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

2 Quality Systems and Continuous Improvement

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

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2.1 What is a Quality System?

A quality system is the method an organisation uses to make sure that the services it provides are delivered as intended and meet the needs and expectations of stakeholders.

The processes that guide the way that things are done by a service provider are a key part of its quality system. These processes direct the activities of management and staff: what is to be done, when it is to be done, how it is to be done, for whom it will be done and by whom it will be done.

A stakeholder is anyone that has an interest, involvement or investment in the organisation. For services funded under the National Aboriginal and Torres Strait Islander Flexible Aged Care Program, stakeholders include:

• service users, their families and friends
• service staff/management/Board
• the community
• governments which fund the service
• other service providers.

Your stakeholders will have different needs and expect different things from your service. For example:

• service users and the community might expect that:
  • they can get the service they need when they need it
  • they can afford the cost of the service
  • their needs are met by qualified staff
  • the service is provided in a culturally safe and respectful way
• governments which fund the service expect it to meet:
  • conditions of funding set out in the funding agreement
  • program guidelines
  • any relevant regulatory requirements.

2.2 Why have a Quality System?

Most service providers believe that they provide a good service. However, it may be hard to show this if they do not have an effective quality system.

An effective quality system includes systems and processes to:

• clearly identify the needs and expectations of stakeholders
• plan and deliver the agreed services
• check that the services delivered meet stakeholders’ needs and expectations
• check that the services delivered are reliable and of a consistently high standard

These systems and processes are important in ensuring:

• sustainable service delivery: A systems and process approach does not rely on one person’s or a few peoples’ knowledge about what, when, how and to whom services are delivered. Rather, the ‘what, when, how and to whom’ is written down and is available to all who may need to know.

A systems and process approach supports the delivery of the right service, at the right time, to each person being cared for, by staff trained to provide the service. This should not change because staff join or leave the organisation.

• consistent practice: We all hear, interpret and respond to information differently. For example, if you ask four people to wash the bathroom floor, all four will probably do this task differently, unless they are given specific instructions.

A systems and process focus supports service delivery that is planned, documented, implemented, reviewed and evaluated. The use of documented systems and processes helps to make sure that staff understand the organisation’s way of delivering services.

This reduces the chance of people complaining that ‘no one seems to know what to do’ and ‘every staff member does things differently’.
An effective quality system provides tools and information to help an organisation show how it monitors, reviews and evaluates the services delivered. In short, it helps the organisation to show how it:

• measures the quality of the service provided; and
• tries to continually improve services and outcomes for all stakeholders.

An effective quality system has processes to pick up if the way things are done may need to be changed.

The need for action or change might come about because of feedback from service users, an accident or incident that has happened, by new policy or change in policy from a funding body, or by the results of file audits.

For example, an audit of service user files might identify that care plans are not consistently reviewed six monthly. Action might include: contacting staff/calling staff together to discuss practice, recirculating the review policy and procedure and more regular file auditing until improvement is noted.

So a service that has a quality system with clear systems and processes might use some of the following examples to show the steps they take to make sure they provide a ‘good’ service to stakeholders:

Our quality processes include:

• explaining our policies and procedures to all new staff and making sure they understand them
• offering a copy of the policies and procedures to all new staff
• looking at our policies and procedures and talking about any changes with our staff at a weekly meeting
• conducting regular service user file audits
• surveying all service users, their families and our staff once every year
• surveying all service users and their families when a service ends
• looking at all surveys and talking about the results at committee, management and staff meetings
• writing any opportunities for improvement in our Quality Improvement Plan
• involving our stakeholders in service planning and review by asking them to come to our annual meetings and making sure they know they can speak with us at any time
• meeting with our community Elders regularly to talk about our service
• we meet the conditions of our funding agreement and reporting requirements.
  

Start thinking about . . . Top of page

What systems and processes does your service have in place to make sure you are providing a ‘good’ service to stakeholders?

