HACC Quality Improvement Strategy Resource Toolkit 2016 · HACC Quality Improvement Strategy...
Transcript of HACC Quality Improvement Strategy Resource Toolkit 2016 · HACC Quality Improvement Strategy...
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Tableofcontents
1.1. Introductionandbackground..................................................................................................2
1.2. Whatisthepurposeoftheresourcetoolkit?..........................................................................2
1.3. Overviewoftheresourcetoolkit.............................................................................................2
1.4. Contentsandlayoutoftheresourcetoolkit............................................................................3
1.5. Whoshouldusetheresourcetoolkit?.....................................................................................3
1.6. TransitiontotheCommonwealthHomeSupportProgram.....................................................3
1.7. Requirementsforquality.........................................................................................................4
1.8. TheAustralianAgedCareQualityAgency(QualityAgency)....................................................6
2.1. Overviewofthissection..........................................................................................................8
2.2. Continuousqualityimprovementpractice..............................................................................8
2.3. Stengtheningyourqualitymanagementsystem.....................................................................9
2.4. Keyfeaturesofaneffectivequalitymanagementsystem.....................................................10
2.5. Monitoringyourorganisation’sCQIperformance.................................................................10
2.6. MeasuringCQIperformanceinyourorganisation................................................................12
2.7. IntegratedplanningtosupportCQI.......................................................................................12
3.1. QualityresourcesmappedtotheHomeCareStandards......................................................16Standard1:Effectivemanagement.......................................................................................16Standard2:Appropriateaccessandservicedelivery............................................................21Standard3:Serviceuserrightsandresponsibilities..............................................................25
4.1. Overviewofthissection........................................................................................................28
4.2. Continuousqualityimprovementplantemplate...................................................................28
4.3. Serviceuserfileaudit.............................................................................................................29
4.4. Stafffileaudittool.................................................................................................................29
4.5. Complaintsandfeedbackform..............................................................................................29
4.6. Complaintsandcomplimentstracker....................................................................................30
4.7. Continuousimprovementform.............................................................................................30
4.8. Stakeholderaudittool...........................................................................................................30
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Listofabbreviations
Abbreviation Definition
AHA AustralianHealthcareAssociates
ASM ActiveServiceModel
CHSP CommonwealthHomeSupportProgram
CQI Continuousqualityimprovement
DHHSortheDepartment VictorianDepartmentofHealthandHumanServices
DoH DepartmentofHealth(Commonwealth)
DSS AustralianDepartmentofSocialServices
HCPP HomeCarePackagesProgram
NDIA NationalDisabilityInsuranceAgency
NDIS NationalDisabilityInsuranceScheme
OHS OccupationalHealthandSafety
QIS DHHSortheDepartment’sQualityImprovementStrategy2016
QualityAgency AustralianAgedCareQualityAgency
1.Introductionandcontext
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1. Introductionandcontext
1.Introductionandcontext
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1.1. Introductionandbackground
TheCommonwealthHomeSupportProgramme(CHSP)providesentry-levelhomesupportforolderpeoplewhoneedassistancetokeeplivingindependentlyathomeandintheircommunity.
From1July2016,theAustralianGovernmentwillassumefullfunding,policyandoperationalresponsibilityforVictorianHomeandCommunityCare(HACC)servicesandspecifiedepisodicspecialistdisabilityservicesforolderpeopleinVictoriatoformpartoftheCHSP.VictoriawillcontinuetofundHACCservicesforpeopleagedunder65years(under50yearsforAboriginalandTorresStraitIslanderpeople).
ThetransitionperiodforthetransferofVictorianHACCserviceproviderstotheCHSPhasbeenextended.Asaresult,VictorianHACCfundedagencieswillnotparticipateinaformalreviewagainsttheCommunityCareCommonStandards(nowknownasHomeCareStandards)duringthe2015–2016period.Inlieuofaformalqualityreviewprocess,theDepartmentofHealthandHumanServices(theDepartment),contractedAustralianHealthcareAssociates(AHA)todevelopanddeliveraseriesofqualityimprovementworkshopsandanaccompanyingresourcetoolkitforVictorianHACCserviceproviders.
1.2. Whatisthepurposeoftheresourcetoolkit?
Thisresourcetoolkit,inconjunctionwiththequalityimprovementworkshops,hasbeendevelopedtosupportVictorianHACCserviceproviderstocontinuetobuildonandconsolidatetheirContinuousQualityImprovement(CQI)effortsduringthetransitionperiodandbeyond.
ThetoolkitaimstosupportfundedagenciestocontinuetoaddresstherequirementsoftheHomeCareStandards.ItbuildsontheextensiveworkundertakenbytheVictorianHACCsectortodevelopqualitysystemsandprocessestoensurehighqualityservicesforserviceusersandprovidespracticaltoolstocontinuetomonitorandimprovequality.
Theresourcetoolkitisalsoavailableonlineatwww.ahaconsulting.com.au
1.3. Overviewoftheresourcetoolkit
ThetoolkitcontainsinformationandpracticaltoolswhichcanbeusedtohelpyourorganisationmonitorandimproveservicedeliverytocontinuetoaddresstherequirementsoftheHomeCareStandards.
Thetoolscanbeusedintheircurrentformoradaptedtosuityourorganisation’sCQIpurposes.
Thetoolsandinformationcontainedinthistoolkitareintendedasaresourceonly.Eachserviceproviderisencouragedtousethetoolsthatworkbestfortheminmonitoringandmeasuringquality.Thetoolsaredesignedtohelpyoubuildonyourexistingsystems.
1.Introductionandcontext
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1.4. Contentsandlayoutoftheresourcetoolkit
ThetoolkitcontainsarangeofqualityimprovementtoolsandprocessesthatcanbeusedtoplanandevaluateCQIactivities.Itisdividedintofoursections:
Section1:Introductionandcontext
Section2:Maintainingqualityandcontinuousqualityimprovement
Section3:ResourcesmappedtotheHomeCareStandards
Section4:Toolstosupportqualityplanningandmonitoring
1.5. Whoshouldusetheresourcetoolkit?
ThetoolkitisdesignedtobeusedbyabroadrangeofHACCserviceprovidersacrossarangeofsettings.ItcanbeusedbyserviceproviderswithdifferentlevelsofexperienceinCQI.Forserviceprovidersrequiringadditionalinformation,linkstoresourcesandreferencestofurtherreadinghavebeenprovided.
1.6. TransitiontotheCommonwealthHomeSupportProgram
FromJuly2016,VictorianHACCservicesforolderpeople(peopleaged65yearsandover,andAboriginalandTorresStraitIslanderpeopleaged50yearsandover)willtransitiontotheCHSPandwillbedirectlyfundedandmanagedbytheCommonwealthDepartmentofHealth(DoH).ThekeyCHSPguidancedocumentsaredescribedbelow.
