Preparing for Certification under the HSQF and the external auditing process.
Services who are funded under Community Services will be familiar with the Community Services
Standards, and self-assessing against these standards. The new Human Service Quality Framework, which
replaces these, will require some organisations to undergo certification and assessment by an external
auditor. Services will be given notice of this requirement and provided time to prepare for this change, but
it is wise to consider your preparation as early as possible. Some services who also receive funding from
other programs, such as Disability Services or HACC/Community Care, will be familiar with external
auditing.
You can find useful information about the process of external auditing requirements here. (This Fact Sheet
refers to Child Safety Services which require a License. However, the HSQF certification process is the same.
The difference for Child Safety Services is that this forms only part of their Licensing requirements.)
You can find some important information about things to consider when selecting a certification body here.
It is important to note that certification is an ongoing process, so your organisation is likely to have an
ongoing relationship with the certification body you contract to undertake your audit.
1. The first step in preparing your organisation for this process is always the self-assessment. This
allows you to match various evidence you have against each standard and indicator to demonstrate
that you comply. This process will also help you to identify any gaps or inconsistencies that need to
be addressed. Most services will have self-assessed against the Community Services Standards
already. The HSQF largely covers the same requirements which are covered under six standards
instead of eleven) As a result, the information from your current self-assessment can be mapped to
the HSQF Standards and Indicators to ensure all areas are covered. The HSQF standards
comparison document maps the two sets of standards, to make it easier to locate your information.
There is a HSQF self-assessment tool here into which you can gather your information.
Prior to your first audit, you will be asked to provide copies of policies and
procedures, and information about your self-assessment and any improvement
actions you have taken/are taking in response to this.
We suggest you start with your existing policies and procedures and map these against the relevant
standard and indicator/s. At some point it will be helpful to number your existing policies and
procedures so they are consistent with each HSQF Standard (more on this later). With only six
standards, the HSQF is less prescriptive, and you may use your discretion to determine the best
“fit” for some policies (and they may be relevant to more than one standard/indicator).
2. Your policies set down the “rules” or standards you aspire to. Auditors will also want to see
evidence of how these are implemented and understood. This may include talking to staff to
check their understanding and practice, and other paperwork which demonstrates implementation,
such as forms you use to implement policy and documents you produce such as strategic plans,
marketing materials and registers. List the examples that you have against the indicators but also
look at your own policies to make sure that you have consistent information and evidence. For
example, if your policy says you collect certain information from clients in order to provide the best
service: do you have a referral/intake form? Does is seek information that is consistent with your
policy? Is it up to date? Does it have a privacy statement on it consistent with that policy? Or do
you do this via a separate notice? If your policy says you do a strategic plan every x years, can you
produce one which is current? Note what you have and what is missing or needs checking.
One way of keeping track of these consistencies is to make sure all relevant forms and
documents are listed at the end of each policy (there is a space for this in the
templates), and to have a clear process for updating policies (see the Information
Management Policy template and guide for some ideas) that includes checking all
associated documents for any necessary changes or updates.
3. This information can be added to your self-assessment and form the basis of an improvement plan
that lists items to be completed in preparation for auditing. This step is important because one
thing auditors will look for is not just evidence of compliance, but of improvement and moving
towards compliance. Record the actions that are needed, and record the work taken towards
achieving these actions. Auditors will look at these items and see that you are working towards
compliance – this is particularly important if you are not likely to have everything in place for the
initial audit. These may become items auditors look at again during the maintenance audits.
Get in the habit of systematically keeping records with the audit in mind.
For example, if you need to train staff in new policies keep an attendance sheet or a
copy of the meeting minutes where this was discussed. Ideally you would maintain a
training register, but even just putting a copy of these documents in a training folder
will help show what you have done when it comes to audit time. If you get a trainer
in, slip the program description into your folder.
4. In a similar vein to recording improvement actions is the development of a document control
system. This allows you (and an auditor) to ensure you have the latest versions of key organisation
documents, policies and procedures and demonstrate how you have improved your systems and
documentation. The general principles of quality assurance relate to ensuring the quality of
products and in the community services context, it is about the consistency referred to in point 2.
The complexity of your systems should be appropriate to the complexity of your organisation. The
Information Management Policy template and guide provides an example of a document control
system you can use or adapt. Simple practices such as numbering policies and forms and using
consistent file naming can help a lot in controlling key organisation documents.
5. As we move into a certification system with JAS-ANZ, we can expect requirements that are
generally consistent across industry sectors. These would include: Continuous Improvement, Risk
Management, and Regulatory Compliance. These are referred to in the HSQF Standards, and policy
templates are provided on Community Door.
