Skip to content

National Disability Advocacy Program Quality Improvement Toolkit

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.

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.

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.

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.

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 systems7
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

4.4 Step 2: Conduct a self-assessment



4.4.1 Examples of evidence

All agencies

4.5 Step 3: Plan quality improvement actions

4.6 Step 4: Review your progress

How to do it!

  • Agree on a 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. Tick actions that have been completed and document any further action that is required.

4.7 Resources

4.7.1 Continuous Quality Improvement Register9

Use this template to record suggestions/ issues for improvement to your agency, who the issue was raised by and the improvement activities that will address the issue and when the activity is complete.  Where an activity does not achieve intended results, plan and record a new activity.  Use this form to keep a summary of, and track, improvements (while your continuous improvement plans will contain more details).  Some examples are included in the sample below.


CQI ID# Date Source Issue Improvement activity/ies Closure
CQI 01 30/5/04 Client assessment Opportunities for client input into policy development Establish a monthly representative client forum, comprised of individuals nominated by other clients Date of first forum meeting
CQI 02 5/6/04 Complaint Dissatisfaction with staff member Review staff allocation rosters and replace the member allocated to that client Date of new roster
CQI 02 18/6/04 WH&S Committee Audit of 15/6/04 identified that access to fire emergency exit door was blocked by stored equipment Clear impediments to emergency exits. Review fire safety requirements at team meeting of 20/6/04. To be reassessed during next WH&S audit Date of satisfactory audit
           
           

4.7.2 Quality Monitoring Schedule10

This template can be used to record your planned annual schedule to enable you to evidence your commitment to quality control and ongoing quality improvement.  Some examples of the major monitoring activities that require the planning and allocation of resources are included in the sample below.


Review subject Process Who When
Planning

eg Strategic Plan 		Annual management/ staff planning day Committee and Staff Month due/ date
Document review

eg review of all policies and procedures for continuing applicability 		Review for effectiveness and currency and re-endorse during annual planning Committee and staff Month due/ date
Performance

eg staff performance reviews 		Performance appraisal process CEO/ Manager Month due/ date
Suppliers

eg quality monitoring of suppliers 		Contract review of requirements and performance CEO/ Manager Month due/ date
Assets management monitoring

eg assets management and maintenance 		Review of Assets Register and updating of warranty details and depreciation

Audit of maintenance schedules for continuing effectiveness 		Manager & treasurer Manager Month due/ date (prior to AGM)
Month due/date
Records

eg client records system 		Random survey of 10% of client records against policy-stipulated content requirements, clarity of entries, security, currency/ archiving procedures Manager Month due/ date
Agency quality/ improvement

eg Staff Satisfaction/ retention rates/ levels 		a) Staff Satisfaction survey

b) Review of retention rates/ reasons for leaving for CQI planning 		CEO/Manager Month due/ date
Client satisfaction a) Survey of clients/ people with disability to assess awareness of their rights, satisfaction levels, and suggestions for improvements.

b) clients/ people with disability agency assessment process 		Program Managers Month due/ date
Continuous improvement a) Review of Continuous Quality Improvement (CQI) Register (template available in this Toolkit), Quality Improvement Plan and minutes of meetings to ensure actions have been recorded

b) clients/ people with disability planning forums 		CEO/ Manager Month due/ date
Complaints Review Complaints Register for patterns/ trends emerging, and actions taken for continuous improvement CEO/ Manager Month due/ date
Workplace Health and Safety

eg staff/ clients safety and regulatory compliance 		a) Standing agenda item for management meetings for review of accidents/ incidents Management Month due/ date
b) Internal environmental safety compliance audits against documented procedures WH&S officer Month due/ date
c) Fire safety environmental audits and inspection of equipment Fire Department Month due/ date
d) Electrical equipment checking and tagging WH&S Month due/ date
Accountabilities/reporting

eg reporting to funding bodies 		a) Preparation and submission of reports against funding agreement requirements CEO/ Manager Month due/ date
b) Annual acquittals and financial reporting to funding bodies CEO/ Manager Month due/ date
etc.      

4.7.3 Action Minutes Format for Meetings11

A format like the one below for recording minutes of meetings ensures that decisions made are recorded in a way that facilitates follow-up in matters arising from the previous minutes. Where an issue is raised requiring an improvement activity, it should then be transferred to your Continuous Improvement Plan.  Tasks not completed by the due date are referred to the following meeting, under the same identification number (ID#), until it is closed out.

