Human Services Quality Framework Self-Assessment Guide for providers registering with the National Disability Insurance Scheme in Queensland – Version 4, November 2017

Human Services Quality Framework Self-Assessment Guide for providers registering with the National Disability Insurance Scheme in Queensland – Version 1.4, November 2017

Introduction

The National Disability Insurance Scheme (NDIS) will progressively roll out in Queensland by July 2019. Until the national NDIS quality and safeguards framework is in place, or 30 June 2019, whichever is sooner, Queensland’s quality and safeguards framework will apply to NDIS providers in Queensland.

This framework applies to providers registering to deliver services that are prescribed under the Disability Services Regulation 2017.

To register with the NDIS, providers need to show evidence of compliance, or a capacity to comply, with the department’s quality assurance requirements under the Human Services Quality Framework (HSQF).

The NDIS Provider Registration Guide to Suitability identifies that in certain circumstances, a self-assessment is a suitable method for demonstrating compliance with the HSQF.

Purpose

This guide is designed to assist providers understand the requirements of a self-assessment for the purposes of registration with the NDIS. A self-assessment system including a workbook for completing and recording the findings of a self-assessment, and a template for developing a continuous improvement action plan is available at: www.communities.qld.gov.au/hsqf

Human Services Quality Framework

The Human Services Quality Framework (HSQF) is the Department of Communities, Child Safety and Disability Services’ (DCCSDS) quality assurance system for assessing and improving the quality of human services and promoting quality outcomes for people using services. The HSQF incorporates:

• 
  a set of quality standards (Human Services Quality Standards) which cover the core elements of human service delivery
  
• 
  an assessment process to measure the performance of service providers against the standards (certification by an accredited independent third party, evidence of an approved alternative accreditation/certification, or self-assessment)
  
• 
  a continuous improvement framework which engages people using services in quality improvement.
  

Human Services Quality Standards

The Human Services Quality Standards (the standards) set a benchmark for the quality of service provision. A set of indicators and evidence requirements support each standard and these outline what a provider needs to have to meet the standard.

The standards cover the core elements for quality service provision, namely:

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  Standard 1 – Governance and management
  
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  Standard 2 – Service access
  
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  Standard 3 – Responding to individual need
  
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  Standard 4 – Safety, wellbeing and rights
  
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  Standard 5 – Feedback, complaints and appeals
  
• 
  Standard 6 – Human resources
  

The standards have been mapped to the National Standards for Disability Services 2013.

A copy of the standards is available at: www.communities.qld.gov.au/hsqf

HSQF and the NDIS

To demonstrate compliance with the HSQF for registration with the NDIS, providers will need to have one of the following:

• 
  current HSQF certification for disability services
  
• 
  evidence of an alternative certification/accreditation approved by DCCSDS on a case-by-case basis
  
• 
  a completed self-assessment against the standards including a signed declaration.
  

In order to complete NDIS registration, providers that do not demonstrate compliance with points 1 or 2 above must complete a self-assessment against the standards unless otherwise advised by the department.

DCCSDS acceptance of self-assessments

Providers must submit their self-assessment to DCCSDS along with a declaration confirming that their business has developed, and will fully implement, the policies, procedures and systems detailed in the self-assessment and in accordance with requirements including the following safeguards:

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  adhering to the safeguards set out in the Disability Services Act 2006 (DSA) and other Queensland state legislation such as:
  

• 
  criminal history screening requirements as outlined in the DSA 2006 and regulation
  
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  working with children check requirements as outlined in the Working with Children (Risk Management and Screening) Act 2000 and regulation
  
• 
  Positive Behaviour Support and requirements for the use of restrictive practices as specified in the DSA 2006
  

• 
  developing, implementing and acting in accordance with the DCCSDS policy for Preventing and Responding to the Abuse, Neglect and Exploitation of People with Disability
  
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  developing and implementing a complaints management framework that is aligned with the Australian/New Zealand Standard Guidelines for Complaint Management in Organisations (AS/NZS 10002:2014)
  
• 
  developing and implementing a risk management framework that is aligned with ISO 31000
  

As part of the self-assessment review process, DCCSDS may request copies of relevant documents such as criminal history screening outcome notices, professional qualifications/membership, key policies and procedures.

When making a decision to approve a provider’s registration, the NDIS will rely on DCCSDS acceptance of completeness of the self-assessment and the provider’s declaration of adherence with the standards and safeguards identified above.