Implementing a quality system can seem like a big task when starting. It is very important to take the time to plan how your service will develop the quality system and who will be involved. You will find some examples below of things to do in the planning phase to get you started. Your service might choose to make a checklist of these things to work through with other staff.

Examples of things to do when planning a quality system:

• list your services stakeholders
• check that you have a copy of all funding agreements
• list all the regulations that your service must meet (see the ‘Resources’ section of this guide)
• decide who should be involved in setting up your quality system: think about those people who know most about your service and how it works
• ask these people to gather to talk about what systems and processes you have in place now
• work out how much of what you ‘do’ is written down
• think about what else should be written down for staff
• think about what else should be written down for the Board/Committee
• think about what else should be written down for service users
• decide who is going to help with doing this and what their job will be
• work out how long it will take to finish the job
• plan regular gatherings to talk about how the work is going
• decide how you will share information with service users and staff: it might be in writing for some stakeholders or talked about at a gathering for others
• decide the best ways for getting feedback from service users to check that they are receiving the service that was planned to be provided and that the service is what your service users want from your service
• decide the best ways for getting feedback from staff to check that what is written down is what your staff do
• decide how you will collect this feedback, who will be responsible for recording it and looking at it
• plan how your service can best use feedback to improve the services you provide
• think about the best person in your service to be responsible for getting back to people to tell them how the service has used their feedback.
  

Start thinking about . . .

What are the best ways to involve not only management and staff, but other stakeholders such as service users, their families and the community in this process?

You might involve these other stakeholders by asking them about how they want to receive information from the service and how and to whom in the service they would like to give feedback.

All services do some things differently. Are there other things that your service might need to think about in this planning phase because of your location, staff, service users or community?

2.3 Implementing a Quality system

An effective quality system must have ways to:

• check that your service is doing what it says it will do and is doing it in the way you said it would be done. That is, that the service is meeting its aims.
• keep checking that stakeholder needs are being met.

The key steps in implementing an effective quality system include developing:
• Mission and Vision statements
• a Strategic Plan
• policies and procedures.

Each of these steps is discussed in detail in the following pages.

2.3.1 Developing a Mission and Vision:

The first step in implementing a quality system is to be clear about what your service is trying to achieve – what is the purpose and aim of your service?

The mission statement is usually a short statement about the purpose of an organisation.

The vision statement looks to the future and is a statement about what your service wants to achieve for its service users, the community and other stakeholders.

Some organisations also have a values statement which describes their approach to service delivery, or their way of doing business.

Example Mission, Vision and Values statements are provided on the next page.

Example Statements:

Mission Statement:

To make sure that all Aboriginal and Torres Strait Islander aged people get quality aged care services that are culturally safe and available when they need them.

Vision Statement:

Our clients, their families and the community will have better health and well being because of the services we provide.

Values Statement:

Our Board/Committee will understand cultural safety and use good governance practices to ensure our service offers quality services that are continually improved.

We will involve our clients, their families and the community in our service planning and review.

We see each client as an individual with unique needs.

We will make sure that each client’s needs are met in a culturally safe way.

Start thinking about . . .

Mission, Vision and Values statements should reflect what your service is about. As many stakeholders as possible should be involved in having a say about them.Top of page

In what ways will you involve stakeholders in developing these statements?

If you already have these statements in your service, when were they last reviewed?

In what ways will you involve stakeholders in the next review?

2.3.2 Developing a Strategic Plan:

Once these statements about the aims and purpose of your service are written down a plan should be developed to show how they will be met. This is known as a strategic plan.

A strategic plan lists the goals of the service and information about what must be done (action to be taken) to meet these.

The plan should be developed with input from stakeholder groups including service users, staff and the community.

There should be a clear link between actions on the strategic plan and the mission, vision and values statement.

A strategic plan would usually include the following information:

• the goal to be met what must be done (the action) to meet the goal
• who will take the action to meet the goal
• by when action is to be taken
• the date when the goal was met.

It is also very important that strategic plans are reviewed and discussed regularly. Each service should have a way to make sure that this happens.

