Asset management and Department of Health Guideline

maintenance planning QH-GDL-354-1-5:2018

1. Purpose
The intent of this guideline is to provide best practice recommendations for asset management and
maintenance planning activities related to building assets and their supporting infrastructure.
This guideline forms part of the Asset management and maintenance policy (QH-POL-354:2015) and
Asset management and maintenance standard (QH-IMP-354-1:2015).
All departments (as defined in Section 8 of the Financial Accountability Act 2009) must comply with
the requirements of the Maintenance Management Framework (MMF). The MMF identifies the policy
requirements to prepare a maintenance strategy, develop a strategic maintenance plan, assess
maintenance demand, allocate adequate maintenance budgets and develop an annual maintenance
works program.

2. Scope
This guideline applies to all employees, contractors and consultants within the Department of Health
divisions and commercialised business units (DoH-CBUs) and does not apply to health technology
equipment or information communication technology equipment.
This guideline can be used by Hospital and Health Services either as it is, by re-branding or as a base
for a Hospital and Health Service specific guideline.

3. Requirements
3.1 Objectives
Asset management and maintenance planning should support the following:
• building and infrastructure maintenance work that complies with legislation, government
policy and best practice requirements while effectively managing associated risks
• appropriate management of whole-of-life building and infrastructure costs
• maintain the physical condition and standard of buildings and supporting infrastructure to
ensure continuity of service delivery functions.
3.2 Asset management and maintenance plan
The Asset Management and Maintenance Plan (AMMP) is a key output of the maintenance
planning process and provides a review of past, current and a forward three year focus on
maintenance planning. The AMMP is an integral element for development of the Total Asset
Management Plan (TAMP) and identifies:
• maintenance requirements
• maintenance strategies and implementation responsibilities
• building maintenance works program
• maintenance budgeting
• perceived risks and proposed mitigation strategies for works not programmed
• continuous improvement opportunities through benchmarking and performance review
• asset management capability.
 A specific AMMP template has been established to assist in the development of annual AMMPs.
It provides a consistent structured tool to identify and record maintenance requirements,
strategies, planned expenditure and the program of works. Detailed instructions and guidance
on how to develop and complete the AMMP are provided within the template. The template is
reviewed and updated annually by the Assets and Facilities Unit. The current version of the
template and associated excel spreadsheets can be sourced via the Asset Services Team: A-Z
Directory of Useful Links on QHEPS.
Roles and responsibilities associated with building asset management and maintenance
planning are defined in Appendices 1 and 2.
3.3 Identification of the asset portfolio and information
It is essential to ensure that all building assets are identified and that associated master data is
appropriately maintained. Prior to the preparation of the AMMP, the Finance and Materials
Management Information System (FAMMIS) asset register should be reviewed and reconciled
with data in the Computerised Maintenance Management System (CMMS) to ensure financial
assets and maintainable assets are identical to those listed in the AMMP for maintenance
purposes. Refer to the Single asset identifier (SAID) guideline for further information on the
numbering system for identifying and recording assets and maintainable items.
As the CMMS is the source for all maintenance data used to develop AMMPs, it is crucial that
the CMMS data integrity is maintained at all times. Maintaining the accuracy of condition
assessment data within the CMMS is critical as this data is used to develop condition-based
maintenance strategies and inform the maintenance works program.
The AMMP utilises information sourced from the CMMS which includes the maintenance activity
data. The CMMS activity types, descriptions, examples, work order types and maintenance
category (planned or unplanned) are provided in Appendix 3. Failure to allocate work under the
correct activity type may distort information and impact on benchmarking and performance
reporting. For further information on maintenance information management refer to the
Maintenance information management guideline.
All asbestos containing materials in buildings whether confirmed or assumed, is to be identified
and recorded in the CMMS, as this is the data source for all Queensland Health asbestos
registers. This is critical to inform asbestos management requirements and scheduled asbestos
surveys. The Queensland Government Asbestos Management Policy for its Assets and the
Asbestos management guideline provides further information on asbestos management.
3.4 Benchmarking and performance review
Key performance indicators (KPIs) are available within the Decision Support System (DSS) and
have been incorporated into the AMMP template to facilitate benchmarking and performance
review. This also assists to identify areas requiring improvement and to guide future planning
strategies.
Once completed, the AMMP will identify the annual maintenance budget for the planned year
which in turn determines the maintenance expenditure target for KPI 2 for benchmarking and
performance reporting for that budget cycle. For further detail on the KPIs refer to the
Benchmarking and performance indicators guideline.
3.5 Maintenance demand assessment
A maintenance demand assessment must be undertaken to financially quantify and ascertain
the maintenance requirements as part of the AMMP process. This process includes all
maintainable, financial and leased assets, components, elements, systems services, plant and
equipment for a building asset and its supporting infrastructure. The scope of the maintenance
work in the demand assessment process should include the following:

