Quality Framework for the National Aboriginal and Torres Strait Islander Flexible Aged Care Program

4 The Quality Improvement Cycle and Review Process

Up to Office of Aged Care Quality and Compliance (OACQC)

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4.1 Introduction

The Quality Improvement Cycle outlines:

• the steps which measure and assess service provider performance against the Standards
• support for service providers to meet and continually improve their quality performance against the Standards.

The design of the review process aims to:
• support capacity building for the service provider
• support continuous quality improvement while addressing accountability through quality assurance processes
• promote development of internal systems and processes.

The Quality Improvement cycle is implemented over two years. Figure 4.1 provides a visual outline of the timing of the Review Process and the Quality Improvement Cycle.
The first year includes a formal review against the Quality Standards including self-assessment by the service provider and a site visit by the Quality Review Team. The key output for year one is the agreed Quality Improvement Plan between the Quality Review Team and the service provider.
The service provider then works on actioning the Quality Improvement Plan and activity is monitored and supported by DoHA Program staff and the Quality Review Team.
In the second year, service providers report on their progress in actioning the Quality Improvement Plan and update their Quality Improvement Plan for the next calendar year. The Progress Report and Updated Quality Improvement Plan is submitted to the Quality Review Team and is the key output for the second year of the cycle.

Figure 4 1: Overview of the Quality Improvement Cycle showing key outputs and timelines
Figure 4.1 shows the Review Process key steps, outputs and indicative timelines in the Quality Improvement cycle.
Cycle One – year one - self assessment, 8-12 weeks from notification
Desktop review - within 2 weeks of receiving self assessment
On site review – 1-2 days
Draft Report and Feedback within 6 weeks
Quality Improvement Plan for next year agreed six weeks after review.
Cycle Two – year two - Monitoring of progress, ongoing
Support visit if required, Progress Report/Updated Quality Improvement plan – one year from agreement to

4.2 Self-assessment

A letter is generated by the Quality Review Team advising the service provider when the self-assessment is due to be submitted to the Quality Review Team. Service providers should be given 8 to 12 weeks notice of the date for submission of the self-assessment report.Top of page

A self-assessment is completed by each service provider. Self-assessment is usually the beginning point and a critical component of a continuous quality improvement process. Self-assessment involves an organisation looking at how it does things, what it achieves, and how it performs against an agreed set of standards. During the process, an organisation’s strengths, weaknesses and opportunities for improvement are identified.

The self-assessment enables a service provider to:

• confirm areas where the service is meeting the Standards
• identify gaps in current systems and processes that do not meet the Standards
• plan action to address any identified gaps in systems and processes, prior to the on-site review being conducted
• identify additional opportunities for improvement, even where the Standards are met, to support continuous improvement.

The self-assessment tool records the things an organisation is currently doing, and information about the systems they have in place. It enables the service provider to identify where there are gaps in their systems and processes. During the self-assessment process there may be opportunities to address these gaps, such as writing a policy or procedure to describe practice.

Once completed, the self-assessment forms the basis of the desk top review and is used to inform the on-site review.

Before the self-assessment process can begin, planning should be done by the service provider to ensure the best use of staff time and to anticipate the impact of the process on service delivery. Realistic timeframes must also be allowed. This may be a few weeks for services that have been assessed against other quality standards and regulatory/accreditation frameworks and have established systems and processes in place. However, those services that have not had this experience may need to allow a longer time to complete this process.

During self-assessment, involving the staff who deliver the service can be a valuable way of establishing agreement on how the service is delivered, and assessing alignment with policy and procedure. Involving staff encourages learning about the Standards and fosters understanding about how everyone is responsible for quality.

Service users, their families, visiting health professionals and other stakeholders can also be encouraged to contribute feedback and suggestions on their experience of service delivery.

Completing a self-assessment can assist services to review feedback that has been collected, and identify who else could be consulted for feedback on service delivery.

Regular self-assessment ensures that up-to-date information about the service’s performance is available. The results of self-assessment can be used to plan improvement activities and, in turn, the results of these activities can be evaluated and fed into the next self-assessment; so the improvement process continues.