Name of meeting

Date/ time

Names of those present

Apologies received

Acceptance of minutes of last meeting

Matters arising

ID # Issue Action to be taken Person responsible Date for reporting back Task completed
           

Correspondence in/ out

Presentation and tabling of reports

New business

ID # Issue Action to be taken Person responsible Date for reporting back
         

4.7.4 Document Control Register12

Use this template to control your agency’s key documents eg policies and procedures – the register is used to record whether documents are up-to-date, where they are located and specifications for limited access.

Disability Services Queensland suggest a good strategy for effective information management is to include in the footer of each document its electronic file path, the document control number, and the date of issue.  You will need to establish and communicate to stakeholders your coding system, for example a prefix allocated to classify document types (P prefix for a policy; F prefix for a controlled form etc.).


ID # Document title Access Electronic file pathway Date last reviewed Archived Disposal method
Policies, forms etc. Name of document Any security access codes required, or specify limited access File location Should be consistent with date in document footer Location of archived documents Disposal method, eg shredding
             
             
             
             
             

4.7.5 Risk Analysis Likelihood Matrix13

This risk analysis matrix enables you to analyse the potential risk of an activity/ event.  By considering both the probability of an incident, and its likely consequence should it occur, you are able to allocate a risk rating.  Where the risk is extreme or high, immediate action should be taken to mitigate the risk.

Risk Analysis Likelihood Matrix

This risk analysis matrix enables you to analyse the potential risk of an activity/event.

The matrix above indicates the following:

Extreme risk results when there is a catastrophic event (death, toxic release off-site with detrimental effect, high financial risk) that is almost certain to happen (the event is expected to occur in most instances).

Extreme risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is likely to happen (the event will probably occur in most instances).

Extreme risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that is almost certain to happen (the event is expected to occur in most instances).

High risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that has a moderate likelihood of happening (the event should occur at some time).

High risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is unlikely to happen (the event should occur at some time).

High risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that is likely to happen (the event will probably occur in most instances).

High risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) and there is a moderate likelihood of it happening (the event should occur at some time).

High risk results when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that is almost certain to happen (the event is expected to occur in most instances).

High risk when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that is likely to happen (the event will probably occur in most instances).

Medium risk results when there is a catastrophic (death, toxic release off-site with detrimental effect, high financial risk) event that is would be rare to happen (the event may occur only in exceptional circumstances)

Medium risk results when there is a major (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) event that is unlikely to happen (the event should occur at some time).

Medium risk results when there is a major event (extensive injuries, loss of production capability, off-site release with no detrimental effects, major financial loss) that would be rare to happen (the event may occur only in exceptional circumstances).

Medium risk results when a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) and there is a moderate likelihood of it happening (the event should occur at some time).

Medium risk results when a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) event that is unlikely to happen (the event should occur at some time).

Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that is almost certain to happen (the event is expected to occur in most instances).

Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that is likely to happen (the event will probably occur in most instances).

Medium risk results when a minor event (first aid treatment, on-site release immediately contained, medium financial loss) and there is a moderate likelihood of it happening (the event should occur at some time).

Low risk results when there is a moderate event (medical treatment required, on-site release contained with outside assistance, high financial loss) that would be rare to happen (the event may occur only in exceptional circumstances).

Low risk results when there is a minor event (first aid treatment, on-site release immediately contained, medium financial loss) event that is unlikely to happen (the event should occur at some time).

Low risk results when there is a minor event (first aid treatment, on-site release immediately contained, medium financial loss) that would be rare to happen (the event may occur only in exceptional circumstances).

Low risk results when there is an insignificant event (no injuries, low financial loss) that is almost certain to happen (the event is expected to occur in most instances).

Low risk results when there is an insignificant event (no injuries, low financial loss) that is likely to happen (the event will probably occur in most instances).

Low risk results when there is an insignificant event (no injuries, low financial loss) and there is a moderate likelihood of it happening (the event should occur at some time).

Low risk results when there is an insignificant event (no injuries, low financial loss) that is unlikely to happen (the event should occur at some time).

Low risk results when there is an insignificant event (no injuries, low financial loss) that would be rare to happen (the event may occur only in exceptional circumstances).


