NATIONAL DISABILITY ADVOCACY PROGRAM QUALITY IMPROVEMENT TOOLKIT

Transcription

1 NATIONAL DISABILITY ADVOCACY PROGRAM QUALITY IMPROVEMENT TOOLKIT Department of Families, Housing, Community Services and Indigenous Affairs 8 May 2009 ARTD Pty Ltd ABN Tel Fax Level 4, 352 Kent St Sydney PO Box 1167 Queen Victoria Building NSW 1230 Australia

2 Parliamentary Secretary Foreword I am pleased to provide you with the National Disability Advocacy Program (NDAP) Quality Improvement Toolkit, which has been developed to provide practical assistance for NDAP agencies to ensure continuous quality improvement for people with disability. NDAP agencies play a vital role in safeguarding the rights of people with disability by recognising and encouraging people with disability to participate actively in the community, by promoting independence and self-reliance and by maintaining their rights as citizens. The NDAP Quality Improvement Toolkit has been developed in consultation with advocacy agencies, who have been closely involved and provided practical tools, resources and advice. I encourage NDAP agencies to use the quality improvement resources in the Toolkit as a means of developing stronger, more sustainable agencies that better meet the needs of people with disability. A quality improvement culture will help agencies work with existing and future quality assurance requirements, and promote high quality agencies which meet the needs of people with disability. THE HON BILL SHORTEN MP Parliamentary Secretary for Disabilities and Children s Services

3 Contents 1. Background The National Disability Advocacy Program Introduction to quality improvement Benefits of quality improvement Getting started Guide to using the Toolkit What you will find in each quality theme section Tips for success Getting staff and volunteers involved in quality improvement Getting people with disability involved in quality improvement Management systems Getting started Advocacy agency s approach to management systems Step 1: Develop a checklist Step 2: Conduct a self-assessment Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links Staff recruitment, retention, training and development Getting started Advocacy agency's approach to staff recruitment, retention, training and development Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Training Advocacy access Getting started Definition and models of advocacy Advocacy agency's approach to advocacy access Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of Evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Tailoring advocacy to individual needs Getting started Advocacy agency's approach to tailoring advocacy to individual needs Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links Decision making and choice Getting started Advocacy agency's approach to decision making and choice...126

4 8.3 Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Complaints and disputes Getting started Advocacy agency's approach to complaints and disputes Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links Privacy, dignity and confidentiality Getting started Advocacy agency's approach to privacy dignity and confidentiality Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of Evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links Participation and integration Getting started Advocacy agency's approach to participation and integration Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of Evidence Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links Valued status Getting started Advocacy agency's approach to valued status Step 1: Develop a checklist Step 2: Conduct a self-assessment Examples of Evidence Step 3: Plan quality improvement actions Step 4: Review your progress Sample policies and procedures Protection of human rights and freedom from abuse Getting started Advocacy agency's approach to protection of human rights and freedom from abuse Step 1: Develop a checklist Step 2: Conduct a self-assessment Evidence guidelines Step 3: Plan quality improvement actions Step 4: Review your progress Resources Sample policies and procedures Useful links...245

5 Appendix 1: Concepts related to quality Appendix 2: Disability Services Standards and Supporting Standards Appendix 3: Draft Disability Advocacy Standards...252

6 Purpose of this Toolkit This Toolkit is designed to provide practical tools, resources and advice to assist NDAP funded organisations develop and improve how advocacy work is organised and controlled to ensure consistent practice in line with agreed standards. These processes are often called quality management. The Toolkit is in no way prescriptive, it is a resource for you to use as needed to support quality improvement. All agencies will approach the quality improvement process from different stages, and it is not expected that you will adopt all policies or practices or use all resources in this Toolkit, particularly where you already have quality management practices in place. Given the different approaches to advocacy, not all of the policies in this Toolkit will apply to you, but effort has been made to ensure a range of resources that suit the different advocacy agencies. It has been developed in consultation with advocacy agencies. The Toolkit is divided into ten sections based on ten quality themes. You do not have to complete all ten sections of the Toolkit. You can choose to start working through any section and might choose to work on only some of the sections that are particularly relevant to the agency. Where you already have systems in place to ensure quality, you may use the sections as a way of gauging how your practice is going. Inside this Toolkit you will find: background information (refer Section 1) an introduction to quality improvement (refer Section 2) a guide to getting started, including the quality improvement process (refer Section 3) ten quality theme sections, each of which contains: o some advocacy agencies approaches to management and quality improvement for the particular theme o o o o o o things to consider to help in writing up a checklist for your agency a self-assessment worksheet to scan and document your agency s practice examples of evidence, as a resource for completing the selfassessment worksheet a quality improvement implementation worksheet to plan and document the improvement actions your agency undertakes practical resources including forms and templates sample policies and procedures useful for your agency. National Disability Advocacy Program Quality Improvement Toolkit Page i

