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Industry Partnership

How to Guide 3 – The Self-Assessment and ASES Workplan

This how to guide explains how to conduct a self-assessment of your organisation against the requirements of the ASES. The main topics covered are:

  • Understand the content and structure of ASES
    • Principles
    • 8 high-level Standards
    • 18 specific Standards
  • Review the ASES Evidence Guide
  • Examine how the Standards apply to your organisation
  • Undertake the self-assessment
  • Implement the Workplan, re-assess and upgrade your evidence
  • Submit your self-assessment and evidence

Definition of terms used in this how-to guide

Self-assessment: “…an internal assessment in consultation with service users, staff and other stakeholders as applicable, to determine whether the service provider’s performance and delivery meet the Service Excellence Standards. The self-assessment provides an opportunity to identify your organisations’ strengths and to prioritise areas for system improvement”.[1]

Ratings: (in the self-assessment) are the scores that you give your organisation against all the requirements of ASES. There are three options:

  • FIP (Fully in Place)
  • PIP (Partly in Place)
  • NIP (Not in Place).

When your organisation is assessed by an External Assessor they will use the same ratings system.

To qualify for an ASES Certificate of Accreditation an organisation must achieve the FIP rating against all requirements.

ASES Workplan: is an internal working document generated by your self-assessment that identifies the ASES Requirements that are not in place (NIP) or partly in place (PIP), and proposes strategies to bring your organisation up to being fully in place (FIP).

The Workplan is different from the Quality Action Plan that is developed at a later stage of the process with the External Assessor and submitted to the ASES Team in the South Australian Department of Human Services (SA DHS) for a final check before accreditation is approved.

Understand the content and structure of the Certificate Level ASES

The Certificate Level ASES comprise 18 Standards (categorised according to 8 high-level Standards) that are founded on eight key principles.

Principles

The eight key principles underlying the ASES are:

Consumer-focus Reflecting, or respecting and understanding of our consumers’ rights (e.g. confidentiality, information and choice, consumer satisfaction, safe and appropriate care.
Outcomes focus Achieving the best possible outcomes in the most efficient, effective and sustainable way.
Clear direction with accountability Providing inspirational leadership with a strong governance structure.
Continuous learning and innovation Establishing quality systems and mechanisms for continuous improvement, which add value to the organisation.
Valuing people and diversity Encouraging and supporting a flexible work environment and providing opportunities for all staff to fulfil their potential.
Collaborative work practices Strengthening and developing relationships with staff, customers and stakeholders.
Evidence-based decision-making Making clear the rationale and analysis of data.
Social, environmental and ethical responsibility. Meeting the community’s needs and adding value to that community.
8 high-level Standards

The Certificate Level of the ASES program has 8 high-level Standards:

  • Planning
  • Governance
  • Financial and Contract Management
  • Human Resources
  • Partnership
  • Communication
  • Service Outcomes
  • Consumer Outcomes

These are grouped into three broad Streams: Sound Management, People and Service Provision as shown in the diagram below.

ASES Certificate Level Standards by Streams.

18 specific Standards

The 8 high-level Standards encompass 18 specific Standards, as indicated in the table below.

Certificate Level Standards Structure

 SOUND MANAGEMENT PEOPLE SERVICE PROVISION
 1. Planning 4. People 7. Service Outcomes
1.1 Strategic Planning

1.2 Business Planning

4.1 Human Resources

4.2 Work, Health and Safety

4.3 Cultural Inclusion

7.1 Outcomes Monitored
2.  Governance 5. Partnerships 8. Consumer outcomes
2.1 Sound Governance

2.2 Policy and Procedures

2.3 Data and Knowledge Management

2.4 Risk Management

5.1 Working Collaboratively

5.2 Teamwork

8.1 Consumer Participation

8.2 Consumer Feedback and

Complaints

 3. Financial and Contract Management 6. Communication
3.1 Financial Management

3.2 Asset and Physical Resource

3.3 Partnering and Contract Management

6.1 Communication

Each of the 18 specific Standards has an information section in the ASES Evidence Guide with:

  • An explanatory statement
  • An outcomes statement
  • Requirements that make up the Standard
  • Client rating options
  • Examples of acceptable evidence
  • Documentation examples.

Review the ASES Certificate Level Evidence Guide

The ASES Certificate Level Evidence Guide provides comprehensive information on the Standards and requirements. It is advisable to become familiar with the contents of the Evidence Guide before starting your self-assessment.