Many services have a strategic plan but it is often not looked at to see if any progress is being made with actions and/or any changes need to be made.

For these reasons it is recommended that a strategic plan:

• is not too lengthy
• uses simple language
• is easily understood
• is made available to all stakeholders
• is regularly discussed and reviewed within the service.

Start thinking about . . .

Who was involved in developing your Strategic Plan?

Is it easy to read and understand?

How often is it reviewed, and who reviews it?

How can stakeholders find out about the Strategic Plan?

2.3.3 Developing Policies and Procedures:

Policies and procedures are a very important part of a quality system. They explain what the service aims to do and how they are to do it.

Some policies and procedures will apply to everyone in the service, but others may just be for the Board/Committee, management or staff.

Earlier in the guide there was information about systems and processes and how they help to make sure that there is sustainable service delivery and consistent practice (see pages 14-15). Policies and procedures should describe the services systems and processes. They direct management and staff in their daily work and tell other stakeholders about how the service ‘works’.

A policy describes what is done and why it is done. Policies should reflect current practice and regulatory requirements. For example, there are regulatory requirements about privacy and occupational health and safety that employers must meet.
A procedure describes how to put the policy into practice. It includes the steps to be taken to implement the policy. A procedure usually gives answers about who is to do what, when and where they are to do it and how they are to do it. Procedures are sometimes supported by work instructions.

Policies and procedures are used to inform the service, staff and stakeholders about issues such as:

• governance
• decision making
• compliance management
• risk management
• roles and responsibilities
• communicating with stakeholders, staff training and development
• day to day operations of the service.

How do I start?

How a service develops its policies and procedures may depend on the size of the organisation, the number and type of services it offers and the number and type of staff. Top of page

When developing policies and procedures first think about:

• what is the message to the reader?
• how much information do they need?
• who is the reader?

All services will need to communicate policies and procedures to a variety of people. Policies and procedures should use clear and simple language and be in a format that is suited to the user.

The service should ask stakeholders to be involved in developing policies and procedures. For example, Board/Committee members, management, staff, and where possible, service users. It is also a good idea to get stakeholder feedback on draft policies and procedures.

The length and detail of a policy statement will depend on the related issue. Some policies may include definitions or parts of relevant standards, legislation or regulations that the service must meet. Development of policies and procedures should also consider:

• funding agreement requirements
• program guidelines
• current accepted good practice
• services provided by the organisation
• whether the issue is simple or complex
• current work practices
• staff knowledge and skills.

Some services may need more than one procedure for each policy. For example, staff might provide services in different settings and need different safety procedures.
Procedures should also include information about any forms or records that need to be completed.

What should they look like?

There are several options for presenting procedures where staff and other stakeholders have varying language and literacy skills. These include:

• pictograms
• diagrams
• flowcharts
• word documents.

Each service will have to decide the best way to present this information by thinking about their service, staff and service users.

Each service should decide how they will develop, present and review their policies and procedures. This is known as document control.

A system for document control should include:

• a procedure that describes how the service develops, presents and reviews/updates policies and procedures and who is involved in each step
• a process for page layout, print type and size and page numbering
• a process for approval of the document, evidenced by signing and dating by the person responsible
• a record of all documents developed
• a process for communicating new or updated policies and procedures
• a list of people to send policies and procedures to.

What next?

Once a policy and/or procedure is approved, it should be sent to those in the service who need to know about it and put into practice.

Processes to make sure that the policy and/or procedure is put into practice and is current include:

• introducing policies and procedures to all new staff at orientation
• making sure that policies and procedures are in an appropriate format for the user and are understood
• making sure that staff and other stakeholders can access policies and procedures, including staff who do not work on site
• checking that what happens in practice matches what the policy and procedure says is to happen
• having a timeframe to formally review policies and procedures
• having a process for staff to report where changes or updates to policies and procedures may be needed between formal reviews.

The service should also decide whether policies and procedures will be in hard copy, computerised, or a combination of both.

