UPDATE OF QUALITY ASSURANCE HANDBOOK

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2 Box 7788 Canberra Mail Centre ACT 2610 Telephone TTY UPDATE OF QUALITY ASSURANCE HANDBOOK I am pleased to enclose the second edition of the Quality Assurance Handbook, which updates information about the new quality strategy for Australian Government funded disability employment services and rehabilitation services. The first edition of the Quality Assurance Handbook was released in December Since then, changes to the Disability Services Act 1986 came into effect from 1 July 2002, and certification assessments are well under way. The contents have been updated to reflect these changes, to clarify issues, and to provide additional examples of evidence against the Disability Services Standards. A summary of the changes appears in the table on the next page. A CD-ROM is supplied with the Handbook, which provides another option for sharing information about the quality strategy. The updated Handbook will be available soon on the Department s website The Continuous Improvement Handbook is being updated, and should be available within the next three months. If you wish to discuss any aspects of the quality strategy, please contact your local Department of Family and Community Services. Contact details are provided in the Handbook. Yours sincerely, Margaret Marsh A/g Director Quality Assurance Team Disability Services Reforms Branch August 2003

3 SUMMARY OF CHANGES TO QUALITY ASSURANCE HANDBOOK ISSUE TWO SECTION CHANGES 1 How to use this Handbook Minor 2. Overview of the Quality Assurance System Update on impact of revised legislation 3. Transition to the new Quality Assurance System Clarification about s14k (Departmental) audits and self-assessments 4. Funding Arrangements Clarification about reimbursement of audit costs 5. Certification Assessment Procedures Minor 6. Step-by-Step Guide to the Clarification about timeframes during Quality Assurance System transition period 7. Links to Continuous Improvement Minor 8. Links to Complaints and Referrals Mechanisms Update on Complaint Resolution and Referral Service 9. Disability Services Standards and Key Minor changes as result of legislation Performance Indicators 10. Evidence Guidelines As for (9), plus additional examples of evidence, and clarification on policy and program context

4 Quality Assurance Foreword Foreword Welcome to the new quality strategy for disability employment services and CRS Australia. The new quality strategy is the product of a great deal of time and energy by the disability sector and Government. In particular, I would like to acknowledge the work and commitment of members of the Disability Quality and Standards Working Party to developing a world class quality system. The new quality assurance system has been developed in light of research, a sixmonth trial and feedback from the disability sector. You may recall that a consultation paper was widely distributed earlier this year based on the findings of a six-month trial of the quality assurance system. This was followed by public consultations held around the country and targeted consumer focus groups. An independent evaluation of the trial of the quality assurance system concluded that it provides a robust and credible system for measuring service quality. Results of the national consultation indicate widespread confidence that this quality system will lead to significant improvement in service quality and consumer outcomes. This system is firmly based on an established system of accreditation/certification and international standards of best practice. Independent, skilled auditors from accredited certification bodies will certify disability employment services and CRS Australia against the Disability Services Standards and related key performance indicators. A groundbreaking feature of the new quality assurance system is that it involves people with disability at every level including accreditation of certification bodies and certification of service providers. A range of information and support will help services meet the requirements of the new system, and in the longer term, identify avenues for continuous improvement. This Handbook is an important source of information for services on the certification process. Early next year, a Continuous Improvement Handbook will be sent to service providers with further information and strategies for embedding a quality system within their service. Continuous improvement is central to the quality strategy and in keeping with this, key components of the strategy will be regularly reviewed and updated in light of feedback and improving practice. On behalf of the Working Party, I encourage you to actively take on board the new quality strategy, which I believe represents a significant step forward for people with disabilities. I look forward to a continuing commitment to improving the quality of disability employment services. Ian Spicer AM Chair Disability Quality and Standards Working Party November 2001 Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Page 1