TheCommonwealthHomeSupportProgrammeGuidelines
TheCHSPGuidelinesformthebasisofthebusinessrelationshipbetweenDoHandtheCHSPgrantrecipient.TheyprovideanoverviewoftheCHSPanditsrelatedactivities,selectioncriteria,performancemanagementandreportingprocesses.
CommonwealthHomeSupportProgramme–ProgrammeManual2015
TheCHSPProgrammeManual(2015)outlinestherequirementssupportingthedeliveryandmanagementoftheCHSP.Itisprimarilyintendedforusebygrantrecipients,andformspartoftheirGrantAgreement.
LivingWellatHome:CHSPGoodPracticeGuide
TheLivingWellatHome:CHSPGoodPracticeGuideisaresourceintendedtocomplementtheCHSPProgrammeManualforserviceproviders.Itdescribestheconceptsandprinciplesofwellness,reablementandrestorativecareapproachesinCHSPservicedelivery.Itbuildsonexistingexamplesofwellnesspracticesanddrawsoncommunications,capacity-buildingandtrainingresourcesthathavebeendevelopedoveranumberofyearsinAustraliaandoverseas.
MoreinformationaboutthetransitionalarrangementsforVictoriacanbefoundatwww.dss.gov.au/ageing-and-aged-care/programs-services/commonwealth-home-support-programme/victorian-hacc-transition
1.Introductionandcontext
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1.7. Requirementsforquality
TheHomeCareStandardswillapplytoVictorianHACCserviceprovidersforolderpeople(aged65yearsandover,andAboriginalandTorresStraitIslanderpeopleaged50yearsandover)throughoutthetransitionperiodandbeyond.
TheHomeCareStandardswillalsocontinuetoapplytoVictorianHACCserviceproviderswithfundsforyoungerpeople(peopleagedunder65years,andAboriginalandTorresStraitIslanderpeopleagedunder50years).TheywillalsoapplytoHACCproviderswhoregisterasNationalDisabilityInsuranceScheme(NDIS)providers.
HomeCareStandards
TheHomeCareStandardsweredevelopedjointlybytheAustralianGovernmentandstateandterritorygovernmentsaspartofbroadercommunitycarereformstosimplifyandstreamlinethewaycommunitycareisdelivered.TherearethreeHomeCareStandards:
Standard1:EffectiveManagment
Standard2:AppropriateAccessandServiceDelivery
Standard3:ServiceUserRightsandResponsibilities
Eachstandardconsistsofaprincipleandanumberofexpectedoutcomes.Thereare18expectedoutcomesacrossthethreestandards.ThestandardsareoutlinedinFigure1-1.
1.Introductionandcontext
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Figure1-1:TheHomeCareStandards
1.Introductionandcontext
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1.8. TheAustralianAgedCareQualityAgency(QualityAgency)
InJuly2014,theAustralianAgedCareQualityAgency(theQualityAgency)assumedresponsibilityforconductingqualityreviewsofagedcareprovidersfundedundertheCHSPandtheHomeCarePackagesProgramme(HCPP).From1July2016,theQualityAgencywillalsoberesponsibleforthequalityreviewsofHACCservicesfundedundertheCHSPinVictoria.TheAgencywillassessallorganisationsreceivingCHSPfundingundertheHomeCareStandards.
ArrangementsforwhichbodywillconductqualityreviewsofVictorianserviceprovidersforyoungerpeopleduringthetransitionperiodhavenotyetbeendetermined.
TheQualityAgency–someusefulresources
TheQualityAgency’swebsiteprovidesarangeofusefulinformationandtoolstoassistorganisationstoplanforqualityimprovement.TheQualityAgencywebsitecanbefoundat:www.aacqa.gov.au
ToolsandresourcesfromtheQualityAgency’swebsitethatmaybeofparticularusetoHACCfundedagenciesinclude:
• QualityReviewGuidelines:TheHomeCareQualityReviewGuidelinesprovideinformationabouthomecarequalityprocessesincludingqualityreviews,assessmentcontactsandcontinuousimprovement.Theyaredesignedtoassistproviderstoprepareforvisitsandtodemonstratecontinuousimprovementintheircareandservicesforcarerecipients.
• SelfAssessmentTool:Thistoolisnotmandatory,buttheQualityAgencydoesrequireproviderstouseselfassessmenttoolsormethodsthatcovertheinformationinthistemplateataminimum.
• HomeCarePlanforContinuousImprovement:TheQualityReviewGuidelinesnotethatintheeventthataqualityreviewfindsthataserviceproviderhasnotmetall18expectedoutcomes,thenthatserviceproviderisrequiredtosubmitaplanforcontinuousimprovement.Providersdonotneedtousethistemplateiftheyhaveanalternativetemplate,howevertheAgencydoesrequireproviderstocovertheinformationinthistemplateataminimum.AnexampleofaQualityImprovementPlanisprovidedinSection4ofthistoolkit.
• PracticesandProcessesGuide:ThisguidedescribesthepracticesandprocessestheQualityAgencymaylookatwhenreviewingorganisationsagainsttheHomeCareStandards.
2.Maintainingqualityandcontinuousqualityimprovement
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2. Maintainingqualityandcontinuousqualityimprovement
2.Maintainingqualityandcontinuousqualityimprovement
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2.1. Overviewofthissection
Thissectionprovidesusefulstrategiestoassistserviceproviderstomaintaintheirqualitymanagementsystemsandtoembedcontinuousqualityimprovementpracticeswithintheirorganisations.
2.2. Continuousqualityimprovementpractice
Continuousqualityimprovement(CQI)isaboutmakingongoing(continuous)effortstoimprovethequalityofservicesandoutcomesforserviceusers.CQIfocusesonimprovingsystemsratherthanontheperformanceofpeople.CQIisusedinmanytypesoforganisationsasamethodofleadershipandmanagement;itisusedtoassesshowwellsystemsareworkingtobringaboutsustainedimprovement.
KeyfeaturesofCQIinclude:
• Accountability
• Linkingevaluationtoplanning
• Achievingimprovementthroughincrementalsteps
• Commitmentandinputfromalllevelsofstaff,managementandotherstakeholders
• Commitmenttoteamwork
• Continuousreviewofprogress.
ThebenefitsofCQIinclude:
• Improvedaccountability
• Enhancedstaffmorale
• Improvedservicesforclients
• Abilitytorecogniseandmeetchangesinserviceusers’needs
• Enhancedinformationmanagement,clienttrackinganddocumentationsystems.
AvarietyofpeopleshouldbeinvolvedinCQI,including:
• Serviceusers,familiesandcarers
• Servicemanagement
• Stakeholders
• Staffandvolunteers.
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2.3. Stengtheningyourqualitymanagementsystem
Whilemostserviceprovidersbelievetheyprovideagoodservice,thiscanbedifficulttodemonstratewithoutaneffectivequalitysystem.
Aneffectivequalitysystemincludessystemsandprocessesto:
• Clearlyidentifytheneedsandexpectationsofserviceusers
• Plananddelivertheagreedservices
• Checkthattheservicesdeliveredmeetstakeholders’needsandexpectations
• Checkthattheservicesdeliveredarereliableandofaconsistentlyhighstandard.
