REHABILITATION MANAGEMENT SYSTEM AUDIT TOOL

REHABILITATION MANAGEMENT SYSTEM AUDIT TOOL Reviewing rehabilitation management systems and compliance under the Safety, Rehabilitation and Compensation Act 1988 and Guidelines for Rehabilitation Authorities 2012 Version 1.2 1 July 2015

ii DISCLAIMER Comcare, its officers, servants and agents expressly disclaim liability and responsibility in respect to, and accept no responsibility for, the consequences of anything done or omitted to be done to any person in reliance, whether wholly or partly, upon this publication, including but not limited to the results of any action taken on the basis of the information in this publication and the accuracy, reliability, currency or completeness of any material contained in this publication. Commonwealth of Australia 2015 All material presented in this publication is provided under a Creative Commons Attribution 3.0 Australia (http://creativecommons.org/licenses/ by/3.0/au/deed.en) licence. For the avoidance of doubt, this means this licence only applies to material as set out in this document. The details of the relevant licence conditions are available on the Creative Commons website (accessible using the links provided) as is the full legal code for the CC BY 3.0 AU licence (http://creativecommons.org/licenses/by/3.0/legalcode). USE OF THE COAT OF ARMS The terms under which the Coat of Arms can be used are detailed on the It s an Honour website (http://www.itsanhonour.gov.au/coat-arms/index.cfm). CONTACT US Inquiries regarding the licence and any use of this document are welcome at: Production Services Comcare GPO Box 9905 Canberra ACT 2601 Ph: 1300 366 979 Email: production.services@comcare.gov.au Published July 2015 To obtain further information about the contents of this audit tool, contact: Authorisation and Audit Team Comcare GPO Box 9905 Canberra ACT 2601 Ph: 1300 366 979

iii CONTENTS DEFINITIONS 1 INTRODUCTION 3 WHAT IS A REHABILITATION MANAGEMENT SYSTEM? 4 The cost of not having a healthy organisation 4 THE REHABILITATION MANAGEMENT SYSTEM AUDIT TOOL 5 APPLYING THE AUDIT TOOL 5 1. Preparation 6 2. Audit 7 3. Finalisation 8 4. Corrective action plans 9 5. Professional standards review 9 AUDIT CRITERIA 10 Element 1: Commitment and corporate governance 10 Element 2: Planning 10 Element 3: Implementation 11 Element 4: Measurement and evaluation 12 Element 5: Review and improvement 13 Table 1: Mapping the Guidelines to audit tool criteria 14

1DEFINITIONS Competent personnel Consultation 1 Corporate governance Documentation (in reference to element 1) Documented commitment For the purposes of auditing rehabilitation management systems, competent personnel are defined as people with knowledge of the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) and relevant experience. Relevant experience in this case would include audit training and experience. Consultation means appropriately informing employees, inviting and considering their response prior to a decision being made. Employees opinions should not be assumed. Sufficient action must be taken to secure employees responses and give the employees views proper attention. Consultation requires more than a mere exchange of information. Employees must be contributing to the decision-making process, not only in appearance but in fact 1. The process, by which organisations are directed, controlled and held to account. The term encompasses authority, accountability, stewardship, leadership, direction and control exercised in the organisation. It includes the transparency of corporate structures and operations, the implementation of effective risk management and internal control systems and the accountability of management to stakeholders. The documentation used by the senior management team to communicate its commitment to minimising the human and financial cost of injury and providing for fair compensation when an injury occurs. It could take the form of a policy, management arrangements or an employer/worker agreement. A statement by the employer of its commitment, intentions and principles in relation to its overall rehabilitation management system performance. It provides a framework for action and for setting rehabilitation management system objectives and targets. 1 The definition of consultation has been taken from the Safety, Rehabilitation and Compensation Commission document Consultation on Health and Safety

