Quality Strategy Toolkit
for Australian Disability Enterprises and Disability Employment Services

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Contents

• Introduction
• Section 1 Overview
• Section 2 Quality assurance
  • 2A: step-by-step guide to Disability Services Standards certification
  • 2B: Disability Services Standards, Evidence Guidelines and self-assessment worksheets
  • Australian Disability Enterprises
  • Disability Employment Services
• Section 3Continous improvement
• Section 4Complaints and referrals
• Section 5Contacts and resources
• Section 6Glossary
• Attachment 1:JAS-ANZ Procedure 18

Section 2: Quality assurance

2A  Quality assurance: step by step guide to Disability Service Standards certification

Key points about the quality assurance system

1. The quality assurance system applies to all Australian Government funded Australian Disability Enterprises and Disability Employment Services.
2. It involves independent assessments to certify that they comply with the 12 Disability Services Standards. Service quality is specified through 26 key performance indicators (KPIs) across the Standards.
3. Third party certification bodies undertake the certification audits.
4. Certification bodies are accredited by the Joint Accreditation System of Australia and New Zealand (JAS-ANZ). Accreditation requirements are contained in JAS-ANZ Procedure 18. JAS-ANZ accredits certification bodies as competent and impartial for undertaking audits against the Disability Services Standards.
5. The quality assurance system has been designed to ensure that people with disability are involved with all aspects and stages of the process.
6. Under the system, the role of government departments is to develop policy and provide support and resources to help services gain certification and pursue continuous improvement.
7. New services need to register their intention to seek certification with their relevant department, and have 12 months to gain certification from the date funding commenced.
8. Under the Disability Services Act 1986, a service that loses its certification and funding needs to regain certification before funding is considered.
9. Certified services receive a Certificate of Compliance that is recognised by the Australian Government as proof that the organisation is delivering services in line with the Disability Services Standards.
10. Within 12 and 24 months of certification, certified services participate in a surveillance audit conducted by their chosen certification body. Then 36 months after certification, services participate in a full recertification audit.

Diagram 2.1 shows the steps involved in the certification process. Each step is then explained in more detail below.

Diagram 2.1: The Certification process

Description of Diagram 2.1

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Step one: start the process

The first step in preparing for the audit process is to gather and review background information about your organisation. This helps you assess exactly what you will need to consider for your certification audit. This scoping exercise is a preliminary process before the more detailed internal audit your organisation will need to undertake later as part of your preparation (step four).

Check that you have considered:
What service types does our organisation have?
Which Evidence Guidelines will we need to refer to? LINK: All Evidence Guidelines are included in Section 2B of this toolkit.
Does our organisation operate any other quality assurance systems? Could these systems contribute any evidence for our certification audits? LINK: A table documenting similarities between the Disability Services Standards and ISO 9001: 2000 requirements is in Section 3, Tool 8b.5
Who will be involved in our audit process? Consider: staff participants/supported employees advocates/carers/interpreters/other Board members and management.
How will we arrange and actively encourage the involvement of participants/supported employees?
Do we have written policies and procedures? Where are they? When were they last updated? Do they reflect all of the Disability Services Standards?
Do we know where our Funding Agreement/Contract is? Do we know what our contractual responsibilities are?
Have we spoken to our departmental contract manager to discuss the process?

Step two: choose your certification body

When choosing a certification body, remember that you will be working together into the future, usually for at least three years. It is a good idea to 'shop around' until you find a certification body that can work well with your organisation.

Consider:

• the quality of service provided by the certification body
• the cost of the certification body's services, compared with the contribution your organisation will receive from the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA).

To find a certification body, you can use the register provided on the JAS-ANZ website:

FaHCSIA also maintains a list of certification bodies on its website.

You can also refer to Section 5 of this toolkit (contacts and resources).