Qualitymanagementreferstotheserviceprovider’sprocessesformaintainingandimprovingthequalityofservicedeliveryandoperations,withtheintentofprovidingthebestpossibleexperienceandoutcomesforserviceusersandotherstakeholders,aswellasforstaff.
Qualitymanagementprocesseshelpserviceproviderstounderstandwhatisworkingwell,identifywhereimprovementsareneeded,andimplementimprovementactionsasrequired.Theyalsohelpinsupportingongoinginnovations.Theseprocessesincludedevelopmentofpoliciesandprocedurestoguidepractice,feedbackandconsultationwithserviceusersandstakeholders,andself-assessmentofperformanceandcompliancewiththeHomeCareStandards.
Aqualitymanagementsystemistherangeofqualitymanagementprocessesusedbyanorganisationinanintegratedandcoordinatedway.Itinvolvesdocumentingriskcontrolsintheformofpolicies,proceduresandworkinstructions.Recordsreflecttheimplementationofthedocumentedprocessesandprovideevidencetosupportthecompliance,orotherwise,withthedocumentedriskcontrol.
Developmentofaneffectivequalitymanagementsystembeginswithdocumentinghowplanning,implementingandmonitoringpracticeswilloccurtosupportongoingimprovements.Developinganorganisation-widecontinuousimprovementpolicywillsupportamoresystematicapproachtodatacollection,analysisandimprovment.Acontinuousimprovementpolicyshouldincludeprocessesforinternalreportinganddataanalysis,informationaboutwhointheorganisationwillanalysethedataandhowtheinformationcollectedwillbeusedtosupportservicedeliveryimprovementsovertime.
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2.4. Keyfeaturesofaneffectivequalitymanagementsystem
Aneffectivequalitymanagementsystemmusthaveprocessestoensurethatopportunitiesforimprovementareidentified,documentedandreported,andthattheactiontakenistimelyandappropriate.Theseprocessesincludebutarenotlimitedto:
• Serviceuserandkeystakeholderfeedbackprocesses
• Serviceusercomplaintprocesses
• Incidentandaccidentreporting
• Identificationofhazards
• Staffappraisalprocesses
• Staffgrievanceanddisciplinaryprocesses
• Afileauditingprocess
• Compliancewithlegislativeandregulatoryrequirements
• Opportunitiestoidentifyinnovation.
Forexample,improvementsmaybeundertakeninresponsetothefindingsofserviceuserfileaudits.Fileauditsareaqualityactivitythatinvolvescheckingthatwhatstaffdoinpracticematcheswhatiswritteninpoliciesandprocedures.Serviceuserfileauditsmightfocusonpracticesaroundassessment,careplanningand/orreviewofserviceuserneeds.Stafffileauditsmaylookatselection,recruitmentandinductionprocesses.
2.5. Monitoringyourorganisation’sCQIperformance
WhiletheexternalqualityreviewprocessprovidesopportunitytodemonstratecompliancewiththeHomeCareStandards,itisimportantthatallorganisationscontinuetomonitortheirCQIperformanceonanongoingbasis.SomemethodsformonitoringperformanceareidentifiedinSection2.4above.TheQualityCyclebelowprovidesausefulapproachtoplanning,monitoringandimprovingyourorganisation’squalitysystems.
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Thequalitycycle
AqualitycyclecanbeusedtoguideCQIimplementation.ThemodelshowninFigure2-1isthefourphasePlan-Do-Check-Actcycle.Thismodelcanassistserviceproviderstoapplycontinuousimprovementtotheiroperations.ItalsohelpsthemtoconsiderCQIasanintergralpartofgoodmanagement,ratherthanastandaloneactivity.Thefourstepsareoutlinedbelow.
Figure2-1: Plan-Do-Check-Actcycle
Step1:Plan Planwhatitisthatyouwanttochangeorachieve.Workoutwhatthegoalisandthenwhatyouneedtodotomeetit.
Step2:Do Putinplacethesystemsandprocessestomakethechangeorreachthegoal.
Step3:Check Lookattheresults.Didthechangehavethedesiredeffect?Wasthegoalachieved?
Step4:Act Ifthelaststep(check)foundthatthechangewasworkingorthegoalwasachieved,continuewithimplementingitintoyoursystems.Ifthelaststepfoundthatthechangewasnotworkingorthegoalwasnotachieved,youwillneedtodecidewhyitdidnotworkandrepeatthecycle,startingbyplanningwhatyouneedtodo.
Selfassessmentprocess
Selfassessmentisanotherwayforservicestoidentifypotentialimprovementsinsystemsandprocesses.AsapartoftheQualityAgencyexternalreviewprocess,allserviceproviderswillberequiredtocompleteaselfassessment.
Selfassessmentinvolvesaservicelookingatthesystemsandprocessesithasinplacetomeetparticularstandardsand/orregulatoryrequirements(inthiscase,theHomeCareStandards).Selfassessmentcanhelpidentifywhenorwherethereisadeviationfromthedocumentedprocess(riskcontrols),andwhetheraparticularprocessorpracticeishavingapositiveornegativeeffectontheorganisationoroutcomes.Sometimesselfassessmentcanidentifytheneedtochangethedocumentedprocesstoreflectpracticesasstaffoftenimprovepracticesovertime.
ImprovedServiceuser
outcomes
Plan
Do
Check
Act
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MoreinformationabouttheselfassessmentrequiredbytheAustralianAgedCareQualityAgencycanbefoundatwww.aacqa.gov.au.
2.6. MeasuringCQIperformanceinyourorganisation
Inordertomonitorandevaluateyourorganisation’sCQIactivites,itisimportanttoselectperformancemeasuresthatareappropriatetothesituation.Thesecanincludebothqualitativeand/orquantitativemeasures.
TherearenomandatoryperformancemeasuresfortheHomeCareStandards.Serviceprovidersareencouragedtodeveloptheirowndatacollectionandperformancemeasuresrelevanttotheirneedsandsituation.Table2-1providesexamplesofpotentialperformancemeasuresforStandard1:EffectiveManagement–ExpectedOutcome1.5:ContinuousImprovement.
Table2-1: Exampleperformancemeasures
HomeCareStandard1:EffectiveManagement–ExpectedOutcome1.5:ContinuousImprovement
Typeofmeasure
Aup-to-dateimprovementplan Qualitative
Numberoffeedbackformsfromkeystakeholdergroupsandproportionofgroupprovidingfeedback
Quantitative
Proportionoffeedbackformsresultinginanimprovement Quantitative
Numberofinternalauditsconducted Quantitative
Numberofsurveysandresultsofsurveys Quantitative
Afulllistofperformancemeasuresthatcouldbeusedtomonitorperformanceanddemonstratequalityservicecanbeaccessedat:SomeExamplePerformanceMeasuresfortheHomeCareStandardsExpectedOutcomes(Section4,pages60–63oftheGuidetotheCommunityCareCommonStandards).