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7 How to use this Handbook 1 How to use this Handbook This Quality Assurance Handbook is for disability employment services funded by the Australian Government Department of Family and Community Services (FaCS) to help you understand your responsibilities under the new Quality Assurance (QA) system and the steps you ll have to follow. Under the changes to the Disability Services Act 1986, all Australian Governmentfunded disability employment services and CRS Australia will have to be certified as complying with the Disability Services Standards. This means each service will be assessed by an accredited certification body to determine whether it meets all the requirements of the Disability Services Standards. This assessment is known as a certification assessment. Basically this handbook is a reference guide outlining the procedures associated with certification assessments. The information presented is closely linked to the other elements of the Australian Government s Quality Strategy continuous improvement and complaints and referrals. The Quality Assurance Handbook has ten sections. They are: How to use this Handbook (Section 1) Overview of the Quality Assurance (QA) system (Section 2) This section contains background information on the legislative basis of the QA system and the roles of key stakeholders including people with a disability, FaCS, JAS-ANZ, certification bodies and funded services. Transition to the new Quality Assurance system (Section 3) This section contains information on the arrangements for transition between the old department-based QA system and the new system. Funding arrangements for the new system (Section 4) This section contains arrangements for FaCS reimbursement of reasonable audit costs. Certification assessment procedures (Section 5) This section contains a plain English description of the formal procedures for certification assessments. Step-by-step guide to the Quality Assurance system (Section 6) This section contains details of registration, preparing for an audit, applying for certification, certification assessments and decisions, preparing for a surveillance audit and reassessment. Links to Continuous Improvement (Section 7) This section contains information on how the QA system links to the Continuous Improvement component of the quality strategy. Links to complaints and referrals mechanisms (Section 8) This section contains information on how the QA system links to the complaints and referrals component of the quality strategy. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 1, Page 1

8 How to use this Handbook Disability Services Standards and KPIs (Section 9) This section details the 12 revised Disability Services Standards and 26 key performance indicators that form the assessment framework for the QA system. Evidence guidelines (Section 10) This section outlines the questions, signposts and examples of evidence that help to define the focus and scope of audit assessments against each of the Standards and KPIs. Sections of the handbook will be continually reviewed and updated, and these updates will be available to all funded services. It is important to keep your copy upto-date. You will note as you go through it that important information is repeated in different sections and links provided to extra details. This is so that each section is completely self-contained and includes all the information relevant to that particular topic. Is your QA handbook up-to-date? Check the FaCS QA website ( for the latest version. The version number of each section of the handbook is shown at the bottom right hand edge of each page. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 1, Page 2

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10 Overview of the new quality assurance system 2 Overview of the new quality assurance system This section provides background information on the QA system and the roles of key stakeholders including people with a disability (Section 2.5), JAS-ANZ and certification bodies (Section 2.6) and FaCS (Section 2.7). What you must know about the new QA system The new system will apply to all disability employment services and CRS Australia. The new system is based on a system of certification that is well established in Australian industry as part of the Joint Accreditation System of Australia and New Zealand (JAS-ANZ). The new system is independent of government. The system has been designed to ensure people with a disability are involved in all aspects and stages of the process. Changes to the Disability Services Act 1986 came into effect from 1 July 2002 The legislation allows for a phased transition from the current system to the new system between 1 July 2002 and 31 December 2004 (see Section 3 for details). To be eligible for funding during the transition period all existing employment services will now either need to be certified or have registered their intention to be certified by an agreed date. This date will need to be negotiated with FaCS State and Territory Offices. Services will need to seek certification before the expiry of their registration period unless they negotiate with FaCS for a later date. Under the legislation existing disability employment services (funded before 1 July 2002) and CRS Australia will have until 31 December 2004 to achieve certification and, therefore, continued funding. New services will need to register their intention to seek certification and will have up to 12 months to gain it. Under the legislation, if services lose certification and funding they will need to regain certification before funding is re-considered. 2.1 Quality Strategy The quality strategy is a key element of the Government s plan to restructure disability employment support programs to improve the quality of services and achieve better outcomes for consumers. The quality strategy addresses concerns with the current system raised in Assuring Quality, a 1997 report drafted by the Disability Quality and Standards Working Party. Of particular concern was the lack of a transparent and universally applied accreditation and certification system to provide an assurance of service quality to Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 1

11 SECTION 2 both consumers and the Government. Other concerns included the lack of incentive for service improvement and an ad hoc complaints and referrals system. The goal of the quality strategy is to ensure that people with disabilities can seek assistance and support from a range of Australian Government-funded employment services certified against the Disability Services Standards. These services will have shown they offer employment support and assistance to people with disabilities, enabling them to enjoy the same basic rights and opportunities generally available to all working Australians. The quality strategy for employment services is designed to: give people with disabilities better confidence in the quality of results that disability employment services achieve for them; ensure all services meet, as a minimum, the Disability Services Standards; make the assessment of quality more objective and measurable; treat all service providers equally (in government and non-government sectors); link certification to funding; reduce government intervention in the day-to-day operation of services; and help services continue to improve. The three-pronged quality strategy is designed to embed quality in all aspects of service delivery. It has three separate, yet interrelated, components. They are: quality assurance; continuous improvement (see Section 7); and complaints and referrals (see Section 8). QUALITY STRATEGY Quality Assurance Continuous Improvement Complaints & Referrals Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 2

