‘Self-assessment’ refers to the process of the service provider checking its own compliance with the standards. For some service providers, this is then submitted to the Department as the final step in demonstrating compliance, Service providers undergoing an independent audit will use their self-assessment results to demonstrate the extent to which they comply with the standards to their third party auditor.
Self-assessment is an essential step for service providers in determining where they are on their quality management journey and what the next development steps are to be. Self-assessment is not about finding fault or blame; rather, it provides opportunity to recognise good work being done, share findings with staff, customers and stakeholders, and inform quality improvement plans. Self-assessment also helps service providers prepare for external audit by identifying areas that need addressing in order to comply with quality and/or industry standards.
The self-assessment process requires some planning and preparation to ensure the process has direction, leadership and resources, and that people involved understand why it is being done and what is to be achieved. The steps outlined below generally flow from one to the next, however, there may be times when it is necessary to return to a previous step or action to reconsider or repeat.
Evidence can be gathered from various sources to show how a service provider is meeting each standard and its performance indicators – this includes assessing whether the evidence collected meets the intent of all common and relevant funding stream/service type requirements outlined in the relevant HSQF User Guide.
The strongest evidence is that which can be verified through interview, observation and documentation – ‘people, process and paper’. Service providers should look for examples of evidence from each of these sources for every standard indicator. There is no set rule about the amount of evidence that should be recorded.
Below are some examples of the types of evidence available from the different sources:
- people using services are satisfied with the support they receive
- people using services participate in activities that are consistent with their individual support plan and their goals people using services are clear about what service they are receiving, who will be delivering it and how they can seek change or provide feedback (if required)
- staff are able to explain how policies and procedures for management of complaints and critical incidents apply to their role.
- people using services are consulted in the development of individualised plans and these plans are regularly reviewed to ensure that goals are being met
- policies and procedures are regularly reviewed and approved by the relevant governance group
- regular meetings are held with appropriate personnel to ensure staff, people using services and visitors are aware of emergency evacuation procedures
- regular emergency evacuation drills are carried out and analysis of outcomes undertaken for continuous improvement
- scheduled maintenance of equipment has occurred and repairs/replacements have been carried out.
- governance documentation (such as Board or Management Committee reports)
- strategic, operational plans and policies and procedures
- information provided to people using services such as handbooks or ‘welcome packs’
- human resource information (both electronic and paper versions) such as personnel files, criminal history and working with children checks, training records, performance reviews and records of disciplinary action
- files of people using services (both electronic and paper versions) including individual case plans
- meeting minutes
- internal review or evaluation reports
- complaints and critical incident reporting registers
- other records, including results of feedback from people using services.
When to do a self-assessment
- There is no ‘right’ or ‘wrong’ time, what works for one organisation may not work for another.
- Consider internal and external factors that may help or hinder the process.
- Challenge presumptions about timing – perhaps waiting until “things settle down” means missing development opportunities.
- Consider what and when the results can be used for: strategic planning, staff work planning, project budget development, etc.
- Think about what needs to be achieved by when and work backwards from that.
Practice tip: Self-assessment support tools
- Analyse what tools will best support self-assessment and longer term quality management: paper based, electronic, and on-line?
- Consider financial costs as well savings on time and effort.
- Consider how easy the tools are to use and whether training is required.
- Identify how can the tools assist and contribute to broader planning, monitoring and reporting.
- Consider if an auditor needs access to the tools as part of the independent audit process (where relevant)
Information Sheet Links:
- Service Provider Self-Assessment