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Human Services Standards accreditation improvement project 2017
Background
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In 2012, the Victorian Department of Health and Human Services (DHHS) introduced the Human Services (HS) standards to help protect vulnerable clients across Victoria. All services that are funded or registered by the DHHS to provide human services to clients must meet the HS standards. In addition, not only must service providers achieve compliance against the HS standards through independent review, but they must also meet the governance and management standards of an independent review body (e.g., the Australian Council on Healthcare Standards [ACHS] EQuIPNational). Further, the HS standards themselves include mandatory file audit tools, a requirement for two independent reviews every three years and strict reporting requirements.
Problem/Aim
Through onsite visits and interviews with service providers, it was uncovered that a number of ACHS members (service providers) had a low level of understanding/ satisfaction with the ACHS HS standards accreditation. On two occasions, failure to list all in-scope funded programs in the pre-survey assessment (PSA) submissions resulted in assessors needing to return and reassess service providers. The overall mission of the project was to improve members’ understanding of and compliance with the ACHS HS standards accreditation programmerequirements.
Measures
Further research uncovered a broad range of issues requiring improvement and enabled a baseline from which to improve. File audit within the ACHS identified that up to 75% of PSA submissions by service providers were not correctly completed, increasing the risk of HS standards requirements not being met. Member feedback forms pertaining to HS standards were reviewed, uncovering low response rates, which could not be relied upon to gain accurate market analysis. A member experience survey was sent out using an online survey tool. A high response rate to this survey enabled a focus on three key improvement areas, with 36% of customers less than satisfied in each of these three areas:
• pre-survey requirements • accessibility of ACHS resources • governance and management requirements. A surveyor/auditor online survey highlighted that over 40% of surveyors found information provided by the ACHS did not meet their needs. The issue of ‘governance and management’ standards was again identified as a concern. A process flowchart was developed, which clearly identified areas of concern and causes of reporting delay.
Design
Through assessment of research, it was decided that initial interventions should focus on the establishment of practical and clear pre-survey resources for HS standards accreditation members and surveyors. In addition, a new survey reporting tool to replace the MS Word version was introduced. A training session was also held with assessors. These all aimed to reduce variation in PSA submissions and ensure that the somewhat complex HS standards requirements were understood.
Results
The initial wave of interventions has not been in place long enough to enable a full Plan-Do-Study-Act (PDSA) cycle to take place. A PSA audit will be regularly conducted in the future to help assess whether interventions are improving member understanding. Further, separate service provider and assessor satisfaction surveys will be conducted again after interventions have had time to take effect to assess satisfaction rates.
Initial customer and auditor interviews and comments received have shown positive feedback on the resources developed and new HS standards reporting tool.
Conclusion
During the course of the project, a number of issues were identified, such as the high number of errors in pre-survey documentation and a high level of assessor dissatisfaction. The establishment of internal ongoing measurements in these areas will enable a more robust and proactive internal reporting system to drive quality improvement.
Next steps
These business measurements could feasibly be rolled out into other accreditation schemes.