2.7. IntegratedplanningtosupportCQI
Aqualityimprovementplanisonewayofmonitoringprogresstowardcompletingimprovementneeded.Theplanshouldinclude:
• Clearidentificationoftheissue
• Recommendedactiontoaddresstheissue
• Responsibilityandtimeframeforaction
• Datecompletedandoutcomeoftheaction.
Itisimportanttoincludedatesintheplantohelpensurethatthereisatimelyresponsetoareasforimprovementinrelationtothelevelofriskidentified.
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Thequalityimprovementplancanbeusedasacentralrepositoryforallqualityimprovementactivitesacrossyourorganisation,including(butnotlimitedto):
• AreasforimprovementidentifiedthoughaselfassessmentprocesstoaddresstheHomeCareStandards
• Diversityplanning
• ActiveServiceModel(ASM)plannedimprovements
• Trainingandworkforcedevelopment.
Byintegratingallqualityimprovementactivitiesontoacentralqualityimprovementplan,thesynergiesandlinksbetweentheseactivitescanbemorereadilyidentified,whichislikelytoleadtoamorecollaborativeapproachtoCQIacrosstheorganisation.
AqualityimprovementplantemplateisprovidedinSection4.
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3. QualityresourcesmappedtotheHomeCareStandards
3.QualityresourcesmappedtotheHomeCareStandards
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3.1. QualityresourcesmappedtotheHomeCareStandards
ThissectionprovidesVictorianHACCserviceproviderswithaguidetothetypesofevidencetheycouldusetodemonstatetheyaremeetingtheHomeCareStandards.Inaddition,arangeofqualityimprovementresourceshavebeenmappedtotherequirementsofeachofthethreeHomeCareStandards.TheresourcescomefrombothCommonwealthandVictorianGovernmentsourcesandencompassprogramandregulatoryrequirements.Thelistisnotexhaustivebutservesasaguideforserviceproviders.
Untiltransitionon1July2016theVictorianHACCProgramManualprovidestheguidelinesandrequirementsfororganistionsdeliveringHACCservicesinVictoria.From1July2016,theHACCProgramManualwillcontinueastheguidelinesfororganisationsfundedtodeliverservicesundertheVictorianHACCprogramforyoungerpeople(agedunder65andAboriginalpeopleagedunder50).Theseguidelineswillbeupdatedtoreflectthenewarrangements,asdetailsofthesearrangementsbecomeavailable.
Servicesforolderpeople(peopleagedover65andAboriginalandTorresStraitIslandersagedover50)willbefundedandadministeredundertheCHSP.CHSP-fundedorganisationswillneedtocomplywiththerequirementsoutlinedintheirgrantagreementandsupportingdocuments,includingtheCHSPManualandGuidelines.
Standard1:Effectivemanagement
Theserviceproviderdemonstrateseffectivemanagementprocessesbasedonacontinuousimprovementapproachtoservicemanagement,planninganddelivery.
Expectedoutcome Evidenceexamples Usefulresources
1.1CorporategovernanceTheserviceproviderhasimplementedcorporategovernanceprocessesthatareaccountabletostakeholders
• Documentedgovernancearrangements,including:− Rolesandresponsibilities(orrules/termsofreference)
oftheboardand/ormanagementcommitteeand/orseniorexecutives
− Boardpolicies,includingdelegationprocesses− Recordsrelatedtoboardand/ormanagement
committeeand/orseniorexecutivemeetings
Victorian:
• VictorianHACCFeesPolicyandFeesSchedule
• HACCprogrammanualdiverstiyplanning
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Expectedoutcome Evidenceexamples Usefulresources
• Orientationandtrainingrecordsforboardand/ormanagementcommitteemembersand/orseniorexecutives
• Audits,reportsandplans• Recordsofcompliancewithcontractualobligationsand
service/fundingagreements(e.g.reportingrequirements)• Organisationalplanandotherplanningdocuments(CQI
plan,activeservicemodelagencyimplementationplans,diversityplan,strategicplan)
• Budgetsandfinancialreports
Commonwealth:
• GovernanceInstituteofAustraliaGoodGovernanceGuides
1.2RegulatorycomplianceTheserviceproviderhassystemsinplacetoidentifyandensurecompliancewithfundedprogramguidelines,relevantlegislation,regulatoryrequirementsandprofessionalstandards.
• Procedurestoidentifyandmonitorregulatorycompliance,including:− Ongoingidentificationofrelevantregulationsand
legislation− Identificationoffundingagreementandprogram
guidelinerequirements− Internalauditresultstomonitorcompliancewith
relevantlegislation− Reviewsandupdatestopoliciesandproceduresto
reflectchangesinlegislativerequirements− Communicationofchangestostaff,volunteers,and
whereapplicable,serviceusers• Appropriatepoliciesandprocedurestoreflectlegislative
requirements(e.g.occupationalhealthandsafety,equalemploymentopportunity,superannuation,awards,privacy,insurances,foodsafety,policechecks,etc.)
• Policecheckregistersandprocessestoensurethatallstaffandvolunteershavepolicechecksasrequiredbyprogramguidelinesandapplicablelegislation
Victorian:• Reportinganddata• HACCintransition:Datacollectionfor
theCHSPandHACC• VictorianHACCProgramManual• Serviceagreementinformationkit
(2011)• Incidentreportinginstruction(DH
2013)
Commonwealth:• DSSCHSPreportingrequirements• AgedCareAct1997 /
AccountabilityPrinciples2014
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Expectedoutcome Evidenceexamples Usefulresources
1.3Informationmanagementsystems
Theserviceproviderhaseffectiveinformationmanagementsystemsinplace.
• Recordsstorageareas• Storageofserviceuserrecordsincludingassessments,
reassessments,recordsofcare/services,medicationrecords,servicedeliverydata,complaintsrecords,accidentandincidentrecords
• Processesforserviceuserstoaccesstheirinformation• Systemsforeducatingandtrainingstaffandvolunteersin
theuseofpoliciesandproceduresandstrategiesforinformingstaffandvolunteersofupdatestopolicy,proceduresandorganisationchange
Victorian:• Reportinganddata• HACCintransition:Datacollectionfor
theCHSPandHACC
Commonwealth:
• TheMyAgedCareproviderportal:informationforserviceproviders
• DataExchangewebsite(DSS)
1.4Communityunderstandingandengagement
Theserviceproviderunderstandsandengageswiththecommunityinwhichitoperatesandreflectsthisinserviceplanninganddevelopment.
• Informationonthecommunityprofile• Informationonserviceusers• Theprocessforidentifyinggapsinservicedelivery• Recordsofconsultationswithserviceusersandkey
communitygroupsorpeople(suchasminutesofmeetings,focusgroups,etc.)
