KIMBERLEY ABORIGINAL MEDICAL
SERVICES COUNCIL (KAMSC)
ABN; 31 892339645
QUALITY MANUAL
Contents
1.
1.1.
Scope and exclusions
4
Scope .......................................................................................................................................................................... 4
1.2.
Exclusions from iso 9001 2008 .................................................................................................................................. 4
1.3.
Purpose of this document ........................................................................................................................................... 4
2.
2.1.
Organisation profile
5
History ........................................................................................................................................................................ 5
2.2.
Legal structure ............................................................................................................................................................ 5
2.3.
Vision ......................................................................................................................................................................... 5
2.4.
Mission ....................................................................................................................................................................... 5
2.5.
Key priorities and strategies ....................................................................................................................................... 6
2.6.
Clients ......................................................................................................................................................................... 7
2.7.
Products and services.................................................................................................................................................. 7
2.8.
Geographical reach of products and services.............................................................................................................. 8
2.9.
KAMSC organisational chart ..................................................................................................................................... 8
3.
3.1.
Definitions, documents and records
8
Definitions .................................................................................................................................................................. 8
4.
4.1.
Quality management system
10
Overview of the quality management system ........................................................................................................... 10
4.2.
Documentation requirements .................................................................................................................................... 14
4.2.1. General ..................................................................................................................................................................... 14
4.2.2. Quality manual ......................................................................................................................................................... 14
4.2.3. Control of documents ............................................................................................................................................... 14
4.2.4. Control of records ..................................................................................................................................................... 15
5.
5.1.
Management responsibility
16
Management commitment ........................................................................................................................................ 16
5.2.
Client focus ............................................................................................................................................................... 16
5.3.
Quality policy ........................................................................................................................................................... 17
5.4.
Planning .................................................................................................................................................................... 17
5.4.1. Quality objectives ..................................................................................................................................................... 17
5.4.2. Quality management system planning ...................................................................................................................... 18
5.5.
Responsibility, authority and communication .......................................................................................................... 18
5.5.1. Responsibility and authority ..................................................................................................................................... 18
5.5.2. Management representative ...................................................................................................................................... 19
5.5.3. Internal communication ............................................................................................................................................ 19
5.6.
Management review ................................................................................................................................................. 20
5.6.1. Review input ............................................................................................................................................................. 20
5.6.2. Review output ........................................................................................................................................................... 20
6.
6.1.
Resource management
21
Provision of resources .............................................................................................................................................. 21
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6.2.
Human resources ...................................................................................................................................................... 21
6.2.1. General ..................................................................................................................................................................... 21
6.2.2. Competence, training and awareness ........................................................................................................................ 21
6.3.
Infrastructure ............................................................................................................................................................ 21
6.4.
Work environment .................................................................................................................................................... 21
7.
7.1.
Service delivery (product realisation)
22
Planning of product realisation ................................................................................................................................. 22
7.2.
Client related processes ............................................................................................................................................ 22
7.2.1. Determination of requirements related to the product .............................................................................................. 22
7.2.2. Review of requirements related to the product ......................................................................................................... 22
7.2.3. Client communication............................................................................................................................................... 22
7.3.
Design and development (exemption claimed)......................................................................................................... 22
7.4.
Purchasing ................................................................................................................................................................ 22
7.4.1. Purchasing processes ................................................................................................................................................ 22
7.4.2. Purchasing information............................................................................................................................................. 23
7.4.3. Verification of purchased product ............................................................................................................................ 23
7.5.
Production and service provision .............................................................................................................................. 23
7.5.1. Control of production and service provision ............................................................................................................ 23
7.5.2. Validation of processes for production and service provision .................................................................................. 23
7.5.3. Client property .......................................................................................................................................................... 23
7.5.4. Preservation of product ............................................................................................................................................. 23
8.
8.1.
Measurement, analysis and improvement
24
General ..................................................................................................................................................................... 24
8.2.
Monitoring and measurement ................................................................................................................................... 24
8.2.1. Client satisfaction ..................................................................................................................................................... 24
8.2.2. Internal audit ............................................................................................................................................................. 24
8.2.3. Monitoring and measurement of processes .............................................................................................................. 25
8.2.4. Monitoring and measurement of product .................................................................................................................. 25
8.3.
Control of nonconforming product ........................................................................................................................... 25
8.4.
Analysis of data ........................................................................................................................................................ 25
8.5.
Improvement............................................................................................................................................................. 25
8.5.1. Continual improvement ............................................................................................................................................ 25
8.5.2. Corrective action....................................................................................................................................................... 26
8.5.3. Preventive action ...................................................................................................................................................... 26
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1.
SCOPE AND EXCLUSIONS
1.1.
Scope
The KAMSC Quality Management System relates to the management and provision of services and
products.
1.2.
Exclusions from ISO 9001 2008
Clause 7.3 (incorporating subclauses 7.3.1 to 7.3.7) relating to Design & Development
Clause 7.5.3 Identification and traceability as unique identification of product and traceability is not
required.
These clauses are not applicable to KAMSC, it does not develop products or employ monitoring or
measuring equipment to plan, deliver or evaluate its products or services.
1.3.
Purpose of this document
This Quality Manual describes the Quality Management System operated by KAMSC and the relevant
roles and responsibilities of office bearers for overseeing and implementing its components.
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2.
ORGANISATION PROFILE
2.1.
History
The Kimberley Aboriginal Medical Services Council (KAMSC) was established in 1986. The council
was initially formed as a cooperative between the Broome Regional Aboriginal Medical Service
(BRAMS) and the East Kimberley Aboriginal Medical Service (EKAMS) now the Ord Valley
Aboriginal Health Service (OVAHS) with membership from the then developing, Halls Creek health
service committee and Fitzroy Crossing community representatives. These communities saw the
benefit of sharing pooled resources and collective effort in the region.
Member services now include;
2.2.

