Department of Human Services Standards
Introduction
Program
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Overview of standards
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Independent review and service agreement requirements
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Scope of independent reviews
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Activities in scope for review
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Independent review bodies
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The review and planning for the review
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Next steps
Department of Human Services Standards
Overview of Standards
Department of Human Services Standards
Features include:
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Department of Human Services Standards
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Independent review body’s standards to assess:
• governance and service management including:
▪ governance processes
▪ strategic planning
▪ cultural competency
▪ legal compliance
▪ financial management and accountability
▪ contract management
▪ risk management
◦ occupational health and safety
◦ infection control
◦ insurances
◦ finance and contracts
◦ information systems
Department of Human Services Standards
• quality systems that incorporate continuous quality
improvement
• complaints, allegations and appeals management
• records management
• information sharing/accessibility, including privacy and
confidentiality
• human resource management
▪ recruitment (including pre-employment criminal
history checks)
▪ training and development
▪ performance review and management
▪ staff competencies
• consumer participation and feedback.
Department of Human Services Standards
The Department of Human Services Standards take a human rights
perspective to support the achievement of personal outcomes for
clients. This is the human side of how the service provider supports the
client. For example:
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how well clients are treated by the service provider
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whether their needs are being met
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whether their rights are being respected
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whether they are safe and adequately cared for in the service
environment
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and importantly, whether they have a choice and opportunity for
active participation in the way the service is delivered.
Department of Human Services Standards
• Empowerment
• Access and engagement
• Wellbeing
• Participation
Criteria
Standard 1 Empowerment
1.1 People understand their rights and responsibilities.
1.2 People exercise their rights and responsibilities.
Standard 2 Access and engagement
2.1 Services have a clear and accessible point of contact.
2.2 Services are delivered in a fair, equitable and transparent manner.
2.3 People access services most appropriate to their needs through
timely, responsive service integration and referral.
Criteria
Standard 3 Wellbeing
3.1 Services adopt a strengths based and early intervention approach to
service delivery that enhances people’s wellbeing.
3.2 People actively participate in an assessment of their strengths, risks,
wants and needs.
3.3 All people have a goal oriented plan documented and implemented.
This plan includes strategies to achieve stated goals.
3.4 Each person’s assessments and plans are regularly reviewed,
evaluated and updated. Exit/transition planning occurs as
appropriate.
3.5 Services are provided in a safe environment for all people, free from
abuse, neglect, violence and/or preventable injury.
Criteria
Standard 4 Participation
4.1 People exercise choice and control in service delivery and life
decisions.
4.2 People actively participate in their community by identifying goals and
pursuing opportunities including those related to health, education,
training and employment.
4.3 People maintain connections with family and friends, as appropriate.
4.4 People maintain and strengthen connection to their Aboriginal and
Torres Strait Islander culture and community.
4.5 People maintain and strengthen their cultural, spiritual, and language
connections.
4.6 People develop independent life skills.
Department of Human Services Standards
Independent review requirements
Department of Human Services service agreement requirements
Under the 2012-15 service agreement organisations that
provide direct client services are required, unless exempt by
the department to:
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undertake an independent review against the
Department of Human Services Standards by an
independent review body once every 3 year service
agreement period (by July 2015 unless a service
provider is required to apply for renewal of registration
prior to this date).
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obtain accreditation and remain accredited by the
independent review body. This entails full compliance
with the Department of Human Services Standards.
Review flow chart
Scope of independent reviews
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Service providers funded for more than $102,000 for inscope activities are required to undertake an
independent review.
• Service providers that receive over $204,000 funding
for in-scope activities to provide goods, aids and
equipment services are required to undertake an
independent review.
• Service providers that receive over $204,000 in total
departmental funding for advice, information, referral
are required to undertake an independent review.
• Exceptions apply.
Exemptions
With departmental approval:
• service providers that receive less than $102,000 in total
funding for in-scope activities may be exempt from
independent review and required to undertake a selfassessment report and quality improvement plan only
• service providers funded for less than $20,400 for inscope activities and/or funded for activities which do not
involve a direct client relationship (e.g. professional
development, research and policy) may be exempt from
the self-assessment report and quality improvement
plan.
Activities in scope for review
Funded activities in scope of an independent review are
detailed in the fact sheet.
New activities in scope for independent review include:
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disability advocacy
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sexual assault services
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youth justice and youth services.
Service providers have a responsibility to check the
activities in scope, which are updated from time to time.
and available from the department’s website.
Activities in scope for review
Service providers that have not been reviewed previously
but now have activities in scope of review are required to
undertake an independent review and achieve
accreditation/certification by June 2015.
The department will notify service providers that receive
departmental exemption from undertaking an independent
review or self-assessment and quality improvement plan.
Funding contribution towards a review cost
The department will be contributing towards the cost of the
Department of Human Services Standards independent
review.
Once determined service providers will be advised in
writing.
Department of Human Services Standards
Independent review bodies
Independent review bodies
• Must be impartial and must declare any conflict of
interest.