• Recordsofparticipationinnetworks/linkswithotherserviceproviders(suchasinteragencymeetings)
• Collectionanduseofconsumerfeedbackforqualityimprovement
• Policiesandprocedures
Victorian:• DiversityPlanningandPractice
Commonwealth:
• ABSinformationonlocaldemographics
• LocalgovernmentandcommunityengagementinAustralia
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Expectedoutcome Evidenceexamples Usefulresources
1.5ContinuousimprovementTheserviceprovideractivelypursuesanddemonstratescontinuousimprovementinallaspectsofservicemanagementanddelivery.
• Internalauditreports• Programevaluations• Activeservicemodelagencyimplementationplans• Diversityplan
Victorian:
• VictorianHACCProgramManualPart1:HACCQualityFramework
• ASMimplementationproforma2014-2015:informationsheet
• DiversityPlanningandPractice• ThePlanDoStudyAct(PDSA)model
forimprovementprojectworkbook• Servicecoordinationcontinuous
improvementframework2012
Commonwealth:
• TheQualityAgencyhome-care-assessment-toolhttps://www.aacqa.gov.au/for-providers/home-careTheQualityAgencyContinuousQualityImprovementPlan
• TheQualityAgencyContinuousQualityImprovmentinformationSheet
1.6RiskmanagementTheserviceproviderisactivelyworkingtoidentifyandaddresspotentialrisk,toensurethesafetyofserviceusers,staffandtheorganisation.
• Proceduresandtoolsforassessmentandcareplanningrelatingtoidentifyingandaddressingoccupationalhealthandsafety(OHS)risks
• Fileauditsthatconfirmcompletedriskassessmentse.g.homesafetyassessments
Victorian:• HACC-program-manualPart1• Vulnerablepeopleinemergencies
policyandguidelines
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Expectedoutcome Evidenceexamples Usefulresources
• Appropriatemethodsusedtocontrolriskssothatserviceprovisioncanoccur
• Incident/accident/hazardreports
Commonwealth:
• RiskmanagementforEmergencyEventsinAgedCare(DSS)
• Emergencypreparedness:clientsandservicespolicySummer2012-13(DSS)
• Guideforcommunitycareserviceprovidersonhowtorespondwhenacommunitycareclientdoesnotrespondtoascheduledvisit
1.7HumanResourceManagementTheserviceprovidermanageshumanresourcestoensurethatadequatenumbersofappropriatelyskilledandtrainedstaff/volunteersareavailableforthesafedeliveryofcareandservicestoserviceusers.
• Dutyofcarestatement• Registerofcurrentstaffqualifications–checkedand
updated• Trainingneedsanalysis,orientationandtrainingrecordsfor
staffandmanagers• Policeandotherchecks(asperCHSPguidelines)• SupervisionprocessesforHACCfundedemployees,
volunteersandvocationalstudentsinalloccupationalroles• Employees,volunteersandvocationalstudentsworking
withserviceusersunder18holdaWorkingwithChildrenCard
• Recruitmentreflectsagencypromotionofactiveageingandawellnessapproach
Victorian:
• VictorianHACCProgramManualPart1(Employeeandrelatedrequirements)
• InductionResourceforHACCAssessmentServices(MunicipalAssociationofVictoria)
• VictorianHACCEducationandTrainingService
• SupportingvolunteerstotakeanActiveServiceApproach:aresourcekitforVictorianHomeandCommunityCareservices.
Commonwealth:• PoliceCertificateguidelinesforaged
careproviders(DSS)
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Expectedoutcome Evidenceexamples Usefulresources
1.8PhysicalresourcesTheserviceprovidermanagesphysicalresourcestoensurethesafedeliveryofcareandservicestoserviceusersandorganisationpersonnel.
• Assestregister• Maintenanceprogramsforvehicles• Staff/volunteertraininginuseofequipment• Theservicedeliveryenvironment
Standard2:Appropriateaccessandservicedelivery
Eachserviceuser(andprospectiveserviceuser)hasaccesstoservicesandserviceusersreceiveappropriateservicesthatareplanned,deliveredandevaluatedinpartnershipwiththemselvesand/ortheirrepresentative.
Expectedoutcome Evidenceexamples Usefulresources
2.1ServiceaccessEachserviceuser’saccesstoservicesisbasedonconsultationwiththeserviceuser(and/ortheirrepresentative),equity,considerationofavailableresourcesandprogrameligibility.
• Referralrecords• Intakeprocessesthatpromoteapersoncentred,activeservice
modelapproach(useofMyAgedCarepathwaywhereappropriate)
• DiversityPlan• Workingwithaccessandsupportorganisations• Informationforpotentialserviceusersontheservices
available,theservicetargetgroupandeligibilityinaccordancewithfundingagreements/guidelines.Thediversityofserviceusersisconsidered
• Timelinessofassessments/intakeandprovisionofservices• Informationonotherrelevantcommunityservices• Waitinglistandprocessestoadviseserviceusersabouttheir
positiononthelist
Victorian:
• VictorianHACCProgramManualPart3(TheVictorianapproachtocare:theactiveservicemodelandAccessandSupport)
• Strengtheningassessmentandcareplanning:AguideforHACCassessmentservicesinVictoria(DepartmentofHealth)
• HACCaccessandassessment• HACCProgramManualPart3:Access
andSupport• CreatingGLBTIinclusiveHomeand
CommunityCareServices:TheHACCPack
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Expectedoutcome Evidenceexamples Usefulresources
• Internalqualityprocesses,includingauditsofserviceusers’filesinrelationtoeligibility
Commonwealth:• CHSPProgrammeManualChapter3• CHSPClientcontributionframework• MyAgedCarewebsite
2.2AssessmentEachserviceuserparticipatesinanassessmentappropriatetothecomplexityoftheirneedsandwithconsiderationoftheirculturalandlinguisticdiversity.
• Thesuitabilityofassessmenttoolsforconductingassessmentsofserviceusersandtheircarer(whenrequired),includingservice-specificassessments
• Theskills,competenciesandtrainingundertakenbystaffcompletingtheassessmentsofserviceusers
• Completedassessments,including:− Timelinessofassessmentsincludingrespondingtothe
referralorinitialcontactandschedulingandcompletingtheassessment
− Considerationofspecialneedsgroups− Involvementoftheserviceuserand/orrepresentative− Completenessoftheassessment− Qualityoftheassessmentinidentifyingrequired
care/services
Victorian:• VictorianHACCProgramManualPart2
(Servicecoordination,assessmentandcareplanning)
• VictorianHACCProgramManualPart3(LivingatHomeAssessment)
• FrameworkforassessmentintheHACCprograminVictoria(2007)
• Strengtheningassessmentandcareplanning:AguideforHACCassessmentservicesinVictoria(DepartmentofHealth)andassociatedworkbook
• StrengtheningdiversityplanningandpracticeinHomeandCommunityCare–planningguide
• StrengtheningagedcareassessmentsforAboriginalconsumers:aguideforagedcareassessmentsforAboriginalconsumers
• CreatingGLBTIinclusiveHomeandCommunityCareServices:TheHACCPack
• HACCLivingatHomeassessmenttool
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Expectedoutcome Evidenceexamples Usefulresources
• PlannedActivityGroups–Makeitmeaningful:assessmentandcareplanningguidelinesandtools
Commonwealth:• EstablishmentoftheMyAgedCare
RegionalAssessmentService(RAS)• WhattheMyAgedCareRegional
AssessmentServicemeansforCHSPproviders
• CHSPProgrammeManualChapter3
2.3CarePlandevelopmentanddelivery
Eachserviceuserand/ortheirrepresentative,participatesinthedevelopmentofacare/serviceplanthatisbasedonassessedneedsandisprovidedwiththecareand/orservicesdescribedintheirplan.