7 Section 1: Background 1. Background A Quality Improvement strategy is currently being developed for the National Disability Advocacy Program (NDAP). The key components of this strategy include quality assurance, continuous improvement and sector development. This Toolkit has been developed in consultation with NDAP funded agencies to support the continuous improvement and sector development components. 1.1 The National Disability Advocacy Program The National Disability Advocacy Program (NDAP) is funded by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) to ensure that people with disability have opportunities to access advocacy. In broad terms, advocacy for people with disability can be defined as speaking, acting or writing with minimal conflict of interest on behalf of the interests of a person or group, in order to promote, protect and defend the welfare of and justice for either the person or group by: being on their side and no-one else s being primarily concerned with their fundamental needs remaining loyal and accountable to them in a way which is empathic and vigorous. Agencies funded under the NDAP adopt various approaches to advocacy that can be categorised into six broad models (see Advocacy delivery section in Section 6), with the majority of agencies undertaking two or more advocacy approaches. National Disability Advocacy Program Quality Improvement Toolkit Page 1

8 Section 2: Introduction to quality improvement 2. Introduction to quality improvement When referring to quality, we are thinking about the systems you put in place to organise and control advocacy work. Ensuring the quality of these systems means consistent practice in line with agreed standards. 1 Ensuring quality involves making sure you have: clearly documented policies and procedures a systematic approach to translating policies and procedures into practice a process for review to ensure practices align with the policies and procedures confidence that implementation of policies and procedures will remain systematic into the future; that is, implementation is not dependent only on the knowledge of individual staff members. Quality agencies are agencies which generally show: strong customer focus clear direction and accountability continuous learning and innovation valuing people and diversity collaborative work practices evidence-based decision making social and ethical responsibility 2. Quality improvement is an integral part of quality management and improvement processes can be integrated into the day-to-day running of your agency. Basically it is the ongoing review of your policies, processes and practices, to create stronger, more sustainable agencies that better meet the needs of people with disability. The intent of quality improvement is to lay solid foundations to underpin service delivery outputs, outcomes and impacts that is, to: improve efficiency (to do things right) improve effectiveness (to do the right things) improve client outcomes/ outcomes for people with disability 3. A quality improvement culture helps you accommodate changes, such as government reforms, variations in the economy and the needs of clients, and continually develop a high quality agency to meet the needs of people with disability. Quality improvement operates at both an individual agency level and a sector level. Ideally, improvement actions at the two levels are related so that information about successful innovations is shared across the sector, and areas of need are identified so that training and support can be provided. For more information on quality see Appendix 1. 1 See Appendix 1 for information on key concepts related to quality. 2 South Australian Department of Families and Communities, Benefits of a Quality System, Service Excellence Program, System.aspx 3 Disability Service Queensland, Introduction to Quality Management, National Disability Advocacy Program Quality Improvement Toolkit Page 2

9 Section 2: Introduction to quality improvement 2.1 Benefits of quality improvement Implementing quality improvement processes has a range of benefits for clients, staff, Board and other stakeholders, as identified by the South Australian Department of Families and Communities Service Excellence Program (see the table below). Benefits of quality improvement 4 Clients Expectation they will get the service they need. Greater confidence that the service is run well. Greater opportunity to be involved in decision-making about the services they receive. Confidence in the continuity and improvement of supports over time. Staff Board/Governing Bodies Managers Funding Bodies Community Find work is less stressful and more satisfying. Experience greater efficiency and effectiveness. Feel more involved and empowered in their work. Have a more interesting learning environment. Confidence that the service is achieving its mission and purpose. Promotes a culture of continuous improvement. Provides a greater opportunity to express agency values and demonstrate these to the community. Promotes a culture of continuous improvement. Increases efficiency and effective work processes. Increases time focused on productive work rather than problems. Cuts time on non-productive accountability processes. Opens opportunities to express your agency's values and demonstrate these to the community. Confidence that service providers use funds to achieve agreed outcomes. Confidence that taxes are being used to effectively assist members of the community. 4 South Australian Department of Families and Communities, Benefits of a Quality System, Service Excellence Program, System.aspx National Disability Advocacy Program Quality Improvement Toolkit Page 3