Broome Regional Aboriginal Medical Service (BRAMS)

Ord Valley Aboriginal Health Service (OVAHS)

Derby Aboriginal Health Service (DAHS)

Yura Yungi Medical Service (YYMS)

Kutjungka Clinical Services (KAMSC Remote Clinic)

Beagle Bay Health Services (KAMSC Remote Clinic)

Bidyadanga Community Clinic (KAMSC Remote Clinic)
Legal Structure
KAMSC is incorporated under the Western Australian (WA) Associations Incorporation Act 1987 and
it adheres to the National Aboriginal Controlled Health Organisations (NACCHO) definition of
Aboriginal health which means ‘not just the physical well-being of an individual but refers to the
social emotional and cultural well-being of the whole community in which each individual is able to
achieve their full potential as a human being, hereby about the total well-being of their community. It
is a whole of life view and includes the cyclical concept of life-death-life’.
2.3.
Vision
The vision for KAMSC includes many aspects of the improvement and management of Aboriginal health
across the Kimberley region. By definition, the vision does not match the current context of Aboriginal
health. Outstanding improvements are required in the provision of culturally safe and appropriate public
health care.
2.4.
Mission
KAMSC exists as a responsible Aboriginal Community Controlled Council to improve Aboriginal health in
the Kimberley region of Western Australia by providing continually improving, essential, cooperative
services along with a unified voice and representation for existing and developing comprehensive primary
health care services and community health services.
In achieving its mission KAMSC will;
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2.5.

Provide Aboriginal Community Controlled Health Services (ACCHS) essential services which are
not otherwise available to them.

Contribute to policy development and representation at a community (community clinic), district
(ACCHS), regional (KAMSC), state (AHCWA) and national (NACCHO) level.

Regularly monitor, evaluate and report on its achievements in improving Aboriginal health.

Provide a single and accepted voice that represents all of its Kimberley Aboriginal constituents.

Be accountable in all of its dealings with its co-operative of Board members and other
stakeholders.
Key priorities and strategies
 Ongoing and improved Aboriginal community control of health services for Aboriginal people in
the Kimberley.
 KAMSC has a high level of acceptance and status amongst its member organisations, throughout
the region and beyond.
 Larger Aboriginal community controlled health services, continue to be involved with public
hospitals with ongoing work outside the hospital system.
 ACCHS have a strong focus on preventive approaches rather than largely curative medical models.
 Comprehensive holistic primary health care services are available, including dental, aged care,
social support suicide prevention and management services.
 Specialist services including dialysis training are available through the central health service.
 Drug problems have been addressed by Aboriginal and Torres Strait Islander peoples.
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Self management by Aboriginal people of health and other primary services is recognised and
accepted as legitimate at regional, state and national levels.
Aboriginal people own and control their health policy, resources, and research and public health
services.
Aboriginal people are supported to take primary responsibility for their own health by health
services in the region.
Aboriginal communities are proud, happy and healthy and strongly involved in managing their
own health and determining their own health needs.
Aboriginal culture plays a strong role in managing the health of Aboriginal people.
Aboriginal people throughout the Kimberley are healthy and there are no inequities in with an
equal standard of health across all Kimberley people.
Chronic diseases such as diabetes, renal failure, rheumatic fever and chronic lung disease have
been dramatically reduced or eliminated.
There is no longer death associated with hepatitis b and HIV.
Access is improved, particularly during the wet season.
Environmental determinants of health status (e.g. housing, sanitation, food security) are
recognised and improved
Aboriginal young people are supported through a scholarship scheme to become involved in
education in health related fields.
Encouragement and assistance is provided to Aboriginal people from the Kimberley region to
become clinicians
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2.6.
Clients
KAMSC has identified 4 client groups as follows;
2.7.

