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Industry Partnership

How to Guide 6 – Planning and Undertaking an External Assessment (site visit)

This how to guide explains how to plan and undertake the external assessment. The main topics covered are:

  • Privacy, confidentiality and notifiable issues
  • Developing an agenda
  • Informing and engaging people
    • Clients
    • Staff
    • The Board
  • Partner organisations and stakeholders
  • Planning the logistics of the site visit.
    • Prepare documentation and evidence
    • Prepare the physical environment
    • Final checks

Privacy, confidentiality and notifiable issues in self-assessment and external assessment

Your organisation and the Board need to be aware of privacy, confidentiality and notifiable issues that apply to the self-assessment and external assessment.

The confidentiality provisions for ASES in the Evidence Guide state:

The information you give as part of your self-assessment and the external assessment report is the property of your organisation and the contents are confidential to you, the Australian Service Excellence Office, External Assessors and licensed providers. The content of your report will not be released to any other third party without your prior written approval, except when required by law (South Australian Department of Human Services: 2019:6).

Assessors are contractually required to abide by:

  • Commonwealth privacy legislation
  • Jurisdictional requirements related to any information sharing guidelines that apply in the jurisdiction.[1]

If Assessors find evidence or allegations regarding serious health, safety or abuse, risk, financial impropriety or professional misconduct, they are contractually required to:

  • Record the details of the disclosure, allegation or witnessed event
  • Immediately notify the service provider’s Board, and
  • Notify the ASES Team (in the South Australian Department of Human Services).[2].

While the ASES Team is not responsible for resolving notifiable issues, it cannot issue an ASES Certificate of Accreditation until the notifiable issues have been resolved.[3]

These events occur rarely. If they do, the Assessor will provide a written account of the issues to the Board and the ASES Team. It is up to the organisation to work to resolve the issue before the external assessment can resume or restart. The SHS should advise DCJ and, if they are part of a JWA and not the lead organisation, the lead organisation in the JWA, of any reportable issues in writing.

Develop an agenda

The External Assessment site visit involves a number of interviews with various stakeholder groups, a review of documents and systems, and inspections of the agreed sites and service outlets.

Most site visits are two days but may be more or less depending on the size, structure and complexity of the organisation, and the scope of the ASES assessment.

It is important that every aspect of the site visit is planned, coordinated and scheduled by liaising with your Assessor and all participants. It is a good idea to start early and allocate enough staff hours as this planning can take some time.

What happens at a site visit?

The typical components of a site visit are described below.

Opening meeting

The Assessor welcomes attendees, explains the purpose of the visit, confirms the agenda, confirms arrangements for keeping key contacts informed and clarifying any issues that arise.

Interviews

The Assessor interviews clients, the management team, staff, the Board and partner organisations and external stakeholders. Interviews can be group sessions or individual sessions and will generally be spread across sites.

Review of documents, systems and artefacts

The Assessor reviews documents (e.g., client and staff records, policies, procedures, reports Board papers), systems (e.g., databases, digital systems, social media, website) and signage, symbols, posters, artefacts.

Observations

The Assessor observes aspects of each site such as access to the site; maintenance of buildings and equipment; work, health and safety measures; staff interactions; client activities and privacy and confidentiality provisions for clients.

Closing meeting

At the end of the site visit the Assessor provides an overview highlighting any strengths and concerns, a summary of the ratings for the ASES requirements, and next steps in the quality review process.

Example: The table below lists the sequencing of the components that captured in a typical, two-day site visit for a single site organisation.