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 • condition assessment and asbestos survey requirements
• preventative and statutory maintenance
• condition based maintenance (results from condition assessments and asbestos surveys)
• deferred (backlog) maintenance
• unplanned maintenance based on historical information
• lifecycle replacement of ageing components
• consider impact of new or proposed major capital works projects.
Other planning documents such as the current TAMP, should be checked to determine if any
disposals, refurbishments or other redevelopment activities are planned for buildings to assist in
identifying appropriate maintenance strategies.
3.6 Maintenance budget preparation
Once the maintenance demand assessment has been completed the annual maintenance
budget can be developed based on the outcome of the assessment. The AMMP template is
required for this activity.
The following categories are used within the AMMP to develop the maintenance budget:
• planned: statutory and preventative service maintenance
• planned: condition-based maintenance
• unplanned maintenance
• lifecycle replacements
• backlog maintenance
• condition assessments / asbestos surveys
• administration.
Review of historical expenditure against the above categories may assist in identifying
appropriate budget allocations for the planned years. Maintenance budgets do not include non-
maintenance activities such as new minor works, operational building costs (e.g. utility charges,
leasing and cleaning costs) and capital works upgrades or improvements. Further guidance on
what is maintenance can be found in the Non-Current Asset Policies for the Queensland Public
Sector, the MMF and the MMF Policy Advice Note on Capital or Expense? - A Guide for Asset
and Maintenance Manager.
An appropriate budget allocation needs to be provided for planned maintenance activities
(preventative, condition-based and statutory maintenance) and a provision for unplanned
maintenance activities (corrective/breakdown and incident maintenance). During the budget
build process, consideration should be given to the specific budget provisions provided to
planned maintenance and unplanned maintenance as this correlates to benchmarking and
performance indicator KPI 5. DoH-CBUs are required to achieve a maintenance target ratio of
60 to 70 per cent planned maintenance expenditure to total maintenance expenditure.
Maintenance identified via lifecycle replacement planning should be prioritised and included in
the AMMP. Lifecycle replacement planning is undertaken as a separate activity to the AMMP.
The outcomes from this planning are used to inform the AMMP. For further information on
lifecycle replacement planning refer to the Lifecycle replacement planning guideline.
Review of backlog maintenance works and the risk of not carrying out works should be
undertaken to prioritise works for inclusion in the AMMP. Very high and high risk backlog
maintenance items identified within the CMMS must be included in the AMMP and should be
given priority to be addressed in the planning year based on criticality. Where risk treatments
are adopted in lieu of funding very high and high risk items, the items must be rerated and the

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 projected risk rating updated against the backlog item in the CMMS. For further information on
backlog maintenance refer to the Backlog maintenance management guideline.
Condition assessments and asbestos surveys are a key element of the asset management and
maintenance planning process as they inform condition-based maintenance strategies. Where
condition assessments or asbestos surveys are due but have not yet been carried out, these
should be included as scheduled work activities in the AMMP for the planning year. For further
information on condition assessments or asbestos management refer to the Condition
assessment and Asbestos management guidelines.
Miscellaneous administration costs associated with the support and delivery of maintenance
need to be included as part of the maintenance budget.
Although new minor works may be undertaken by employed engineering and maintenance staff,
it is not classified as a maintenance activity and should not be funded out of allocated
maintenance budgets. However, new minor works should be identified in the AMMP and their
potential impacts on maintenance considered as part of the maintenance planning process.
Any maintenance expenditure that has been capitalised will not reflect in KPI 2 in DSS and
therefore will need to be tracked separately for capital maintenance reporting purposes. The
AMMP template allows for capital expenditure to be identified for benchmarking purposes.
3.7 Risk management
Where available maintenance budgets are unable to meet the maintenance demand, it may be
necessary to defer maintenance items identified from the maintenance demand assessment.
Where this occurs, all risks should be evaluated and risk treatments implemented to ensure the
safety of staff, visitors and patients. For further guidance on risk management governance refer
to the Risk Management Policy QH-POL-070:2015, Risk Management Standard (QH-IMP-070-
1:2015), Risk Assessment and Treatment Guideline (QH-GDL-070-1-1:2015) and AS/NZS ISO
31000:2009 Risk management - Principles and guidelines.
3.8 Asset management capability
As part of asset management and maintenance planning, consideration should be given to the
current and future resource availability and the capability of the resources to deliver on the
AMMP. A capability assessment tool has been developed to assess asset management
capability and is available from the Assets and Facilities Unit. A section has also been included
in the AMMP template to annually assess and benchmark asset management capability.