Funding bodies

Member services - Aboriginal Community Controlled Health Services (ACCHS).

Patients attending the KAMSC clinics

KAMSC staff
Products and services
KAMSC (Kimberley Aboriginal Medical Services Council) is a regional Aboriginal Community
Controlled Health Service (ACCHS), providing a collective voice and regional level support services for
a network of member ACCHS from towns and remote communities across the Kimberley region of
Western Australia.
The Broome Regional Aboriginal Medical Service (BRAMS) was the first Aboriginal Community
Controlled Health Service (ACCHS) established in the Kimberley in 1978, and was followed by the
East Kimberley Aboriginal Medical Service (EKAMS, in Kununurra) in 1984. The vision for a unified
voice, to provide centralised resources and collective advocacy for the sector, achieved reality in 1986
with the establishment of KAMSC.
Today, the KAMSC collective represents four independently incorporated ACCHS – the Ord Valley
Aboriginal Health Service (OVAHS, previously EKAMS), the Derby Aboriginal Health Service
(DAHS), Yura Yungi Medical Service (YYMS in Halls Creek), Broome Regional Aboriginal Medical
Services.
KAMSC Governing Council is made up of one representative from each of its independent member
services and one representative from the community councils of Beagle Bay and Bidyadanga, where
independent ACCHS are not yet established. KAMSC general meetings are held quarterly in different
locations across the region.
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KAMSC provides a wide range of regional services to support member ACCHS, with business units
including:
Population Health
Social and Emotional Well Being
Business Support
Health Promotion
Information Communications Technology
Pharmacy support and training
Corporate Services including payroll support, HR, stores, accounting and administrative services
Accredited health training and education
Research
Regional renal services including dialysis
Remote Area Clinics
Together KAMSC and its member ACCHS’s are a major employers in the Kimberley, with Aboriginal
people representing more than 70% of its 300+ strong workforce.
KAMSC is a member of the Aboriginal Health Council of WA (AHCWA) and of the National
Aboriginal Community Controlled Health Organisation (NACCHO)
2.8.
Geographical reach of products and services
KAMSC (Kimberley Aboriginal Medical Services Council) is a regional Aboriginal Community
Controlled Health Service (ACCHS), providing a collective voice and regional level support services for
a network of member ACCHS from towns and remote communities across the Kimberley region of
Western Australia.
2.9.
KAMSC organisational chart
Whilst KAMSC delivers a comprehensive range of services and programs, it operates within a simple line
management structure with all managers having direct accountability and reporting responsibilities to the
CEO. The CEO reports directly to the board of directors.
Over-riding responsibility and accountability for the KAMSC Quality Management System (QMS) rests
with the board of directors. Within the KAMSC organisational structure, responsibility has been delegated
by the board of directors. Within the KAMSC organisational structure, responsibility has been delegated by
the board of management to the CEO as its representative to progress our quality policy and quality
objectives. As the quality manager, the CEO has delegated authority and responsibility to the Quality
Coordinator and management team for maintenance of the QMS.
KAMSC Board
Chairperson
Medical Director
HR
Executive
Assistant
Corporate
Services
Population
Health
CEO
Remote Area
Services
- Resourcing
- Administration
- Remuneration
- OH&S
- Industrial
Relations
- Information
Services
- Population
Health
- Asset
Management
- Health
Promotions
- Policy
Development
- Professional
Dev
- Admini
- Reception
- Executive
Office
- Research
-Remote Area
Services
- Beagle Bay
- Bidyadanga
- Kutjungka
- Clinical G’vnce
- Clinical Support
3.
DEFINITIONS, DOCUMENTS AND RECORDS
3.1.
Definitions
Renal Services
CAPTER
- KSDC
- Derby Dialysis
- Cultural
Training
- Fitzroy Dialysis
- AHW Training
- Kununurra
Dialysis
- Rural Clinical
School
- KRSS; kidney
disease
prevention
- GP Registrar
Training
- UWA/KAMSC
Research
- Home
Therapies
SEWB
- Headspace
- Workforce
Support Unit
- Kimb/Pilbara
Projects
Financial
Services
- AMS Accounts
- Accounts
- Payroll
- Risk
Management
- Travel
- Business Dev
- Agreement
Audits
The following terms and definitions are generally defined within ISO 9001:2008 Quality management
systems – Requirements and have been adapted to our organisation.
Audit
refers to a systematic, independent and documented activity aimed at verifying that the
organisation’s policies and procedures are being fulfilled.
Client
refers to a client, Client, patient or person or organisation that is provided with a product or
service.
(client)
Contract
refers to agreed requirements between us and our partners and funding bodies. These may
be also be MOU’s and Service Level Agreements.
Continual improvement
refers to both corrective action and preventive action that is taken to correct or address a
(corrective and preventive
action)
problem and make change in the organisation that improves service delivery or our
operations. Corrective action generally involves making changes to policies or procedures
to respond to an idea or incident. Preventive action generally involves taking action before