12 Overview of the new quality assurance system 2.2 Quality Assurance System A key component of the quality strategy is the new QA system which was developed and trialed by FaCS, along with key representatives of the disability sector (through the Disability Quality and Standards Working Party, a subcommittee of the National Disability Advisory Council). The new system implemented on 1 July 2002 is based on a system of accredited certification, well established in Australian industry, which uses international standards of best practice. Its key features are: a revised set of 12 Disability Services Standards, including two new Standards, based on industry recommendations in Assuring Quality; service quality specified in terms of 26 key performance indicators (KPIs) across the 12 Standards. This means all disability employment services (covering the old Section 10, 12A and 13 services) have to meet the same requirements for the quality of the service they provide; certification of funded services compliance with these requirements on the basis of assessments undertaken by independent, accredited certification bodies; accreditation of certification bodies by JAS-ANZ. Accreditation requirements are contained in JAS-ANZ Procedure 18 General Requirements for Bodies Operating Assessment and Certification of Disability Employment Services, available on the JAS-ANZ website ( and annual internal audits by services to self-assess their compliance with the Disability Services Standards. Guidelines on conducting internal audits are available in the Continuous Improvement Handbook. Certification is recognition by a third party that a disability employment service conforms to the requirements of the Disability Services Standards. Disability employment services that achieve certification will receive a certificate that will be recognised by the Australian Government Government as proof that the organisation is delivering services in line with the Disability Services Standards. Such certificates will only be recognised where they have been issued by certification bodies accredited by JAS-ANZ to undertake certification audits against the Disability Services Standards. Accreditation is the process by which JAS-ANZ formally recognises that a certification body is competent to carry out specific tasks in this case to undertake assessments and offer certification against the Disability Services Standards, according to JAS-ANZ Procedure 18. The Australian and New Zealand Governments established JAS-ANZ to ensure that certification bodies are competent and impartial. JAS-ANZ offers accreditation programs in many other sectors, including quality (ISO 9000 certification - JAS-ANZ Procedure 10), environment (ISO certification - JAS-ANZ Procedure 8) and occupational health and safety (AS 4801, SafetyMAP certification - JAS-ANZ Procedure 2). Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 3

13 SECTION 2 JAS-ANZ (Accreditation Body) Accredited certification bodies Certified disability employment services JAS-ANZ accredits certification bodies as competent and impartial for undertaking audits against the Disability Services Standards Certification bodies certify disability employment services for compliance against the Disability Services Standards 2.3 Legislative basis of the QA system The changes to the Disability Services Act came into effect on 1 July Parliament agreed that to be eligible for continued funding all Australian Government funded disability services and rehabilitation programs must be independently certified as complying with the standards and Key Performance Indicators by 31 December The Impact of the Quality Assurance legislation The Guidelines associated with the new Quality Assurance legislation came into effect in September To assist organisations to understand the new requirements, Section 5 of Guidelines which explain the legislation, are summarised below. Requirements for currently funded organisations Currently funded organisations: will need to achieve certification under the new quality assurance Standards by 31 December 2004 to receive Australian Government funding beyond that date; must continue to meet the Standards which applied to the service before 1 July 2002 until they have achieved certification under the new quality assurance system. Requirements for newly funded organisations New organisations seeking a grant will need to have either: sought certification by an accredited Certification Body; formally registered their intention to be certified by an acceptable date (this should be no later than 12 months from the date their grant was approved). After 1 January 2005, new organisations applying for a first-time grant will still be eligible to receive a grant if they have registered their intention to seek certification. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 4