In making this decision, services will again need to think about the skills of their workforce and the services information management systems. This may depend on whether the service is highly ‘computerised’ or usually relies on hard copy information. Top of page

Some example policies and procedures are provided on the following pages in different formats. Keep in mind that the language and format used is very important. There is no value in having policies and procedures that cannot be understood by the user.

Example Policy and Procedure: Dot points

The example policy and procedure below are brief and use dot points. This style may suit a small organisation that does not require more complex policies and procedures.

Client Assessment Policy

• all potential clients will participate in an assessment of their aged care needs
• all referrals must be forwarded to the manager when received
• assessments should be done by the assessment officer within one week of referral
• the date of assessment should be recorded in the appointment book and the client’s file, once created
• the number of client assessments is reported to the Board/Committee quarterly.

Date:
Person authorising:
Review due date:

Client Assessment Procedure

• all client assessments are conducted by the assessment officer with their consent
• assessments are done in consultation with the client and their nominated representative/family member/people
• all sections of the Client Assessment Tool are to be completed at assessment
• all clients are to be informed about service choices, their rights and responsibilities and given a copy of the ‘Welcome Pack’
• the client and/or their nominated representative/family people are informed about the outcome of the assessment immediately. The result of the assessment must also be documented in the assessment notes.

Date:
Person authorising:
Review due date:

Example Policy and Procedure: Flow Chart

Procedures can be presented in an alternative format, such as a flowchart to better meet the needs of the target audience.

Assessment Flow Chart

This diagram consists of several boxes each labelled with an action and joined by dots to indicate the order in which the different actions in the process occurs. Where boxes sit next to one another, this indicates that the actions occur in parallel.

The top line has three boxes labelled: referral received, assessment booked by manager and details entered in appointment book.
The second line has two boxes labelled: assessment (home or community), assessor explains process, obtains consent
The third line has one box labelled: assessment outcome and care needs discussed with client
The fourth line has two boxes labelled: client provided information about services available, visit to residential/respite services arranged
The fifth line has two boxes labelled: care plan developed by assessor in consultation with client, care coordination and referrals completed by assessor
The last line has one box labelled: assessment outcome documented – copy provided to client and service provider.

Handwashing

Picture titled: Example Procedure – Pictogram
There are four pictures of hands that demonstrate the hand washing procedure: picture one shows washing palms, picture two shows washing between fingers, picture three shows washing back of hands, picture four shows washing wrists.Top of page

Start thinking about . . .

Who will need to know about your policies and procedures?

What format best suits the needs of your audience?

Will you need to use a few different formats to communicate our policies and procedures?

Who should be involved in developing and commenting on policies and procedures?

Who should be involved in reviewing policies and procedures?

2.4 Continuous Quality Improvement

The previous sections have looked at:

• What is a Quality System?
• Why have a Quality System?
• Implementing a Quality System.

This information highlighted the importance of involving people, having processes and developing documentation in establishing a quality system.

Once a quality system has been developed and implemented the next step is to make sure that the results achieved for stakeholders are continually improved.

Continuous quality improvement (CQI) is about making ongoing (continuous) effort to improve the quality of services and outcomes for stakeholders.

CQI focuses on improving systems, rather than on the performance of people or things. CQI is used in all types of organisations as a way of leading and managing the service; it is used to test how well systems are working, the quality of care being given and to bring about lasting improvement.

The key elements of CQI include:

• accountability
• linking evaluation to planning
• achieving improvement through incremental steps
• being driven by input from all levels of staff, management and other stakeholders
• a commitment to team work
• continuous review of progress.

CQI can improve:

• accountability
• staff input and confidence
• services for clients
• the ability to recognise and meet changes in service need
• information management, client tracking and documentation systems.

To be effective, CQI must be a strong focus within an organisation that is understood and accepted by all staff and management.

CQI should involve a variety of people, including:

• service users, families and carers
• staff and volunteers
• members of the Board/Committee of Management
• community members
• advocates.