2 Rehabilitation authority For the purpose of this document, means: (a) for defence-related claims, the Service Chief or the Military Rehabilitation and Compensation Commission as set out in section 39 of the Military Rehabilitation and Compensation Act 2004; (b) if the employer is an exempt authority, Comcare; and (c) for all other cases, the person who is principal officer of the employer; and except where the employer is an exempt authority, also includes the employer. 2 If there is no such employer, the Commonwealth entity, authority or licensee that most recently employed the employee. 3 Rehabilitation management system Senior executive Stakeholders The part of the overall management system which includes organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing and maintaining the rehabilitation policy. At the level required for the endorsement of the employer s documented commitment to rehabilitation Chief Executive Officer/ Principal Officer and/or senior management team. Includes, but is not limited to, employees, managers/supervisors, service providers, rehabilitation providers, case managers, medical practitioner, the claims manager, and Comcare. 2 NOTE: Many of the performance requirements measured by this audit tool are shared by the employer and the rehabilitation authority, being the person described above. Some performance measures which refer to the rehabilitation authority may be the responsibility of the employer. 3 NOTE: See paragraph 9 of the rehabilitation guidelines

3INTRODUCTION Comcare partners with employees, their employers and unions to keep employees healthy and safe, and reduce the incidence and cost of workplace injury and disease. One of our areas of focus is working with employers to create best practice in rehabilitation and ensure an early, safe and durable return to work for injured employees. Organisations with self-insurance licences (licensees) under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) are required to meet the standards set by the Safety, Rehabilitation and Compensation Commission (the Commission) for the rehabilitation of injured employees. These standards require licensees to develop, implement and maintain rehabilitation management systems consistent with the Commission s performance standards and the SRC Act. An important deliverable for Comcare is to support employers and other duty holders to create and maintain healthy and safe workplaces through our regulation of work, health, safety and rehabilitation, including expanding national safety and rehabilitation audit programmes to federal government employers. On 1 July 2012, Comcare issued the Guidelines for Rehabilitation Authorities 2012 (the Guidelines) under section 41 of the SRC Act that require, amongst other things, that all rehabilitation authorities develop and implement a rehabilitation management system that delivers effective rehabilitation and meets the performance standards and measures prescribed therein. This Rehabilitation management system audit tool is based on the tool used by Comcare to regulate licensees and the outcomes of a pilot project. 4 It reflects the requirements of a rehabilitation management system as well as the legislative requirements of the SRC Act and the associated Guidelines. Where a rehabilitation authority is establishing a rehabilitation management system, the tool can be used to undertake a gap analysis of its existing processes against the requirements of a rehabilitation management system. Where the rehabilitation authority already has an established system, the tool assists with assessing and auditing its management of the rehabilitation and return to work of its injured employees, and establishes areas for improvement. 4 A pilot project during 2011 trialled a program of audits of federal government employers and reviewed the performance of their rehabilitation management systems.

WHAT IS A REHABILITATION MANAGEMENT SYSTEM? A rehabilitation management system is defined as part of an overall management system which includes organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing and maintaining the rehabilitation policy. 5 A rehabilitation management system is a mechanism, which may be used to ensure that you have in place the necessary controls to: > understand and comply with relevant legislation, guidelines and corporate policy > establish and maintain your organisation s performance against relevant requirements > identify areas for improvement > implement improvement plans. It is a system which provides a systematic and structured approach to managing rehabilitation performance. THE COST OF NOT HAVING A HEALTHY ORGANISATION There are many direct and indirect costs associated with unhealthy organisations. Costs can arise from: > reduced staff and client satisfaction, which lowers morale, reduces productivity and leads to absenteeism 4 > downtime for supervisors and managers while they address underperformance and absenteeism (cost of the supervisor s lost time) > workers compensation claims (incapacity and medical costs) > high turnover (recruitment, induction and training costs) > absenteeism (salary costs). Effective management systems are integral to maintaining healthy and productive workplaces and consequently reducing premiums. Rehabilitation management systems will help employers ensure they: > provide a safe and healthy workplace > meet their duty of care > assist injured employees (and maintain their productivity) > demonstrate compliance with legislation. 5 Adapted from AS/NZS 4801:2001.