The Service Provider Self-assessment tool is included at Appendix 1. The Self-assessment tool includes:

• an Assessment Matrix
• a Self-assessment Rating against each Expected Outcome of the two Quality Framework Standards and Quality Improvement Actions
• a Checklist.

Examples of completed Service Provider Self-assessments are included at Appendix 2.

4.3 Desk Top Review

Within two weeks of receiving the completed Service Provider Self-Assessment the Quality Review Team will undertake the desk top review.

The desk top review assists in prioritising areas for focus at the on-site review and examines other information such as records of previous review findings and/or other relevant information provided in the Service Provider self-assessment. Any other relevant information, for example information about compliance with requirements for submission of Financial Activity Reports or Service Activity Reports may also be considered at the desk top review.

Reviewers must complete a Desk Top Review Record for each review conducted. The Desk Top Review Record is an itemised checklist incorporating notation of any required actions/follow up where any concerns with the completed self-assessment are identified.

Indicators raising concern about readiness for the on-site visit may include submission of an incomplete self-assessment or a self-assessment with limited relevant information. If necessary, the reviewers will make contact with the service provider for additional information or request that the self-assessment be resubmitted.

Service providers will be notified of the outcome of the desk top review and subsequent plans for the On-Site Review in writing.

The Desk Top Review RecordTemplate is at Appendix 3.

4.4 On-site Review

Following the desk top review, the on-site review will be scheduled and conducted by at least two reviewers, normally lasting between one and two days, depending on the service types delivered. The Quality Review Team would generally allow one day for on-site review of community care providers, and up to two days for residential and mixed service type providers. Large residential service providers may require two full days for on-site review.

Prior to an on-site visit, the Quality Review Team will liaise with the Service Provider to make the necessary arrangements which will be confirmed in writing. On-site review planning tools and templates are at Appendix 4.

The on-site review is a quality assurance process which assesses how the service provider meets the Standards. Reviewers will use the service providers most recent Service Provider Self-Assessment Report and the Desk Top Review Record to guide them in conducting the on-site review.

The visit will be collaborative in approach and focus on acknowledging good practice and encouraging the development of sustainable quality systems. Top of page

The on-site review will include the following steps:

• Entry Meeting - to introduce key staff and explain the onsite review process
• Tour of the Site - to observe e the physical environment from which services are run
• Document Review - includes a review of documented evidence to demonstrate if the expected outcomes are being met
• Review a sample of service user records and staff, carer and volunteer records - to demonstrate if the expected outcomes are being met
• Stakeholder interviews - to confirm written evidence or observations made by the reviewers
• Exit Meeting - to provide verbal confirmation of the review findings and advise of ratings against the Standards including actions required to meet the Standards

Quality Reviewer tools and templates are at Appendix 5.

The organisation’s performance will be assessed against each expected outcome of the Standards by applying the following ratings:

• Met: written and verbal evidence clearly demonstrates that the service provider meets all the requirements of the expected outcome.
• Part Met: written and verbal evidence clearly demonstrates that the service provider only meets part of the requirements of the expected outcome.
• Not Met: written and verbal evidence clearly demonstrates that the service provider does not meet the requirements of the expected outcome.
• Not Applicable: a not applicable rating may apply, for example, where a service does not provide clinical care to service users (refer to expected outcome 1.4).

Once each expected outcome has been rated, the overall Review Result will be determined as follows:

• Met: all the requirements of each expected outcome have been met.
• Part Met: the requirements of one or more expected outcomes have not been fully met.
• Not Met: the requirements of no expected outcomes have been met.

4.5 Draft Report and Feedback

Within two weeks of the visit a draft report of the on-site review is submitted to the service provider. The On-site Review Report will use the same format as the self-assessment report completed by service providers and will include:

• an Executive Summary
• an Assessment Matrix
• evidence examples sighted during the visit to demonstrate compliance with each expected outcome
• review findings detailing the reasons for the reviewers’ rating for each expected outcome and the applicable rating
• Quality Improvement Plan to address any identified gaps in meeting the Standards and/or plans to support continuous quality improvement, where applicable.

