Department of Human Services Standards self-assessment report and quality improvement plan for service providers operating under DisabilityCare Australia
June 2013
Department of Human Services self-assessment report and quality improvement plan - DCA
1. Introduction
Service providers operating under DisabilityCare Australia (DCA) that apply for initial registration under the Disability Act 2006 are required to undertake a self-assessment and quality improvement planning process using this tool.
Service providers operating under DCA that apply for renewal of registration under the Disability Act may also be required to undertake a self-assessment and quality improvement planning process using this tool.
DCA service providers that provide direct care but are not required to undertake an independent review (a review) are required to undertake a self-assessment and quality improvement planning process using this tool developed by the Department of Human Services (the department). This applies in exceptional circumstances and under agreement from the department and from DCA.
The completed self-assessment report and quality improvement plan should be provided to the department’s Standards and Regulation Unit (SRU) via email at .
2. Why self-assessment is important
Self-assessment is an opportunity for service providers to:
· confirm areas where the service is meeting the standards
· confirm areas where the service is meeting governance and management indicators
· identify gaps in current systems and processes that do not meet the standards
· identify gaps in current systems and processes that do not meet governance and management indicators
· plan actions to address any identified gaps in systems and processes
· identify additional opportunities for improvement, to support continuous improvement.
Self-assessment involves an organisation looking at how it does things, what it achieves and how it measures up against criteria. During the process, an organisation’s strengths, weaknesses and opportunities for improvement will be identified.
The self-assessment will report each service provider’s findings about how well they are meeting the Department of Human Services Standards and governance and management indicators.
Self-assessment needs to be informed by input from clients. Organisations must ensure there are accessible ways for clients to provide feedback and actively contribute to how services are delivered. There are huge benefits for organisations that link quality management with client outcomes, staff wellbeing, organisational sustainability and practice improvement.
2.1 Relationship to registration
To be registered or to apply for renewal of registration under the Disability Act, organisations need to demonstrate capacity to comply, or compliance with, the gazetted Department of Human Services Standards respectively. The Department of Human Services Standards have been gazetted under the Disability Act and are required to be met by registered organisations. A standard requiring organisations to meet the governance and management standards of their selected independent review body has also been gazetted. Organisations may be required to submit a completed self-assessment as part of their registration application.
The Disability Act defines ‘disability service provider’ and sets out the requirements for the registration of disability service providers.
All DCA service providers operating as a disability provider under the definition in the Disability Act, are required to be registered and operate within the requirements of the Disability Act, including compliance with the relevant standards.
Further information is available in the Policy, Procedures and Forms for the Registration of Disability Service Providers registered/registering with DisabilityCare Australia or by contacting the department’s Standards and Regulation Unit via email at .
2.2 Department of Human Services Standards
The Department of Human Services Standards (the standards) represent a single set of service quality standards for funded organisations delivering services to clients.
The standards are summarised as:
· Empowerment
· Access and Engagement
· Wellbeing
· Participation.
All DCA service providers operating as a disability provider under the definition in the Disability Act, are required to meet the Department of Human Services Standards. The standards are contained in this departmental self-assessment tool. Further information is available from the Department of Human Services Standards evidence guide on the department’s website. The evidence guide includes examples of evidence that can be used to demonstrate that each applicable criteria and evidence category has been met.
2.3 Governance and management criteria
Corporate governance is ‘the system by which companies are directed and controlled’ (Cadbury Committee, 1992). It involves a set of relationships between the board, management, the people who use the services and other stakeholders. Governance sets the strategic framework, determines accountability and the prevention or mitigation of risks and conflict of interests between stakeholders.
Sound governance and management are critical for quality service delivery to occur. Inversely where poor quality services are provided the organisation’s governance and management are often deficient.
The departmental self-assessment tool also includes management indicators to guide systems such as human resource management and contract management.
The Department of Human Services Standards and independent review model states that a funded organisation’s governance and management will normally be reviewed and accredited by an independent review body that utilises their own internationally or nationally recognised governance and management standards.