5THE REHABILITATION MANAGEMENT SYSTEM AUDIT TOOL The tool is based on the following Australian/New Zealand standards: > AS/NZS 4801:2001 Occupational health and safety management systems Specification with guidance for use > AS/NZS 4804:2001 Occupational health and safety management systems General guidelines on principles, systems and supporting techniques The tool assesses rehabilitation management systems against five elements across 27 criteria: 1. Commitment and corporate governance (3 criteria) 2. Planning (4 criteria) 3. Implementation (13 criteria) 4. Measurement and evaluation (6 criteria) 5. Review and improvement (1 criterion) Related documentation Rehabilitation management system audit workbook APPLYING THE AUDIT TOOL AUDIT PROCESS The audit process is a three stage process: 1. Preparation Notification of audit Audit scope Competent auditors 2. Audit Entry interview Documentation review Site visit, file review and interviews Exit interview 3. Finalisation Report preparation Report finalisation Corrective action plans Professional standards review

6 1. PREPARATION Notification of audit The auditor will contact the rehabilitation authority to advise that a rehabilitation management system audit is to be undertaken. The auditor will organise the timing of the audit process in consultation with the rehabilitation authority. The auditor will provide the rehabilitation authority with a copy of this audit tool and the Rehabilitation management system audit workbook. Audit scope Audit findings should be representative of the state of the rehabilitation authority s overall rehabilitation management system. The scope of any rehabilitation management system review needs to be sufficient to produce reliable and robust findings regarding the state of the rehabilitation authority s rehabilitation management systems. If a rehabilitation authority does not manage rehabilitation centrally then site selection will be at the discretion of the auditor. The auditor will need to be satisfied that the site selection sufficiently represents the organisation and will produce reliable outcomes. A rehabilitation management system review involves examining a certain number of rehabilitation files. The auditor needs to apply the population sampling technique in the following table. The sample may be increased if multiple sites are being tested. It should be noted that the auditing timeframes are the minimum requirements. Where organisations are in the process of establishing their systems, the auditors may provide for more audit days. Claims with rehabilitation activity in 12 months prior to audit Suggested number of rehabilitation files to be sampled Allocated days per person for 2 person team (including preparation and report writing) 1 15 All 3 days 16 100 16 4 days >100 30 5 days Where an auditor uses discretion in relation to the sampling methodology outlined above, the auditor must provide an explanation for the alternate sampling methodology in the audit report. The scope of the audit should be confined to examination of the current rehabilitation management system to ensure that the audit findings are timely and relevant. The audit sample should therefore be confined to an investigation of rehabilitation cases that have had some form of activity within 12 months before the audit date. To adequately assess how well a rehabilitation authority is exercising its powers and meeting its responsibilities under the SRC Act, the auditor must choose an appropriate sample from the rehabilitation file population. The breadth of activity that should be reviewed includes rehabilitation assessment and program determinations under sections 36 and 37 of the SRC Act, the provision of suitable employment under section 40 and the implementation of early intervention activities under section 41.

7Competent auditors Auditors in claims management and rehabilitation must have knowledge of the SRC Act and Safety, Rehabilitation and Compensation Regulations 2002, relevant experience and be independent of the area being audited. Relevant experience in this case would include audit training and experience. Confidence in this audit process and the ability to administer its objectives depends on the competence of those individuals who are involved in planning and conducting audits. Guidance on assessing the competence of an auditor can be obtained from the International Standard ISO 19011 Guidelines for auditing management systems, Chapter 7 Competence and evaluation of auditors. 2. AUDIT This audit tool contains 27 criteria grouped into five elements. An auditor will make judgements as to whether the criteria have been met. Their judgement is informed by evidence that verifies that systems exist and that they are being effectively and appropriately administered. The types of evidence that the auditor may take into account includes: > documentation such as reports, minutes of meetings, policies and procedures > rehabilitation files > interviews with relevant personnel > workplace observations > IT system review. Entry interview The auditor will hold discussions with the rehabilitation authority or their representatives to explain the purpose of the audit, the audit process and the scope of the audit. Documentation review The rehabilitation authority will need to collate documentation to assist the auditor with evaluating their performance against the audit criteria. The auditor will generally spend the first day of the audit reviewing documentation. However, the auditor has discretion to request that the evidence be provided at an earlier date and assessed off-site. Examples of the types of evidence that may be supplied to the auditor include: > policies and procedures > minutes or outcomes of meetings > training records > internal audit reports > internal performance reports > staff bulletins. The Rehabilitation management system audit workbook will assist rehabilitation authorities to identify and prepare relevant documentation for the auditor.