4.7.6 Information for Board members on Governance

Corporate governance can be described as:

'The system by which companies are directed and managed.  It influences how the objectives of the company are set and achieved, how risk is monitored and assessed, and how performance in optimised.

Good corporate governance structures allow companies to create value...and provide accountability and control system commensurate with the risks involved.'14

Why is corporate governance important?15

Good corporate governance helps your agency to achieve its outcomes and obligations through sound planning and risk management.  It provides a means to assist in decision-making and to improve accountability.  It also helps to provide a framework for establishing responsibility to your agency’s members, the people served by your agency and other stakeholders.

Features of good corporate governance

There are some key features of good governance that should be central to an agency’s corporate governance framework and should be included in governance related documentation which may include organisational plans, business plans, marketing plans, policy and procedures manuals, risk management reviews and/or quality assurance manuals.  Features are described below.

Strategy setting and planning

Planning is a critical element of good governance.  Overall strategy setting and planning for your agency must be clearly documented and communicated.  Some points for good planning include:

Good planning helps clearly set the objectives, strategies and actions for a period. It also provides a means to monitor your agency’s performance.  Plans should be regularly reviewed and updated given changing circumstances.

Risk management

Risk management is an important concept in agency management.  The Board should consider whether it has a clear risk management framework that covers your agency’s operations.

Risk should be thought of in terms of what, and how, losses (or gains) may affect your agency through a wide range of sources.

The Board is not directly responsible for risk management but is responsible for ensuring that managers and staff of your agency have an appropriate risk management framework in place to mitigate or reduce identified risks.

You should have an ongoing process to identify risk, assess its impact, take treatment actions to address and/or monitor risk, and report this to the Board.

If your agency has never undertaken a formal risk assessment of its operations or key aspects of its operations, it would be advisable to do so.

Consultation

Consultation with key stakeholders is an essential feature of good governance.  It enables the stakeholders to understand your objectives and strategies and helps them to work with your agency in achieving those objectives.

Stakeholders might include:

Roles and responsibilities

Board members need to clearly understand their role and responsibilities under relevant legislation and the rules of incorporation.  The agency should develop a documented policy describing the roles and responsibilities of the Board, of individual Board members and of management.  The policy should be clearly communicated and understood by the Board, management, staff, consumers and members of your agency.

Skills, independence and resources

The Board should have the right mix of skills to manage your agency’s affairs.  As an individual Board member it is difficult to have the expertise across all areas, but you should have experience or skills in at least one of the following:

Your Board should include people who are independent of the agency to provide a balanced, objective representation on the Board.  There should be a balance in the number of Board members between those who meet the criteria of independence and those who have a keen interest and advocacy background.

The Board needs access to adequate and appropriate resources to ensure that it can fulfil its roles and responsibilities effectively.  There should also be an induction process for new members to the Board so they are aware of their role and responsibilities and understand your agency’s objectives and operations.

Conduct and ethics

In setting a standard that you expect people in your agency to work to, it is very important that a Code of Conduct be established, which covers the Board members, management and staff.  The Code of Conduct should be developed with management and staff.

Performance

You should have a process for assessing the performance of Board members.  As they are largely volunteers, the requirements should not be overly oppressive and onerous, but it is important to have some formal means of establishing an expected level of performance and to assess if it is being achieved.

Means of performance measurement should be established based on the definition of the roles of each Board member.

Succession planning

At some point in the future a successor will be required to continue the management of your agency.  If possible, the current manager should be responsible for grooming other senior staff as potential successors.

However, if your agency does not have access to these resources, the Board should be aware of this risk and review it and act accordingly.

The selection of a business manager, whether internally or externally, should be based on specific selection criteria and their qualifications, experience and suitability for the role.  If possible, the Board should develop the selection criteria in consultation with the previous business manager.

Financial and operational reporting

Timely financial and operational reporting is important in ensuring that you are able to assess your agency’s performance and to assist in decision making.  Reports should incorporate not just actual achievements, but projected or budgeted targets that should have been achieved.

Reporting should be against key actions in the business plans and against other initiatives put in place by the Board.  As a Board, you should establish an agreed format for reporting to ensure that all matters that should be reported are in fact reported.

Reports need to be made available to you allowing sufficient time to enable you to properly consider them before Board meetings. Management should also be available to present their reports to the Board meetings.