Quality checklist

Check:
Is the certification body formally accredited by JAS-ANZ to assess services against the Disability Services Standards? LINK: JAS-ANZ or FaHCSIA can confirm accreditation status.
Is the certification body experienced at auditing organisations similar to ours? Can it provide references?
Does the certification body offer a gap analysis prior to the official certification audit?
What sampling of sites and participants/supported employees does the certification body require?
Is it possible to meet with the audit team prior to audit (may not be feasible in rural and remote areas)?
Can the audit team provide examples of past de-identified reports? Are these reports of good quality?
What kind of feedback will the audit team give? How will they conduct the exit interview?
If we operate an existing quality assurance system: Can the audit team offer an integrated audit process (e.g. with ISO 9001)?

Cost checklist

Have we considered:
What is the cost of the certification body's services?
What is the partial contribution reimbursement we are likely to receive from FaHCSIA? How does this compare to the amount charged by the certification body? LINK: see Box 1 below for an explanation of the Australian Government's contribution to certification costs.
Do we need to get a comparative quote from another certification body?

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Step three: notify the appropriate department (new services only)

If your service is new to the disability employment quality assurance certification system, you will need to notify the appropriate department that provides your funding or contracts your organisation that you intend to obtain a Certificate of Compliance against the Disability Services Standards. To do this you will need to complete a Notice of Intention to Obtain a Certificate of Compliance Form.

In order to receive the Australian Government contribution for certification and surveillance audit costs, paid to you by FaHCSIA, if you have not already done so you will need to complete a FOFMS New Organisation Request Form, and provide banking details. The bank account information, including account name and number, and BSB number, needs to be on an official letterhead signed by an authorised person. If this information is provided and once the audit report is submitted online to FaHCSIA by your certification body, the contribution payment is processed automatically and transferred into your bank account.

If your funding body is the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA):

• Contact your FaHCSIA Contract Manager to obtain both Notice of Intention to Obtain a Certificate of Compliance Form and, if not already registered on FOFMS, a FOFMS New Organisation Request Form.  Once completed these need to be returned to FaHCSIA together with bank account details.

If your funding body is the Department of Education, Employment and Workplace Relations (DEEWR):

• Contact your DEEWR Contract Manager to obtain the Notice of Intention to Obtain a Certificate of Compliance Form and, if not already registered on FOFMS, a FOFMS New Organisation Request Form.  Once completed these need to be returned to DEEWR, together with bank account details.  DEEWR will forward the documentation as required to FaHCSIA.

If you operate multiple service types with different funding bodies:

• Contact your DEEWR and FaHCSIA Contract Managers, advise them that you will be funded by both Departments, and discuss your administrative requirements.

Check:
Have we submitted Notice of Intention to Obtain a Certificate of Compliance Form and (if required) a FOFMS New Organisation Request Form?

Step four: conduct your internal audit

Internal audits are a way for you to assess how well your organisation performs against the Disability Services Standards. Certification bodies may require you to submit material related to your internal audit, along with your policies and procedures, before they decide whether to proceed with a certification audit. This is why it is important that you conduct and submit an internal audit in plenty of time before the official certification assessment is scheduled. This will give you time to address any major issues identified by the certification body prior to the audit.

This toolkit contains some resources and tools that can help you with conducting an internal audit:

• Disability Services Standards and Evidence Guidelines (see Section 2B)
• self-assessment worksheets against each Standard (see Section 2B)
• a sample internal audit system and internal audit worksheet (see Section 3, Tool 8b.1 and Tool 8b.2).

Check that you complete the following steps:
1.	Involve participants/supported employees in the audit process (see Box 2 below).
2.	Conduct a document review against the Disability Services Standards.
3.	Conduct on-site reviews of your organisation's practices against the Disability Services Standards.
4.	Take action to address gaps identified by the internal audit process.
5.	Submit materials relating to the internal audit to the certification body prior to the official audit.

Some organisations negotiate with their certification body for a preliminary assessment (or a gap analysis) to help them prepare for the certification audit. If you are planning to have a preliminary assessment, make sure you leave plenty of time to address any issues that might come up, before your scheduled official certification assessment begins.

Step five: prepare for your certification audit

During this step, you need to prepare material, schedule activities and meetings and generally organise, in partnership with your certification body, how the certification audit will proceed.

Box 3 (below) describes the activities that generally take place during a certification audit so that you can anticipate what you will need to organise. It is followed by a checklist of activities that you should consider for this step.