4. Supporting documents
Forms and templates
 Asset Management and Maintenance Plan template
 Asset Management and Maintenance Plan spread sheet template
 Asset management capability tool
 Total Asset Management Plan template
Related references/information
 Asbestos management guideline
 Asset management and maintenance policy (QH-POL-354:2015)
 Asset management and maintenance standard (QH-IMP-354-1:2015)
 AS/NZS ISO 31000:2009 Risk management - Principles and guidelines
 Backlog maintenance management guideline
 Benchmarking and performance indicators guideline
 Capital Works Management Framework

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  Condition assessment guideline
 Financial Accountability Act 2009
 Lifecycle replacement planning guideline
 Maintenance information management guideline
 Maintenance Management Framework
 Maintenance Management Framework Policy Advice Note on Capital or Expense? - A Guide for
Asset and Maintenance Managers
 Queensland Health Building Infrastructure Maintenance Task Specification Library
 Queensland Government Asbestos Management Policy for its Assets
 Capital infrastructure project delivery policy (QH-POL-374-2015)
 Finance Management Practice Manual Policy (QH-POL-267:2015)
 Non-Current Asset Policies for the Queensland Public Sector
 Risk Management Policy (QH-POL-070:2015)
 Risk Management Standard (QH-IMP-070-1:2015)
 Risk Assessment and Treatment Guideline (QH-GDL-070-1-1:2015)
 Single asset identifier (SAID) guideline

5. Definitions
Term Definition
Asset A resource controlled by the entity as a result of past events and
from which future economic benefits are expected to flow to the
entity.

Asset management The coordinated activity of an organisation to realise value from

assets (ISO 55000 definition).

Asset management and A structured tool that demonstrates a plan for managing, recording
maintenance plan and reporting asset activities including planned expenditure through
a program of works, asset management and maintenance strategies,
performance, risk management and related actions to assist in
budget discussions with finance departments and executive
management.

Backlog maintenance Maintenance that is necessary to prevent the deterioration of an

asset or its function but which has not been carried out.

Computerised Maintenance The CMMS (SAP Plant Maintenance Module) is Queensland Health’s
Management System (CMMS) corporate asset maintenance system which is used to identify,
manage and maintain the buildings and associated infrastructure. It
is a module within FAMMIS. The CMMS provides comprehensive
reporting on all aspects of maintenance activities and performance.

Condition assessment A technical inspection by a competent assessor to evaluate the

physical state of building elements and services and to assess the
maintenance needs of the facility.

Finance and Materials A computer based integrated business management solution which
Management Information System utilises SAP enterprise resource planning software and contains
(FAMMIS) financial, asset accounting, materials management and maintenance
information.

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 Term Definition
Lifecycle replacement The replacement of buildings, items or equipment with the intention
of replacing components at the end of their useful/economic life with
modern engineering equivalents.

Maintenance demand Is an assessment of the maintenance requirements for a portfolio of

assessment building related assets, and will be a combination of:
• condition assessment
• preventative and statutory maintenance
• condition based maintenance (results from current condition
assessments)
• deferred maintenance
• unplanned maintenance based on historical information
• lifecycle replacement of aging components
• special works (e.g. removal of asbestos)
• impact of any new works recently completed (new building).
To ascertain the maintenance requirements of the building portfolio
being assessed.