• Are required to follow either the relevant Joint
Accreditation System of Australia and New Zealand
(JAS-ANZ) Procedure or Deed of Agreement.
• Are independent of the Department of Human Services.
• Bound by a code of ethics, have a police check and a
working with children check.
Department-endorsed independent review bodies
As at 20 August 2012, department-endorsed independent review bodies are:
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Joint Accreditation System of Australia and New Zealand (JAS-ANZ)
accredited bodies:
▪ AHA Quality Certification Services
▪ BSI Group
▪ Global-Mark
▪ International Standards Certifications (ISC)
▪ NCS International (NCSI)
▪ SAI Global
Australian Council of Healthcare Standards
Health and Disability Auditing Australia (HDAA)
Quality Improvement and Community Services Accreditation (QICSA)
Quality Management Services (QMS)
The Council on Quality and Leadership (CQL)
Department-endorsed independent review bodies governance and
management standards
• Joint Accreditation System of Australia and New Zealand (JAS-ANZ)
accredited bodies use the 9001:2008 quality management system
(ISO standards)
• Health and Disability Auditing Australia (HDAA) use the 9001:2008
quality management system (ISO standards)
• Quality Management Services (QMS) use the Australian Service
Excellence Standards
• The Council on Quality and Leadership (CQL) use its own Quality
Measures including Basic Assurances and Responsive Services
• Quality Improvement and Community Services Accreditation
(QICSA) use the Quality Improvement Council (QIC) Health and
Community Services Standards
• Australian Council of Healthcare Standards use the Evaluation and
Quality Improvement Program (EQUIP) Standards
Selecting an independent review body
• Look for an independent review body as soon as
possible.
• Approach more than one independent review body.
• Consider what is important for your organisation and
develop questions to ask at the interviews.
• Make sure that the independent review body
understands the work your organisation does.
Department of Human Services Standards
The review
Outcomes of a review
• Compliance
• requirements of each standard met
• outcomes shown to be effective
• Partial Compliance
• Non-compliance (must be rectified to achieve
accreditation/certification)
• outcomes shown to be partly or non-effective.
• Other opportunities for improvement, not required to
meet the standards
Department’s responsibilities in relation to the review
• Track reviews and completion dates.
• Convene moderation forums with IRBs.
• Respond to notifiable issues.
• Monitor quality, compliance trends and training needs.
• Analyse data and develop a statewide report.
• Report to stakeholders.
• Ensure that IRBs adhere to their responsibilities as
defined in the JAZ-ANZ procedure or Deed of
Agreement.
Service providers responsibilities in relation to the review
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Appoint a key contact person throughout the review.
Ensure relevant stakeholders and clients understand
what is involved for them and are supported to make a
meaningful contribution.
Provide the IRB with:
▪ documentation, access to staff and client files
▪ a snapshot of the organisation e.g. staffing,
facilities, client groups, special features etc.
Independent review bodies responsibilities in relation to the review
• Specified in the Deed of Agreement or JAS-ANZ
Procedure.
• Advise the department when it is engaged by a service
provider and review dates are booked.
• Review of service provider’s systems/policies/
documents/reports etc.
• Review a sample of sites and files (client/staff/carer).
• Opening and closing meetings.
Independent review bodies responsibilities in relation to the review
• Advise the department of any notifiable issues.
• Client participation/interviews (interviews will not include
children and young people under the age of 18 years in
out-of-home care, youth justice or disability services).
• Stakeholder feedback (includes staff, clients, carers,
management, partner organisations, etc).
• Provide a report at completion of the review to the
service provider and Standards and Regulation Unit.
• Mid-cycle review.
Sampling methodology for site visits
The site and/or outlet selection criteria should consider:
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results of the service provider’s self-assessment
processes or previous audits by an independent
review body
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records of complaints and communications and other
relevant aspects of corrective and preventive action
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significant variations in the size of the sites and/or
outlets and number of consumers
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whether sites and/or outlets are based in homes,
rather than offices
Sampling methodology for site visits
• whether sites are operated by subcontractors
• modifications since the last audit
• geographical location and dispersion
• each IRB will utilise its own sampling formula
• the formula will be similar to the square root of the
total number of sites, plus 1 (or rounded up)
• selection of sites by IRBs will be random and must
represent a cross section of services delivered by
the service provider.
Sampling methodology for staff, carer and client file audits
• The formula will be similar to the square root of the
total number of staff, carer and client records, plus
1, (or rounded up).
• Selection of files by IRBs will be random and must
represent a cross section of services delivered by
the service provider.
Notifiable issues
Where the review team suspects, has evidence of, or receives a
complaint or allegation about:
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the health, safety, abuse or risk to a client or where there is a failure
to meet basic client needs
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a service provider is experiencing significant organisational
disruption and executive mismanagement
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the independent review body has serious concerns about the
ongoing financial viability of the service provider
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a service provider engages in conduct which is fraudulent or
potentially fraudulent or is engaged in other criminal activities.