• Careplantemplatesthatreflectagoaldirected,individualisedapproach
• Serviceuserfilesshouldinclude:− Careplan/serviceplanthatreflecttheclient’sassessed
needsandbuildontheirinterests,strengths,aspirationsandgoals
− Careplansthatreflectconsumer(andcarer)involvementindecisionmaking
− CareplansareprovidedtotheclientandallparticipantsintheclientplanincludingtheCommunitySupportworker
Victorian:• VictorianHACCProgramManualPart2
(Servicecoordination,assessmentandcareplanning)
• Strengtheningassessmentandcareplanning:AguideforHACCassessmentservicesinVictoria(DepartmentofHealth)
• Goal-directedcareplanningtoolkit• PlannedActivityGroups–Makeit
meaningful:assessmentandcareplanningguidelinesandtools
Commonwealth:• CHSPGoodPracticeGuide(Livingwell
athome)• QualityofCarePrinciples2014
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Expectedoutcome Evidenceexamples Usefulresources
2.4ServiceuserreassessmentEachserviceuser’sneedsaremonitoredandregularlyreassessedtakingintoaccountanyrelevantprogramguidelinesandinaccordancewiththecomplexityoftheserviceuser'sneeds.Eachserviceuser’scare/serviceplansarereviewedinconsultationwiththem.
• Processesforformallyandinformallymonitoringtheeffectivenessofcareplansandanychangesinhealthandwellbeingofthepersonortheircarer
• Thatreviewsareoccurringtocheckonprogresstowardsgoalsandimplementationofthecareplan
• Thatinformationisactedonandreassessmentsoccurinatimelymannerwhenrequired
Victorian:• Strengtheningassessmentandcare
planning:AguideforHACCassessmentservicesinVictoria(DepartmentofHealth)
2.5ServiceuserreferralTheserviceproviderrefersserviceusers(and/ortheirrepresentative)tootherprovidersasappropriate.
• Linksandprotocolswithotherserviceproviders• Processesforensuringtheconsentofserviceusersortheir
representativestoreferralsandtothesharingofinformationbetweenagencies
• Coordinationprocessesbetweenagenciesthatensureserviceuser’sneedsaremetincluding:− Informationsharing(withconsentfromserviceuser)− Caseconferencing− Documentingofcareresponsibilitiesofotherservice
providersintheserviceusercarerecord− Provisionofsupportforserviceusersduringthetransition
tootherservices− Participationinserviceprovidernetworks(wheretheyare
established)− Referralformsorotherinformationonreferrals,suchas
inserviceusercarerecords− Policiesandprocedures
Victorian:• PrimaryCarePartnerships• HACCProgramManualPart2:Service
coordination,assessmentandcareplanning
• VictorianServiceCoordinationPracticeManual
• Servicecoordinationtooltemplatesandonlinelearningmodule
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Standard3:Serviceuserrightsandresponsibilities
Eachserviceuser(and/ortheirrepresentative)isprovidedwithinformationtoassistthemtomakeservicechoicesandhastheright(andresponsibility)tobeconsultedandrespected.Serviceusers(and/ortheirrepresentative)haveaccesstocomplaintsandadvocacyinformationandprocessesandtheirprivacyandconfidentialityandrighttoindependenceisrespected.
Expectedoutcome Evidenceexamples Usefulresources
3.1InformationprovisionEachserviceuser,orprospectiveserviceuser,isprovidedwithinformation(initiallyandonanongoingbasis)inaformatappropriatetotheirneedstoassistthemtomakeservicechoicesandgainanunderstandingoftheservicesavailabletothemandtheirrightsandresponsibilities.
• Serviceuserinformationprovisionincludes:− RightsandResponsibilities− Privacy− Serviceaccess− Fees− Considerationofspecialneedsgroups− Complaintsandfeedbackmechanism− Processestoperiodicallyremindserviceusersofthis
information− Recordstoevidencethatacomplaintspolicyprovidedto
serviceusers
Victorian:• HACCActiveServiceModel
communicationsresources• HomeandCommunityCare(HACC)
StatementofRightsandResponsibilities
Commonwealth:• CHSPProgrammeManualChapter5• MyAgedCare
3.2PrivacyandconfidentialityEachserviceuser’srighttoprivacy,dignityandconfidentialityisrespectedincludinginthecollection,useanddisclosureofpersonalinformation.
• Recordstoevidencethatinformationaboutprivacyandconfidentialityhavebeenprovidedandexplainedtoserviceusers,carersandfamilies
• Completedconsentforms• Arrangementsforpeoplewithspecialneeds• Policyandproceedures
Victorian:• VictorianInformationPrivacyAct2000• HealthRecordsAct2001• LocalGovernmentAct1989
3.3Complaintsandserviceuserfeedback
Complaintsandserviceuserfeedbackaredealtwithfairly,promptly,confidentiallyandwithoutretribution.
• Processformanagingcomplaints• Informationoncomplaintsandfeedbackprocessesprovided
toserviceusersand/ortheirrepresentatives
Victorian:• VictorianHACCProgramManualPart1:
VictorianHACCProgramComplaintsPolicy
• EMRHACCAllianceConsumerFeedbackToolkit
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Expectedoutcome Evidenceexamples Usefulresources
Commonwealth:• CHSPProgrammeManualChapter5• AgedCareComplaintsScheme
3.4AdvocacyEachserviceuser’s(and/ortheirrepresentative’s)choiceofadvocateisrespectedbytheserviceproviderandtheserviceproviderwill,ifrequired,assisttheserviceuser(and/ortheirrepresentative)toaccessanadvocate.
• Processtoensureserviceuserscanaccessanadvocateoftheirchoice
• Informationontherighttohaveanadvocate• Arrangementsforpeoplewithspecialneeds• Staff/volunteertraining
Victorian:• ElderRightsAdvocacy• HACCprogrammanual
Commonwealth:• AgedCareAdvocacy(DSS)
3.5IndependenceTheindependenceofserviceusersissupported,fosteredandencouraged.