14 Overview of the new quality assurance system Varying certification dates If any organisation needs to vary the intended date of certification they will need to complete the Request to Vary Intended Certification Date form and submit a onepage plan which outlines: Key dates and milestones for achieving certification their progress to date a new proposed certification date A questionnaire is available for organisations to use as a guide when completing the form. The Request to Vary Intended Certification Date form, information is available from FaCS State and Territory Offices and on the FaCS website The certification assessment Certification assessments involve a range of activities designed to collect evidence to demonstrate that a disability employment service is complying with the Disability Services Standards. These include interviewing service staff and consumers, reviewing consumer files and observing service delivery. The time needed for the on-site assessment will vary depending on the service size, type (supported or open), and the communication abilities and support needs of consumers. Services will receive a written report following the certification assessment that includes conformity ratings against each KPI and each Disability Services Standard. The certification decision will be made by personnel not involved in the assessment, on the basis of the assessment report. After certification, the certification body will carry out surveillance assessments at least once a year to check services continue to comply with the Disability Services Standards, and a full reassessment (similar to the certification assessment) will be undertaken every three years. Special arrangements will apply for certification of services with multiple sites. Normally assessment for certification should take place at every site of a disability employment service. However, where a service s activities are carried out in a similar manner at different sites, all under the service s control, the service may be certified based on assessment of a sample of sites. Attachment A (JAS-ANZ Procedure 18, Annex 1) provides further details. While every certification body has its own procedures, practices and terminology, each must comply with the general requirements in JAS-ANZ Procedure 18. It is important to note that Procedure 18 contains requirements for certification bodies (not disability employment services) and covers requirements governing their impartiality, confidentiality, competence and certification processes. Certification bodies must inform potential clients about their certification processes. While this handbook outlines key elements of the certification process, your chosen certification body will provide further information. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 5

15 SECTION 2 Want more details? Section 5 outlines the formal procedures for certification assessments Section 6 provides a step-by-step guide and checklists covering registration, applying for certification and the ongoing audit cycle Attachment A provides a copy of JAS-ANZ Procedure Role of people with a disability in the QA system The QA system has been designed to ensure consumers are involved in all aspects and stages of the process and occupy roles in which power can be exercised. These include: The participation of consumers in preparing for certification assessments Services need to inform their consumers about the certification process and the requirements of the new system and its assessments. They must also involve consumers in internal audits. Certification bodies under Standard 3 will look at the scope and quality of consumer involvement. Independent support for consumers before and during certification will be available if needed. Contact your State and Territory FaCS officers to discuss options. The participation of consumers during certification assessments All certification assessments must include interviews with consumers. Certification bodies will liaise with services about selecting consumers for interview. Information on sampling consumers can be found at Section 3.10; and in JAS- ANZ Procedure 18, Annex 3, available on the JAS-ANZ website ( The inclusion of consumers on assessment teams Each assessment team includes a person with a disability (who is not from the service being assessed) either as an auditor or technical expert. Typically, an assessment team will consist of a lead auditor and a person with a disability. If the person with a disability also has the necessary qualifications and experience to be a lead auditor, a one-person team is possible. The team member with a disability is involved in: planning consumer participation in the assessment; interviewing consumers during the assessment; reviewing consumer files or following-up issues with consumers; contributing to the review of assessment evidence; and, contributing to the written assessment report. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 6

16 Overview of the new quality assurance system Consumers involvement in the new QA system JAS-ANZ involves people with disabilities in the process of accrediting certification bodies, including accreditation assessments, an accreditation review panel and an appeals panel. Certification bodies also have to involve people with disabilities in their certification processes, such as monitoring their certification principles and policies, making the decision to certify a disability employment service and hearing any appeals. 2.6 Role of certification bodies and JAS-ANZ Certification assessments are undertaken by audit teams nominated by certification bodies accredited with JAS-ANZ. The competence and impartiality of audit teams is monitored by JAS-ANZ. Service providers choose the certification body to undertake their audits. JAS-ANZ regularly updates and circulates a list of accredited certification bodies. FaCS can also advise service providers of the certification bodies that are accredited to assess disability employment services. There were six certification bodies involved in the trial of the new system, but it is expected more certification bodies will apply for JAS-ANZ accreditation when the system is fully operational. It is important to note that there are strict rules in JAS-ANZ Procedure 18 governing the independence of certification bodies from the services they assess. This means that certification bodies cannot provide consultancy services. For example, they are not allowed to tell you how to fix any problems they find with your system. How do I choose a certification body? For more information - see Section Role of the Australian Government Unlike the old system, the process of certification is now completely independent of government. As an industry-owned process, FaCS does not approve certification bodies and is not involved in undertaking certification assessments. Under the new system, the role of FaCS is to develop policy and to provide support and resources to help services gain certification and pursue continuous improvement. Contact details for your FaCS State or Territory office appear in Attachment C. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 7