Template agenda for a typical, two-day site visit for an organisation with one service outlet

Day 1 Day 2
Welcome, WHS tour and site inspection Short debrief of day 1 with senior staff
Opening meeting Review of Human Resources (HR) system and interview with HR Manager
Interviews with senior staff and Board members Interview with middle managers
Review of Xero and CIMS systems Lunchtime interview with partner organisations
Lunch Review onsite documentation, onsite documentation, key project files, documentation related to the Board such as meeting minutes
Interviews with clients Report writing and preparation for the closing meeting
Report writing
Review of client files and personnel files
End of day 1 meeting with CEO and Operations Manager Closing meeting, feedback on key findings and next steps

As part of the resources in this module, two examples of an actual site visit agenda, completed by SHSs with their Assessors, are provided.

External Assessment Site Visit Timetable 1

External Assessment Site Visit Timetable 2

Informing and engaging people

The site visit will involve interviews with four groups of people: clients, staff (and volunteers), the Board, and partner organisations and external stakeholders.

The purpose of all the interviews is to verify, clarify and gain new information about how your organisation implements its processes and practices in relation to the ASES.

You will need to inform and engage these people before the site visit and interviews with the Assessor.

The number of people to be interviewed in each group depends on the size of the organisation and number of sites and programs. Your Assessor will provide guidance about this.

Clients

The external assessment requires:

  • Interviews with a representative sample of clients
  • Review of a representative number of client files[4]
  • Client representatives invited to attend both the opening and closing meeting of the site visit.

In arranging interviews and access to client files your organisation will need to:

  • Obtain client consent for file reviews
  • Uphold client rights such as
  • right to choose or refuse involvement
  • right to receive support to participate in the assessment
  • right to confidentiality and privacy.
The focus of interviews with clients

The purpose of interviews with clients is to learn how clients experience all of the organisation’s obligations relating to service provision requirements in the ASES. The Assessor will focus on whether service provision aligns with the organisation’s policies, processes and systems.

Resource

Typical interview questions are included in the handout, Example Interview Questions,

Obtain client consent for file reviews

You will need to provide the Assessor with written consents from clients whose files will be reviewed during the site visit. Advise your clients that their rights to privacy and confidentiality will be observed in this process.

See two examples of consent forms developed by SHSs for their external assessment which you can use and adapt for this purpose:

Example Client Consent Form 1

Example Client Consent Form 2

Client right to choose or refuse involvement

All clients have a right and opportunity to be involved and consulted or to refuse to be involved. This includes the right to withdraw consent previously given at any time. Organisations are required to invite client representation at both the opening and closing meetings of external assessment site visits.

To exercise these rights, clients need to be informed about ASES, what it means, and the opportunities available to them to participate.

In arranging interviews with clients (and their representatives, where relevant), you need to explain:

  • What ASES accreditation is, why it is being undertaken and its benefits
  • What is involved in an external assessment, including client interviews
  • Their rights in relation to participating
  • What the opening and closing meetings are
  • The purpose of client interviews (i.e. that it is important for the Assessor to hear firsthand about their experience of the service – both positives and areas where things could be improved)
  • The particulars of the site visit, such as the dates and location/s.
Resources

Examples of posters used by one SHS to communicate with clients about ASES and the external assessment are provided as part of this module:

These examples may help you develop communication tools about the external assessment that are appropriate to your clients. It is good practice to engage clients to help you to develop these tools, if possible.

You may choose to send out written information to clients about ASES first, and then follow up with a visit or phone call to provide additional information about how they can participate and answer any questions.

Your Assessor may also have handouts with information about how different groups can participate in the external assessment that you can use and adapt.

Client right to receive support to participate in the external assessment

Clients have a right to receive the level and type of support they need to enable them to participate in the external assessment.[5]  Clients have the right to advocacy and support to assist in having their say. People from ATSI or CALD backgrounds and people with disabilities and their support persons are not to be excluded. They should be provided with timely, plain language information, in line with their communication needs about the audit process, to allow for their full and informed contribution.

You should inform clients that they have a choice about how they will be interviewed – in person, by phone, in a one-to-one session or a group session. Ask your clients what they would prefer and factor that in when preparing the agenda with your Assessor.