10 Section 3: Getting started 3. Getting started 3.1 Guide to using the Toolkit This Toolkit is divided into ten quality theme sections that are relevant to the practice of disability advocacy agencies. Each section follows a four-step quality improvement process and provides a range of resources and tools that you can use or refer to for support and ideas as you go through each step. Each section is a stand-alone process. You do not have to work through the quality theme sections in any particular order and do not have to complete all sections. You might choose to work only on some of the quality theme sections identified as a priority area for improvement for your agency. The four-step quality improvement process is outlined below and further information is provided in the following pages Step-by-step guide to the Quality improvement process Step Step one: Develop a checklist Step two: Conduct a selfassessment Step three: Plan quality improvement actions Step four: Review your progress Actions and resources Read the list provided of things to consider in approaching quality management for the particular theme Consider your current practices, policies and procedures for this theme Using this information, draw up your own checklist of the considerations for quality that will be important for you to address in the quality improvement process you may select some from the list provided and there might be others that your agency has identified Select up to five points from the checklist in Step 1 Think about examples of evidence that you can use to demonstrate quality Involve staff / volunteers, people with disability and other stakeholders in rating your agency s performance and suggesting improvement actions Drawing on the improvement actions suggested in your self assessment (Step 2), decide on the actions you want to implement ie those actions that are most likely to improve your systems and practices and which are feasible to implement Consider the resources provided in this Toolkit and consider which might be useful or could be adapted for use in your agency Identify other resources that could support quality improvement (eg working with other agencies) Identify any gaps (eg areas where staff/ management/ volunteers may need training to implement quality improvement) Fill in the quality improvement worksheet, deciding on responsibilities, resources needed, timeframe for implantation and a review date DO NOT complete the last column, which is to be filled in when you review your progress (Step 4) At the review date (usually after 12 months) go back to your quality improvement worksheet and review your progress and achievements If the improvement action has been successful and involved a new process or policy, you might now formalise this process If the improvement action has been unsuccessful, you will need to consider new strategies Fill in the final column of the worksheet National Disability Advocacy Program Quality Improvement Toolkit Page 4

11 Section 3: Getting started 3.2 What you will find in each quality theme section The ten quality theme sections into which this manual is divided broadly cover the Disability Services Standards applicable to disability advocacy agencies, and the draft set of Disability Advocacy Standards. The ten quality theme sections are: Management systems Staff recruitment, retention, training and development Advocacy access Tailoring advocacy to individual needs Decision making and choice Complaints and disputes Privacy, dignity and confidentiality Participation and integration Valued status Protection of human rights and freedom from abuse. The Disability Services Standards are included as Appendix 2 and the draft set of Disability Advocacy Standards are included as Appendix 3. Advocacy agency s approach to the theme In this section advocacy agencies describe how they think and talk about quality management and quality improvement for the theme; some of their practices; and how they ensure quality. Things to consider A list is provided for each quality theme highlighting some of the key considerations for ensuring quality. Refer to the checklist when you are considering your current practices for this theme, and refer to it when drawing up your own checklist of considerations for quality that will be important for you to address in the quality improvement process. You will select some of these points against which to assess your agency s performance in the self-assessment completed at Step 2. Self-assessment worksheet Self-assessment is a critical review, conducted internally, that documents the extent to which your existing policies, procedures and practices ensure you have quality systems and advocacy practice. The self-assessment process is also designed to highlight the evidence you can use to demonstrate your agency s practice and improvement opportunities to ensure you maintain quality systems and practices in the future. To begin on the self-assessment worksheet, select up to five points from the checklist of considerations for quality that you want to concentrate on. You should select a mix of indicators both aspects where you are currently doing well and aspects that you are aware you need to address. Once you have selected the five points, working across the worksheet, rate your current performance for each, record evidence of your current practice, and ideas for improvement your agency might consider [see Box 3.1, following, for more information on the self-assessment process]. The worksheets prompt discussion about future quality management, and document your current strengths and weaknesses and areas where you lack clear evidence about your performance. National Disability Advocacy Program Quality Improvement Toolkit Page 5