Planned maintenance Preventative service maintenance – prevents asset failure by

systematic inspection and monitoring to detect and avoid
deterioration or failure. It also entails testing to confirm correct
operation.
Condition based maintenance – Programmed maintenance work,
based on condition assessment or other priorities, that returns any
maintainable asset to an acceptable standard.
Statutory maintenance – Compulsory maintenance to meet
requirements mandated in acts, regulations and other statutory
instruments. This includes standards and codes.

Total Asset Management Plan An overall summary plan that consolidates all separate asset
management plans into a single organisational plan. The TAMP will
cover the total lifecycle of an asset from conception, creation,
maintenance and operation to disposal.

Version Control
Version Date Comments
1.0 19 December 2017 New document

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 Appendix 1
Asset Management and Maintenance Roles and Responsibilities Matrix

DoH Capital Infrastructure

DoH Senior Management

Strategy Planning Branch

Procurement and Supply

DoH Asset Management

QH FAMMIS Help Desk

DoH Asset Information

DoH Property Services

DoH Decision Support

QH FAMMIS Security

QH FAMMIS Training

DoH-CBUs (e.g. HSQ)

DoH Priority Capital
Management Team

DoH Infrastructure

DoH HSQ Strategic

Activity Comments

Program Team

DoH Facilities

Delivery Unit

DoH eHealth
DoH Finance
QH FAMMIS

System
Team

Team

HHS
DoH Asset Management and Maintenance Policy, Standard and Guidelines -
R C C/I C/I C/I C C C C A
Develop and maintain HHSs are responsible to develop their own policies, standards
Policies, SPMndMrds Mnd Guidelines

DoH Asset Management and Maintenance Policy, Standard and Guidelines - and guidelines or may adopt the DoH's.
S I I R/A I R/A I
Implement

Real Property Management Policy and Standards - Develop and maintain R C C C A

HHSs are responsible to develop their own policies, standards
and guidelines or may adopt the DoH's.
Real Property Management Policy and Standards - Implement I R/A R I I R I

Monitor and implement legislative requirements on building related assets S S S R/A S R/A R/A I

Corporate Task Specifications - Develop and maintain R/A C C C C

AsseP MMnMgemenP Mnd MMinPenMnce PlMnning

Local Task Specifications - Develop and maintain S/I S/I R/A R/A R/A

Corporate Task Specifications - CMMS templates S R/A C/I C/I C/I

Corporate and Local Task Specifications - Implement S S R/A R/A R/A

DoH CBUs Asset management and maintenance procedures, processes,

C/I S R/A C R/A HHSs are responsible to develop their own.
frameworks and systems
Climate change strategies and policies including emission targets (under
S/C/I R/A R/A R/A I
development)
DoH Corporate KPIs and other benchmark measures - Develop and maintain
R S C/I C/I C/I S A
(including new KPI's)

DoH Corporate KPIs and other benchmark measures - Report R S/I R/A R/A S A

Utility benchmarking, analysis and reporting S/C/I R/A R/A

e.g. building condition / performance assessments, backlog,
Maintenance demand assessment C R/A R/A R/A
preventative, statutory and reactive maintenance.
PlMnning C AnMlysis

Asset Management and Maintenance Plan (AMMP) - Template R/A C C C C

Asset Management and Maintenance Plan (AMMP) - Populate template S S R/A R/A S I

DoH Life Cycle Planning - Tool R/A S C/I C/I

Life Cycle Planning S S R/A R/A C

DoH CBUs - Asset management and maintenance budgets I R/A C R/A C

Total Asset Management Plan (TAMP) - Templates I C C C R/A A

Total Asset Management Plan (TAMP) - Populate templates S R/A R/A R/A R
Total Asset Management Plan (TAMP) - Queensland Health Consolidated
S I I S S S S R A
(portfolio level)

State Health Infrastructure Plan (SHIP) - Develop S I I S S S R A

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 Asset Management and Maintenance Roles and Responsibilities Matrix (continued)

DoH Capital Infrastructure

DoH Senior Management

Strategy Planning Branch

Procurement and Supply

DoH Asset Management

QH FAMMIS Help Desk

DoH Asset Information

DoH Property Services

DoH Decision Support

QH FAMMIS Security

QH FAMMIS Training

DoH-CBUs (e.g. HSQ)