a negative event (or non-conformance) occurs to reduce the chances of a negative event
occurring.
Non-conformance
refers to a deficiency in characteristic, measured quality, documentation, or procedure that
renders a service, program or product unacceptable to specified requirements.
Procedure
refers to a document that specifies the purpose, scope, responsibilities, actions and methods
for a quality related activity.
Process
refers to a task or activity that involves staff or other resources to provide a service or
conduct our operations.
Quality
refers to circumstances where all characteristics conform to requirements.
Quality Management
refers to a set of coordinated activities aimed at controlling an organisation with regards to
quality.
Quality Project Plan
refers to a document that specifies the resources, activities, and methods necessary to
control a specific project, service, product or contract.
Quality Review Group
Refers to the internal staff committee chaired by the CEO to conduct management review
Quality system
refers to a planned and documented set of policies, procedures, resources, methods, and
actions aimed at fulfilling our quality and service delivery objectives
Services (Product)
refers to the products and services delivered to meet our aims.
Service delivery
(product realisation)
refers to product realisation or the fulfilment or achievement of a plan or objective to
deliver a service or product.
Supplier
refers to an individual or organisation that provides any services, materials or products that
form part of the product supplied to the Client. This may include those otherwise referred
to as subcontractors.
Validation
refers to evidence or proof that the product meets requirements, and is fit for its intended
purpose.
Verification
refers to confirmation that a product or action conforms to specified requirements.
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4.
QUALITY MANAGEMENT SYSTEM
4.1.
Overview of the quality management system
The purpose of our Quality Management System is to support our operations so that our services and
products consistently and effectively meet Client expectations, applicable regulatory requirements and to
provide a mechanism for continual improvement.
The Quality Management System provides a framework from which our staff, subcontractors and partners
can make appropriate decisions whilst ensuring that applicable minimum standards are met.
The Quality Management System applies to all activities of the organisation, and has been developed in
accordance with ISO 9001:2008. The Quality Management System is fully documented and structured in
three levels. The diagram below is a representation of this structure.
Level 1
Quality Manual
& Quality Policy
Level 2
Processess and Systems
Level 3
Procedures, Forms, Templates etc
Level 4
Records
Quality System Elements
Level 1: Quality Manual and Quality Policy – The Quality Manual describes the scope of the quality
management system, the processes and documented procedures established to operate the quality
management system and the interactions between these processes. The Quality Policy describes <org
name>’s commitment to implementing, maintaining and continually improving the quality management
system.
Level 2: Processes and Systems – The systems deployed across the organisation to support the
management of critical processes.
Level 3: Procedures, Forms, Templates - These documents describe the actual process, and controls
applied, to all activities concerned with the attainment of a quality assured services and programs.
Level 4: Records - These documents demonstrate evidence of activity.
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Quality Management System Process Map
The Quality Management System Process Map below provides a high level description of our quality management system.
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Quality Management System Functional Specification
The diagram below describes a set of specific electronic management systems (registers) used for initiating, actioning, monitoring and evaluating key business processes
within the organisation. It should how our systems map to the ISO 9001:2008 standard.
Resources we need to
do our work
Staff and subcontractors
Equipment and Facilities
Training/Licensing Register
Repairs Register
OHS Register
Suppliers register
Clients and
Stakeholders
Client and stakeholder
requirements
The work we do
and how we do it
How well we do our work
Contracts and MOU’s
Project plans and specifications
Legislative requirements
Electronic feedback forms
Plans
Policies and procedures
Forms, checklists, templates
Evaluations
Audits
Reports
Contract Register
Compliance Register
Feedback Register
Document Register
Audit Register
Quality Records Register
Improvement
Clients and
Stakeholders
Learnings
How we improve
Client and stakeholder
satisfaction
Ideas for improvement based on
reviews, evaluations, audits,
feedback and staff ideas
Surveys
Feedback
Continual Improvement Register
Feedback Register
Quality Management System Functional Specification
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4.2.
Documentation requirements
4.2.1.
General
Our quality management system documentation comprises:

A quality manual including quality objectives

A quality policy
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Documented procedures and policies

Documents relating to client requirements and statutory requirements

Documents relating to planning of operations and product realisation (service delivery)