12 Section 3: Getting started Completing the worksheet can be a way of getting everyone involved in thinking about quality and improvement processes. You may want to complete the worksheet at a staff/ volunteer meeting or you may want to copy the worksheets and provide to staff/ volunteers individually. Examples of evidence The examples of evidence that you can use to demonstrate quality were developed based on feedback from NDAP agencies provided during consultations on a Quality Assurance system for advocacy in The examples are not prescriptive and do not constitute a compliance checklist. Some of the examples will be more relevant to you than others, dependent on your agency s approach to advocacy; some apply across all approaches of advocacy; and others are specific to a certain approach. Use the examples of evidence as a guide when completing the self-assessment worksheets. You can use the examples of evidence as tools to help you gather and develop evidence to: use internally to assess your agency s performance for each quality theme use internally to help find ways to continually improve and innovate. Think of evidence not in terms of what your agency does, but how you can demonstrate what your agency does. You should have documentation to substantiate your practice, such as policies, work instructions, protocols, promotional materials, checklists and plans. You should also be able to demonstrate that staff understand and consistently apply documented policies, and have clients/ people with disability confirm your policies are consistently applied. Quality improvement worksheet To begin on the quality improvement worksheet, decide on the improvement actions you want to pursue from the suggestions made in the self-assessment worksheet and based on the key priority areas for your agency. In deciding on improvement actions, the idea is not to select actions for every area. Instead select the key changes you will concentrate on to improve your systems and practices. Record the improvement actions you chose in the first column of the quality improvement worksheet. Use the sheet to plan and document implementation of the improvement actions, recording who has responsibility for implementation, the resources that will be dedicated to implementation and a timeframe for actions and review. For example, in the column for budget considerations you might consider physical resources, activity expenses, facilitator/ external consultant expenses, and wages. Resources A range of resources is provided for each quality theme to support you in planning your quality improvement actions. Again, these are not prescriptive and where you decide to use a resource to support your quality improvement actions you can adapt it based on your agency s purpose and practices. Where your agency has already developed your own resources, you may want to use the resources in the Toolkit to gauge your own systems and practices. Sample policies and procedures Sample policies and procedures are provided for each quality theme. Some of these will be relevant to all approaches to advocacy while others may not be relevant to certain approaches to advocacy. Where there are policies and procedures that are relevant to your agency and you don t already have them in place, you may want to use these as a starting point for National Disability Advocacy Program Quality Improvement Toolkit Page 6

13 Section 3: Getting started developing your own. Where you already have your own policies and procedures in place, you may want to use the sample provided to check against the elements in your policy. National Disability Advocacy Program Quality Improvement Toolkit Page 7

14 Section 3: Getting started Box 3.1: How to conduct a self-assessment How do we give our agency a self-assessment rating? The self-assessment worksheets in this Toolkit use a rating scale similar to that which may be used for any future quality assurance system using third party certification. You should assess your agency s performance, and improvement, according to the following scale: 0 = major nonconformity 1 = nonconformity 2 = conformity A major nonconformity means that the requirements of an indicator are not met, or the outcome is ineffective A nonconformity means that the requirements of an indicator are not fully met, or the outcome is only partly effective Conformity means that the requirements of the indicator are fully met. What methods can be used to do the self-assessment? feedback from staff, clients and people with disability either through interviews or a survey a desktop-review of policies and procedures workshops/ meetings to discuss where you are working well and where there are gaps in your systems Depending on the size and arrangements of your agency, you may decide that the task of completing the self-assessment worksheets will be shared, with individuals or working groups taking on the assessment of specific draft Standards. The sheets may be printed out, so they can be used around the office or, in some circumstances, it might be more appropriate to keep a version in electronic format on the server (with consideration given to version control) to save re-entering information. Your agency may decide to allow time to work through the self-assessment during existing meetings. If multiple persons or groups complete self-assessments, then the results should be summarised into an overall self-assessment to give your agency a picture of where you are now and to allow you to take the next step to prioritise areas for improvement. Collecting and storing evidence As you undertake the self-assessment, you will collect evidence of your practice and consideration should be given to how your agency goes about collecting and storing this evidence, for example: keep evidence in central locations use simple methods, for example, a folder for documentation have a secure filing system for clients advocacy plans and staff/ volunteer plans save your self-assessment worksheets and other evidence online under a clear filing structure if your agency has one, you might consider using your Intranet keep planning and systems documents build data collection into your agency s processes so that evidence does not need to be recorded after the fact ensure strong evidence doesn t necessarily mean lots of documentation the relationship between the sources of evidence is important. National Disability Advocacy Program Quality Improvement Toolkit Page 8