DoH Priority Capital
Management Team

DoH Infrastructure

DoH HSQ Strategic

Activity Comments

Program Team

DoH Facilities

Delivery Unit

DoH eHealth
DoH Finance
QH FAMMIS

System
Team

Team

HHS
CMMS - Help desk S R/A
DoH Asset Information Management Team is FAMMIS District
CMMS - Review and authorise access including training requirements R/A I R/A R/A
Coordinator for Statewide plant maintenance only.
CMMS - Provide access I R/A I I
Asset Management and Maintenance Planning

Information Management

CMMS - Training delivery S R/A

CMMS - Training records S R/A R R

CMMS - Master Data S S R/A R/A e.g. data health checks

FAMMIS - Financial asset register R/A R/A R/A C/I R/A

CMMS - Changes (system configuration) C/I A C/I R/C C/I C/I

Decision Support System (DSS) - Maintain CMMS module and provide access C/I A C/I C/I C/I R/C

CMMS - Review and maintain upload templates e.g. condition assessments C/I R/A C/I C/I C/I

iCMMS - Web-based Application S I R/A

cmmsMobile Application S I R/A

CMMS - Undepreciated Asset Replacement Value review and update (business
C/I S R/A R/A R/A S
area level)

Energy and utility procurement management S/C/I R/A R/A R

Operational

Energy productivity solutions S/C/I R/A R/A

Demand management solutions S/C/I R/A R/A

Facility management R/A R/A R/A

Note: Capital Works are excluded

R RESPONSIBLE Responsible – owns the problem/project, responsible for doing.

A ACCOUNTABLE To whom “R” is accountable – who must sign-off (approve) on work before it is effective.
S SUPPORTIVE Can provide resources or can play a supporting role in implementation.
C CONSULTED To be consulted – has information and/or capability necessary to complete the work.
I INFORMED To be informed – must be notified of results, but need not be consulted.

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 Appendix 2

Asset Management and Maintenance Plan Responsibilities Chart

Department of Health commercialised business units (DoH CBUs) / Hospital and Health Services (HHS)

Asset Management and Maintenance Plan Information Asset Management and Maintenance Plan
Collection and Analysis Endorsement

Information is gathered and analysed in accordance with the The senior management endorses the AMMP, which
AMMP template to align with best practice asset aligns with best practice asset management principles
management principles that reflect the service delivery and reflect the service delivery outcomes of the HHS /
outcomes of the HHS and DoH CBUs. This includes a DoH CBUs. This includes a maintenance plan, which is
maintennce plan based on a maintenance demand based on a maintenance demand assessment and asset
assessment and lifecycle planning. lifecycle planning.

Some of the information required to develop the AMMP are Some of the items to be addressed in the AMMP are:
sourced from the following: - Maintenance budgets align with the maintenance
demand assessment
- FAMMIS / CMMS - Benchmarking and performance review / improvements
- Preventative and statutory maintenance plans - Preventative and statutory maintenance
- Historical budgets - Condition based maintenance
- Project reports - Update undepreciated asset replacement values
- Clinical services plan - Facility Condition Index no greater than 4 percent
Responsibilities

- Master plan - Very high and high risk backlog maintenance works
- Lifecycle replacement of aging components
- Total asset management plan - Condition assessments and asbestos surveys
- Capital works - Risk identification and management
- Health technology equipment replacement program - Asset management capability
- Operational plans - CMMS data is maintained and data quality issues are
- Future projections and trend analysis. addressed.

Asset Management and Asset Management and Asset Management and

Maintenance Plan (AMMP) Maintenance Plan - Draft Maintenance Plan - Final
Template Completed Endorsed by Chief Executive

HHS and DoH CBUs senior Yes HHS and DoH CBUs senior Yes HHS and DoH CBUs AMMP
management approval to management approval to has Chief Executive
review information and submit AMMP to the Chief endorsement.
polulate AMMP template. Executive for review and
No No
endorsement.

Yes
Department of Health Corporate Services, Capital and Asset Services (CAS)

Asset Management and Asset Management and

Maintenance Plan Maintenance Plan
Template Collection

CAS senior management CAS senior management are

approval to update and provided an update on the
distribute AMMP template. AMMPs provided.
Responsibilities

Asset Management and

Maintenance Plan
Review and Reporting

Elements of the AMMP are

reviewed and reported as
required to senior
management (e.g. Director-
General and Minister).