• Activeservicemodelagencyimplementationplans• Careplanningprocesses
Victorian:• PuttingtheActiveServiceModelinto
practice• Strengtheningassessmentandcare
planning:AguideforHACCassessmentservicesinVictoria
• Enablingtheuseofeasylivingequipmentineverydayactivities
• ResourceforprovidersofHACCandprimaryhealthservices:howtheASMandICDMpoliciesalign(DH)
• RDNSMedicationremindercards
Commonwealth:• CHSPProgrammeManual• CHSPGoodPracticeGuide(Livingwell
athome)
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4.1. Overviewofthissection
Thissectioncontainsarangeofpracticalandeasytousetoolstosupportassessing,planningandmonitoringqualityinyourorganisationagainsttheHomeCareStandards.Internalauditingisawayofcheckingthatpracticeisbeingimplementedasplanned;thatis,accordingtotheorganisation’spolicyandprocedures.Dataiscollectedusinganinternalaudittool.SmallerdatacollectiontoolsmayaddressoneprocessoranumberofprocesseswhichrelatetooneormoreHomeCareStandards.
Thesectioncontainsthefollowingaudittoolstoassistyourorganisationtocollectinformationtoallowyoutomonitorandimprovethequalityofyourservices:
• Continuousqualityimprovementtemplate
• Monitoringandmeasuringtools:
− Serviceuserfileaudittool
− Staff/volunteersfileaudittool
− Complaintsandfeedbackform
− Continuousimprovementform
− Stakeholderfeedbacktool
Eachtoolisdescribedbelow.Blanktemplatesareprovidedattheendofthissectionforuseormodificationbyserviceproviders.
4.2. Continuousqualityimprovementplantemplate
ThiscontinuousqualityimprovementplantemplateisdesignedtoassistserviceproviderstorecordandmonitoractionsforimprovementidentifiedthroughaselfassessmentagainsttheHomeCareStandardsaswellasotherareasforimprovementidentifiedthroughreviewingotherpracticesandprocess(forexample,reviewingdiversityplanningandactiveservicemodelactivities).
Itissuggestedthatthetemplatebeusedinconjunctionwithaselfassessmenttool.TheselfassessmenttoolprovidedbytheQualityAgencyisausefulresourcetosupportserviceprovidersinundertakingaselfassessmentagainsttheHomeCareStandards(availableatwww.aacqa.gov.au/for-providers/home-care).
Aboutthequalityimprovementplantemplate
Whereanimprovementopportunityisidentified,itisimportanttorecordthisonaqualityimprovementplan,andtoplanimprovementactivities.Thetemplateprovidesastructuredwayto:
• Recordareasforimprovement,suchasidentifieddeviationsfromthedocumentedprocess
• Outlinetheplannedactions/taskstobeundertaken
• Allocateresponsibilityforimprovementactivitiestorelevantpeopleinyourorganisation
• Prioritiseimprovementactivitiesbasedonanassessmentoftheimpacttheywillhaveforyourorganisationandthepeoplewhouseyourservices
• Setrealistictimeframesforthecompletionoftasks
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• Monitor,measureandreportontheeffectivenessoftheimprovements.
Oncedevelopedandimplemented,thisplanprovidesabasisforassistingserviceproviderstomonitorongoingimprovementactivites.
Acontinuousimprovementplanshouldreflecttheongoingeffortfromanorganisationtoimproveprocessesandservicedeliveryforserviceusers.Anexampleoftheinformationthatmightbeincludedinaplanareprovidedinthetemplateattheendofthissection.Pleasedeletebeforebeginningyourplan.
4.3. Serviceuserfileaudit
Afileauditinvolveslookingatthedocumentsinaserviceuserfiletocheckthattheyarecompletedasrequiredbyyourorganisation’spoliciesandprocedures.Thisusuallyinvolvesusinganaudittool,whichissimilartoachecklisttorecordtheauditfindings.
Theauditfindingsarethenreportedandanynecessaryactiontakenwhereanopportunityforimprovementindocumentationisidentified.Howthereportingandfollowupoccurswilldependonyourorganisation’squalitysystem.Forexample,amanagermightselectonefileoroneprocesseachfortnighttoauditanddiscusstheresultsatstaffmeetings.
Anexampleofaserviceuserfileaudittoolisprovidedattheendofthissection.
4.4. Stafffileaudittool
Aninternalstafffileaudittoolhelpstomeasurewhetherpracticeandprocessmatchtheorganisation’shumanresourcepolicy,proceduresandworkinstructions.
ThedirectcarestafffileaudittoolprovidedattheendofthissectionrelatestoHomeCareStandard1:EffectiveManagement–ExpectedOutcome1.7:HumanResourceManagement.
4.5. Complaintsandfeedbackform
Effectivequalitymanagementsystemsincludeacomplaintsandfeedbacksystemforserviceusers.Standard3:ServiceUserRightsandResponsibilitiesoftheHomeCareStandardssetsouttheexpectationsforaserviceusercomplaintsandfeedbackmechanism.
Thisformprovidedattheendofthissectioncanbeusedoradaptedbyserviceproviderstoprovideaneasyandaccessiblewayforcarerecipients,familymembers,representativesandotherstoprovidefeedbacktotheservice,includingcomplimentsandcomplaints.AComplaintsActionFormisalsoincluded,whichcanbeusedtorecordthecomplaintreceivedandtheactionundertakenbytheorganisationtoresolvetheissue.Theissueshouldalsoberecordedontheorganisation’scontinuousqualityimprovementplan.
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4.6. Complaintsandcomplimentstracker
Thisdocumentassistsserviceproviderstotrackallcomplaintsandcomplimentsreceivedbytheirserviceandusethisinformationtoinformcontinuousimprovementactivities.Thetemplateisdesignedtocapturede-identifiedinformationaboutcomplaintscollectedviathecomplaintsandfeedbackform.
4.7. Continuousimprovementform
Anexamplecontinuousimprovementformisprovidedattheendofthissection.ReaderscanrefertoSection2Maintainingqualityandcontinuousqualityimprovementformorecontextastooptionsforitsuse.Thisformcanbeusedtorecordanysuggestionsforimprovementidentifiedbystaff,volunteers,serviceusersortheircarers.AnImprovementActionPlanisalsoincluded,whichdocumentstheorganisation’sresponsetotheimprovementsuggestions.
4.8. Stakeholderaudittool
ThestakeholderfeedbacktoolisdesignedforthesituationwhereaVictorianHACCserviceprovidermaybrokerpartofitsservicedeliverytoanotherserviceprovider,andwishestocheckwhetherthehumanresourcemanagement,recruitmentandselectionrequirementsofthesub-contractingagreementarebeingfollowed.
CompletionofthisqualitytoolwouldassistserviceprovidersindemonstratingcompliancewithHomeCareStandard1:EffectiveManagement–ExpectedOutcome1.1:CorporateGovernance.