15 Section 3: Getting started 3.3 Tips for success Agencies participating in quality improvement processes have found the following factors as important for their success 5. Create a supportive environment: Be clear in your purpose and plan how it will occur. It is important that the process benefits your agency and enables it to better serve people with disability. Gather a team together: Engagement in learning groups from broad areas across your agency (including volunteers, Board members, clients and people with disability) is highly valuable. Use the quality improvement worksheet: Record evidence of your quality practice, using the examples of evidence as a guide and improvement actions you will take where these are identified. Action plan: This will help you clarify your priorities. Go the extra mile: Record examples of where staff members/ volunteers have gone beyond expectations to meet the needs of people with disability and improve the quality of advocacy delivery. Compare yourselves with others: Contacting similar agencies to see how they approach different systems and measures can be useful. Continuous improvement: Quality improvement is not a one-off; it is an ongoing commitment. Celebrate success: Share success with your staff/ volunteers and clients/ people with disability through newsletters, posters, meetings and the media. 5 Adapted from the South Australian Department for Families and Communities, National Disability Advocacy Program Quality Improvement Toolkit Page 9

16 Section 3: Getting started 3.4 Getting staff and volunteers involved in quality improvement Sample exercise for engaging staff in quality improvement 6 This activity warms staff to the continuous improvement process. You might want to introduce this activity in a regular staff/ volunteer meeting or in another forum where all staff/ volunteers are present. The exercise is called the five in five game. You can use it to: encourage staff/ volunteers to generate ideas for improvement link ideas and suggestions to continuous improvement plans increase overall agency ownership of continuous improvement. Step one: play the five in five game 1. Everyone in the room has five minutes to think of five things that they would change to improve your agency. The changes could relate to internal issues (facilities, ideas for staff training) or to providing advocacy to people with disability. 2. Each person must announce their list of five improvements to the room. 3. Staff/ volunteers cannot repeat an idea that has already been mentioned, but can refine or develop ideas mentioned by others. 4. Encourage and motivate staff/ volunteers by giving out rewards and small prizes for good ideas. 5. Designate one or two people in the room to write the ideas up onto a whiteboard or butcher s paper. Step two: review the results 1. Type up the results from the game into a list, with the idea recorded next to the name of the staff member/ volunteer who recommended it. 2. Review the results. The structure of your agency will determine who reviews the results (for example, CEO and regional managers). It needs to be someone with the capacity to implement decisions based on the review. As part of the review: a. assess the practicality of the ideas b. for ideas that are practical, designate a person from a relevant area of your agency to be responsible for action/investigation, and a reasonable timeframe c. for ideas that are not practical, note that the idea will not be followed-up, and the reason why not d. record all decisions made, as well as timeframes and responsible people, on the list of ideas. 3. Reviewers designate a person responsible for maintaining the list. Step three: re-circulate the list 1. Re-circulate the list to all staff/ volunteers, so that they can see what will happen with their idea and who is responsible for it. 6 Disability Employment Services Quality Strategy Toolkit, Prepared with the assistance of NOVA Employment and Training, NSW, Disability Employment Network and Business Services. National Disability Advocacy Program Quality Improvement Toolkit Page 10

17 Section 3: Getting started Step four: action and review the ideas 1. As items on the list are actioned or investigated, the person responsible should notify: a. the staff member/ volunteer who thought of the idea originally b. the person responsible for maintaining the list. 2. At the next staff/ volunteer meeting, the list should be reviewed. Any ideas which have not been actioned or investigated should become priority matters. 3. Start the process again for more improvement ideas! Step five: use your records 1. The list of improvement ideas linked to documented actions can be used as evidence of continuous improvement activities. National Disability Advocacy Program Quality Improvement Toolkit Page 11