Where, in exceptional circumstances, the department and DCA have agreed to exempt a DCA service provider from undertaking an independent review, a self-assessment process will be required. Refer to the Department of Human Services Standards Policy available from the department’s website for information regarding exemption from independent review.
As organisations that are undertaking a self-assessment will not be a member of a department endorsed independent review body there is a requirement for the department to define and monitor governance and management criteria. The self-assessment tool lists the governance and management indicators that should be used to conduct a self-assessment.
3. The self-assessment tool
The self-assessment tool includes:
· an assessment matrix
· self-assessment record
· quality improvement plan
· checklist of actions.
3.1 Assessment matrix
The assessment matrix is in the first section of the toolkit. The assessment matrix is a summary of the findings of the self-assessment, and allows service providers to identify their organisation’s overall performance against the standards and the governance and management standards.
· Met: written and verbal evidence clearly demonstrates that the service provider meets all the requirements of the criteria
· Part Met: written and verbal evidence clearly demonstrates that the service provider only meets part of the requirements of the criteria.
· Not Met: written and verbal evidence clearly demonstrates that the service provider does not meet the requirements of the criteria.
· Not Applicable: a not applicable rating may apply, for example, where a service does not provide direct care to people.
3.2 Self-assessment record
The self-assessment record is used to record evidence of current good practice and identify areas for further improvement. From this, issues for priority action can be identified.
3.3 Quality improvement plan
The quality improvement plan (QIP) provides a summary of the actions for improvement required to meet the indicators. The QIP assists organisations to prioritise the actions for improvement and ensures the self-assessment is linked to continuous quality improvement.
Service providers are also encouraged to document any opportunities for improvement that they identify even where the criteria is fully met. These are considered to be optional actions to promote continuous quality improvement and should also be documented in the QIP.
3.4 Checklist of actions
A checklist is included at the back of the self-assessment tool to assist service providers in reviewing the completed self-assessment prior to submitting it to the Department of Human Services, Standards and Regulation Unit.
4. Conducting the self-assessment
4.1 Preparing for the self-assessment
The self assessment process should be completed by people within your organisation who have the skills to coordinate the process, such as engaging other staff in examining the standards and criteria, conducting interviews and deciding which policies, records or other documents might need to be examined or revised. Depending on the size of your organisation this activity may require the cooperation of a number of people.
A number of methods can be used to conduct the self-assessment including:
· feedback from staff, management, board of management and clients
· desktop review of your organisation’s policies and procedures
· workshops/meetings to discuss where your organisation is working well and where there are gaps in the system.
To promote involvement it is useful to explain why the self-assessment is being undertaken and why their involvement is important.
4.2 Collecting evidence
Conducting the self-assessment involves collecting and assessing evidence for each standard. Organisations must provide evidence to demonstrate they are addressing each of the following evidence categories:
· documents
· knowledge and awareness
· evaluation and monitoring
The Department of Human Services Standards evidence guide includes evidence examples that can be used to demonstrate that each applicable criteria and evidence category has been met.
4.3 Categories of evidence
The three categories of evidence are described below.
Category / Description /Documents / The documents evidence category includes a wide range of written material that demonstrates how an organisation meets the Standards while also addressing relevant external requirements e.g. legislation, regulations, and departmental and program specific requirements. Documentation might include:
· policies, procedures, protocols, work instructions describing the organisations processes and practices
· information available and/or provided to people or displayed, such as: brochures, pamphlets, newsletters, photographs, or posters or other written material given to people who use the service or other stakeholders
· records and other tools used by staff or people who use the service, examples may include: referrals, intake and assessment tools, care plans, attendance records, feedback and complaint forms, improvement forms, personnel files, meeting minutes, memorandums, emails.
Knowledge and awareness / The knowledge and awareness evidence category provides information about the methods the organisation uses to demonstrate implementation of the documented processes and systems. This should include assisting board members, management, staff, carers, volunteers and other stakeholders in understanding the processes and systems developed for the service and service delivery. This might include:
· training plans/records (planned training, orientation)
· agenda items in meetings
· manuals/guidelines/memos.