17 SECTION What criteria will we be assessed against? The criteria used to assess compliance are specified in terms of 26 key performance indicators (KPIs) across a revised set of 12 Disability Services Standards. Are you familiar with the revised Disability Services Standards and the 26 KPIs? For more information - see Section 9. To gain certification, funded services are required to demonstrate compliance with all 26 KPIs. To help services understand the scope and intent of certification assessments, evidence guidelines have been drawn up which outline questions, signposts and examples of evidence for each of the Standards and KPIs. Are you familiar with the evidence guidelines for each Standard and KPI? For more information - see Section What happens if we are found to be not fully compliant? At the end of an assessment the certification body will tell you whether your organisation meets all the KPIs. Where an organisation meets all 26 KPIs it will be recommended for certification. Certification bodies use the term nonconformity to indicate that the requirements of a particular KPI are not met. Where one or more nonconformity is identified the service will be required to prove it has fixed the problem before being eligible for certification. Certification bodies will specify a time limit to address the nonconformities. A service will not be eligible for certification until all non-conformities have been fully addressed. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 8

18 Overview of the new quality assurance system What is a nonconformity and what are the implications? For definitions - see Section 5.4 For step-by-step guidelines - see Section 6.5 Certification bodies must also report any notifiable issues identified during an assessment. Notifiable issues are defined as evidence or allegations of a serious health, safety or abuse risk, financial impropriety and/or professional misconduct. If such evidence is found or specific allegations are made, the certification body has to record the details and immediately notify the disability employment service s manager (unless there is justifiable reason for not doing so) and FaCS. The certification body is not responsible for resolving the issue. However, certification cannot proceed until FaCS advises the certification body that the notifiable issue is resolved. If the disability employment service is already certified, the certification body will seek advice from FaCS What are the checks and balances in the system? Strong and impartial complaints and appeals processes are vital components of the quality strategy. They are there to: assist services and consumers resolve any concerns about certification decisions or the certification process; and assist consumers to resolve concerns about a service, the delivery of services, or other consumers within the service. JAS-ANZ Procedure 18 requires certification bodies to have effective complaints and disputes processes, and also an impartial appeals mechanism. Certification bodies must inform anyone who needs to know about these processes how to use them. If you have a complaint about certification, a certification body, or a certified disability employment service, you should first complain to the relevant certification body. (Make sure you ask them about their complaints and appeals processes before you engage their services.) If you are not satisfied with that outcome you can then approach JAS-ANZ for assistance. Certification bodies can also complain to JAS-ANZ about accreditation issues, or, for example, the practices of other certification bodies. JAS-ANZ does not have Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 9

19 SECTION 2 authority to overturn a certification decision, although it can question the judgement of the certification body and reassess its accreditation status if accreditation requirements have not been met. JAS-ANZ Procedure 9 - Appeals and Procedure 12 - Complaints and Disputes has more details on processes and requirements. This is available from the JAS-ANZ website ( Complaints from service users should be handled initially by the disability employment service. If a service user is not satisfied with the results of the internal complaints investigation or does not wish to use the service s internal complaints process, they can contact the Complaints Resolution and Referral Service (CRRS). The CRRS will: attempt to resolve issues at the local level; make recommendations to assist in resolving the complaint; treat all parties to the complaint with dignity and respect and will be sensitive to the needs of people with disabilities; give full reasons for decisions and information about further rights; use information from complaints to improve the CRRS and the delivery of disability employment services. Providers should also be aware of the National Disability Service Abuse and Neglect Hotline. The Hotline is a single contact point for anyone to report claims of abuse and neglect in government funded services. Both the Complaints Resolution and Referral Service and the National Disability Service Abuse and Neglect Hotline can be contacted as follows: Telephone: FREECALL Telephone Typewriter (TTY): FREECALL National Relay Service (NRS): Telephone Interpreter Service: Facsimile: Postal Address: Locked Bag 2705 Strawberry Hills NSW 2012 The National Disability Services Abuse and Neglect Hotline has a website: What if I already have a quality system? You don t have to run and document separate systems. You can integrate an existing QA system (eg one which complies with ISO 9002) with a system that complies with the 12 Disability Services Standards and 26 KPIs. If your existing system is certified by a certification body accredited to offer certification to the 12 Disability Services Standards, you can ask them to conduct integrated assessments, particularly if you have integrated your systems. This should result in substantial cost savings but you will need to negotiate this with your certification body. If the certification body that has certified your ISO 9002 system says it cannot offer accredited certification to the Disability Services Standards, ask them why not. And then perhaps consider finding a certification body that can offer both certification services. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 2, Page 10

