Department of Human Services StandardsIntroduction

Program

• Overview of standards

• Independent review and service agreement requirements

• Scope of independent reviews

• Activities in scope for review

• Independent review bodies

• The review and planning for the review

• Next steps

Department of Human Services Standards

Overview of Standards

Department of Human Services Standards

Features include:

• Department of Human Services Standards

• Independent review body’s standards to assess:

• governance and service management including:▪ governance processes▪ strategic planning▪ cultural competency▪ legal compliance▪ financial management and accountability▪ contract management▪ risk management

◦ occupational health and safety◦ infection control◦ insurances◦ finance and contracts ◦ information systems

Department of Human Services Standards

• quality systems that incorporate continuous quality improvement

• complaints, allegations and appeals management• records management• information sharing/accessibility, including privacy and

confidentiality• human resource management

▪ recruitment (including pre-employment criminal history checks)

▪ training and development▪ performance review and management▪ staff competencies

• consumer participation and feedback.

Department of Human Services Standards

The Department of Human Services Standards take a human rights perspective to support the achievement of personal outcomes for clients. This is the human side of how the service provider supports the client. For example:

• how well clients are treated by the service provider

• whether their needs are being met

• whether their rights are being respected

• whether they are safe and adequately cared for in the service environment

• and importantly, whether they have a choice and opportunity for active participation in the way the service is delivered.

Department of Human Services Standards

• Empowerment

• Access and engagement

• Wellbeing

• Participation

Criteria

Standard 1 Empowerment

1.1 People understand their rights and responsibilities.

1.2 People exercise their rights and responsibilities.

Standard 2 Access and engagement

2.1 Services have a clear and accessible point of contact.

2.2 Services are delivered in a fair, equitable and transparent manner.

2.3 People access services most appropriate to their needs through timely, responsive service integration and referral.

Criteria

Standard 3 Wellbeing

3.1 Services adopt a strengths based and early intervention approach to service delivery that enhances people’s wellbeing.

3.2 People actively participate in an assessment of their strengths, risks, wants and needs.

3.3 All people have a goal oriented plan documented and implemented. This plan includes strategies to achieve stated goals.

3.4 Each person’s assessments and plans are regularly reviewed, evaluated and updated. Exit/transition planning occurs as appropriate.

3.5 Services are provided in a safe environment for all people, free from abuse, neglect, violence and/or preventable injury.

Criteria

Standard 4 Participation

4.1 People exercise choice and control in service delivery and life decisions.

4.2 People actively participate in their community by identifying goals and pursuing opportunities including those related to health, education, training and employment.

4.3 People maintain connections with family and friends, as appropriate.

4.4 People maintain and strengthen connection to their Aboriginal and Torres Strait Islander culture and community.

4.5 People maintain and strengthen their cultural, spiritual, and language connections.

4.6 People develop independent life skills.

Department of Human Services Standards

Independent review requirements

Department of Human Services service agreement requirements

Under the 2012-15 service agreement organisations that provide direct client services are required, unless exempt by the department to:

• undertake an independent review against theDepartment of Human Services Standards by anindependent review body once every 3 year serviceagreement period (by July 2015 unless a service provider is required to apply for renewal of registration prior to this date).

• obtain accreditation and remain accredited by the independent review body. This entails full compliance with the Department of Human Services Standards.

Review flow chart

Review flow chart

Scope of independent reviews

• Service providers funded for more than $102,000 for in-scope activities are required to undertake an independent review.

• Service providers that receive over $204,000 funding for in-scope activities to provide goods, aids and equipment services are required to undertake an independent review.

• Service providers that receive over $204,000 in total departmental funding for advice, information, referral are required to undertake an independent review.

• Exceptions apply.

Exemptions

With departmental approval:

• service providers that receive less than $102,000 in total funding for in-scope activities may be exempt from independent review and required to undertake a self-assessment report and quality improvement plan only

• service providers funded for less than $20,400 for in-scope activities and/or funded for activities which do not involve a direct client relationship (e.g. professional development, research and policy) may be exempt from the self-assessment report and quality improvement plan.

Scope fact sheet June 2012

Activities in scope for review

Funded activities in scope of an independent review are detailed in the fact sheet.

New activities in scope for independent review include:

• disability advocacy

• sexual assault services

• youth justice and youth services.

Service providers have a responsibility to check the activities in scope, which are updated from time to time. and available from the department’s website.

Funded activities in scope

Activities in scope for review

Service providers that have not been reviewed previously but now have activities in scope of review are required to undertake an independent review and achieve accreditation/certification by June 2015.

The department will notify service providers that receive departmental exemption from undertaking an independent review or self-assessment and quality improvement plan.

Funding contribution towards a review cost

The department will be contributing towards the cost of the Department of Human Services Standards independent review.

Once determined service providers will be advised in writing.

Department of Human Services Standards

Independent review bodies

Independent review bodies

• Must be impartial and must declare any conflict of interest.