Audit committees

An audit committee’s role is to assist the Board in fulfilling its oversight responsibilities for the financial reporting process, the system of internal control over financial reporting, the audit process, and your agency’s process for monitoring compliance with laws and regulations.

For larger agencies, an audit committee of non executive (independent) Board members can be useful in considering audit related issues in more depth than would normally be undertaken by the full Board.  However, the audit committee should not act as a barrier between the auditor and the full Board or presume to overtake the functions of the full Board.

Small to medium sized agencies may not require an audit committee.


4.7.7 Corporate governance questionnaire16

(When completing this form if you are unsure, or don’t know the answer you should enter a ‘no’ response).

Question Yes No
1. Do you have Board members with experience and skills in the following areas? (Please tick the skills that are held by Board members and score a ‘yes’ accordingly)
  • strategic planning
  • human resource management
  • financial management
  • business operations
  • sales and marketing
  • legal
  • industrial relations
  • disabilities
  • business planning
1 (for each ‘Yes’ answer) 0
2. Does the Board establish goals for your agency? 2 0
3. Has the Board identified potential risks to your agency and developed strategies to combat the risks? 2 0
4. Are the roles and responsibilities of the Board clearly defined in your agency’s policies? 2 0
5. Are the responsibilities of the Board understood by its members? 2 0
6. Are Board members involved in policy development and monitoring? 2 0
7. Is the Board involved in setting objectives and priorities for your agency’s business and strategic plan? 2 0
8. Do the Board members understand the legislative requirements which affect your agency? 2 0
9. Do the Board members understand the legislative requirements which affect your agency? 2 0
10. Do Board members understand your agency’s financial reporting and control systems? 2 0
11. Does the manager’s report to the Board include the following: -
  • sales
  • reports to funding body
  • costs
  • gross margin
  • profit/ surplus
  • stocks and debtors
  • cash flow
  • report against budget ?
 1 (for each ‘Yes’ answer) 0
12. Is the Board familiar with, and understand budget projections? 2 0
13. Does the Board monitor and evaluate agency performance? 2 0
14. Is there a clear distinction between what decisions should be made by the Board and those decisions that should be made by your agency’s management? 2 0

Interpreting Your Score

Between 27–39
The Board appears to be well informed of its responsibilities in the area of corporate governance.

Between 17–26
The Board appears to be effective but there is scope for improvement.

Between 5–16
The Board requires more information on corporate governance and issues to do with disability advocacy agencies to operate effectively.

Between 0–4
The Board requires assistance to fulfill its corporate governance role.

Do you think corporate governance could be improved at your agency?

YES              NO

If you answered yes the above question, what practical assistance do you think would assist your agency?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


4.7.8 Sample business planning process17

Appropriate governance related documentation should also include a business plan which is the product of a business plan process.  A business plan should include the documented goals, the strengths, weaknesses, opportunities and threats and key objectives and strategies of your agency — all underpinned by budgets and, where necessary, a marketing plan.  A business plan should support the overall governance related organisational plan.  The following is a suggested business planning process:

Establish team
  • sub-committee of Board or portfolio director
  • key management
  • outside expertise
  • define responsibilities for tasks
Determine overall goals and stakeholders
  • identify goals of agency by reference to objectives or corporate plan
  • identify key stakeholders
  • confirm goals and key stakeholders with Board
Carry out research
  • perform a SWOT (strengths, weaknesses, opportunities, threats) analysis
  • perform market analysis and consider strategies
  • undertake product or service research and development
  • identify current operations, resources, infrastructure and personnel
  • consult with stakeholders
Undertake financial analysis
  • compile historical financial data covering three years
  • estimate income/ costs of new initiatives or ventures
  • prepare financial forecasts for next three years
  • identify funding needs
  • assess viability of existing activities, new initiatives or ventures and identify those to be pursued
Establish and monitor business plan
  • identify key objectives and strategies
  • identify key actions to achieve objectives and strategies
  • allocate responsibility
  • establish timeframe for actions
  • review and update plan

4.7.9 Information on duty of care overall considerations18

Duty of care is a hot topic for disability agencies.  Legally, we all have a duty to take reasonable care not to cause foreseeable harm to other people or their property.  This is also known as the law of negligence.

Key areas for consideration in relation to duty of care could include:

Simple framework for duty of care

This diagram shows the overall considerations regarding duty of care, depicting them in flowchart format.