Provide additional supports that clients may need to attend the site visit, such as transport or child care. Let clients know that they are welcome to bring an advocate or a support person to their interview.

Provide clients with timely, plain language information about the external assessment process and make sure these communications are inclusive of all your clients. Organise translations and interpreter services for the interview, when necessary.

Brief the Assessor about any assistance to be provided to clients and any issues, communication needs and sensitivities they need to be aware.

Client rights to confidentiality and privacy

Advise your clients that the Assessor will respect their right to confidentiality and privacy in any interaction with them and that there will be no retribution to the client for freely expressing their views about your service.

Resource

The key issues outlined in this section are outlined in Communication Tool for the External Assessment Site Visit. This document provides sample texts that you can use and adapt to develop communication tools with clients about ASES, the site visit, options for participation and client rights.

Incentives and encouragement

To encourage client participation, you can employ strategies such as providing lunch, morning or afternoon tea and giving clients gift vouchers or movie vouchers. However, make sure that any gifts offered to clients are not so valuable that they could be interpreted as an inducement.

Staff (and volunteers)

The external assessment requires:

  • Staff participation in interviews
  • Staff members to answer questions that arise during the site visit
  • Review of a sample of personnel files.
Consents for review of personnel files

Verbal consent from staff is generally sufficient for the Assessor to review their files but check this before the site visit as some Assessors require written consents.

The focus of interviews with staff

The focus of interviews with staff is twofold since staff are both service providers and internal clients of the organisation. Assessors explore:

  • How staff approach service provision and test whether this aligns with the organisation’s relevant policies, processes and systems
  • Whether the organisation is fulfilling its commitments and obligations to staff in aspects such as induction, work health and safety, flexible work arrangements, staff development, training and supervision.

Staff at each level of the organisation are interviewed separately, not with their supervisors. They are only asked questions related to their role.

Sometimes staff are worried that the interviews will be onerous or that they will say ‘something wrong’. You should advise staff that the best approach is to:

  • Be open and honest and view the external assessment as an opportunity for quality improvement, and to acknowledge the positive practices already in place
  • Seek clarification if they don’t understand what is being asked.
What kind of questions can staff expect in their interview?

Examples of questions are included in the handout, Example Interview Questions, which is provided as part of this guide.

Organising staff participation in the external assessment

Ideas for organising participation in the external assessment include:

  • Conducting a team meeting about the site visit well in advance of the visit and going through the agenda
  • Educating staff about the site and what they might expect at the interview – refer to resources or other tools for staff provided by your Assessor
  • Role-playing using typical questions, in a team meeting
  • Inviting as many staff as are available to the interviews, as long as the final numbers are in line with the sample size required by your Assessor
  • Scheduling staff attendance through electronic diary invitations
  • Inviting all staff to any celebratory event that you will hold after the site visit.

Informing staff of the outcomes of the visit and thanking them for their contribution is crucial for their ongoing engagement in the work that will follow.

The Board

The external assessment requires:

  • Interviews with a representative sample of Board members
  • Review of Board documentation.
The focus of interviews with the Board

The focus of the Board interviews is to identify how the Board:

  • executes its governance responsibilities
  • provides leadership and exercises its overall responsibility for strategic directions, policy, planning and monitoring the service (South Australian Department of Human Services: 2019).

The Assessor will explore how these roles are applied in practice within the operational context and constraints of the organisation.

What kind of questions can the Board expect in their interview?

Examples of questions are included in the handout, Example Interview Questions, which is provided as part of this guide.

Organising the Board’s participation in the external assessment

The Board will be aware of the accreditation process through their approval and monitoring of your ASES Project Plan. The main tasks for organising participation of the Board include:

  • Scheduling a session for planning the finer details of the site visit at a Board meeting, well in advance of the visit
  • Deciding how the Board will participate and which sessions they will come to
  • Scheduling their attendance through electronic diary invitations
  • Providing the Board with example questions and any handouts and tools provided by your Assessor.