Records required by recognised standards and by the organisation

Documented procedures relating to 4.2.1c of the ISO 9001 Standard
4.2.2.
Quality manual
A Quality Manual (this document) has been created that describes our quality management system and
other operational management processes. The Quality Manual also includes a quality policy, quality
objectives, and references to the required procedures in 4.2.1c of the ISO 9001 Standard.
4.2.3.
Control of documents
Documents as referred to in 4.2.3 of the ISO 9001:2008 Standard are stored electronically in the Document
Register. The Document Register holds key data about a document such as version, date last reviewed,
location, and the deadline for the next review of the document. The Document Register provides an index
of all controlled documents held by our organisation and provides hyperlinks to those documents.
QMS Document Register (example data only)
All documents on the Document Register carry a unique reference number and each document is authorized
by a designated approving officer. Formal documents produced by the company are reviewed, modified
and authorized, as part of this document control procedure.
The Document Register displays and provides access to key documents, such as policies, procedures,
templates and forms that have been approved for use in the organisation.
The Document Register is used to:

Upload, approve and view quality system documents eg. policies, procedures, forms and templates
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Set and manage the timely review of quality system documents
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Print reports on the documents stored on the system
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4.2.4.
Control of records
Records as referred to in 4.2.4 of the ISO 9001:2008 Standard are stored electronically in the Quality
Records Register and in physical files located in the organisation. The Records Register primarily holds
audit reports, program evaluations and minutes of the senior Management Team and Clinical Review
Committee.
The Records Register provides an index of these records held by our organisation and provides hyperlinks
to those records.
QMS Records Register (example data only)
All records on the Record Register carry a unique reference number and each record must be authorized by
a designated approving officer to appear of the Register. An audit trail of such approvals is kept by the
system.
The Control of Records Procedure provides details of the location, retrieval, retention and disposition
of records held by KAMSC including those required by the ISO 9001:2008 Standard.
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5.
MANAGEMENT RESPONSIBILITY
5.1.
Management commitment
The process of managing the business is performed by the Directors who define the overall strategy of the
business and the CEO who is responsible for the day-to-day management of the organisation. The CEO
carries out this function in collaboration with subcontractors and staff as available.
The Directors and CEO have leadership responsibility for the Quality Management System and associated
processes. This includes ensuring availability of resources, establishment and review of the Quality Policy
and Quality Objectives, and implementation and continual improvement of the Quality Management
System.
The Directors and CEO also have the responsibility to communicate the importance of meeting Client,
client, statutory and regulatory requirements.
The KAMSC Quality Policy is posted in a prominent location and in public view at the KAMSC Office and
is available on the KAMSC website at www.kamsc.org.au/
In 2012 KAMSC Directors implemented the quality management system so described in this manual.
5.2.
Client focus
Statutory and regulatory requirements of Clients and stakeholders are documented in the Contracts
Register.
QMS Contracts Register (example data only)
The compliance requirements related to the contractual and statutory obligations are scheduled in the
Compliance Register in our quality management system.
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QMS Compliance Register (example data only)
QMS Compliance Register (example data only)
5.3.
Quality policy
The following Quality Policy describes our commitment to quality and continual improvement and how the
policy relates to our Clients’ requirements; Doc099_KAMSC Quality policy_v1_rev date 01/08/2013
5.4.
Planning
5.4.1.
Quality objectives
The Quality Objectives of KAMSC support our Quality Policy, goals and aims. The following table
outlines our Quality Objectives and how the organisation’s performance against these objectives will be
measured.
Quality Objective
Performance Measure
Target result
1. Governance; maintain an
effective Quality Management
System compliant with ISO
9001:2008 and driving
improvement across the
company
QMS implemented
Quality Coordinator go-live in the
organisation by June 2012
QMS compliance with ISO 9001:2008
Certification achieved by May 2013
Audit program implemented
Audit program implemented by
February 2013. >90% of scheduled
audits completed in timeframe
Improvement actions implemented
>90% of approved corrective or
preventive actions completed within
required timeframe
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Quality Objective
2.
Deliver high quality services
that meet or exceed our
clients’ expectations.
Performance Measure
Target result
Management review
Senior Management Team and Clinical
Review Committee meeting minutes
show regular meetings and compliance
against QRG procedures
Credentialing, registration, education
and training of staff.
All staff will be appropriately
credentialed /registered / licensed to
undertake the role for which they have
been employed. Minutes of CRC show
evidence of credentialing processes.
>90% of staff undertaken mandatory
training e.g. emergency management,
CPR, manual handling as appropriate.
3.
Effective resource
management
Provision of adequate resources
(human, ITC, infrastructure)
Departmental internal audit program
implemented by February 2013.
Availability and utilisation of current
best practice standards/local guidelines.
Minutes of SMT and CRC evidence that
all clinical and organisational
policies/procedures/guidelines/standards
etc, are reviewed and updated as
appropriate (at least every 3 years).
Patient outcomes, e.g. as measured in
the OCHRE streams report. Data
supplied to funding bodies.
>90% of funding body reporting
requirements completed within the
required timeframe.
Customer feedback
(complaints/compliments/suggestions
etc)
>90% of approved continual
improvement suggestions actioned
within required timeframe. Staff
satisfaction survey undertaken every 3
years.
Compliance with financial /contract
management statutory requirements and
reporting.
>90% of financial/contract reporting
requirements are completed within the
required timeframe.
Review of financial management
processes through internal audit
committee.
Internal financial audit committee to be
established by Dec 2012, minutes show
regular meetings and compliance
against ORG standards.
Quality Objectives
5.4.2.
Quality management system planning
Planning and review of all aspects of the KAMSC quality management system is undertaken by the
KAMSC Quality Coordinator, the KAMSC management representative (CEO) and agreed at the SMT on
an annual basis.
5.5.
Responsibility, authority and communication
5.5.1.
Responsibility and authority
All staff have a shared responsibility to contribute to the effective management of quality safety and risk
and all staff share the authority and responsibility to identify non-compliances and possible improvements,
and record these instances in order for corrective or preventive action can be taken.
All staff are given the authority to perform their allocated responsibilities and these authorities are detailed
in the relevant duty statements.
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Specific responsibilities have been identified to key roles to help ensure compliance with statutory and
quality related requirements.
Responsibility
Directors
Management
Staff