• Are required to follow either the relevant Joint Accreditation System of Australia and New Zealand (JAS-ANZ) Procedure or Deed of Agreement.

• Are independent of the Department of Human Services.

• Bound by a code of ethics, have a police check and a working with children check.

Department-endorsed independent review bodies

As at 20 August 2012, department-endorsed independent review bodies are:

• Joint Accreditation System of Australia and New Zealand (JAS-ANZ) accredited bodies:

▪ AHA Quality Certification Services ▪ BSI Group▪ Global-Mark▪ International Standards Certifications (ISC)▪ NCS International (NCSI)▪ SAI Global

• Australian Council of Healthcare Standards• Health and Disability Auditing Australia (HDAA)• Quality Improvement and Community Services Accreditation (QICSA)• Quality Management Services (QMS)• The Council on Quality and Leadership (CQL)

Dept endorsed IRBs

Department-endorsed independent review bodies governance and management standards

• Joint Accreditation System of Australia and New Zealand (JAS-ANZ) accredited bodies use the 9001:2008 quality management system (ISO standards)

• Health and Disability Auditing Australia (HDAA) use the 9001:2008 quality management system (ISO standards)

• Quality Management Services (QMS) use the Australian Service Excellence Standards

• The Council on Quality and Leadership (CQL) use its own Quality Measures including Basic Assurances and Responsive Services

• Quality Improvement and Community Services Accreditation (QICSA) use the Quality Improvement Council (QIC) Health and Community Services Standards

• Australian Council of Healthcare Standards use the Evaluation and Quality Improvement Program (EQUIP) Standards

Selecting an independent review body

• Look for an independent review body as soon as possible.

• Approach more than one independent review body.

• Consider what is important for your organisation and develop questions to ask at the interviews.

• Make sure that the independent review body understands the work your organisation does.

Selecting an IRB fact sheet

Department of Human Services Standards

The review

Outcomes of a review

• Compliance

• requirements of each standard met

• outcomes shown to be effective

• Partial Compliance

• Non-compliance (must be rectified to achieve accreditation/certification)

• outcomes shown to be partly or non-effective.

• Other opportunities for improvement, not required to meet the standards

Department’s responsibilities in relation to the review

• Track reviews and completion dates.

• Convene moderation forums with IRBs.

• Respond to notifiable issues.

• Monitor quality, compliance trends and training needs.

• Analyse data and develop a statewide report.

• Report to stakeholders.

• Ensure that IRBs adhere to their responsibilities as defined in the JAZ-ANZ procedure or Deed of Agreement.

Service providers responsibilities in relation to the review

• Appoint a key contact person throughout the review.• Ensure relevant stakeholders and clients understand what is involved for them and are supported to make a meaningful contribution.

• Provide the IRB with:▪ documentation, access to staff and client files▪ a snapshot of the organisation e.g. staffing,

facilities, client groups, special features etc.

Independent review bodies responsibilities in relation to the review

• Specified in the Deed of Agreement or JAS-ANZ Procedure.

• Advise the department when it is engaged by a service provider and review dates are booked.

• Review of service provider’s systems/policies/ documents/reports etc.

• Review a sample of sites and files (client/staff/carer).• Opening and closing meetings.

Independent review bodies responsibilities in relation to the review

• Advise the department of any notifiable issues.• Client participation/interviews (interviews will not include

children and young people under the age of 18 years in out-of-home care, youth justice or disability services).

• Stakeholder feedback (includes staff, clients, carers, management, partner organisations, etc).

• Provide a report at completion of the review to the service provider and Standards and Regulation Unit.

• Mid-cycle review.

Sampling methodology for site visits

The site and/or outlet selection criteria should consider:

• results of the service provider’s self-assessment processes or previous audits by an independent review body

• records of complaints and communications and other relevant aspects of corrective and preventive action

• significant variations in the size of the sites and/or outlets and number of consumers

• whether sites and/or outlets are based in homes, rather than offices

Sampling methodology for site visits

• whether sites are operated by subcontractors

• modifications since the last audit

• geographical location and dispersion

• each IRB will utilise its own sampling formula

• the formula will be similar to the square root of the total number of sites, plus 1 (or rounded up)

• selection of sites by IRBs will be random and must represent a cross section of services delivered by the service provider.

Sampling methodology for staff, carer and client file audits

• The formula will be similar to the square root of the total number of staff, carer and client records, plus 1, (or rounded up).

• Selection of files by IRBs will be random and must represent a cross section of services delivered by the service provider.

Notifiable issues

Where the review team suspects, has evidence of, or receives acomplaint or allegation about:

• the health, safety, abuse or risk to a client or where there is a failure to meet basic client needs

• a service provider is experiencing significant organisational disruption and executive mismanagement

• the independent review body has serious concerns about the ongoing financial viability of the service provider

• a service provider engages in conduct which is fraudulent or potentially fraudulent or is engaged in other criminal activities.

Process to address non-compliance with the standards

• Service providers must address all non-compliances in order to achieve accreditation/certification.