Ongoing HSQF quality requirements

Registered providers will be accountable for on-going adherence to the standards and have up to 18 months from the date of registration with the NDIS, to achieve HSQF certification for in-scope services (refer to the HSQF – Demonstration method table for NDIS Registration Groups (prescribed disability services) in Queensland found at www.communities.qld.gov.au/hsqf)

About self-assessment and its importance

Self-assessment provides an opportunity to understand the requirements of the standards and DCCSDS safeguards and to review performance against these standards. It does this by identifying which processes are working well and which may need further development. Self-assessment is an important step in helping providers to build and embed systems and processes that assure service quality and safety, and drive and promote continuous service improvement.

Where a provider is new to HSQF requirements and does not have evidence of an approved alternative accreditation or certification, a self-assessment will enable the provider to demonstrate an understanding of the requirements and identify the systems and processes to implement and maintain over time.

The process of self-assessment relies on the provider undertaking an honest appraisal of its ability to meet the standards. The process is not about finding fault; it is about quality, safety and improvement. Self-assessment is a reflective process, looking at what is already in place, what improvements need to be made, what gaps need to be addressed, and sharing this information with the staff, people using services and stakeholders.

Benefits of self-assessment

Self-assessment offers providers an opportunity to:

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  complete a detailed management review of the service so that people with disabilities receive quality services that are risk managed
  
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  reflect on the alignment of the provider’s management system with agreed performance expectations in Queensland
  
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  confirm areas that meet the requirements of the standards
  
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  identify improvements to the provider’s management system and its implementation
  
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  plan, implement and monitor progress with actions identified for improvement
  
• 
  give stakeholders such as DCCSDS and NDIS increased confidence that services function in accordance with recognised quality standards and manage risks associated with service delivery
  
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  identify additional opportunities for improvement that support continuous improvement.
  

Self-assessment workbook

The self-assessment workbook provides an introduction to the HSQF, instructions for completion and the specific requirements (safeguards) that need addressing against relevant standards.

The workbook is in a template format and can be adapted to reflect a provider’s requirements and the maturity of its quality systems. Providers should refer to the NDIS Provider Registration Guide to Suitability to identify their provider type and the evidence requirements to be submitted to the NDIS for registration.

The self-assessment workbook is available in two alternative formats for use by providers:

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  an Excel system which includes instructions, submission form, self-assessment workbook and continuous improvement action plan
  
• 
  Word version of a self-assessment workbook (including instructions and submission form) and a separate continuous improvement action plan template.
  

Core and development requirements

The self-assessment includes ‘Core’ and ‘Developmental’ requirements.

Core requirements (such as policy, procedures, processes and/or systems) must be in place prior to the provider commencing delivery of prescribed disability services identified on an NDIS participant’s plan in Queensland. Evidence of meeting core requirements must be included in the self-assessment.

Developmental requirements allow providers to focus their efforts and resources on future action. Implementation of developmental actions does not need to occur at the initial self-assessment, but will be required over time. Evidence of developmental actions must be included in the self-assessment; e.g., evidence may state what the provider has in place that will support future implementation.

Declaration

The self-assessment workbook includes a ‘Declaration’ of a provider’s commitment to implementing and maintaining the policies, procedures, processes and systems as documented in the self-assessment. The Declaration is a statement by a person authorised by the provider that certifies that the information in the self-assessment is correct, complete and genuine. The person who is certifying the accuracy of the self-assessment must do so in an official capacity and this binds the provider to the accuracy of the self-assessment.

Self-assessment process

Preparing for the self-assessment

Self-assessment requires planning and preparation to ensure the process has direction, leadership and resources, and that people involved understand why it is being done and what is to be achieved. The steps of the process are:

1. 
   Prepare
   

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  Set the scene (communicate the purpose, process & how the outcomes will be used)
  
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  Allocate resources (assign responsibilities & different roles, commit people, time & tools)
  
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  Identify support tools
  
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  Establish coordination & schedule timeframes & activities (map out a plan)
  

2. 
   Assess
   

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  Review requirements for each standard
  
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  Collate & rate evidence
  

3. 
   Plan Improvements
   

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  Analyse self-assessment
  
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  Develop action plans
  
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  Report & communicate
  

More information about how to undertake a self-assessment and practical tips are in the HSQF Quality Pathway for Service Providers information sheets on the DCCSDS website at: www.communities.qld.gov.au/hsqf

Self-assessment evidence

When submitting a self-assessment to DCCSDS for a completeness assessment, providers may also be required to submit supporting evidence (e.g. copies of policies, procedures, professional membership or qualifications) as identified by the department.

Evidence comes from various sources and demonstrates how the provider is meeting, or intends to meet the performance indicators and expected outcome of each standard. Interviews (people), observations (processes), and documentation (paper) provide verifiable evidence. Where possible, when completing the self-assessment for each indicator, providers should consider evidence from each of the above three sources. There is no set rule about the amount of evidence recorded; the aim is to identify sufficient evidence so that an independent person is likely to accept that the requirement is met.