6. Prepare for your site visit. Your auditor will request you to provide some documents before they
visit. Auditors may have specific requests based on the desktop review of the documents you have
provided.
A useful process is to go back to your self-assessment and look at the evidence you have listed
against indicators. For each item, ask yourself where it is and how can you access it. You may find
you can gather some items and put them in a folder (or folders). This may seem like a lot of work,
but remember the audit process will continue happening, so once you have your material together,
you can add in new materials or replacements ready for the next auditing visit. You can set up your
folders with dividers for each Standard, which makes it easier to find information during the audit
visit.
Sometimes this approach is not workable, or, in a small office, it may be easy to lay your hands on
information in various formats. Another approach is to simply note the location of the information
– the computer filename, the filing cabinet, storage containers, etc, and this as a reference during
your audit visit. It can be useful to be on the front foot and have this list printed out before the
audit, with a copy for the auditor. They can then indicate which items they would like to see and
you will be able to find them efficiently and create a great impression.
7. Auditors will also look at
 Staff – being adequately qualified for the task, which includes performance management
and ongoing training.
 Performance data – this may include the standard data you provide to your funders. Do
you have other performance objectives and targets (consistent with the expectations of the
Standards)? Can you provide data demonstrating how you are performing against these?
 The Board or Management Committee – governance is one of the Standards, but it is also
important to demonstrate consistency and commitment across all levels of the
organisation. Make sure your Board or Management Committee are aware of and
understand the audit process, and have the necessary briefings beforehand. They will
generally be required to meet with the auditors during the site visit.
 Clients/service users (usually a sample). This will necessarily vary depending on the nature
of your service/s. Give consideration to how this may work for your organisation, and
discuss this with your auditor. Consider how you will gain consent (if necessary) and protect
the privacy of individuals.
 Client files – discuss requirements with your auditor. Make sure files are complete and up
to date. It is also useful to conduct internal file audits at regular intervals. Keep records of
these audits and any corrective actions taken.
8. Large organisations with multiple sites and services
The HSQF allows for multiple site organisations to receive a single certification. The audit process
includes a head office audit, as well as visits to different service sites so that the auditors can assess
how well policies and procedures work in practice and whether service delivery is aligned to the
standards. Auditors use a sampling processes to determine which service sites to visit. You should
discuss how this sampling process works and what it means for your service with your certification
body during the audit planning stage. This will o allow you to prepare and brief those sites who will
be directly involved.
Information about these requirements are included in the following documents from the JAS-ANZ
site:
http://www.jas-anz.com.au/images/stories/Documents/Procedures/HS_Scheme_Pt1.pdf
and
http://www.jas-anz.com.au/images/stories/Documents/Procedures/HSQFSchemePt2.pdf
9. Following the audit site visit
You will be provided with a written report following your site visit and you have 5 days to respond
to the facts/correctness of the report. Essentially, you must comply with all the Standards and
Indicators. The report will identify any “non-conformities” and you will need to come to agreement
with the auditors as to how these will be addressed. These might apply to some aspect of an
indicator that you don’t currently meet adequately, and need to be closed out within 12 months of
the audit. Auditors may also identify “major non-conformities”. These may be major noncompliance with an Indicator, but may also include:
 Non-conformities within 3 indicators or more in one Standard or
 Non-conformities across 3 or more of the Standards.
Major non-conformities must be closed out or downgraded to a non-conformity within three
months. Certification may be withheld or suspended while there are unresolved major nonconformities.
Of course, you will need to keep records of all improvement actions you take to address nonconformities.
Please Note:
“If an auditor considers that a human service organisation’s processes for the periodic review
of compliance with the prescribed requirements of relevant legislation, regulation or policy
are inadequate, the auditor shall progress the issue as a major nonconformity to Standard 1.1,
as well as to any other relevant standard.”
http://www.jas-anz.com.au/images/stories/Documents/Procedures/HSQFSchemePt2.pdf (P27.4.9)
10. Maintenance Audits
Certification audits are held every 3 years, with a maintenance audit held mid-cycle (18 months
from certification). Maintenance audits will look at 4 Standards from HSQF. Auditors are to include
the following in these audits:
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reviewing any changes to services, organisational structure or personnel
reviewing the effectiveness of actions taken in response to consumer complaints
a review of the effectiveness of actions taken in response to concerns raised by staff
a review of the effectiveness of service or process controls and self-assessments
a review of the effectiveness of responses to nonconformities identified during self
assessments and external audit where applicable
a review of the organisation’s practices to achieve the requirements of the standards within the
scope of the audit
interviewing the responsible managers and a sample of consumers