• To attain accreditation, a service provider must immediately resolve any non-compliance that places a client at significant risk; or resolve any other non-compliances within a maximum of six months.

• Response will be led by the Standards and Regulation Unit (SRU) if the service provider has immediate risk issues or fails to meet requirements after completion of the review process.

Content of written review reports shall include

• Service provider’s sites and those sampled by the review team.

• Service provider’s staff and effective full-time positions as provided by the service provider.

• Number of people accessing the service provider’s services.

• An executive summary.

• Number of staff, client and volunteer files reviewed.

Content of written review reports shall include

• Table outlining compliance with the Department of Human Services Standards.

• A separation of performance data for:

• disability residential services

• out-of-home care

• community-based child and family services.

• Summary of service provider’s strengths and opportunities for each of the Department of Human Services Standards.

Content of written review reports shall include

• Actions undertaken to meet the Department of Human Services Standards.

• Aggregate data for client and staff file audits.

• Aggregate feedback from stakeholder consultation.

• Comparison of the service provider’s performance across different sites / geographic locations where this is relevant.

• Accreditation/certification status.

Department of Human Services Standards

Planning for the review

Planning for the review

• May involve initial site visit, or may be conducted remotely

• Objectives and scope of review confirmed

• Profile of organisation provided to reviewers to ensure representative sample

• Review plan/schedule developed

• Undertaking the selected independent review body’s self-assessment or pre-review process

• Collect evidence for each of the criteria

Things for service providers to consider

• Is there a policy/procedure in place?

• How is it made available or communicated?

• Is it accessible and to whom?

• Do staff know how to use it?

• What is in place so that they use it?

• Are your systems evaluated?

• How do you know?

Quality system

D I C E D

D Documented/described in writingI Implemented/integrated into practiceC Communicated E EvaluatedD Designated responsibility

Triangulation methodology

• Documentation is reviewed by thereview team.

• The practice is observed by the review team.

• Staff, clients and stakeholders speak to the review team.

Reviewers will need to satisfy themselves that the standard is being met.

Service providers will be rated against each criteria.

Supporting tools

The Department of Human Services has developed an:

• evidence guide

• staff and carer file audit tool (mandatory for review bodies)

• client file audit tool (mandatory for review bodies)

• self-assessment report and quality improvement plan

Client File Audit Tool

Self-Assessment Tool

Staff and carer file audit tool

Department of Human Services Standards evidence guide

The Department of Human Services Standards Evidence Guide provides information in the following areas:

• each standard is summarised and describes the intent of that standard. The standard has criteria which describes the key components.

• examples of evidence that support the provision of services across more than one service area (common evidence)

• service-specific evidence relevant to the needs of particular client groups

• evidence indicators to be used to ‘measure’ the extent to which the service provider has met each standard, however, they are not

prescriptive.

• information on which supporting documents may help provide evidence to address the standards.

Standards model

Independent review body:odetermines governance and management standards

ocriteria required to achieve accreditation/certification

Department of Human Services:odefines the Department of Human Services Standards and performance criteria

Department of Human Services Standards model

Independent review body undertakes the review

Funded organisation selects a department-approved independent review body

One independent review during each 3 year service agreement period

Timing of review determined by independent review body and funded organisation.Requirement to ensure compliance with registration and other legislative requirements.

Accreditation / CertificationReview report to DHS

Department of Human Services Standards

Next steps

Self-evaluation processes

• Read the evidence guide.

• Expect everyone to participate - create an environment for reflection and quality improvement.

• Plan and prepare.

• Self evaluate including client and staff file reviews.

• Include all stakeholders – service users, board, volunteers, partnering organisations etc.

Be informed

• Review standards and tools i.e. Department of Human Services Standards, evidence guide, staff and carer file audit tool (mandatory), client file audit tool, self-assessment tool.

• Familiarise yourself with the procedures and requirements of the reviewing body.

• Talk to your Program and Service Advisers, regional contacts, independent review bodies or the Standards and Regulation Unit.

• Department of Human Services’ website at www.dhs.vic.gov.au/about-the-department/documents-and-resources/policies,-guidelines-and-legislation/department-of-human-services-standards

Questions?

More information

To learn more about the implementation of the standards, ask questions or provide feedback you can:

• Visit the department’s website (http://www.dhs.vic.gov.au) (http://www.dhs.vic.gov.au/about-the-department /documents-and-resources/policies,-guidelines-and- legislation/department-of-human-services-standards)• Visit the department’s Policy and Funding Plan webpage (http://www.dhs.vic.gov.au/about-the-department/plans,-programs-and-projects/plans-and-strategies/key-plans-and-strategies/policy- and-funding-plan-department-of-human-services)

• Contact:

• Standards and Regulation Helpdesk on 9096 2745 or email: dhsstandards@dhs.vic.gov.au

• Anna Barnes on 9096 2577 or email anna.barnes@dhs.vic.gov.au