The report will clearly document what needs to be done to meet the Standards and optional actions to support continuous quality improvement. These actions form the basis of the Quality Improvement Plan.

The service provider will have four weeks to work through the draft Report and return their feedback to the Quality Review Team. Feedback may include any service provider comments and factual errors in the draft Report, as well as completing the Quality Improvement Plan, that will include who will be responsible for each action and the due date for completing actions. Feedback may be provided verbally, electronically via email or in a letter. Feedback may include any errors, omissions or requested changes to the draft Report.

Where the service provider disagrees with content in the draft report, the Quality Review Team requires the following information:

• specific detail about the part/s of the draft report that are in dispute
• the evidence the service provider is relying on to substantiate the requested change.

Where agreement on the content of the draft Report cannot be reached, the matter should be referred to the Quality Review Team Manager for review.

The On-site Review Report template is at Appendix 5 and the Quality Improvement Plan template is at Appendix 6.

4.6 Quality Improvement Plan for next year

The Quality Review Team then has two weeks to finalise the draft Report and Quality Improvement Action Plan with the service provider.

The service provider is responsible for completing the plan with:

• name/position of the person responsible within their organisation for completing the action
• timeframe within which the action is to be completed.

The return of the final Report and agreed Quality Improvement Plan for the next year to the service provider by the Quality Review Team is a key output of Cycle One.

4.7 Monitoring Progress of Quality Improvement Plan

The service provider will use the Quality Improvement Plan to schedule, monitor and report on the planned actions required to meet the expected outcomes of the Quality Standards.

The Quality Review Team and Program staff will use the Quality Improvement Plan to monitor the service’s progress in implementing the planned actions. The plan will assist to identify any additional support that the service provider may need, including assistance from the Service Development Assistance Panel.

If serious matters relating to health, safety and well being of care recipients arise, the issue will be referred to the Quality Review Team to manage in consultation with the Program manager and further assessment by the Quality Review Team may be necessary.

4.8 Support Visit to achieve Quality Improvement Plan

To monitor progress of the Quality Improvement Plan, Program staff and/or the Quality Review Team, must include at least one support visit to the service provider following the On-site Review. The timing of this will depend on the support required by the service provider and their progress in implementing their Quality Improvement Plan.

4.9 Progress Report/Quality Improvement Plan for next year

In order to maintain the momentum of Continuous Quality Improvement, service providers will be required to submit a Progress Report against the agreed Quality Improvement Plan a year after that plan has been agreed. The service provider will also update their Quality Improvement Plan for the next calendar year.

The Progress Report - template is at Appendix 6.

4.10 Complaints

A service provider may make a complaint about any aspect of the quality review process or the conduct of a Quality Reviewer at any time. In the first instance, service providers are encouraged to discuss their complaint with the Quality Review Team Manager, who may be able to resolve the issue. Alternatively, the service provider may prefer to put their complaint in writing via email or letter to the Quality Review Team Manager.

The following information is required from the service provider:

• specific detail about the nature of the complaint
• the evidence the service provider is relying on in making the complaint
• confirmation the service provider’s nominated representative (and contact details) with whom DoHA should liaise during the management of the complaint.

DoHA will investigate the complaint and respond to the service provider as soon as practicable.

4.11 Mutual recognition

Where an Aboriginal and Torres Strait Islander Flexible Aged Care Service is funded separately to provide Home and Community Care Services, the service provider will also participate in reviews under the Community Care Common Standards (CCCS) and may report on some of the same information required under this Quality Framework (or visa versa).

In this event, the quality reviewers and the service provider will liaise to identify any relevant information common to both processes that can potentially be shared between reviewers, to avoid a duplication of effort. It will however, be important for the quality reviewers to determine that the information is current and relevant to the expected outcome of the particular standard.

This will need to be on a case-by-case basis in consultation with the service provider and the relevant areas of DoHA

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