8 The privacy and confidentiality of all information collected for the purposes of the audit is protected under the Privacy Act 1988 (the Privacy Act). File review After considering the documentation provided, the auditor will review the selected rehabilitation files. Interviews The rehabilitation authority will need to arrange a time for the auditor to meet with and interview a selection of employees. Groups of employees who may be interviewed include: > senior management > workplace managers > rehabilitation case managers > rehabilitation providers > injured employees The Rehabilitation mangement system audit workbook identifies questions that the auditor may ask the groups of employees during the audit process to assess the extent to which policies and procedures are being followed in practice. Any information collected through interviews is protected under the Privacy Act and respondent confidentiality will be respected. Individual responses will not be made available to the rehabilitation authority. Exit interview Once the auditor has completed the documentation and file review at the site they will provide representatives of the rehabilitation authority with a verbal overview of the key audit findings. The auditor will broadly identify areas where the system is working well and areas where improvement and/or corrective action are required. The auditor will provide a timeframe for completing a draft audit report. 3. FINALISATION The auditor will consider the evidence reviewed during the audit and prepare a draft report identifying how the rehabilitation authority performed against the audit criteria. Late submission of evidence Evidence submitted after the close of the audit and prior to the draft report being issued cannot be used to change a rating for a criterion. However, it will be considered, and if satisfactory, the auditor may note in the commentary that the matter was closed-out after the audit.

9Opportunity to provide comments The rehabilitation authority will receive the draft audit report for comment within 15 working days of when the auditor completed the audit. The rehabilitation authority needs to provide the auditor with comments on the report within 15 working days of receiving the draft. The auditor will consider these comments and finalise the audit report within 10 working days. 4. CORRECTIVE ACTION PLANS The rehabilitation authority is required to develop, within established timeframes, action plans to address any identified areas requiring corrective action. The rehabilitation authority is also required to monitor the implementation of these corrective actions to ensure that there is continuous improvement within the management system. Where an audit is conducted by Comcare, there is a requirement for Rehabilitation Authorities to provide the corrective action plans to Comcare for ongoing monitoring and review. 5. PROFESSIONAL STANDARDS REVIEW If the rehabilitation authority disputes the audit findings or is dissatisfied with the manner in which the audit was undertaken by Comcare, they may request a review. Comcare adopts an escalating model of review and seeks to resolve all matters internally as a first priority in all cases providing natural justice and procedural fairness to parties affected by audit. Comcare will seek to resolve your concerns in a two-staged process: Decision-maker review For audit findings, this stage occurs when the auditor considers any submissions made in relation to the draft report, and prior to the report being issued as final. Any concerns in relation to the manner in which the audit was undertaken should be directed to the Director of Authorisation and Audit. Independent review If dissatisfied with the results of the above process, then the rehabilitation authority may request a professional standards review that will be formal and independent. The rehabilitation authority should put their reasons for seeking review in writing to the General Manager, Regulatory Operations Group, Comcare. Applications should be made within 30 days of receiving the final audit report. Comcare will conduct an independent review and inform the rehabilitation authority of its progress within seven days. ADVICE AND ASSISTANCE All enquiries about this audit tool and Rehabilitation management system audit workbook should be directed to the Director, Authorisation and Audit at Comcare, GPO Box 1993, Canberra ACT 2601 or Rehab.Compliance@comcare.gov.au