Quality Management Representative
Compliance with contractual and regulatory
obligations
CEO
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Approval of Quality Management System
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Monitoring effectiveness of Quality Management
System
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Service delivery planning and implementation
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Supplier selection and purchasing
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Internal Audit
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Document control
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Continual improvement
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Contract management and control
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Processing of invoices
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Purchasing
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Planning
Control of Finance and Accounts
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New service and product identification
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IT planning and management
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Staff responsibilities
5.5.2.
Management representative
The KAMSC CEO is the management representative for the company. The management representative
will:
5.5.3.
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ensure that processes needed for the quality management system are established, implemented and
maintained
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report to top management on the performance of the quality management system and any need for
improvement
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ensure the promotion of awareness of Client requirements throughout the organization
Internal communication
The SMT and CRC meetings are minuted, scheduled in the Meetings Register (below), and are supported
by standard agendas. The minutes of the SMT and CRC are held in the Quality Records Register in the
Quality Coordinator QMS and the Director’s meeting minutes are held on the CEO’s office.
KAMSC also holds a range of team meetings with minutes of these meetings held in the administration
office. These meetings are scheduled on the Meetings Register.
2020 Meetings Register
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5.6.
Management review
Management review of the suitability and effectiveness of the quality management system takes place
annually through the SMT meetings. During the review meetings, actions are allocated and minuted to
record the development of the organisation's quality management system.
The objectives of Management Review are:

To establish that the quality (management) system is achieving the expected results and meeting the
company’s requirements, continuing to conform to the Standard, continuing to satisfy Client needs
and expectations, and functioning in accordance with established operating procedures.

To identify weaknesses and evaluate possible improvements to the system.

To review the effectiveness of previous corrective actions, and to review the adequacy and suitability
of the management system for current and future operations of the organisation.

To review any complaints received, identify the cause and recommend corrective action if required.

To review the findings of internal/ external audits and identify any areas of recurring problems or
potential improvements.

To review the reports of nonconforming items and trend information to identify possible
improvements.
A terms of reference exists to control and communicate the purpose of the meeting.
5.6.1.
Review input
A standard template guides the meeting purpose. The input into the SMT includes:
5.6.2.

Follow-up actions from previous management reviews

Results of audits

Analysis of data relating to Client feedback

Analysis of data relating to process performance and extent to which <org name> services meets
Client requirements

Status of preventive and corrective actions (continual improvement)

Recommendations for improvement

Status report on the Audit Register

Status report on the Document Register

Status report on staff training and professional development

Status report on occupational health and safety

Status report on compliance management
Review output
A standard template ensures consistent and comprehensive documentation of the outputs of the meeting.
The outputs of the SMT shall include:

Recommendations and actions related to improvement of services related to Client requirements