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21 Transition to the new QA system 3 Transition to the new QA system This section provides information on the arrangements for transition between the old department-based system and the new system. What you must know about the transition to the new QA system There will be a phased transition from the old system to the new system between 1 July 2002 and 31 December (The new system actually commenced on a voluntary basis from 1 January 2002) Under the new system all services will be audited against the revised Standards and KPIs. This means all disability employment services and CRS Australia have to meet the same minimum level of quality. Three-year certification assessments undertaken by accredited certification bodies will replace the current five-year departmental audits (Section 14K audits). Annual surveillance audits will also be undertaken by accredited certification bodies and will replace annual self-assessments. Organisations will, however, be required to undertake annual internal audits under the new QA system. Until formally certified, employment services will be subject to the existing departmental system of five-yearly audits against the existing Standards and the supporting standards. During the transition period between 1 July 2002 and 31 December 2004, services that have not achieved certification will be required to undertake Section 14K audits if the five-yearly audit is due and a certification assessment is not scheduled within 3 months. During the transition period services that have not achieved certification will be required to undertake annual self-assessment if a certification assessment is not scheduled within 3 months. Non-employment services (advocacy, print disability and information services) will continue to be subject to the FaCS system of review against the existing applicable Standards. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 3, Page 1

22 SECTION Who does the new QA system apply to? The new system applies to all disability employment services and CRS Australia. Non-employment services (advocacy, print disability and information services) will continue to be subject to the old department-based system of review against the existing Standards. 3.2 What quality standards will apply? Under the new system all services will be audited against the same Standards and KPIs. This means that all disability employment services (covering the old Section 10, 12A and 13 services) and CRS Australia have to meet the same minimum level of quality. The level of quality is defined in terms of a revised set of 12 Standards and new set of 26 KPIs (see Section 9). To gain certification funded services are required to demonstrate compliance with all 26 KPIs. 3.3 What will happen to the five-year departmental audits (Section 14K audits)? Under the new system three-yearly certification assessments undertaken by accredited certification bodies will replace the current five-year department audits (Section 14K audits). Certification assessments are a formal, external assessment of the service undertaken by accredited certification bodies approved by JAS-ANZ. Typically a certification assessment will involve a minimum of two to four on-site auditor days for each site covered by the audit (see Section 5). 3.4 What will happen to the annual self-assessments? Under the new system annual surveillance audits undertaken by accredited certification bodies will replace the old annual self-assessments, although organisations will be required to undertake annual internal audits. Details of the annual surveillance audits are in Section 5. Background information on internal audits is in Section 6. Detailed guidelines are in the Continuous Improvement Handbook that was distributed to service providers in However, it is important to remember that under the new system the thoroughness of a service s internal audit processes will be assessed as part of each certification assessment. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 3, Page 2

23 Transition to the new QA system 3.5 How will the transition occur? The QA system will be phased in between 1 July 2002 and 31 December This takes into account the different levels of support needed by service providers depending on the maturity of their management system. Step-by-step information on preparing for the new system is in Section 6. Strictly speaking, until services are formally certified they will be subject to the existing departmental system of self-assessments and five-yearly audits against the existing Standards and the supporting standards that apply to Section 10, 12A and 13 services. However, FaCS State and Territory officers will aim to achieve a balance between flexibility and government accountability. Where the certification audit is due to commence within 3 months or at the same time as the Section 14K audit, the certification audit would take the place of the Section 14K audit. The same approach applies to self-assessments. 3.6 What will happen to Consumer Training and Support (CTS) services? During the transition period CTS services will continue to provide support to consumers under both the old standards monitoring system and the new Quality Assurance system. Such independent support for consumers could be available as part of: the existing self-assessment process; internal audits; and before and during certification assessments. 3.7 How will the new QA system be reviewed? During the transition period FaCS will undertake a mid-term review of the quality strategy to assess its effectiveness. This review will also include a review of the appropriateness of the KPIs and evidence guidelines, with a view to establishing some performance benchmarks for the disability sector. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 3, Page 3