10 AUDIT CRITERIA ELEMENT 1: COMMITMENT AND CORPORATE GOVERNANCE The rehabilitation authority will document its commitment to rehabilitation. This documentation will benchmark the organisation s objectives, be used to formulate strategic direction and be reviewed to ensure it remains relevant. The documentation will also demonstrate that the organisation strives for continuous improvement. It will be endorsed and supported at the executive level and be relevant to the organisation s overall values, vision and business objectives. Sound corporate governance is the process by which organisations are directed, controlled and held to account. The rehabilitation authority s executive will provide stewardship for its rehabilitation management system and commit adequate resources to ensure continuous improvement. 6 Documented commitment 1.1 The rehabilitation authority sets the direction for its rehabilitation management system through a documented commitment by senior executive. Corporate governance 1.2 The rehabilitation management system provides for internal and external accountability. 1.3 The rehabilitation authority identifies, assesses and controls risks to the rehabilitation management system. ELEMENT 2: PLANNING The successful implementation and operation of a rehabilitation management system requires an effective planning process with well-defined and measurable outcomes. Planning is essential for both the initial implementation of an overall management system and for specific elements that make up that system and should be done in consultation with relevant stakeholders. Administrative arrangements 2.1 The rehabilitation authority has a delegation schedule, signed by the principal officer, as per section 41A of the SRC Act Rehabilitation planning 2.2 The rehabilitation authority recognises legislative obligations and plans for legislative and regulatory compliance, having regard to any policy advice that Comcare or the Commission may issue. 2.3 The rehabilitation authority sets objectives and targets and identifies key performance measures for its rehabilitation management system. 6 See definitions on page 4

11 2.4 The rehabilitation authority establishes plans to: (i) achieve its objectives and targets (ii) promote continuous improvement (iii) provide for effective rehabilitation arrangements. ELEMENT 3: IMPLEMENTATION A rehabilitation authority shall achieve its rehabilitation management system objectives, identified in its rehabilitation management system plans, by involving its people as well as focusing and aligning its systems, strategies, resources and structure. Resources 3.1 The rehabilitation authority allocates adequate resources to support its rehabilitation management system. Communication and awareness 3.2 The rehabilitation authority defines and communicates responsibilities to relevant stakeholders. 3.3 The rehabilitation authority communicates relevant information regarding the rehabilitation process to its employees including their rights and obligations. Training 3.4 The rehabilitation authority identifies training requirements, develops and implements training plans and ensures personnel are competent. Compliance with SRC Act and the Guidelines The rehabilitation management system must ensure effective rehabilitation occurs and legislative obligations are met in relation to: Early intervention 3.5 The rehabilitation authority implements an early intervention program, including the early identification and notification of injury. Rehabilitation assessments 3.6 The rehabilitation authority effectively uses the provisions of section 36 to conduct rehabilitation assessments in accordance with the SRC Act and the Guidelines.

12 Rehabilitation programs 3.7 The rehabilitation authority provides rehabilitation programs in accordance with the provisions of section 37 of the SRC Act, and the Guidelines, and ensures consultation occurs between all parties in regards to the rehabilitation process. Suitable employment 3.8 The employer takes all reasonable steps to provide employees with suitable employment or to assist employees to find such employment. Determinations, suspensions and reconsiderations 3.9 The rehabilitation authority makes determinations in accordance with the SRC Act and the Guidelines: (i) that are in writing and give adequate reasons (ii) that are signed by the delegate (iii) that are not retrospective 3.10 The rehabilitation authority makes determinations in relation to employee non-compliance in accordance with the SRC Act, Guidelines and their written policy and procedures 3.11 The rehabilitation authority complies with the provisions of the SRC Act when managing reconsiderations or reconsiderations of own motion [criterion applicable to licensees only]. Confidentiality 3.12 The rehabilitation authority maintains the confidentiality of information and applies legislative requirements. Document and file management 3.13 The rehabilitation authority maintains the relevant level of reporting, records and/or documentation to support its rehabilitation management system and legislative compliance. ELEMENT 4: MEASUREMENT AND EVALUATION A rehabilitation authority shall measure, monitor and evaluate its rehabilitation management system performance and take corrective action where required. Measuring, monitoring and evaluating are key activities which ensure that the rehabilitation authority is performing in accordance with its documented commitment to rehabilitation, objectives and targets as well as initial and ongoing planning. The results should be analysed and used to determine areas of success and to identify activities requiring corrective action and improvement.

