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How To Guide 2 – Planning ASES Implementation

This how-to guide explains how to develop your Project Plan for ASES accreditation. The main topics covered are:

  • Preliminary considerations
    • Purpose
    • Decisions
  • Preparation time
    • Indicative time frames for completing accreditation
    • Timing of QAPs and Accreditation Certificates
    • Consider client rights

Preliminary considerations


The purpose of the ASES Project Plan is to document how your organisation will meet the milestones and steps involved in implementing ASES. It should include:

  1. A list of tasks with a timeline for completion
  2. The roles and responsibilities of everyone involved (staff, management, the governing body, dedicated quality positions and any external providers who will be involved)
  3. The strategies for involving and engaging clients and stakeholders and keeping everyone informed about progress
  4. The approval process for the plan and any changes in line with your organisation’s delegations.

In developing your ASES Project Plan you will need to make decisions such as:

  • Which year to apply for accreditation and when will you start work on it?
  • Who will coordinate and oversee the process?
  • Who will do the work and how will it be shared?
  • Will any of the work need to be outsourced?
  • How to give a voice to clients and stakeholders?
  • Which tools to use for self-assessment: the BNG Online SPP Portal or the manual method using the ASES Workbook? If using BNG, will you use the ‘mapped’ or ‘unmapped’ version?
  • Which External Assessor will you engage to undertake your external assessment and site visit?

Preparation time

From October 2020, providers are no longer required to register indicative time frames for the ASES assessment with DCJ and the Industry Partnership.

You are required to send your Certificate of Accreditation to SHSProgram@facs.nsw.gov.au.

Throughout the process, keep DCJ Community and Planning teams updated on your progress. You can do this through your usual contract meetings with your CPO.

Indicative time frames for completing the accreditation process
Milestone Time frame Cumulative months
The External Assessment Report The External Assessment Report requires completion and submission to you and the ASES Team at DHS within 6 weeks of the date of the last site visit. The draft report is due to you for comment 3 weeks after the site visit.

Recommendations that address identified gaps should also be transferred into a Quality Action Plan by the Assessor within 6 weeks of the site visit.

Completing the Quality Action Plan If your organisation has any requirements that are not fully met, you have 6 months to complete and submit the Quality Action Plan. 7.5
Issue of the Certificate of Accreditation Following receipt of your completed Quality Action Plan, the ASES Team will conduct quality checks and administrative tasks. It can take up to 6 weeks for the certificate to be issued. Up to 1.5
Total time elapsed from the date of your last site visit until the issue of the certificate Up to 10.5*

*Many organisations do not take the full 6 months to complete their Quality Action Plan – however, to be on the safe side in planning the timing of your accreditation it is wise to allow for an additional 10 to 11 months after the site visit.

Most organisation take around 12 months of preparation time before the site visit, although this can vary.

The timing of Quality Action Plans and Certificates of Accreditation
  • After completion of the site visit, you will receive your report with recommendations within 2 to 3 weeks. You have 6 months to address any recommendations through a Quality Action Plan – note the 6 months starts from the last date of your site visit.
  • When you receive your Certificate of Accreditation it will be dated from the last date of your site visit.
Consider client rights

Client engagement and participation is a key part of the ASES program. The handout Tips for  Project Leaders has advice on providing clients and, where appropriate, client representatives with information and opportunities to participate in ASES.

The South Australian Department of Human Services has ethical guidelines for External Assessors’ relating to client participation. These may be useful when you are developing strategies for client information and engagement. It is included as a handout for this module.[1]


Handout: Tips for Project Leaders

Handout: Client Rights in Participating in ASES External Assessments

Developing your Project Plan


The approach you take to managing accreditation for your organisation will be influenced by:

  • Size of the organisation
  • Available resources
  • Length of time you have to prepare
  • Personal approach to managing projects of this scope
  • Organisation culture
  • Familiarity with the ASES or other accreditation processes
  • Stage of accreditation readiness
  • Current state of quality management and data collection processes.

What is important is that you develop a workable plan that is suited to your organisation and available resources.

Successful accreditation outcomes generally feature:

  • Leadership that champions change and embraces quality improvement
  • Stakeholder and client participation
  • Open channels of communication
  • A systemic approach to quality improvement
  • Identifying local issues and problems and integrating improvement strategies for these into the accreditation process.[2]

Consider how your organisation can integrate these features into your ASES Project Plan.