Who conducts certification audits?

Audits are conducted by a team, which always includes an Auditor and a Consumer Technical Expert:

• Lead Auditor - a person who is certified as a Lead Auditor under the Disability Services Audit Personnel Certification Scheme, with knowledge in the area of disability employment and quality management practices and skills in collecting and analysing data, as well as leadership experience. They are responsible for organising and directing the activities of the audit team, as well as participating in general audit activities.
• Auditor - a person who is certified as an auditor under the Disability Services Audit Personnel Certification Scheme, with knowledge in the area of disability employment and quality management practices and skills in collecting and analysing data. Auditors conduct evidence gathering, participants/supported employees feedback and have input into audit ratings.   
• Consumer Technical Expert - a person, who is certified as a Consumer Technical Expert under the Disability Services Audit Personnel Certification Scheme, with disability engaged for his/her specialist knowledge and abilities (e.g. empathy with the life experience of people with disability) and ability to plan and facilitate the effective input of people with disability in an audit process.  They must themselves have been a service recipient of a State or Commonwealth funded disability organisation in Australia, and able to provide evidence of this to the certification body employing them for the audit..
• Witness auditors - additional auditors may participate in your audit. Called witness auditors, they are appointed by JAS-ANZ and are there to observe how your certification body conducts your audit. Witness auditors are part of JAS-ANZ's system for ensuring that organisations receive quality certification services.

Checklist for your completion
1.	Liaise with your certification body to discuss how the certification audit will proceed including the details to be covered by the audit, such as the: sample of participants/supported employees that they require inclusion of all service types inclusion of all demographics (e.g. age, disability type, varying work tasks).
2.	Provide general information to the certification body about your participants/supported employees and the disability employment service types you deliver.
3.	Prepare the sample of participants/supported employees to provide feedback at the certification audit. The sample should represent different service types, work sites and work activities and consider disability type, gender, age, home or living situation, cultural, religious or language differences, whether working or not working, and length of tenure with the service (including those on a waiting list and those who have exited).
4.	Actively encourage participants/supported employees to participate and arrange their involvement (see Box 4 below, regarding how you can encourage and trainparticipants/supported employees to participate).
5.	Arrange consent forms and consent for access to files for participatingparticipants/supported employees.
6.	Organise appropriate support/advocates for participating participants/supported employees.
7.	Coordinate audit activities in line with your certification body's requirements, including: preparing the formal entry meeting (e.g. arranging a room and alerting attendees) scheduling interviews with staff and participants/supported employees preparing the formal exit meeting.

 

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Step six: participate in your certification audit

Participating in the certification audit means assisting your certification body to obtain the information it needs, as well as ensuring that the interviews and feedback sessions you have organised proceed as scheduled.

This checklist contains some of the activities you need to consider.

Ensure that you do the following:
Prepare the venue for the formal entry meeting and ensure that it is an empowering environment for all individuals present.
Take the opportunity to ask any questions you need about the audit process at the formal entry meeting.
Assist your certification body to gather evidence and observe activities.
Ensure that staff and participants/supported employees are present for scheduled interviews or feedback sessions.
Prepare the venue for the formal exit meeting and ensure that it is an empowering environment for all individuals present.
Take the opportunity to comment on findings of the audit team at the formal exit meeting.

Step seven: follow-up if required

After your certification audit, you will receive an audit report from the certification body. This report will also be given to your funding body. Box 5 below explains the ratings system for your audit report. After receiving the audit report, you will need to take follow-up action, as indicated in the checklists below.

Feedback checklist

When you have received your audit report, provide feedback about the results to:
Participants/supported employees
Staff and management of your organisation
The Board of your organisation

Certification results checklist

If you have received a 0- major nonconformity rating, you must:
1.	Send a corrective action plan to the certification body within five working days.
2.	Take corrective action within three months.
3.	Participate in a follow-up visit by your certification body to assess the corrective action within three months. If your certification body thinks that corrective action has been partly successful, the 0 rating may be upgraded to a 1. This will give you an additional three months to correct the nonconformity.
If you have received a 1 - nonconformity rating, you must:
1.	Send a corrective action plan to the certification body within five working days.
2.	Take corrective action within six months.
3.	Participate in a follow-up visit by your certification body to assess the corrective action within of six months.