Steps

The steps outlined on page 6 of the Evidence Guide (screenshot below) provide practical advice for undertaking a self-assessment.

Screenshot of the ASES Certificate Level Evidence Guide, page 6

Streams

The Evidence Guide contains a page on each of the three broad streams which describes the focus and intention of each. This overview provides important context for the individual Standards and requirements.

Screenshots from the ASES Certificate Level Evidence Guide explaining the three Standards Streams: Sound Management, People and Service Provision

 

See the full section on Sound Management on page 7 of the Introductory Section of the Certificate Level Evidence Guide

 

See the full section on People on page 35 of the Certificate Level Evidence Guide

 

See the full section on Service Provision on page 57 of the Certificate Level Evidence Guide

Specific Standards – Requirements

Each of the 18 specific Standards has an  information section in the Evidence Guide with:

  • An explanatory statement
  • An outcomes statement
  • Requirements that make up the Standard
  • Client rating options
  • Examples of acceptable evidence
  • Documentation examples.

Note that you are not required to have all of the documents listed. These are examples only. You should use any evidence that you think fits the requirement and aligns with the guidelines  provided in How-to guide 4: A Guide to Good Evidence.

If you have a lot of evidence for a requirement choose one or a few documents, or pages on your website that are enough to satisfy the requirement. For more information about what constitutes quality evidence, refer to How-to guide 4: A Guide to Good Evidence.

Screenshot of Standard 1.1.1 from the ASES Certificate Level Evidence Guide, page 1 after the Introductory Section

 

Examine how the Standards apply to your organisation

After reviewing the Standards and requirements you can examine how they apply to your organisation. This step is vital preparation for your self-assessment and is best done as a team effort to ensure a shared understanding of the practical application of ASES.

Resources

PowerPoint presentation – What Does ASES Mean to Us? Let’s Start the Conversation

  • This presentation will assist in examining how the ASES requirements apply to your service setting. It introduces the key concepts in each Standard with questions about how your current practices and documentation align with, or depart from, the requirements. Group discussions can be helpful in not only doing the ‘spadework’ for the self-assessment but also to promote ideas for quality improvement.
  • The presentation is divided into 8 sections that address the 8 Standards.

Handout – Reflective Questions for Teams (by Standard)

  • A set of reflective questions for each of the 8 Standards is designed to promote further discussion and reflection on the application of ASES.
  • After the PowerPoint presentation gets the conversation about ASES implementation started, these questions aim to progress that discussion and enhance the organisation’s approach to quality.

Both of these resources can be used with staff, the Board and any committees associated with ASES implementation.

Suggestions for discussing ASES in your organisation
  • Assign a person or small group to each Standard to focus the discussion
  • Focus on one Standard at each team meeting.
  • Set aside a day or 2 half-days to cover more ground. External Assessors can provide an information session as part of their role, based on your organisation’s needs.
  • Develop your own tools and resources to promote an understanding of how you measure up to ASES
  • Clarify the meaning of each Standard so everyone understands its application in your organisational context.
  • Discuss what you will do to demonstrate the requirements of the 8 Standards – the processes you undertake, your documentation and output.
  • Make notes of your strengths and the gaps in preparation for your self-assessment.

Undertake the self-assessment

Choose your self-assessment tool

Make a decision about the tool you will use for self-assessment as early as possible because this decision can affect how you reference your evidence to the self-assessment. Use the tool that best suits the circumstances and needs of your organisation.

There are three options for self-assessment (with some exceptions[2]).

1. Work offline using the ASES Certificate Level Workbook and provide evidence to your External Assessor on a flash drive or on document-sharing software.

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This is the ‘low tech’ solution and is simple and fast for organisations that do not have to meet other Standards or those who prefer not to work on software.

The Workbook reflects the content and structure of the Evidence Guide, which is also repeated in the format of the ASES Assessment Report and the Quality Action Plan, so this option provides for continuity of processes involved in accreditation.

Using this option you will answer 98 questions, one for each requirement.

2. Use the ‘unmapped’ version of the Breaking New Ground Standards and Performance Pathways (BNG SPP) portal.

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This self-assessment option was developed specifically for NSW Specialist Homelessness Services (SHS) and tested by some organisations that participated in the ASES Resource Pilot Project. It arose from feedback that the standard self-assessment tool, which is mapped to many other Standards, does not follow the structure and language of the ASES Certificate Level Evidence Guide.

The term ‘unmapped’ refers to the stand-alone nature of the self-assessment, not integrated with other Standards on the platform.