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25 Funding arrangements for the new system 4 Funding arrangements for the new system This section provides information on the funding arrangements for the new system. What you must know about the funding arrangements Certification costs will be market driven and so each certification body will charge according to their standard commercial rates. During the three-year transition period FaCS pays a fixed amount for audit costs. The amount reimbursed is based on an average cost for the minimum number of sites to be audited. 4.1 Funding arrangements It is recognised there will be both direct costs (certification fees and charges) and indirect costs (such as staff time) associated with the new system. These costs will vary from service to service. Many services that have implemented other QA systems already incur such costs and believe strongly that the benefits are worth the investment. The direct costs of certification fees and charges will be market driven, with each certification body charging according to their standard commercial rates. During the three-year phase-in period, FaCS will contribute to reasonable audit and assessment costs. The average certification and annual surveillance costs are based on the following three components. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 4, Page 1

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27 Certification assessment procedures 5 Certification assessment procedures While every certification body has its own procedures for certification assessment, they must comply with the general requirements outlined in JAS-ANZ Procedure 18 General Requirements for Bodies Operating Assessment and Certification of Disability Employment Services. This section presents a summary of these requirements. What you must know about the certification assessment procedures Services will need to prepare for certification by collating all policies and procedures relevant to the revised Disability Services Standards and undertaking an internal audit. Services can choose any accredited certification body to undertake their assessments. Services need to formally apply to a certification body for certification. Certification assessments involve a range of auditing activities over two to four days, including meetings with service managers, consultations with consumers, reviews of consumer files and observations of core service delivery activities. Special arrangements apply for multi-site services. Services receive a written report following the certification assessment that includes conformity ratings against each KPI and each Disability Services Standard. Where one or more nonconformity is identified the service will have to correct it before being eligible for certification. Once certified a service will be required to participate in an annual surveillance audit and a full reassessment audit every three years. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 5, Page 1

28 SECTION Preparing for certification There is no right way to prepare for or select the timing of a certification assessment. Basically, each service needs to decide when it is ready to seek certification based on the answers to two key questions: Do we have comprehensive policies, procedures and systems in relation to the 12 Standards? Do the results of our internal audit confirm that we are currently meeting the requirements of all 26 KPIs? The critical importance of preparing for certification is recognised in JAS-ANZ Procedure 18, which requires services to: collate copies of all policies and procedures relevant to the Disability Services Standard before a certification assessment. To assist with this process many services have collated their policies and procedures into a quality manual. A copy of these documents must be provided to the certification body before the on-site assessment. undertake an internal audit against the Disability Services Standards at least once a year. This process ensures that when certification bodies undertake a certification or surveillance audit the service has a record of work they have done to ensure ongoing compliance, and to address any non-compliance. Guidelines on conducting internal audits are available in the Continuous Improvement Handbook. An internal audit is defined in Procedure 18 as: Self-verification, in consultation with consumers, to see whether disability employment service activities and related results comply with planned arrangements, and determine compliance with the Disability Services Standards. Internal audits will be a requirement of the revised Standard 8. (See Section 9.) The internal audit could involve: reviewing policies and procedures in the light of the requirements of the Disability Services Standards; consulting with consumers and other stakeholders about the areas where the service is meeting the requirements of the Disability Services Standards and areas where improvements are needed; identifying the sources of evidence a service can use to demonstrate compliance with the Standards; and documenting achievements and priority areas for improvements. The records of any internal audits, including records of consumer participation during internal audits, will need to be made available to the certification body during an audit. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 5, Page 2

29 Certification assessment procedures 5.2 Applying for certification Services need to formally apply for certification. The process of applying for certification will typically cover three steps. They are: Contracting a certification body Service providers can choose any certification body to undertake their audits that has been accredited to assess disability employment services against the Disability Services Standards. A commercial contract will need to be negotiated. You are strongly encouraged to really look into the strengths and weaknesses of a number of different certification bodies before entering into a contract. It is likely that the contract will cover a full three-year cycle including arrangements for the initial assessment, annual surveillance audits and a reassessment after three years. Formal application Services will be required to submit a formal application to the chosen certification body. Certification bodies are required to have established application procedures and forms. As part of the application process services will be asked to provide the certification body with copies of all policies and procedures relevant to the Disability Services Standards and documentation relating to internal audits. Decision to proceed Certification bodies are required to review the policies and procedures of the service provider before any on-site assessment. The certification body is expected to report back to the service with a decision on whether to proceed or not with the on-site assessment. If the document review shows the service has limited or no chance of meeting the requirements of the Standards, the certification body will recommend postponing the on-site assessment. The service must be informed about the areas that need to be addressed. At this point the service and the certification body should negotiate a new date for the initial assessment. The service will need to advise the relevant State and Territory FaCS offices of this new registration date. If the document review is satisfactory the certification body will negotiate with the service about the: time frame for the on-site assessment (eg dates and duration); requirements for consumer consultation (eg sample and consultation methods); and reporting arrangements. Procedure 18 says that the certification body must provide applicants with a detailed description of the assessment and certification procedure to ensure that the requirements for certification are clearly defined, documented and understood. Any differences in understanding between the certification body and the applicant are resolved. Services should not agree to go ahead with the certification assessment until they are clear about the process and their roles and responsibilities. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 5, Page 3