One way of introducing CQI is by using a quality cycle. The quality cycle involves steps to continually evaluate and improve services and the results for stakeholders.

The CQI model shown below is known as the ‘Plan-Do-Check-Act’ cycle.

Figure 1: Plan-Do-Check-Act Cycle - This figure shows four circles labelled Plan, Do, Check and Act with arrows indicating that CQI does not stop and is never finished.

The circle shows that CQI does not stop and is never finished.

CQI is ongoing because there will always be opportunities for improvement, with better results seen as each cycle is completed. Top of page

The four steps of the CQI model (quality cycle) are as follows:

Step 1: Plan

Plan what it is that you want to change or achieve. Work out what the goal is and then what you need to do to meet it.

Step 2: Do

Put the systems and processes to make the change or reach the goal in place.

Step 3: Check

Look at the results. Did the change work/was the goal achieved?

Step 4: Act

If the last step (check) found that the change was working or the goal was achieved, continue with implementing it into your systems.

If the last step found that the change was not working or the goal not achieved you will need to decide why it did not work and repeat the cycle, starting by planning what you need to do.

The quality cycle helps to identify opportunities for improvement. However sometimes quality improvement activities result from ‘gaps’ that are found in systems and processes. Action is then taken to ‘fix’ the gap (corrective action).

Corrective action might be taken in response to a complaint, feedback, an accident or incident or where performance has not met the required standard.

Opportunities for improvement and corrective actions usually identify:

• practice and/or service delivery that does not reflect the services policy and procedure
• where policy and/or procedure need to be reviewed or changed.

An effective quality system must have processes to make sure that opportunities for improvement are identified, documented and reported, and that the action taken is timely and appropriate.

These processes usually include:

• stakeholder feedback processes
• stakeholder complaint processes
• incident and accident reporting
• identification of hazards
• staff appraisal process
• staff grievance and disciplinary processes
• a file auditing process.

For example, corrective action might be taken in response to the findings of service user file audits. File audits are a quality activity and a way of checking that what staff do matches what is written in policy and procedure. File audits might look at practices around assessment, care planning and/or review of service user needs or staff files to check selection, recruitment and induction processes.

A file audit involves looking at the documents in the files to check that they are completed as required by a services policy and procedure. This usually involves using an audit tool, which is similar to a ‘checklist’ to record the audit findings.

The audit findings should then be reported and any necessary action taken where opportunity for improvement in documentation is identified. How the reporting and follow up occurs will depend on each services quality system and way of doing things. For example, a manager might select one file each week to audit and discuss the results at staff meetings.

An example client file audit tool is provided on the next page. However the audit tool used by your service will need to reflect the practices, policies and procedures of your organisation.

Example service user file audit tool:

Service user file audit tool Date: Completed by: Reported to: Please audit a sample of x files and complete the following for each:
File Contents	Yes	No	Comments/Action Required
Intake/referral documents
Details of nominated/authorised representative
Consent to share information
Service agreement offered
Evidence that the following information has been explained and a copy given to the service user: service brochure rights and responsibilities privacy complaints feedback advocacy
Completed assessment tool
Completed care plan, including a cultural support plan
Copy of care plan given to service user
Care plan reviewed six monthly

Another way of identifying ‘gaps’ in systems and processes, is by a service conducting a self-assessment. Service providers are required to meet certain conditions of funding and/or Standards to receive government funding.

Self-assessment involves a service looking at the systems and processes it has in place to meet particular Standards and/or regulatory requirements. Self-assessment can help identify where policies and procedures or other documents may need to be reviewed or changed.

More information about self-assessment required under the Quality Framework can be found in Section 3 Service Provider Guide to Self-Assessment).

Each service should have clear processes to show that the quality cycle and quality activities are key processes in their organisation. Services will have different ways of documenting and sharing information about quality activities. Top of page

For example,

• a small service might have CQI as a standing agenda item at staff meetings and activities and opportunities for improvement discuss recent quality
• a large organisation might have a Quality Manager and/or a Quality Committee that regularly reports on quality activities, including file auditing.