18 Section 3: Getting started 3.5 Getting people with disability involved in quality improvement Your agency is responsible for ensuring that people with disability are able to provide feedback and be involved in providing feedback on your agency. Depending on the nature of the advocacy your agency undertakes, people with disability may or may not be your direct clients. When considering how you will involve clients and people with disability in the quality improvement process, there are a number of methods you might use: feedback forms or questionnaires telephone interviews face-to-face or group interviews a suggestion box focus groups. The tools you use in involving people with disability will differ between agencies, based on your approach/es to advocacy and the needs of the people with disability involved. When developing your assessment tool, remember that the purpose is to find out about clients / people with disability s perceptions of the systems and processes your agency has in place and what can be done to maintain and/or improve these. Broader feedback may also be used to develop and improve opportunities for people with disability to participate in the activities of your agency. Consultation is not intended to provide general feedback or personalised complaints although where this occurs, your agency will need to address the concern. You might want to trial your assessment tool with a few clients/ people with disability initially to see that it is relevant and that they understand the questions. To encourage clients/ people with disability to participate in the processes you have selected, you might consider: explaining to them why their contribution is important and how it will have an effect on agency operations integrating feedback gathering into other activities you currently operate providing incentives for participation, such as linking feedback activities to an event like an afternoon tea linking the internal feedback to an event like afternoon tea to show your appreciation of the contribution clients and people with disability make. National Disability Advocacy Program Quality Improvement Toolkit Page 12

19 Section 3: Getting started Key questions In planning for consultations with people with disability, you will need to consider the following questions: What are you hoping to achieve from consultation with clients/ people with disability? How do clients/ people with disability want to participate and provide feedback? What consultation strategies will suit your clients or people with disability that will be involved? Who do you need to include? What processes for participation do you already use, and can they be used in the audit process? Who else will need to be involved? (eg family members/ carers, facilitators) What resources will be needed? What time is best to hold the consultations? Is it necessary to provide an option for anonymous feedback? What tools do you need for the consultation? (eg a survey, an agenda) What support is needed for people with disability to fully participate? What information do people with disability need to participate? How will you record the feedback? How will the feedback be used? How will you inform your clients/ people with disability about the outcomes of their feedback? National Disability Advocacy Program Quality Improvement Toolkit Page 13

20 Section 4: Management systems Management systems National Disability Advocacy Program Quality Improvement Toolkit Page 14

21 Section 4: Management systems 4. Management systems A management system simply refers to all the things an agency does to establish the outcomes it wants to achieve and the policies and procedures it uses to ensure these outcomes are attained. However, the type and complexity of the management systems used by agencies are expected to vary greatly, depending on the size of the agency and the type of advocacy undertaken. Clearly, a small agency is not expected to have the same management system as a large multi-site agency. In addition, where an agency is part of a larger organisation, it will need to consider what management systems are needed at the local level and how these link to management systems across the organisation as a whole. In all cases, what is important is that each agency has a management system that best enables it to optimise outcomes for people with disability. 4.1 Getting started Use this section of the Toolkit to help your agency assess your practices and implement quality improvement actions related to your management systems. Work through the four step process: 1. develop a checklist 2. conduct a self-assessment 3. plan quality improvement actions 4. review your progress. Your agency is not expected to adopt all policies or practices or use all resources provided in this section. You will find that some of the resources will be relevant to all agencies, while others will only apply depending on your agency s approach to advocacy. Where you already have your own quality management practices in place, you may use the resources as a way of gauging how your own practice is going. Remember, your agency does not have to complete all sections of the Toolkit so start with the sections that are most relevant for your agency. National Disability Advocacy Program Quality Improvement Toolkit Page 15