Recommendations to improve the quality management system in relation to document control, internal
audit, continual improvement and compliance management
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6.
RESOURCE MANAGEMENT
6.1.
Provision of resources
The Directors of KAMSC enter into funding contracts to ensure adequate financial resources are available
to legally operate the business, implement the quality management system and meet Client requirements.
The CEO is responsible for managing processes to obtain self-generated income from other sources.
6.2.
Human resources
6.2.1.
General
KAMSC follows its staff recruitment procedure when appointments are made. These procedures support
comprehensive, consistent and transparent assessments of adequacy.
6.2.2.
Competence, training and awareness
Staff positions define the competencies required for staff to perform their work. The CEO consults with
staff to determine training needs and in some cases KAMSC supports staff to access and attend formal and
informal training.
Training is documented in the Training Register. Required licences and registrations are documented in the
Licensing Register.
6.3.
Infrastructure
Infrastructure planning is discussed on a needs basis and is formally reviewed on an ongoing basis at
Director and staff meetings. Vehicle leases are signed off by Directors. KAMSC uses the Repairs Register
in the QMS to record infrastructure maintenance requirements. Infrastructure planning is also undertaken
prior to executing contracts that may have impacts on facilities and staffing.
6.4.
Work environment
Facilities, including workstations and associated equipment, shall be maintained in an appropriate state of
order, cleanliness, and repair for their use. All work areas must comply with established safety, regulatory
and environmental standards and codes.
Staff have responsibility for providing cleaning services at the KAMSC offices.
Regular environmental safety audits and compliance checks (see Audit and Compliance Register) are
conducted, documented on the QMS and reviewed at SMT meetings.
Regular fire and safety staff briefings are scheduled in the QMS.
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7.
SERVICE DELIVERY (PRODUCT REALISATION)
7.1.
Planning of product realisation
The methods and materials used for planning for product realisation differ depending on the service under
consideration. All service planning is discussed at both the SMT and CRC and the KAMSC Board meeting
as appropriate.
7.2.
Client related processes
7.2.1.
Determination of requirements related to the product
Requirements specified by our Clients can be in any of the following forms;
7.2.2.

Formal contracts

Memorandum of Understanding

Service Level Agreements

Funding body specified requirements
Review of requirements related to the product
Client requirements are reviewed every three years or sooner as required as part of the strategic planning
process.
7.2.3.
Client communication
KAMSC maintains a website at www.kamsc.org.au, produces a ‘quality’ newsletter and produces
brochures promoting its products and services.
Client feedback is recorded on the Client Feedback Register and complaints are managed in accordance
with operational procedures.
7.3.
Design and development (exemption claimed)
7.4.
Purchasing
7.4.1.
Purchasing processes
Purchases for equipment are generally made against a written quote from the supplier which specifies the
details of the product. Purchase orders for services e.g. electrical maintenance at housing owned by
KAMSC are supported by a print out of the job specification held in the QMS Repairs Register. All
requests for maintenance are recorded in the QMS repairs register.
Suppliers are evaluated and once approved will appear on the Suppliers Register. The criteria for evaluation
is determined by top management and specified in the Suppliers Register.
Regular review of suppliers occurs and is documented in the Suppliers Register. Issues arising from
supplier reviews are recorded in the Continual Improvement Register.
The supplier management process is structured to:

identify and select suppliers with the capability to meet operational needs

establish criteria for selection, evaluation, qualification, and certification of suppliers

ensure continuity of supply

ensure that critical materials and services are purchased only from qualified sources

monitor and provide feedback on supplier performance.
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The supply process incorporates supplier assessment, order placement, receipt and where required inspection of goods, control of non-conforming goods and the authorisation of payment to suppliers and
contractors.
7.4.2.
Purchasing information
Purchasing of subcontractor services is controlled through purchase orders.
The purchase process is documented and structured to meet the following requirements:
7.4.3.

ensure that purchasing documents clearly describe the product ordered

ensure that purchased products conform to purchase requirements

communicate to suppliers the appropriate product, quality, and delivery requirements

ensure that purchased materials and services used meet government, safety, and environmental
regulations