Each service should also have a process to inform stakeholders about the quality system.

All CQI requests and activities should be recorded. Depending on the service and their stakeholder group, this may include the use of one or more forms that can be used by service users, staff and other stakeholders. For example, a service may use one form for all stakeholders to record feedback, suggestions and complaints. Another service may have separate forms for feedback, suggestions and complaints.

A third option is to have some forms for staff use only and separate forms for other stakeholders. Each service should collect and record this information in the way that works best for them and their stakeholder group.

Each service should also have processes for collecting and recording information about complaints, accidents and incidents, hazards and maintenance issues.

An example form to record opportunities for improvement is provided on the next page.

Example Opportunity for Improvement Form

Suggestion for Improvement Form
Name:	Date:
Contact details:
Tell us about your issue or concern:
Tell us about your suggestion for improvement:
Please note: You do not have to tell us your name and contact details. However without this information we will not be able to tell you about the action we have taken on your suggestion.
Thank you for helping us to improve our services! Date: Person authorising: Review due date: Page 1 of 2

Example Opportunity for Improvement Form

Suggestion for Improvement Form (This section for Office Use Only)
Reported to:	Date:
Action required:
Date by which action to be completed:
Describe action taken (include dates):
Describe outcome (include dates):
Note further action required (if applicable):
Note date entered on Quality Improvement Plan:
Date: Person authorising: Review due date: Page 2 of 2

Start thinking about . . .

Who is involved, or will be involved in CQI in your service?

How do you/will you make sure that stakeholders know about the CQI program?

What is the best way for your service to collect information about improvement opportunities?

What forms will you use to record this information?

How do you collect information about complaints, incidents and accidents, hazards and maintenance

How do you record and report on the action taken in response to these issues?

2.5 Quality Improvement Plans

A Quality Improvement Plan is one way of recording and checking progress in completing improvement activities. It is used as a central register to help track the progress of and report on quality improvement activities. Top of page

The Quality Improvement Plan should be regularly reviewed and updated and record:

• the issue/s raised
• recommended action to address the issue
• responsibility and timeframe for action
• date completed and outcome of the action
• It is important to include dates in the plan to help check that there is a timely response to all issues raised by stakeholders.

An example quality improvement plan is provided on the next page.

Example Quality Improvement Plan

Quality Improvement Plan
Quality Standard [insert no]
Expected outcome [insert no]
Planned action	Who is responsible	Due Date	Date completed	Comments
Date: Person authorising: Review due date:

This section has provided a large amount of information and suggestions related to quality systems and continuous quality improvement.

An example checklist is provided below to help you think about your service’s systems and processes.

The checklist can help identify areas where you may need to review or further develop documentation and processes as part of your quality system.

It is not suggested that this is a complete list, but instead, some examples to assist your service.

Example checklist for implementing a quality system:

• Mission and Vision Statement
• Strategic Plan
• Policies and Procedures:
  • Cultural safety
  • Governance
  • Strategic and Business Planning (including community consultation)
  • Service provider networks and partnerships
  • Regulatory compliance
  • Risk management
  • Financial management
  • Document management systems
  • Environmental safety (staff, service users and other stakeholders)
  • Human Resource Management
  • Training and Professional Development
  • Service user access, eligibility criteria, service entry and exit
  • Information to be provided to service users (service agreement, privacy, feedback and complaints, rights and responsibilities)
  • Assessment, planning and review of service user needs
  • Service user health and wellbeing, independence, maintaining family/community
  • Privacy, dignity and confidentiality
  • Feedback and complaints
  • Advocacy

Example checklist for implementing a quality system (continued):

• Quality Cycle implemented
• Corrective action system
  • Service user complaint process
  • General feedback processes
  • Incident/accident reporting system
  • Hazard identification system
  • Staff grievance/disciplinary process
  • Staff appraisal process
• Supporting documentation:
  • Opportunity for improvement forms
  • Corrective action forms
  • Quality Improvement Plan

• Document Control System

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