Your organisation cannot be granted certification until all major nonconformities and nonconformities have been corrected, and that correction has been verified by the certification body.

As new services have 12 months from the date funding commences to obtain certification, you will need to ensure that all nonconformities are corrected and verified within that 12 month period in order that you can continue to be funded. It is advisable for new services to schedule their certification audit early so that non-conformities or major non-conformities can be corrected within the 12 month period.

 

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Step eight: start three-year audit cycle

Once you have achieved certification, you begin a three-year audit cycle involving internal audits, annual surveillance audits and recertification audits. Box 6 explains this process, while the checklists below set out what you will need to do.

Audit cycle checklist

During the first year after certification:
1.	Conduct an internal audit to continuously improve against the Disability Services Standards. Refer to Step Four: Conduct an Internal Audit for what to consider.
2.	Participate in a surveillance audit with certification body before the end of the first year.
During the second year after certification:
1.	Conduct an internal audit to continuously improve against the Disability Services Standards.
2.	Participate in a surveillance audit with certification body before the end of the second year.
During the third year after certification:
1.	Conduct an internal audit to continuously improve against the Disability Services Standards.
	Re-negotiate your contract with your current certification body or negotiate a contract with a new certification body. Refer to Step Two: Choose a Certification Body for what to consider. Additional considerations include: how professionally, fairly and efficiently you feel the audit team conducted certification and surveillance audits in the last cycle quality and quantity of feedback provided at audits quality of the audit report.
3.	Prepare for your recertification audit. Checklist for your consideration: Where is our last audit report? What comments did the audit team make? Are there any priority issues we can identify for this audit cycle? What did we learn from the last audit cycle? What strategies could we use to overcome barriers we identified? Has our organisation substantially changed since our last audit cycle (e.g. staff or structural changes)? How will this impact our organisation's performance against the Disability Services Standards?
4.	Participate in a recertification audit with your certification body.

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Summary of the step-by-step guide to quality assurance certification audits

This is an overall summary of the steps involved, timeframes and actions required for achieving initial certification and entering into the three-year audit cycle.

Step	Time frame	Milestones/Notes
1. Start the process	No later than one month after your funding is approved	review your organisation's structure, policy and procedures review contractual requirements
2. Choose your certification body	No later than three months after your funding is approved	select certification body negotiate contract
3. Notify the appropriate department	New organisations should register their intent to be certified as soon as possible after funding is approved	submit Notice of Intention to Obtain a Certificate of Compliance Form, FOFMS New Organisation Request Form and bank account details to funding body
4. Conduct your internal audit	During the first six months after your funding is approved	internal audit involving  participants/ supported employees
5. Prepare your certification audit	On-site dates negotiated with certification body should be no later than six months after your funding is approved	liaise with certification body about audit activities, including sampling prepare participant/supported employees involvement in audit
6. Participate in your certification audit	On-site dates negotiated with certification body should be no later than six months after your funding is approved	assist with streamlining audit activities use opportunities to ask questions, make comments on the audit findings in exit meeting
7. Take follow-up action if required	Address major nonconformities within three months and nonconformities within six months of assessment (depending on whether major nonconformities are identified) Decision on certification must be made no later than 12 months after the date on which your funding is approved	provide feedback to staff, Board, participants/supported employees if nonconformities are identified, undertake corrective action
8. Start three-year funding cycle
a) Prepare for first surveillance audit	Within 12 months of initial certification audit	internal audit documentation of ongoing corrective action
b) Prepare for second surveillance audit	Within 24 months of initial certification audit	internal audit documentation of ongoing corrective action
c) Re-negotiate contract with certification body	Between 24 and 36 months of initial certification audit	review certification body's cost and quality of its work
d) Prepare for recertification audit	Within 36 months of initial certification audit	internal audit documentation of continuous improvement

 

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Next: 2B: Quality assurance: Disability Services Standards, Evidence Guidelines and self-assessment worksheets

Previous: Introduction

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Last modified 29 October, 2010