22 Section 4: Management systems 4.2 Advocacy agency s approach to management systems Regional Information and Advocacy Council, Victoria It s important to put the foundations in place before you build. Good agency management means clear management roles and responsibilities; sound administration practices; formal systems not dependent on individual staff members; and taking opportunities to improve. It s important that it s more than rhetoric; that there are solid practices to back us up. It takes time to do things properly. To continue providing better advocacy, we need to focus on good management systems, not only current advocacy provision. Four years ago, we started looking at our management systems, beginning with the Board; working from that overall organisational level down. There was a lack of clarity around management roles and responsibilities so we implemented an annual corporate governance program for the Board a corporate governance trainer now spends one day a year with the Board. So the Board is clear about their role in providing strategic management, and about operational management issues that aren t in their role to consider. Having the annual update tops up existing Board members knowledge and educates new Board members. Next, over a seven month period, we put resources into getting a comprehensive suite of policies and procedures together. So these remain up-to-date, the Board reviews them annually. Each of our three offices (Shepparton, Bendigo and Swan Hill) can access policies and procedures electronically via a shared drive. Each office also has a hard copy, which is updated when changes are made. The distance between offices can be a challenge, but we focus on making sure the communication flows evenly between offices. We organise face-to-face team meetings monthly, which are important to cover issues, reinforce policy and practice, and provide debriefing for advocates. As we have grown and have more employees, we ve also made sure there is a structure in place for management and clear lines of reporting to ensure clarity and accountability. It s important to have the basics right, for example, having good administration practices in place. We re disciplined about keeping an organised filing system, updating client files, and documenting important information in client files. All client files include an Intake form which includes details relating to the client, the issue they are seeking assistance with and details including their consent for their information to be shared and with whom. Good management also involves finding more efficient and effective use of time and resources making good use of the resources we have. For example, thinking about the way we collect client data centrally so that we can adapt it to use for all of our different reporting requirements to funders. In terms of improvement, we re just beginning a quality improvement partnership. We identified two other Victorian advocacy agencies that are on the same page as us and approached them about the partnership they were very enthusiastic. We held our first meeting in February and will meet on a monthly basis to progress. We will work to develop performance standard measures for each year for an initial three year period. The plan is to develop a set of minimum standards and self- and peer-assessment tools we can each use to assess our agencies. National Disability Advocacy Program Quality Improvement Toolkit Page 16

23 Section 4: Management systems Once it is developed, each agency will be able to use the self-assessment tool to assess their compliance with the performance standards. The Manager/CEO of one quality improvement partnership member agency will conduct a peer review of another member agency in March each year using the peer assessment tool. Following the review, a report will be forwarded to the Board Chair and CEO/Manager for rectification and each July, the three Board Chairs and CEOs/Managers will meet to verify the rectification is complete. The kinds of things we ll assess are policies, procedures, practice and reporting. The idea behind the peer review is that although we think we re doing pretty well, another agency might see a hole that we haven t considered. By giving the results to the agency s Board they will be able to see where things are working and where there are problems. Citizen Advocacy South Australia We have developed and documented a vision of where we want to be in the next five years and how we want to get there. Working towards this vision keeps everyone focused on a united goal and on where we re going. Planning and review are also key to management. We undertake strategic planning every three years; annual forward planning; annual Board program review; annual relationship review; bi-annual work flow review that preserves the focus on developing and sustaining citizen advocacy relationships and the organisational capacity to respond to the needs of vulnerable people with intellectual disability. Our practice evolves based on learning and environmental changes, for example, in relation to contemporary management practice. In reviewing our practice, where we find a weakness, we work to address that and identify the resources we need to help us do this. We think about the skills we need and seek out people with experience to advise us and to learn from. As a program we also focus on change management; identifying and seeking out people to advise us who may later become program associates who contribute to ensuring longevity. These associates may provide advice to the Board in areas including management, policy and government. As with anyone associated with CASA other than staff, they give their time freely because they believe in what the program is doing. We have found that having program associates around us helps to remain informed on some of the broader issues and to minimise staff time away from the core function. From time to time, we have engaged paid professionals for some issues. For example, we needed someone with experience to lead us through our strategic planning process so we hired a consultant. The OHS&W Audit was conducted by a registered auditor and a 12 month implementation plan was produced for Board consideration. In our view, Standards for Citizen Advocacy Program Evaluation (commonly referred to as CAPE) is also an important part of practice review. In our experience, CAPE assesses what a citizen advocacy program is doing, where the strengths and weaknesses are and makes recommendations that are designed to improve the program s implementation of citizen advocacy over time. It encourages continuous improvement and contributes toward quality improvement. It all comes back to strengthening the probability that vulnerable people with disability will be matched with the most suitable citizen (the advocate), who will be supported by a program that is clear on its own role, independent and knows what it s doing. It all impacts on the person with disability. National Disability Advocacy Program Quality Improvement Toolkit Page 17