Partner organisations and external stakeholders

The external assessment requires interviews with a sample of the organisations that have an interest in, or are affected by, the business of your organisation. These include:

  • Organisations that provide a service to your clients
  • Partners
  • Peak bodies
  • Funding bodies
  • Consumer reference groups
  • Community groups, and
  • Special interest groups.[6]

These interviews are generally conducted in a group setting but a phone interview may also be possible with any organisations that are not able to make it.

The focus of interviews with partner organisations and external stakeholders

The purpose of the interviews with this group is to examine the effectiveness of your communication, partnership agreements (formal and informal) and joint working agreements.

The Assessor will interview representatives of partner organisations and external stakeholders only – these interviews do not include your organisation’s staff or Board members.

What kind of questions can partner organisations and external stakeholders expect in their interview?

Examples of questions are included in the handout, Example Interview Questions, which is provided as part of this guide.

Organising participation in the external assessment

The steps involved in planning the Assessor’s interviews with partner organisations and external stakeholders are:

  • Decide which organisations you will invite to the site visit interview
  • Advise the organisations that you are undertaking ASES accreditation and invite them to participate in an onsite interview
  • Check their availability and schedule their attendance through electronic diary invitations.

Planning the logistics of the site visit

Prepare documentation and other evidence

At the site visit the Assessor will need to see:

  • any documentation and other evidence that you referred to or cited in your self-assessment, that was not submitted with it
  • Any additional evidence that your Assessor requested to view at the site visit after reviewing your self-assessment and the evidence you submitted with it
  • Client consent forms for the file review.

A comprehensive list of evidence examples if provided in How to guide 4: Guide to Good Evidence. Not all evidence is printed evidence. It can include artefacts, digital records, audio or video recordings and web-based evidence.

Prepare the physical environment

Preparing the physical environment includes:

  • Ensuring that all buildings, surrounds and equipment are in good working order
  • Checking that there are sign-in registers and current WHS audits at each outlet. The Assessor will start the visit at each site by signing in, getting an orientation to the site and observing WHS arrangements, for example:
    • location of fire equipment and first-aid kits
    • evacuation notices
    • staff ergonomics
    • information displayed on staff and client noticeboards
    • privacy issues.
  • Checking that the asset/equipment register is current and available at each outlet
  • Booking a room for the Assessor with a desk, chair and preferably internet access
  • Booking rooms for interviews
  • Arranging a light working lunch for the Assessor and checking their dietary requirements beforehand
  • Arranging morning and afternoon tea refreshments for the Assessor and interviewees.
Resource

A site inspection checklist is provided as part of this module that includes the key items Assessors observe and document at each site.

Final checks

In the days leading up to the site visit:

  • Check that all the participants are still available for their scheduled interview times
  • Hold a brief staff meeting, if needed, to ensure everyone understands the arrangements and to answer any questions that staff have
  • Check that any supports and incentives being provided to clients are in place (e.g. transport to the venue, child care, gift vouchers)
  • Check that any transport arrangements you are providing to the Assessor are in place
  • Check that all venues and rooms for interviews are booked.

Resource

You can use the Checklist: Planning the External Assessment Site Visit provided as part of this module to keep on track.

[1] Government of South Australia, Standard Goods and Services Agreement, DHS76 Australian Service Excellence Standards Panel: Assessments, Quality, Performance, 1 July 2019, p. 13.

[2] Government of South Australia, op. cit., p. 12.

[3] Government of South Australia, op. cit., p. 13.

[4] Your Assessor will advise you of the sample size for client interviews and client file reviews.  This will be based on the sampling methodology involved in auditing and the size and structure of your organisation.

[5] Government of South Australia, Standard Goods and Services Agreement, DHS76 Australian Service Excellence Standards Panel: Assessments, Quality, Performance, 1 July 2019, p. 13.

[6] Based on the 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, Third Edition, version 7, 2019, p. 81.

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