Below are some examples of the types of evidence available from the different sources:

People

The people component refers to the people who use your service and your staff and management committee/governing body (where relevant). When collecting evidence from people for the self-assessment, you listen to people who currently use your service or who intend to use your service. For example, you could look at:

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  an individual’s support plan and goals to ensure that these were being met and they are satisfied with their current plan and their progress in meeting their goals
  
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  whether people using the service know and understand about how to make a complaint or provide feedback
  
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  records that show people using your service or intending to use your service are satisfied with the support or assistance they receive.
  

The people who work in or for your business (including volunteers) are also a valuable source of information in completing a self-assessment. For example, you could look for evidence that people working in or for your business:

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  understand their role and responsibilities within the business and how this contributes to service delivery
  
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  have knowledge of policies, procedures and systems for preventing and reporting harm, management of complaints and critical/serious incidents
  
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  have access to training, support and supervision as relevant to their role.
  

Process

Processes relate to the actions and functions that your business and staff perform to provide services. When collecting evidence about the processes and systems that operate within your business, you should look at:

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  how policies and procedures are developed, implemented and reviewed
  
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  the process involved in developing, implementing and reviewing an individualised person-centred plan
  
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  systems for managing safety such as fire safety and emergency procedures, medication storage and management, infection control, internal/external reviews of occupational health and safety including building and equipment maintenance, pool safety, etc.
  

Paper (includes electronic or hard copy records or documents)

The paper component relates to the documentation, such as documents and records implemented by your business to guide processes and service delivery. Examples of evidence include:

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  governance documentation (such as Board or Management Committee reports and records), strategic or operational plans, business plan
  
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  strategic and operational policies and procedures
  
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  information provided to people using services, such as handbooks or ‘welcome packs’
  
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  complaint and critical incident reporting registers
  
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  human resource information (both electronic and hard copy versions), such as personnel files, criminal history and working with children checks, training records, performance reviews and records of disciplinary action etc.
  

Continuous Improvement

Continuous improvement is an important part of a provider’s ongoing functioning. It involves regular review and action on service delivery, processes and planning activities. Continuous improvement can be identified from results of a self-assessment, feedback from people using services, complaints or other service delivery issues that have been experienced.

The ‘Plan, Do, Check, Act’ model demonstrates a continuous improvement cycle that applies to all aspects of service delivery, management and operations. There are four interrelated phases in this continuous improvement cycle as outlined below:

Plan	Establish the goals and processes (activities) necessary to implement improvement
Do	Implement planned improvement activities
Check	Monitor, measure and report on the effectiveness of results
Act	If the desired result has been achieved, formalise the process so it becomes sustainable and imbedded in practice. If monitoring suggests that the planned activity has not been successful, there is a need to develop another strategy. This means commencing the cycle again.

The information collected during a self-assessment will help to demonstrate areas for improvement and the reasons to make changes in those areas. This process can be seen as building a case for change, as it helps stakeholders understand why the business is seeking to make changes to processes and systems.

After the self-assessment is completed, the provider should act on any identified areas for improvement as soon as possible. It is important to prioritise these giving consideration to:

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  improvements that promote the safety and wellbeing for people using the service and staff
  
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  improvements to service delivery and deliver better outcomes for people using services
  
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  the urgency to implement improvement action
  
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  resources and abilities required to achieve the change.
  

The continuous improvement action plan

The continuous improvement action plan records and monitors the progress with implementing required actions. It includes:

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  areas for improvement
  
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  planned actions to be taken
  
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  who is going to undertake the actions required
  
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  timeframes for completion.
  

For providers new to the HSQF process, a continuous improvement action plan provides a useful way of tracking progress in implementing policies, procedures and systems to ensure compliance with HSQF and DCCSDS safeguard requirements.

Resources

This guide is part of a suite of resources and tools for service providers. These aim to help providers develop and maintain a quality system, which drives continuous improvement and promotes service quality. These resources include:

• 
  Human Service Quality Framework resources: www.communities.qld.gov.au/hsqf
  
• 
  Criminal History Screening resources: https://www.communities.qld.gov.au/disability/key-projects/criminal-history-screening
  
• 
  National Disability Insurance Scheme resources: http://www.ndis.gov.au/
  

Further Information

Further information is available from:

Contact: HSQF Team

Department of Communities, Child Safety and Disability Services

Telephone: [phone]

Email: [e-mail]

Useful websites:

QCOSS Community Door: http://communitydoor.org.au/organisational-resources/quality-assurance/human-services-quality-framework

NDIS in Queensland: https://www.communities.qld.gov.au/gateway/reform-and-renewal/disability-services/national-disability-insurance-scheme-in-queensland

National Disability Services Queensland: https://www.nds.org.au/