The resources provided with this module can assist your organisation to develop your own approach to ASES including handouts, tips and guiding documents. Resources provided by DCJ, the SA DHS and BNG Online are also available.


There is no specific format for an ASES Project Plan. They can take the form of:

  • A Word document describing the key approach with a table showing tasks, dates and responsibilities
  • A Gantt chart setting out all the steps in a timed sequence
  • An Excel spreadsheet showing key milestones, time frames, responsibilities, tasks and status
  • A formal plan developed using software such as Microsoft Project
  • Any combination of the above.

This how to guide includes examples of ASES Project Plans that have been developed by Specialist Homelessness Services (SHS) that participated in the development of this Resource Kit – a small, medium-sized and large organisation

Whichever format your organisation decides to use, it is important to:

  • Describe the roles and responsibilities of staff members, the governance body and the governance arrangements for the Plan
  • List all the tasks you need to complete
  • Record time frames and responsibilities for each task
  • Include a method for tracking progress.

Resource: Annotated ASES Project Plan Template

An annotated ASES Project Plan Template in Microsoft Word has been included as a resource in this module with a task list that you can use and adapt to your organisation’s circumstances. The template is in two parts:

Part 1 is the Plan overview that prompts organisations to describe their overall approach to accreditation and record decisions. It includes the following headings:

  1. Time frames
  2. Introduction
  3. Roles and responsibilities
  4. Staff engagement and participation
  5. Client and stakeholder engagement and participation
  6. Potential barriers to successful accreditation and strategies to overcome them
  7. Self-assessment tool selection
  8. Tracking progress.


Part 2 is the task list and tracking table for recording the particulars of the actions that need to be taken.

Main stages in the process

Overview of the process

You may find it helpful to develop your ASES Project Plan in three stages:

  • Stages 1 and 2 focus on preparing your service for the external assessment
  • Stage 3 focuses on the external assessment and the steps that immediately follow.

A summary of the actions and concerns at each stage is


See the handout provided with this module: Planning ASES Stages – High Level Overview

Main tasks at each planning stage

Stage 1 (covered in how-to guide 2 and 3)
  • Develop your ASES Project Plan – include strategies for client input, staff and external stakeholder communication and engagement
  • Study the official ASES Evidence Guide so you are familiar with the requirements
  • Undertake a self-assessment and rate organisation (meets/doesn’t meet) for the 98 requirements at the ASES Certificate Level
  • Develop an ASES Workplan to address any gaps identified in the self-assessment
  • Start gathering evidence supporting your self-assessment that you will provide to your External Assessor
Stage 2 (covered in 3, 4 and 5)
  • After completing your ASES Workplan repeat your self-assessment to ensure you meet all requirements
  • Link all of your evidence to your updated assessment
  • Select an External Assessor (from the External Assessors Provider Panel at <link>) and sign a contract with them
  • Provide your self-assessment and evidence to your External Assessor
  • Plan your site visit and agenda with your External Assessor
  • Advise staff, clients and partner organisations of the details so that they are available for interviews during the site visit
  • Get written consent from a representative sample of clients for the Assessor to review their files
Stage 3 (covered in 6 and 7)
  • Carry out your external assessment site visit
  • Review the Draft Assessment Report
  • Comment (with evidence) on any ratings you think are incorrect
  • Work with your External Assessor to develop a Quality Action Plan (QAP) for any areas that require more work
  • Complete and submit your QAP
  • Respond to any queries about your QAP from the External Assessor and the ASES Team in the SA DHS
  • Receive your Certificate of Accreditation and ASES logos

After you have achieved accreditation you can promote your ASES accreditation to your clients and stakeholders and use the logo on your website, emails and other materials.

Additional guidance

More information about each of the three stages is provided in the PDF for Module 1 including:

  • The decisions you need to make at each stage
  • The tasks that are involved
  • The resources available
  • The outcomes
  • The outputs

The key milestones and outputs in the tables are also integrated into the ASES Project Plan Templates task list.

[1] Based on the Government of South Australia Standard Goods and Services Agreement DHS76 Australian Service Excellence Standards Panel, 2019.

[2] Johnson, R., & Grieder, D. (2005). In a rush towards accreditation? Behavioral Healthcare Tomorrow, p. 4, 18–24.

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