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 Appendix 3

CMMS Maintenance Activity Types

Work
Activity type Description Examples order Category
type *
Used to identify miscellaneous • workshop cleaning
AD – administrative activities
MST planned
administration associated with the support and
delivery of maintenance.
AR – Used to identify asbestos • replacing / repairing a roof
asbestos containing material removal made of asbestos MAM planned
removal activities. containing material
AS – Used to identify an ad hoc • project asbestos survey MAM planned
ad hoc survey asbestos survey.
Used for the tasks to restore the • replacing worn carpeting
condition or performance of • repainting of hospital
CB – equipment and building corridor MAS
condition infrastructure to an acceptable
MPM planned
based standard. It is also used for any
MWR
assessment identified corrective maintenance
arising from assessment
activities.
Used to identify corrective work • Identification of a leaking
CF –
that has been identified when panel seal on an air-
corrective
performing planned / preventative conditioning unit during MWR planned
(follow-up
maintenance which was not part regular monthly inspection
work)
of the planned activity.
FS – Used for a five-yearly asbestos • five-yearly asbestos
five-yearly survey. survey MAM planned
survey
Used for the replacement of • replacement of standby
equipment and/or infrastructure generating sets
LR – deemed to be at the end of its • replacement of a lift MAS
lifecycle useful life. Note the replacement • replacement of a nurse MWR
planned
replacement of equipment and/or call system
infrastructure is always to be on a
basis of “like with like”.
Used for systematic inspection, • replacement of motor oil
monitoring, adjustment and parts every 10,000 hours
PM – replacement tasks to detect • inspection of an automatic MPM
preventative and/or avoid deterioration or opening door planned
MST
maintenance failure. It can also be used for • check operation of public
any testing undertaken to confirm address system
correct operation.
Used to identify equipment or • monthly inspection air
SM – facilities that have a statutory filters
MPM
statutory requirement to be maintained • annual inspection of fire MST
planned
maintenance under a defined policy or hydrants and smoke
legislation. detectors
TT – Used for the common • test and tag of electrical
maintenance task of testing and equipment MPM
test and planned
tagging electrical equipment MST
tagging

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 Work
Activity type Description Examples order Category
type *
TS – Used for a three-yearly asbestos • three-yearly asbestos
three-yearly survey. survey MAM planned
survey
Used in order to meet and • three-monthly inspection
maintain a warranty for and service of on-site
equipment or facilities. For sewerage system
example, equipment may need to • monthly load test and
be serviced every three months inspection of standby
WA – in order to satisfy its two-year generating sets
warranty pre- warranty. Failure to service the • monthly inspection of MPM planned
expiry checks equipment may void the laboratory analysis
warranty. Therefore a planned / equipment
preventative work order with an
activity type of WA would be
created for the three monthly
services.
YS – Used for a yearly asbestos • yearly asbestos survey
MAM planned
yearly survey survey.
Used to restore equipment and • door handle is broken and
CM – facilities to an operational needs replacement MAS
corrective condition following an unforeseen • pan sanitiser is leaking MST unplanned
maintenance failure. • blocked toilets, guttering MWR
and drains
IM – To be used for an unexpected • graffiti and vandalism
incident breakage or failure that requires • break and entry MWR unplanned
management an immediate response. • storm or fire damage
Used to identify emergency • water main has burst
situations. These situations call • air supply system is
for a rush corrective maintenance blocked
RC –
work order to ensure that the
rush corrective MWR unplanned
work is promoted in priority
maintenance
before all others. Note this
activity type is very similar to
corrective maintenance.
To be used for work undertaken • new wall needs to be built
NW – that results in enhancements or to divide a room
MAS
new minor additions being performed on an • new shelving for an office minor works
MWR
works existing asset. • new whiteboard for a
training room
To be used for costs not directly • moving furniture
OA – chargeable to an asset. • regular landscaping and
operational grass mowing MWR operational
activities • training and meetings
• replacing gas bottles
* CMMS Work Order Type descriptions:
MAM: asbestos maintenance
MAS: maintenance assessment
MPM: preventative maintenance
MST: standing order
MWR: maintenance work request

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