For people who use the service, this may include:
· when, how and what information is provided
· provision of information in other formats to facilitate understanding and to meet the language, cultural and communication needs of individuals
· use of interpreters.
Monitoring and evaluation / The monitoring and evaluation evidence category provides information to demonstrate the organisation’s approach to continuous quality improvement and the methods used to measure the effectiveness of processes and systems in day to day service delivery. Evidence should confirm implementation, and identify outcomes or outputs of systems and processes. This might include:
· client records, complaints register, incident register
· reports including; management reports, financial reports, annual reports, audit report
· feedback mechanisms e.g. focus groups, surveys, complaints
· documentation audits e.g. client files, personnel files,
· internal and/or external audits
· benchmarking
· quality plans and associated activities
· risk management plans
· other monitoring processes e.g. incident reports, hazard identification
o meeting minutes
o observations
o interviews.
4.4 Assessing the evidence and applying a rating
This requires your organisation to examine the three categories of evidence against the standards to identify strengths and any areas requiring improvement. As part of this process you are required to apply a self-assessment rating of met, part met, not met or not applicable for each of the criteria.
To achieve a met, your organisation must have evidence that your processes and systems are documented, the appropriate people are aware of them (staff, people using the service and stakeholders) and that these are regularly monitored and reviewed. Where your organisation identifies a part met or a not met, improvements must be identified to address the requirements of that particular criteria. These improvements need to be documented in the quality improvement plan included in the tool.
4.5 Complete the quality improvement plan
Following the self-assessment a quality improvement plan (QIP) must be developed for instances where your organisation has decided it does not fully meet a criteria. In addition, your organisation may identify areas for improvement to further enhance your systems and processes. These should also be included on the QIP to assist your organisation with prioritising the actions for improvement.
Improvement plans would normally include the following detail:
· the improvement action that is planned
· the name/position of the person responsible for completing the action
· the timeframe within which action is to be completed
· the outcome of the action and the date the action is completed.
Examples of the type of improvement actions that may be required are:
· develop and introduce new or additional policies and/or procedures
· review current policies and/or procedures
· change orientation and/or staff training programs
· further develop written information for care recipients
· consistently implement the agreed organisational processes
· introduce new or additional quality improvement processes, for example:
develop an internal audit schedule
increase opportunities for stakeholders to provide feedback.
4.6 Completing the assessment matrix
On completion of the self assessment the assessment matrix should be completed. Completing the matrix requires inserting a rating against each criteria, reflecting the self-assessment findings.
Where a funded organisation considers any criteria to be not applicable to their service type, (for example where no services are delivered directly to people) they should tick ‘not applicable’ in the assessment matrix.
Department of Human ServicesDCA SERVICE PROVIDER
SELF-ASSESSMENT REPORT AND QUALITY IMPROVEMENT PLAN
SERVICE provider
Main Site ADDRESS
Additional Sites
Contact name
position
due date
date submitted
submitted to
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Department of Human Services self-assessment report and quality improvement plan - DCA
Standards indicators, evidence and actions for quality improvement planStandard 1: Empowerment
Criteria 1.1 People[1] understand their rights and responsibilities.
Common evidence indicators
· The relevant charters of rights are displayed and provided in an accessible format that facilitates understanding by all people.
· Rights and responsibilities are developed and provided in an accessible format that facilitates understanding by all people.
· Information is provided in an accessible format about: the quality of service they can expect to receive from the service provider; their right to an advocate including how to access one; their right to privacy and dignity; the process for accessing their records; feedback processes; complaints, appeals and allegations processes; the extent of their rights; their right to be free from abuse, neglect, violence and preventable injury.
· People’s understanding of their rights and responsibilities is confirmed.
Documents
Knowledge and awareness
Evaluation and monitoring
SELF-ASSESSMENT RATING:
Action required to meet the criteria: Must be transcribed to quality improvement plan
Action to support continuous quality improvement: Must be transcribed to quality improvement plan
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