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Continuousqualityimprovmentplan
Standard/expectedoutcome
Ratingfromselfassessment/date
Issueandimprovementrequired
Responsibleperson
Requireddate Outcomeanddateclosed Reviewdate
1.7HumanResources
NotmetJuly2016
Notallstaffhaveuptodatepolicechecks
JaneS(HR) September2016 HRpolicyupdatedtoreflectpolicecheckrequirementsQualityPolicyupdatedtoincludeinternalauditingofstafffilestoensurepolicechecksarekeptuptodate
July2017
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Serviceuserfileaudit
PracticesandprocessesInserviceuserfileorotherrecord(ü,XorNA)
1 2 3 4 5 6
EO2.1ServiceAccess
Intakeform/s
Accessoccursasperpoliciesandprocedures
EO2.2Assessment
Suitableassessmenttool
Toolcompletedandidentifiesrequiredcare/serviceneeds
Considersinformationfromotherproviders,ifapplicable
Serviceuser/representativeinvolvement
Arrangementsforpeoplewithspecialneeds
Riskassessserviceuser’shome,applicable(1.6and1.8)
Assessmentincludesphysical,socialandpsychosocialindependencefocusingonstrengths&
abilities(referto3.5)
Assessmentoccursasperpoliciesandprocedures
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PracticesandprocessesInserviceuserfileorotherrecord(ü,XorNA)
1 2 3 4 5 6
EO2.3CarePlanDevelopmentandDelivery
Suitabilityofcare/serviceplan
Care/serviceplancompletedandidentifiesneedsAND:
• Isgoalorientatedand/oroutcomesbased
• Recognises&addressescomplexcareneeds,includingcoordinationofcare/services
withotherproviders
• Promotesindependence/qualityoflife(and3.5)
Serviceuser/representativeinvolvement
Serviceuser/representativegivencopyofthecare/serviceplan
Theserviceagreementorofferincludes:
• Servicesthatmaybeofferedtomeettheservicesusers’needs
• Thecircumstancesunderwhichthetype,duration,orfrequencyofservicedelivery
maybechanged,refused,suspendedorwithdrawn(andEO3.1)
• Timeframesforreviewofthecare/serviceplan
• Careplandevelopmentasperpoliciesandprocedures
EO2.4ServiceUserReassessment
Regularmonitoring/reassessmentofserviceuser’sneeds,preferences,goalsandoutcomes
Care/serviceplansarerevisedasrequired
Servicedeliverychangesmadeinconsultationwiththeserviceuser
Reassessmentoccursasperpoliciesandprocedures
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PracticesandprocessesInserviceuserfileorotherrecord(ü,XorNA)
1 2 3 4 5 6
EO2.5ServiceUserReferral
Referralsto/carecoordinationwithotherproviders,ifapplicable
Serviceuser’srepresentative’sneedsconsidered/referraltootherprovidersifneeded
Referraloccursasperpoliciesandprocedures
EO3.1InformationProvision
Evidencethatserviceuserhasreceivedrequiredinformation
Provisionofinformationasperpoliciesandprocedures
Summaryoffindings:
Datecompleted:
AreasforimprovementaddedtoCQIplan:
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Directcarestaffaudittool
PracticesandprocessesInStaff/VolunteerFileorOtherRecord(ü,XorNA)
1 2 3 4 5 6
EO1.7HumanResourceManagement
Staff/volunteerpositiondescriptions&selectioncriteria
Recruitmentprocessesanddocumentation:
• Advertisingofpositions
• Receiptofapplication/resume
• Shortlisting/interviewing
• Referencechecks
• Policechecks(andEO1.2)
• WorkingwithChildrenChecks(andEO1.2)
• Appropriateskills,competence,qualificationsevidenced(andEO1.2)
• Regularcheckingofdrivinglicencesand/ormotorvehicleinsurance,asrequiredby
organisationalprocedures
Employmentcontract
Inductionororientationprogramrecord
Educationandtrainingrecords,asapplicable:
• Compulsoryeducationandtraining,e.g.
− OHS,infectioncontrol(1.6)
− Emergencyprocedures(1.8)
− Privacylegislation(3.2)
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PracticesandprocessesInStaff/VolunteerFileorOtherRecord(ü,XorNA)
1 2 3 4 5 6
− Complaintsandfeedback(3.3)
− Advocacy(3.4)
• Othereducationandtraining
• Trainingneedsidentificationstrategy
• Participationrecords
• Evaluationofeducationandtraining
• Orientationandtrainingtoaddressanyspecialorspecificneedsofserviceusers
Performancereviewsconducted
Summaryoffindings:
Datecompleted:
AreasforimprovementaddedtoCQIplan:
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Complaintsandfeedbackform
Date: Name:(optional)
Thisisa: qComplaintqComplimentqComment
Contactdetails:(optionalifyouwouldlikeustofollowupwithyou)
Pleasenote:Youdonothavetotellusyournameandcontactdetails.However,withoutthisinformationwewillnotbeabletotellyouabouttheactionwehavetakenonyoursuggestion.
Iama: qCarerecipientqFamilymemberqRepresentative
qStaffmemberqStaffmemberonbehalfofcarerecipientqOther:
Pleasetellusaboutyourissueorconcern:
Thankyouforhelpingustoimproveourservices!
Date: Personauthorising:
Reviewduedate: Page1of2
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Complaintsactionform (ThissectionforOfficeUseOnly)
Reportedto: Datereported:
Actionrequired: Actiontobecompletedby:
Describeactiontaken(includedates):
Describeoutcome(includedates):
Notefurtheractionrequired(ifapplicable): DateenteredonQIPlan:
Date: Personauthorising:
Reviewduedate: Page2of2
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Complaintsandcomplimentstracker
RefNo. Datereceived
ComplaintType
ComplainantType
MainIssue Actionstaken Policy/Proceduresaffected
Dateclosed
0312 21.2.16 Servicequality carer Workerskeepchangingtimesandthisisnotcommunicated
Client/carerprovidedwithanupdatedserviceplan
Schedulingprocedureupdated.
28.2.16
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Continuousimprovementform
Date: Contactdetails:(optionalifyouwouldlikeustofollowupwithyou)
Name:(optional)
Pleasenote:Youdonothavetotellusyournameandcontactdetails.However,withoutthisinformationwewillnotbeabletotellyouabouttheactionwehavetakenonyoursuggestion.
Pleasetellusaboutyourissueorconcern:
Pleasetellusaboutyoursuggestionforimprovement:
Thankyouforhelpingustoimproveourservices!
Date: Personauthorising:
Reviewduedate: Page1of2
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Improvementactionform
Reportedto: Datereported:
Actionrequired: Actiontobecompletedby:
Describeactiontaken(includedates):
Describeoutcome(includedates):
Notefurtheractionrequired(ifapplicable): DateenteredonQIPlan:
Date: Personauthorising:
Reviewduedate: Page2of2
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Stakeholderaudittool
Criteria 1 2 3 4 5
Nopersonalidentifyinginformationistoberecordedonthisreportform.
S=SatisfactoryNS=NotSatisfactoryNA=NotApplicable
Appropriatequalificationisheld:CertificateIIIlevelasminimum(CertificateIIIinHACC/CertificateIIIinIndependentSupport)
Evidenceofinterviewsheld
Referencechecksoccuraspartofselectionprocess
Pre-employmentpolicecheck(internationalifnecessary)
CurrentWorkingwithChildrenCardifworkingwithserviceusersunder18years
Validdrivinglicencecheckrecord