Process to address non-compliance with the standards
• Service providers must address all non-compliances in
order to achieve accreditation/certification.
• To attain accreditation, a service provider must
immediately resolve any non-compliance that places a
client at significant risk; or resolve any other noncompliances within a maximum of six months.
• Response will be led by the Standards and Regulation
Unit (SRU) if the service provider has immediate risk
issues or fails to meet requirements after completion of
the review process.
Content of written review reports shall include
• Service provider’s sites and those sampled by the
review team.
• Service provider’s staff and effective full-time
positions as provided by the service provider.
• Number of people accessing the service provider’s
services.
• An executive summary.
• Number of staff, client and volunteer files reviewed.
Content of written review reports shall include
• Table outlining compliance with the Department of
Human Services Standards.
• A separation of performance data for:
• disability residential services
• out-of-home care
• community-based child and family services.
• Summary of service provider’s strengths and
opportunities for each of the Department of Human
Services Standards.
Content of written review reports shall include
• Actions undertaken to meet the Department of
Human Services Standards.
• Aggregate data for client and staff file audits.
• Aggregate feedback from stakeholder consultation.
• Comparison of the service provider’s performance
across different sites / geographic locations where
this is relevant.
• Accreditation/certification status.
Department of Human Services Standards
Planning for the review
Planning for the review
• May involve initial site visit, or may be conducted
remotely
• Objectives and scope of review confirmed
• Profile of organisation provided to reviewers to ensure
representative sample
• Review plan/schedule developed
• Undertaking the selected independent review body’s
self-assessment or pre-review process
• Collect evidence for each of the criteria
Things for service providers to consider
• Is there a policy/procedure in place?
• How is it made available or communicated?
• Is it accessible and to whom?
• Do staff know how to use it?
• What is in place so that they use it?
• Are your systems evaluated?
• How do you know?
Quality system
DICED
D
I
C
E
D
Documented/described in writing
Implemented/integrated into practice
Communicated
Evaluated
Designated responsibility
Triangulation methodology
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Documentation is reviewed by the
review team.
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The practice is observed by the review team.
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Staff, clients and stakeholders speak to the review team.
Reviewers will need to satisfy themselves that the standard is
being met.
Service providers will be rated against each criteria.
Supporting tools
The Department of Human Services has developed an:
• evidence guide
• staff and carer file audit tool (mandatory for review bodies)
• client file audit tool (mandatory for review bodies)
• self-assessment report and quality improvement plan
Department of Human Services Standards evidence guide
The Department of Human Services Standards Evidence Guide
provides information in the following areas:
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each standard is summarised and describes the intent of that
standard. The standard has criteria which describes the key
components.
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examples of evidence that support the provision of services across
more than one service area (common evidence)
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service-specific evidence relevant to the needs of particular client
groups
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evidence indicators to be used to ‘measure’ the extent to which the
service provider has met each standard, however, they are not
prescriptive.
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information on which supporting documents may help provide
evidence to address the standards.
Standards model
Department of Human Services Standards model
Independent review body:
odetermines governance and management standards
ocriteria required to achieve accreditation/certification
Funded organisation selects a department-approved independent
review body
Department of Human Services:
odefines the Department of Human Services Standards and
performance criteria
One independent review during each 3 year service agreement period
Timing of review determined by independent review body and funded organisation.
Requirement to ensure compliance with registration and other legislative requirements.
Independent review body undertakes the review
Accreditation / Certification
Review report to DHS
Department of Human Services Standards
Next steps
Self-evaluation processes
• Read the evidence guide.
• Expect everyone to participate - create an environment
for reflection and quality improvement.
• Plan and prepare.
• Self evaluate including client and staff file reviews.
• Include all stakeholders – service users, board,
volunteers, partnering organisations etc.
Be informed
• Review standards and tools i.e. Department of Human
Services Standards, evidence guide, staff and carer file audit
tool (mandatory), client file audit tool, self-assessment tool.
• Familiarise yourself with the procedures and requirements of
the reviewing body.
• Talk to your Program and Service Advisers, regional contacts,
independent review bodies or the Standards and Regulation
Unit.
• Department of Human Services’ website at
www.dhs.vic.gov.au/about-the-department/documents-andresources/policies,-guidelines-and-legislation/department-ofhuman-services-standards
Questions?
More information
To learn more about the implementation of the standards, ask questions
or provide feedback you can:
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Visit the department’s website (http://www.dhs.vic.gov.au)
(http://www.dhs.vic.gov.au/about-the-department /documents-andresources/policies,-guidelines-and- legislation/department-of-humanservices-standards)
Visit the department’s Policy and Funding Plan webpage
(http://www.dhs.vic.gov.au/about-the-department/plans,-programsand-projects/plans-and-strategies/key-plans-and-strategies/policyand-funding-plan-department-of-human-services)
Contact:
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Standards and Regulation Helpdesk on 9096 2745 or email:
dhsstandards@dhs.vic.gov.au
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Anna Barnes on 9096 2577 or email
anna.barnes@dhs.vic.gov.au