This option provides some of the benefits of working offline using the Workbook in that the questions reflect the language, structure and order of the Evidence Guide. It is good for organisations who do not have to meet other Standards and would like to use the Evidence Guide to directly inform their self-assessment. As in the previous option, in the unmapped option, you will be answering 98 questions, one for each requirement.

Using this option your evidence is electronically uploaded and maintained, and your External Assessor will have access to it with your permission. It also provides access to the various tools, resources and reports offered by the BNG SPP platform.

Note that any evidence uploaded in the past using the standard ‘mapped’ version will not transfer across to the unmapped version. Similarly, any evidence you upload now will not transfer across to any Standards that you may wish to self-assess against in the future as it is a stand-alone tool.

3. Use the ‘mapped’ version of the BNG SPP portal.

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The ‘mapped’ version of the BNG SPP self-assessment is the standard version on the platform. ‘Mapped’ means the self-assessment tool is integrated with multiple other Standards.

This option is good for organisations that are required to (or wish to) comply with multiple sets of Standards. It also offers all the benefits of the unmapped version in terms of access to BNG’s various tools and resources and also for storing evidence.

Note that the questions in the mapped version use a different structure, language and sequence to  the official ASES Certificate Level Evidence Guide. The 98 ASES requirements are broken down into their various components and expressed as separate questions so you will answer multiple questions for each of the 98 requirements.

Using the ASES Workbook and BNG SPP for self-assessments

Organisations may opt to use both the ASES Workbook and one of the BNG self-assessment tools –  making notes in the Workbook before starting the electronic self-assessment on BNG. This approach is inefficient if you intend to use the mapped version due to the differences in structure and language between the ASES Certificate Level Evidence Guide (reflected in the Workbook) and the mapped self-assessment format.

Complete the self-assessment and develop an ASES Workplan

Undertake the self-assessment using your chosen tool and in line with your ASES Project Plan.

If you are working offline using the Workbook you can use the ratings described in the Introduction and enter them directly into the Workbook for each requirement:

  • FIP (Fully in Place)
  • PIP (Partly in Place)
  • NIP (Not in Place).

If you are using the BNG SPP portal, you will only be offered two options as a rating: ‘met’ and ‘not met’.

For each requirement that you rate as PIP or NIP (or not met in BNG), you need to develop strategies to address the gaps. Enter those strategies onto your ASES Workplan or another plan format of your choice. You can add quality improvements to those requirements where you have self-assessed as already meeting the Standards.

The BNG SPP self-assessment (either the mapped or unmapped version) software will generate a task list, which is effectively a Workplan to address the gaps. You can add custom actions to improve any elements if you already meet the Standard.

The allocation and timing of tasks should be realistic and achievable. Check the timing in the Workplan against your ASES Project Plan and adjust to ensure consistency and clarity.

Obtain any necessary approvals for the Workplan in line with your organisation’s structure and delegations. Share the Workplan with your whole organisation and any working groups and steering committees.

Implement the Workplan, re-assess and upgrade your evidence

As you implement your Workplan, three things will happen in relation to your self-assessment:

  • The ratings for each of the requirements not fully in place will improve if your strategies were effectively designed
  • Additional evidence supporting your new ratings as you develop new practices, documents and systems that were listed in your Workplan, and
  • Parts of your original evidence may become outdated.

You can choose whether to re-assess your ratings and add evidence as you go along or to complete your whole Workplan and then re-assess and revise your evidence at the end. Remove any evidence that is no longer current from your evidence base.

It is important to monitor progress, motivate and support staff by sharing progress reports and learnings, and celebrating achievements along the way.

The BNG SPP portal provides progress reports (screenshots below). SHSs that participated in the ASES Pilot Resource Project commented positively on the usefulness of this report in tracking progress and motivating staff.

Screenshots of BNG SPP My Progress Report

Submit your self-assessment and evidence to your External Assessor

Once you have updated your self-assessment and compiled and linked your evidence, you can  provide it to your External Assessor so that they can commence the desktop review of your submission.

[1] South Australia. Dept. for Communities and Social Inclusion (now the Department of Human Services). Australian Service Excellence Standards: A road map to an excellent organisation, 3rd Edition, version 7, 2019, Page 82.

[2] Note that one External Assessor organisation Quality, Innovation, Performance (QIP) has its own portal for self-assessment called AccreditationPro. It is available via the BNG portal for organisations choosing to be assessed by QIP.

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