firefighters looking for the next great thing to come to Mount Dora. As an employee of the city, they are concerned about several upcoming decisions, but feel that recent decisions, including the initiation of this study, along with the corresponding consultant s operational report and standard of cover, are setting the stage for a very positive future for the department. The following questions were used to prompt discussions among the firefighters and staff during the group sessions. All responses were grouped together and were considered in the creation of this summary. My personal notes related to the meetings are available upon request. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

5 1. What are your top three-five positive things about the Mount Dora Fire Department? a. Positive workforce (firefighters and staff). b. Professionalism of the city and the fire department. c. Department culture is positive and caring. d. Positive outlook on the immediate future. 2. In your mind, what are the top three-five things that need immediate attention with the department? a. Selection of the next fire chief b. Minimum firefighter staffing at three people c. Updating of the facility at Fire Station 35 d. Updating all department policies and procedures e. On-duty shift supervision Chief Officers assigned to each shift 3. Where do you see the department in five years? a. Addressing the growth in the community with additional stations and resources b. More involvement of the fire department in the community c. Exploring additional services such as marine rescue, dedicated truck operations, patient transport 4. Do you see the department headed in the right direction? a. All groups responded YES to this question b. Some did feel the jury remained out on several issues including the selection of the fire chief c. All respondents were hoping for more positive decisions going forward. 5. As firefighters, are you accountable for any performance measurements or training standards? a. Not really, some people have been allowed to operate outside the standards. b. More accountability is needed. c. Implementation of physical requirements using job related skills. 6. As firefighters, has the direction and policies of the city and the fire department been made clear to you? a. Some policies and procedures are adhered to by everyone, others are not. b. Clear policies are sorely needed. Current documents need to be updated. c. The interim leadership was praised for their direction and policy decisions. d. Policies from the city s Human Resources department were current. Fire department policies needed much attention. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

6 7. Do you see this audit and review as a beginning or a turn in the right direction, or simply a waste of time? a. Seen by most as a large step in the right direction. b. Not considered a waste of time. c. Seen as building a roadmap for the future. d. An opportunity to become a better organization, very positive. e. The fire department is being given an opportunity to walk through the door to something new. 8. Overall, do you like coming to work at MDFD? a. Yes, never disliked coming to work to do the job. b. Current conditions are much better. c. Months ago it was much worse; now, yes, very much like working in Mount Dora 9. Is your employment with Mount Dora causing you to seek another position elsewhere? a. No, but a lack of a well-defined career ladder could change perspectives in the future. b. No, prior to move with the fire chief, that would have been different. c. Much happier at this point. 10. What is the first thing that needs to happen at MDFD that would lead towards success? a. Continuing to seek employee buy-in and support. b. Updating policies and guidelines. c. Leadership training for new officers d. Improve software used in the records management system e. Offer social gatherings to build culture of the agency The second phase of the audit was intended to identify any gaps in the administrative structure, documentation, and field operations which could impede the agency s efficiency and continuous improvement. The department offered numerous documents for my review. These documents included the current organizational chart, company response areas, personnel directives, and strategic plan. Those documents a department would consider as basic to the operational success of the organization were not presented. Examples of these basic documents would include apparatus and equipment operational policies and practices, daily training, conduct policies, promotional and hiring practices, and fireground command guidelines. These, along with many others, will be necessary for the agency to stabilize and move forward. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

7 The following areas of the department s operations were assessed against the criterion and performance indicators currently identified by the Commission on Fire Accreditation International (CFAI) in their publication Fire and Emergency Services Self-Assessment Manual 9 th Edition. The audit did not allow time to measure the department against all 258 indicators. Assumptions could be made as to the immediate direction of effort which could lead to a successful future recommendation of accreditation for the agency. The CFAI accreditation model requires the fire department, and the community, to accept a business plan which demands continuous improvement. Administrative plans and philosophies must remain focused on moving the agency in a positive direction at all times. The department s initial status is accomplished through a self-assessment plan that examines all aspects of the fire department s administration, programs, and operations. These self-assessment responses to the provided performance indicators are the core of the CFAI accreditation process. An agency, such as the Mount Dora Fire Department, must adopt a model of continuous improvement in order to be considered credible. Once all documentation is prepared, the agency will request from CFAI, a peer review of their documents and procedures. If the agency s documents are considered complete, the peer assessors will complete their investigation of the agency with a visit to the community. The peer review process verifies and validates that what the department documented as practice is actually occurring throughout the organization. It requires, in most all cases, a change in current processes, procedures, and performance outcome measurements of the fire department. This administrative audit was not intended to measure the readiness of the Mount Dora Fire Department to seek CFAI agency accreditation, it was however, able to see, and set, a path for the agency should they become interested in seeking this status in the future. The following are my general recommendations, which if followed, will better position the agency to seek accredited status. Some of the recommendations are required by the CFAI of all accredited agencies (*). Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

8 Recommendations 1. (*) The agency must designate an agency Accreditation Manager. While CFAI does not require a full-time person (FTE), an individual, designated as the Accreditation Manager, is required. This individual will act as the point of contact throughout the accreditation process. It is recommended that the fire chief not serve as the accreditation manager. 2. The fire department should become Registered Agency with the CFAI. This is the first step in the process as it affords the community access to important information and documentation needed to complete the process. 3. (*) The Accreditation Manager must attend the Quality Improvement through Accreditation and the Peer Assessor training classes offered by the CFAI. 4. The agency should continue to use the current community-driven Mount Dora Fire Department Strategic Plan, document, including the previously identified goals and objectives, to address any previously identified issues. I would also recommend an addendum be added to the existing strategic plan outlining the changes in both the city and fire department administrations. This should include a memo of acceptance of the stated goals and objectives by the current city manager and fire chief. 5. The agency should assure that the Community Risk Assessment / Standard of Cover (CRA-SOC) document currently in process meets the 6 th edition of the CFAI Community Risk Assessment Standard of Cover manual outline and format. Since the agency is having this process completed outside the fire department, it will be critical for the fire chief, accreditation manager, and key fire department leadership, to be intimately familiar with the CRA/SOC process being developed. 6. The agency should establish teams of people to initiate the Research and Information Collection Guide process found in Chapter 4 of the FESSAM 9 th Edition. The collection guide is critical in setting the work plan for the accreditation process with the responses being able to identify where effort needs to be placed, and what the path to accreditation success will require. 7. The agency should establish a team of fire department personnel who can begin to review all of the existing agency policies and guidelines, ultimately creating a list of any new policies which might be needed to address gaps. This team should be working closely with the accreditation manager to assure congruency with the CFAI performance indicators found in the FESSAM 9 th edition. 8. After reviewing the CFAI process, fire administration should adopt strict, outcomes-based, performance measures. All program performance reviews, and reports, should be scheduled and made available to the city administration and the community. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,

9 9. The agency should establish what will be considered their effective response force (ERF) for all responses. Response time and outcome performance measurements are based on the performance of the ERF to each call. 10. The agency should review existing response time data for the previous three years matching the data to the criteria found in the CFAI s CRA/SOC 6 th edition manual. This action should include response time data for all emergency responses when the identified effective response force (ERF) of personnel arrived at the scene. This data must include all responses and all units and personnel designated to respond to an event, including those units from other agencies. I have appreciated the opportunity to work with Chief Griner and the staff with the fire department throughout this process. Taking a look inside the organization has helped me develop professionally. My agency and I stand ready to assist the City of Mount Dora, Chief Griner, and the firefighters of the Mount Dora Fire Department with these goals. Final Report / Administrative Audit Mount Dora (FL) Fire Department July 12,