30 SECTION Participating in certification assessments (on-site activities) The on-site assessment will typically include: a formal entry meeting in which the audit team must formally explain the scope and objectives of the audit, the timetable and planned audit activities, as well as allowing adequate time for questions; evidence gathering, most of which will involve observations, reviewing records and conducting interviews with service management and staff. A specific component of the evidence gathering will involve consultation with consumers. Certification bodies are required to have developed a consumer consultation plan before the on-site assessment, and communicate with the service about sample size, selection and consultation methods; an audit review meeting in which the audit team will synthesise findings and develop their assessments; and a formal exit meeting in which the audit team presents its findings, including the service s compliance with each of the 26 KPIs. Service consumer representatives must be given the opportunity to participate in all steps of the on-site assessment Consumer consultation All certification assessments will involve interviews with service consumers. Certification bodies will liaise extensively with services in planning and preparing for the consumer interviews. This could involve negotiating procedures for obtaining consent and advising on the sampling strategy. Given that it is not practical to speak with all consumers the certification body will select a sample. The certification body is expected to observe the following principles when sampling consumers for an audit: the certification body should select the sample of consumers to be interviewed; the sample should reflect the demographics of the consumers being assisted by the service, taking into consideration disability type, gender, age, home or living situation, cultural, religious or language differences, whether working or not working, and length of tenure with the service (including those on a waiting list and those exited); and the audit should be widely promoted so that any consumer who wants to has the right to talk with any of the audit team members. Although the focus of the consultation is on consumers, certification bodies will also try to gather useful evidence from other key people including staff, consumers parents, carers, advocates, other workers in open employment and employers. Procedure 18 requires the sample size of consumers be related to the total number of consumers. If a service has 25 consumers the minimum sample size will be 5, if it has 50 it will be 7, and if it has 100 consumers then 10. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 5, Page 4

31 Certification assessment procedures Of those, at least half should be interviewed individually face-to-face and the remainder consulted by other means such as focus groups, telephone interviews, written surveys or informal conversation (eg a factory walk-around) Reviewing consumer files Certification assessments will also involve reviewing consumer files to crosscheck the verbal information gathered from consumers and to check implementation of the disability employment service s policies and procedures. Appropriate consent should be obtained to ensure as many files as possible are available for review. As a minimum the audit should involve a review of at least five consumer files On-site audit duration The actual amount of time needed for the on-site audit will vary depending on the service size, type (supported or open), and the communication abilities and support needs of consumers. Typically, an on-site audit of single-site service will take between two days (for services with less than 30 consumers) and four days (for services with more than 100). This is based on an eight-hour working day for a single auditor (including one hour for lunch), and excludes all activities other than auditing (such as planning, preparation, travel time and reporting). Where two or more team members work together (say, an auditor plus a technical expert asking questions of the same consumers) that time is counted as if a single auditor was involved Multi-site audits Normally assessment for certification should take place at all the disability employment service s sites. However, where a service s activities are carried out in a similar manner at different sites, all under the service s control, a certification assessment can be undertaken at a sample of sites. A multi-site disability employment service is defined as a service having a central function (referred to as a central office) with authority to plan, control or manage activities and a network of local offices or branches (sites) at which such activities are carried out. This could include either services with multiple outlets performing different business functions (eg both open and supported employment services) or services with multiple outlets all performing similar activities at different sites. For multi-site services, the certification bodies will use a formula to determine the number of sites where assessments will take place. In all cases, the central office will be visited. A service with a central office and nine sites would need assessments at the central office and three sites. Australian Government Department of Family and Community Services, 2003 Quality Assurance Handbook Issue 2, May 2003 Section 5, Page 5