The framework is a useful tool for thinking through, in a group, issues related to duty of care in your agency. The key is to balance the rights of all stakeholders with possible risks. Training is critical to help minimise risk to all stakeholders and to ensure all stakeholders are informed of the potential risks and benefits involved.

It is important when considering duty of care to consult your own state or territory legislation.


4.7.10 Sample process for developing a quality network19

This sample process outlines the key steps to establishing a quality network, a group of local agencies who collaborate for reasons including developing quality management systems and addressing quality assurance issues.  The sample process outlines the elements your agency will need to consider from practical matters of where and when meetings will be held to issues such as the structure or purpose of the group.

  1. Determine the type of quality network that you want

    For example, what do you want to achieve?  Do you want to:

    • work on developing a quality management system?
    • address quality assurance issues?
    • work with agencies with a similar work output etc?

    Goals:

    _____________________________________________________________________

    _____________________________________________________________________

  2. Identify potential agencies

    Identify agencies that you would like to develop a quality network with.

    Name:                             Contact information:


    If you do not know any appropriate agencies to develop a network with, contact:

  3. Decide on a structure

    For example, will the quality network be:

    • action based?
    • for information sharing?
    • for resource sharing?

    Structure:

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

  4. Set up the network

    5. Here are some key elements to consider when developing a meeting system, with examples of what you might choose to do.

    Where:  (For example, choose a mutually convenient venue, or if the agencies in your network operate near one another, each agency could take a turn hosting the meeting at their premises.)

    _____________________________________________________________________

    When:  (For example, meet once every month for one day, or 4–5 hours, allowing for travel time.)

    _____________________________________________________________________

    Who is responsible:  (For example, have each agency in turn be responsible for running the meeting and appointing a chairperson.)

    _____________________________________________________________________

    What will be done at each meeting:
    For example, for a quality network you could:

    • have each monthly meeting focus on a particular quality theme.  In this way, you will have achieved a complete review of the quality themes within a calendar year.
    • identify which quality theme will be discussed at the meeting.  Request that all attendees bring material for discussion relating to that quality theme, such as queries, barriers, obstacles, best practice examples and ideas for evidence gathering.  Request the chairperson of the meeting (or another member of their agency) research and prepare an overview of the quality theme to present to the group).

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

  5. Conduct your meetings

    For example, for a quality network:

    1. chairperson presents an overview of the quality theme to the group.
    2. group members discuss and share their practices and experiences relating to this quality theme.
    3. group members work through any tools or resources relating to the quality theme that agencies may have (including the Toolkit).
    4. identify any gaps in knowledge in the group.  You may wish to seek outside help (for instance, a guest speaker, consultant or trainer) to help your network develop in this particular area.

    Agreed meeting structure:

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

  6. Develop the network

    Review the progress of your network to adapt to changes in the aims and goals of network agencies.  The focus of your network should change to reflect new directions and changing needs.

    Document future directions:

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

4.8 Sample policies and procedures

4.8.1 Policy Format20

This is a sample policy format that can be used as a basis when developing your policies.  You may also want to use the quality theme checklists as a guide for policy content.

Policy Number (as entered in Document Control Register):

POLICY TITLE

(N.B. Enter electronic file path and date of endorsement/ currency in the document footer and in the Document Control Register)

POLICY STATEMENT

The policy statement/ purpose provides the direction and rationale.

SCOPE

The scope may need to be specified to clarify applicability (eg are any program areas exempted from any clauses, where specific criteria may apply for their agency type — otherwise, delete this heading).

PRINCIPLES

Explicit values which drive this policy.  May link to agency values, constitutional objects, or principles of practice etc.

REFERENCES

Identify regulatory or situational references (eg QDSS, strategic plan, cross-referenced policies, legislation/ regulations, Australian standards).

ATTACHMENTS

Controlled forms mentioned in the procedures, which form part of this policy.  Delete if not applicable.

PROCEDURAL FRAMEWORK

1. Heading

1.1 Sub-heading if more than one element to this procedure

Identification of clauses under this heading.

4.8.2 Code of Conduct 21

If you have not yet developed a Code of Conduct, this template can be used as a starting point for discussion within your agency.  Ideally, your Code of Conduct will be developed collaboratively by management and staff, and reflect the core values held by your agency.  Management and staff should then be invited to sign it, and a copy held in each individual’s personnel file.