ensure that the finished product and packing materials meet the provisions of regulatory and Client
requirements
Verification of purchased product
Goods received are managed in accordance with procedures which ensure the goods are cross-checked
against purchase order. Payment for goods and services is made only after cross-checking
statement/invoice against proof of delivery. Non-conforming goods are managed in accordance with the
Control of Non-Conforming Product procedure.
7.5.
Production and service provision
7.5.1.
Control of production and service provision
The control of service provision is managed though the operational procedures and operational plans
located on the QMS Document Register.
Validation of processes for production and service provision
Validation of services delivered by KAMSC is determined by ongoing funding and support received from
government stakeholders, commitment of community volunteers to act as the Board of Directors, and
through feedback received from clients. Disputes are managed in accordance with our complaints policy or
through the provisions in contractual agreements. KAMSC retains appropriate public liability and workers
compensation insurances to assure against damages claimed as a result of service delivery.
7.5.2.
Identification and traceability (exemption claimed)
7.5.3.
Client property
Client property left unintentionally at KAMSC premises is managed in accordance with the KAMSC lost
property procedure.
7.5.4.
Preservation of product
Equipment relating to the delivery of our services is maintained through maintenance schedules on the
Compliance Register or through repair requests through the Repairs Register.
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8.
MEASUREMENT, ANALYSIS AND IMPROVEMENT
8.1.
General
KAMSC measurement and analysis and improvement processes includes: internal and external audits,
client surveys, assessment of statistical data and records, and review of client, staff and stakeholder
feedback. Related improvements (corrective and preventive actions) actions are recorded and monitored in
our Continual Improvement Register.
8.2.
Monitoring and measurement
8.2.1.
Client satisfaction
KAMSC maintains a register of feedback about client and stakeholder satisfaction. Processes in place to
gathering this information include: feedback reported at staff meetings, client suggestion boxes located
throughout the organisation and community events. Satisfaction of funding bodies is assessed through the
ongoing offers of financial support.
8.2.2.
Internal audit
Internal audits of the Quality Management System are regularly undertaken to confirm that the operation
concerned conforms to organisational procedures. The Internal Audit Procedure details our audit process.
Audits are undertaken by staff auditors who are trained in auditing and not directly responsible for the
functions being audited within the organisation (where possible). Non-conformance observed is brought to
the attention of the person responsible, and is recorded, documented and subject to timely corrective action
to ensure full rectification.
Audit reports are kept on the QMS Quality Records Register and related corrective and preventive action is
to ensure full rectification.
The Audit Register displays audits that have been scheduled or completed, and the action taken, as part of
the organisation’s audit program.
Audit Register
The Audit Register is used to:
 Schedule internal and external audits
 Delegate tasks to a staff member to carry out or oversee audits
 View all current and past audits recorded and any associated action taken
 Print reports on the audit schedule
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8.2.3.
Monitoring and measurement of processes
The Audit Register contains scheduled audits to examine the effectiveness of the QMS and internal
operational procedures. The Quality Coordinator QMS also produces a report providing statistics on
activity within the electronic QMS. The SMT monitors and assesses the effectiveness of the QMS on a
annual basis.
8.2.4.
Monitoring and measurement of product
The Audit Register contains scheduled audits to examine the effectiveness of service delivery. Service
delivery is also measured through client feedback and approval from funders for ongoing financial support
for the services provided.
8.3.
Control of nonconforming product
Non-conforming product can mean any process, service or product that is considered not to conform with
agreed specifications, policies sand procedures. Non-conformances may be determined through incident,
observation, client feedback or internal audits. This includes:
 Incoming goods from suppliers
 Services to the organisation provided by external sources
 Processes being carried out by the organisation that do not conform the stated policies or procedures
Details of non-conformances are entered into the Continual Improvement Register and categorised as either
corrective of preventive action. The QMS provides statistics on related non-conformities created as a result
of supplier non-conformance, audit findings, client feedback, equipment failure and OHS incidents. The
Control of Non-conforming Product Procedure details our processes.
8.4.
Analysis of data
Data relating to audit findings, program evaluations, compliance monitoring, client feedback, OHS
incidents, equipment maintenance, and suppliers are recorded in the QMS which automatically reports the
matter to management for decision and action. Statistics regarding how effectively the organisation is
responding to this data is provided in statistical reports generated by the QMS. These statistics are provided
as inputs to the SMT and CRC as per our agenda and reporting templates.
8.5.
Improvement
8.5.1.
Continual improvement
Continual improvement is an ongoing activity through which opportunities for improvement are identified
and actions are generated.
This process is managed through the use of our Continual Improvement Register located in the Quality
Coordinator Software. The Continual Improvement Register is used to:
 Record issues relating to non-conformance and suggestions for improvement from staff or from outside
the organisation
 Delegate tasks to a staff member to carry out corrective or preventive action
 View all current and past client improvement suggestions and any associated action taken
 Print reports on continual improvement suggestions
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8.5.2.
Corrective action
Corrective action is determined and delegated by management through the Continual Improvement
Register in our QMS. The Continual Improvement Register displays the background issue, suggestions for
improvements to service delivery or business processes, and the action determined.
8.5.3.
Preventive action
Preventive action is determined and delegated by management through the Continual Improvement
Register in our QMS. The Continual Improvement Register displays the background issue, suggestions for
improvements to service delivery or business processes, and the action determined.
Continual Improvement Register
Pre-set categories within the Continual Improvement Register allow for the source of action to be identified
eg audit finding, staff suggestion etc. Statistics can be generated to provide for analysis of the source of
improvement actions and the occurrence of corrective and preventive actions within the organisation.
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