24 Section 4: Management systems The CAPE process we have undertaken has been a five day process, conducted by a team of six made up of a team leader (who is experienced in CAPE evaluation leadership) and other members who may be a mixture of coordinators and/or Board members from other citizen advocacy programs. We look at it as peer review inviting people who do the same work as us in other places to come and listen to what we are doing, talk to people being supported by the program and then give us some honest feedback. Sometimes when you re heavily involved with what you re doing, you can be missing something, and as humans we all tend to focus on what we re doing well. As part of the process, staff are interviewed extensively, and all Protégés, Citizen Advocates, Advocate Associates, Program Associates and Board members are given the opportunity to participate and be interviewed by members of the CAPE team. The team rate the program against criteria in three categories: adherence to the principles of citizen advocacy, office effectiveness, program continuity and stability. After the evaluation is completed, the CAPE team leader compiles a written report of the team s findings and recommendations for the Board s consideration. National Disability Advocacy Program Quality Improvement Toolkit Page 18

25 Section 4: Management systems 4.3 Step 1: Develop a checklist How to do it! Read the list of things to consider for ensuring quality in management systems Consider your agency s current practices, policies and procedures for this theme Using this information, draw up your own checklist of the considerations for quality that will be important for you to address in the quality improvement process you may select some from the list provided and there might be others that your agency has identified Things to consider management systems 7 1. We have a clear identification and understanding of the powers, roles, responsibilities and accountabilities between the Board, the Chief Executive Officer and management 2. Responsibilities are clearly communicated to key stakeholders 3. The Board has appropriate decision making processes. There is clear distinction between what decisions should be made by the Board and those decisions that should be made by our agency s management 4. We have processes governing policy development, implementation and review, which ensure that the Board approves new policy 5. Appointments are made to the Board with regard to the skill requirements of the Board. The Board has an appropriate mix of skills and knowledge and the majority of the Board is independent of the Chief Executive Officer, management team and commercial dealings with our agency 6. We have adequate induction processes for new Board members 7. Regular Board meetings are held and financial reports tabled 8. We have a written Code of Conduct that is communicated, understood and followed by the Board, Chief Executive Officer and staff 9. We have an overall organisational plan, and is it supported by a business plan, budgets and marketing plan 10. We have a risk management plan that is supported by risk management strategies and reviewed regularly 11. We have mechanisms to monitor performance of the Board and individual Board members 12. We have a process that identifies all legislation relevant to our agency, and monitors changes to the legislation and new legislation impacting on our agency 13. The Board fully understands and continually assesses its contractual requirements under the terms and conditions of Service Agreements eg with FaHCSIA 14. We have practices in place to ensure that as far as possible there is no breach of duty of care 7 Adapted from Corporate Governance Handbook for the Board, Prepared for FACS by Walter & Turnbull, October National Disability Advocacy Program Quality Improvement Toolkit Page 19

26 Section 4: Management systems 4.4 Step 2: Conduct a self-assessment How to do it! Select up to five points from the checklist in Step 1 Think about examples of evidence that you can use to demonstrate quality Involve staff / volunteers, people with disability and other stakeholders in rating your agency s performance and suggesting improvement actions Self-assessment worksheet Checklist No. Selfassessment Rating (0-2) Evidence of practice Improvement action National Disability Advocacy Program Quality Improvement Toolkit Page 20

27 Section 4: Management systems Examples of evidence All agencies documented agency aims and objectives established practices and policies for promotion and communication of agency aims and objectives with people with disability and stakeholders eg through agency s promotional materials agency documentation clearly outlines on what basis advocacy is undertaken eg by supporting individuals with disability, pursuing systemic actions, by facilitating matches with volunteer advocates, so people wishing to access your agency know whether it will meet their needs review of agency management systems involving people with disability this may involve agency self-assessments and continuous improvement plans systems for regular monitoring and evaluation of the effectiveness of advocacy practice, including systems for obtaining feedback from relevant stakeholders evidence of the involvement of people with disability in all aspects of the quality system (eg participation in agency self-assessment) agency structure and governance arrangements clearly documented minutes of management committee meetings documented roles and responsibilities of Management Committee office bearers strategic, business, and/or operational plans are in place, with stipulated goals and objectives established practices and policies for performance and risk reporting to the governing body appropriate financial management system in place evidence of internally identified corrective and preventative actions to improve advocacy programs and activities [these may arise from your agency s complaints mechanism or self-assessments] documented policy on agency independence clear procedure for dealing with conflict of interest where it arises eg referral to another advocate or agency agency does not provide direct disability services and is not aligned with any service providers National Disability Advocacy Program Quality Improvement Toolkit Page 21