It is expected that all members of ......................................................will conduct themselves at all times in accordance with our Code of Conduct.

Our Code of Conduct encapsulates the professional ethics and behaviours expected of both management and staff.  The signing of the Code to confirm acceptance of the responsibilities it entails is a prerequisite of employment and/or nomination to the management committee.

Name: .......................................................................            Position: ............................................................................................................

I accept and agree to adhere to the following Code of Conduct.

I will:

Date: ....................................................................................          Signature: ................................................................................


4.8.3 Agency Charter

You can use the following as a template or starting point for developing your agency’s policies and procedures.  Or you may use them to gauge your agency’s existing policies and procedures.

Our agency will create a Charter, which will indicate:

4.8.4 Governance and Management

Our agency will create a Management Committee.  The Committee will be composed of people with legal or financial expertise.  All practicable arrangements will be made for the Committee to also include people with disability, their families and carers and representatives from the community.

The role of the Management Committee will be to:

Our agency will create Management Committee guidelines, specifying:

Members of the Committee will be subject to the conflict of interest and dispute resolution procedures specified elsewhere in this document.

All practicable arrangements will be made for the Management Committee membership to include people with disability, including people from Culturally and Linguistically Diverse (CALD) backgrounds with disability. Where people with disability are members of the Management Committee, the necessary supports will be provided to allow those members to fully contribute to the decisions and operation of the Committee.

The Management Committee will appoint staff/ volunteers to be responsible for the day-to-day running of our agency, including staff working at a managerial level to oversee decision-making.

Depending on agency size and funding, management staff may include:

These assigned responsibilities will be clearly documented on an organisational chart established and maintained by our agency.

Management staff will report regularly on agency performance to the Management Committee.


4.8.5 Review and Reporting

Financial Reporting

While management staff will have responsibility for the day-to-day financial conduct of our agency, responsibility for financial oversight will rest with the Management Committee.

Our agency should develop an annual budget.  This budget will be monitored as part of monthly Management Committee meetings, keeping track of year-to-date spending and projected financial targets.  Where specific programs are separately funded, they will be separately assessed within the budget to prevent cross-subsidisation.  A delegated member of the Management Committee will have principal responsibility for this financial monitoring.

Our agency should also produce annual audited financial statements, in accordance with the National Accounting Framework.

To prevent against the possibility of fraud:

Reporting on Agency Performance

The management staff of our agency will submit quarterly reports on the performance of our agency to the Management Committee.  These reports will contain information to allow the Management Committee to make strategic and planning decisions for the direction of our agency.

These reports should contain, at a minimum:

To enable this reporting, staff of our agency must ensure that they keep reliable records of the operations of our agency and that this data is collated to be submitted to the Management Committee (in a manner that does not compromise client confidentiality).

Risk Management

As part of the planning activities of our agency, we will produce documented risk management plans.  To create these plans, the Management Committee will:

The risk management plans of our agency will be regularly reviewed, and added to when new risks are identified.

Review

Our agency will participate in annual review of its policies, procedures and systems for providing advocacy.  Where possible, our agency will seek stakeholder feedback for this review process.  Policies, procedures and systems will also be reviewed whenever:

Administrative Systems

The management staff of our agency will designate a person to be responsible for establishing and maintaining effective administrative systems for our agency.  

These include:

4.8.6 Occupational Health and Safety policy

General guidelines

Risk Management

Our agency will adopt a risk management system for occupational health and safety as follows:

Our agency will develop safe working procedures for specific hazards in the workplace which address the needs of agency clients, staff and volunteers with particular disabilities.  These procedures will be incorporated into the general operating procedures for our operations and advocacy activities and programs.  We will develop procedures for the following areas:

Injuries to staff

In the event of an injury occurring on the way to/ from work or at work, the following action is required:

Injuries to members, clients and other visitors to our agency

If anyone visiting agency premises is injured, any staff member who witnesses the injury or its aftermath must report it to a manager, who will assess what action is required, in consultation with our agency’s first aid officer and the person injured, if s/he is conscious (eg contacting an ambulance, medical practitioner, injured person’s contact person).

The incident should be recorded in the Register of Injuries and reported to WorkCover on 13 10 50 if the incident involves a serious injury or illness.