13 A rehabilitation authority shall establish, implement and maintain documented procedures to monitor and measure, on a regular basis, the key characteristics of its rehabilitation management system operations and activities. Periodic audits of the rehabilitation management system are necessary to determine whether the system has been properly implemented and maintained and whether the rehabilitation authority has met its performance objectives. Monitoring 4.1 The rehabilitation authority monitors planned objectives and performance measures for core rehabilitation management activities. 4.2 The rehabilitation authority monitors rehabilitation providers performance in terms of quality of service delivery, costs, progress reports and outcomes. Auditing and reporting 4.3 The rehabilitation authority conducts an audit program performed by competent personnel and in accordance with the requirements of the Commission and Comcare to measure performance of its rehabilitation management system. 4.4 Audit outcomes are appropriately documented and actioned. The rehabilitation authority reports to senior executive on its rehabilitation management system performance, including audit outcomes. 4.5 The rehabilitation authority communicates the outcomes and results of rehabilitation management system audits to its employees. 4.6 The rehabilitation authority provides the Commission or Comcare with reports or documents as requested. ELEMENT 5: REVIEW AND IMPROVEMENT A rehabilitation authority shall regularly review and continually improve its rehabilitation management system with the objective of improving its overall rehabilitation performance. Continuous improvement 5.1 The rehabilitation authority analyses rehabilitation management system performance outcomes against documented objectives to determine areas requiring improvement and promotes and implements continuous improvement strategies.

14 Table 1: Mapping the Guidelines to audit tool criteria Guidelines performance standard Audit tool criterion 1.1.1(i) 1.1 1.1.1(ii)(a) 2.2 1.1.1(ii)(b) 2.4 1.1.1(ii)(c) 3.3 1.1.1(ii)(d) 1.2 2.1.1(i) 2.2 2.1.1(ii) 2.3 & 2.4 2.1.1(iii) 2.4 2.1.1(iv) 3.4 3.1.1(i) 3.1 3.1.1(ii) 3.4 3.1.1(iii) 3.2 3.1.1(iv) 3.3 3.1.1(v) 3.13 3.1.1(vi) 3.12 3.1.1(vii) 3.7 4.1.1(i) 4.1 4.1.1(ii) 4.3 4.1.1(iii) 4.3 4.1.1(iv) 4.4 4.1.1(v) 4.3 4.1.1(vi) 4.5 4.1.1(vii) 4.6 5.1.1(i) 5.1 5.1.1(ii) 5.1 10.4 2.1 and 3.4 11.1 and 34 2.1 and 3.11 12(a) and 12(b) 2.2 and 3.9 12(c) 2.2

15 Guidelines compliance clause Audit tool criterion 14.2 2.2 and 2.3 14.3(a)(b) 4.2 15.1 3.8 16.1 2.1 17.1 3.5 17.4 3.6 and 3.4 18.1 3.6 20.3 3.9 22.1 3.2, 3.3 and 3.6 24(a), 24(b) and 24(c) 3.7 25 3.9 27 3.7 29 3.7 30 3.7 and 3.9 31.1 3.9 31.2 3.7 32.2 3.7 and 3.9 32.4 3.3 32.6 3.2, 3.3, 3.7 and/or 3.13 33.1 3.3 33.2, 33.3, 33.4 and 33.5 2.2 and 3.10 33.5(c) 2.2 and 2.1 33.6, 33.7 and 33.8 3.10 35 4.2 and 4.6 36.1(a) 4.3 36.1(b) 5.1 36.1(c) 4.4 36.1(d) 4.3 36.1(e) 4.6

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For further information contact Comcare GPO Box 1993 Canberra ACT 2601 Telephone 1300 366 979 Internet www.comcare.gov.au PUB 073 July 2015 1300 366 979 COMCARE.GOV.AU