Consultation Strategy

Our agency will consult with employees on OH&S matters by having OH&S as a permanent agenda item at regular staff meetings.

Training

Our agency will provide training to staff in OH&S issues.

Personal Safety

Staff and management are required to take adequate precautions to ensure that they and others are safe from injury and health risks when working out of the office or in the office alone.

Strategies to ensure safety may include:

4.8.7 Conflicts of Interest

Management Conflict of Interest

Conflict of Interest Register:

Our agency will maintain a conflict of interest register, where all staff, management Committee members and volunteers will declare any personal or professional interests that may give rise to a conflict.  The conflict of interest register will be publicly available.

To minimise conflict of interest, our agency will:

Client–Advocate Conflict of Interest

Where a client–advocate conflict of interest arises:

Where either the client or the advocate feels that advocacy activities will be compromised by the potential conflict of interest, the client should be referred to another agency or advocate.  Once the client has been provided with the full information of the circumstances of the conflict of interest, the client can decide to continue using our agency with the existing advocate.

Client – Client Conflict of Interest

Our agency will sometimes encounter situations where there are dilemmas for advocates involved in assisting clients with conflicting needs.  To deal with this issue:

Conflict of Interest – Person with a Disability – Carers

Our agency tries to assist both carers and individuals with a disability in the advocacy process.  However, if there is a conflict of advice from the carer and person with disability, our agency will in general take the advice of the person with disability.

Sexual Relationships with Clients

Staff (including volunteers) should under no circumstances engage in sexual activities or sexual contact with clients whether such contact is consensual or not.  Staff (including volunteers) should not engage in sexual activities or sexual contact with relatives of clients or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client.

Gifts and Other Benefits from Clients

Staff (including volunteers) should be conscious of the perception to others of accepting gifts and other benefits.  Staff must not solicit or accept anything of value from a client or associate which might interfere with their independence and the conduct of their duties and responsibilities.  The very acceptance of a gift may create the perception that staff member’s independence and integrity has been compromised.

In general, gifts of any type should be politely declined.  However, a token gift may be accepted if there are circumstances where it would cause offence or disrespect to the gift giver to refuse the gift or where it may jeopardise the positive working relationship with the person.  An example of a token gift might be flowers, chocolates, home-made produce, and modest refreshments etc with a value of no more than $50.  If a staff member is unsure about the status of a particular gift he or she should discuss with the Coordinator.

Staff (including volunteers) should not enter into any financial transactions or arrangements with clients.  Examples of a financial transaction with a client may be purchasing agency/ equipment or accepting a loan of money/ goods.  If there is any doubt, the staff member should discuss the matter with our agency management.

4.9 Useful links

Corporate Governance Handbook for the Board, prepared for FACS by Walter & Turnbull, October 2001, for more information on corporate governance.

The Council on Quality and Leadership, resources on leadership and Board development you might find useful.

Disability Services Queensland, for tools and resources.

The Disability Advocacy Resource Unit (DARU), Victoria.

Federation of Community Legal Centres, Managing the organisation, policies and procedures.

The National Association of Community Legal Centres’ National Management Committee Guide for Community Legal Centres.

Volunteering Queensland, Volunteer Management Resource Kit, includes policies, and procedures, recruitment and selection, and orientation and training.

 

  1. Adapted from Corporate Governance Handbook for the Board, Prepared for FACS by Walter & Turnbull, October 2001.
  2. Disability Services Queensland.
  3. Disability Services Queensland.
  4. Disability Services Queensland.
  5. Disability Services Queensland.
  6. Disability Services Queensland.
  7. Disability Services Queensland.
  8. ASX Corporate Governance Council, Principles of Good Corporate Governance and Best Practice Recommendations, March 2003 in Disability Employment Agencies Quality Strategy Toolkit.
  9. Corporate Governance Handbook for the Board, Prepared for FACS by Walter & Turnbull, October 2001.
  10. Adapted from Disability Employment Services Continuous Improvement Handbook.
  11. Corporate Governance Handbook for the Board, Prepared for FACS by Walter & Turnbull, October 2001.
  12. Disability Employment Agencies Quality Strategy Toolkit.
  13. Disability Employment Services Quality Strategy Toolkit, Developed with the assistance of The Ascent Group, NSW].
  14. Disability Services Queensland.
  15. Disability Services Queensland
    16. .

[ top ]