Allied Health NDIS Registration Support

Pathways / Certification Overview

Governance and Operational Management

Introduction

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Governance and Operational Management – it can sound a bit overwhelming. This module is a simple and practical guide for small businesses with up to six or eight employees. For larger businesses this will be a good starting point but you will need to expand on the documentation we provide here. The larger the business, the greater the risks and consequently the more governance and operational systems required.

What is Governance?

The Governance Institute of Australia, defines governance as “the system by which an organisation is controlled and operates, and the mechanisms by which it, and its people, are held to account. Ethics, risk management, compliance and administration are all elements of governance”.

Simply put, governance is the set of rules which guides what you do and how you do it.

The previous module on Rights and Responsibilities looked at rules and processes to ensure you maintain the legal and human rights of your participants. This makes up part of your Governance and Operational Management. While there are not many new policies and forms in this section, it is important to understand all the documents, forms and registers you are developing through this NDIS registration process that become part of your Governance and Operational Management.

In addition to what we provide here you may want to look at:

Why do we have to do this?

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The NDIS wants to know:

  • you have a governing body – a group of people who ensure the organisation has a plan, stays true to their purpose and are compliant with legislative requirements, and set the culture of the organisation. For larger organisations this would likely be a board. For small businesses who are sole traders or sole directors you may have a group of external advisors who you meet with formally to determine your strategic direction and formulate your business plan
  • you follow a formal pathway to ensure your business knows and complies with its financial, legislative, regulatory, and contractual responsibilities associated with delivering supports to NDIS participants and these are considered when determining the strategic direction of your business
  • your governing body or group of advisors has the skills and knowledge to perform their duties effectively – if you feel you lack skills in this area you need to be able to show this is part of your professional development or you have external advisors / consultants who have the skills to assist you
  • your governing body considers governance and operational risks within the context of the needs of the participants, your workers and relevant stakeholders
  • you monitor performance and drive continuous improvement
  • you have clearly defined delegated levels of governance and operational responsibilities in particular the governing body’s understanding of its role in governance and the Director’s role in managing the operations. Personnel know who takes over in the absence of a decision maker and the related responsibilities
  • you understand the importance of recognising conflict of interest, be it perceived or real, and have documented policies and processes to manage conflict
  • you have comprehensive participant engagement processes that provide opportunities for people with disabilities to contribute to governance and have input to the policies and processes that /underpin their rights and supports received: develop Participant Engagement Policy
  • your organisation contributes positively to the larger community
  • you have ways to stay up to date with changes in legislative, regulatory and standards requirements, e.g. tax laws, employment laws, NDIS Terms of Business

What are the auditors looking for?

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Auditors want to see:

  • you have a governing body with the appropriate skills for the size of your organisation and the supports you provide NDIS participants
  • you have a suite of policies and procedures that inform disability care services that are easy to understand and accessible to all care workers, support workers and participants
  • you have documented evidence on how you engage people with disability to have input to your governance and operational policies and procedures
  • people working in the business know the organisational structure of the business and who has what responsibility
  • people working in the business know who fills in for who and who makes decisions when a key person is away, and what the responsibilities are
  • who reports what and when to the governing body and what the governing body does with this information to drive improvement
  • you have a strategic plan which identifies where your business is heading and how you are planning to get there
  • your team receive appropriate supervision, performance review and professional development
  • you have a Register of Interests and you manage any perceived and/or actual conflicts appropriately
  • you have active feedback and complaints processes for participants
  • you record feedback from the community and stakeholders demonstrating a positive impact on your stakeholders and community
  • the governing body knows its responsibilities for governance and the oversight of the Director who manages the operations.

Next steps

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  • WATCH the Webinar (coming soon)
  • REVIEW the provided documents
  • READ and UNDERSTAND the Spiel
  • CUSTOMISE each document to reflect your practice
  • ADOPT the documents

Company Profile and Structure

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Why do I need this document?

This document provides a clear and concise overview of your organisation: what its structure is, what your purpose is, what your principles are, how you behave, what you do, how you are funded and who you see. This document is a also great place to outline the lines of reporting and the meetings that take place to oversee, report and discuss your organisation’s processes.

This profile is not something you should just use for NDIS registration and then forget. It will be a valuable resource for marketing and for tender applications. It can also be given to prospective employees to give them an overview of your business.

Your organisational structure needs to be proportional to the size of your business. A small business of less than 6 employees does not need a large governing body but you need to consider who makes up your advisory board i.e. who do you consult with when making decisions?

Regardless of the size of your governing body or advisory group, you need to make sure they have the skills and background to assist you properly. You should have sound processes for appointing someone to this role – ensure they have the skills you are seeking and look at what education or professional development they may require to better understand your operating environment. Your strategy and implementation plans also need to have input from people living with a disability.

The resources on this website are intended to support smaller organisations with their NDIS registration and be a starting point for larger organisations. Larger organisations will need a diverse board and will need to explore further.

Why the auditors like it

They can see:

  • you have a clear purpose or mission
  • you have considered the values to guide your operation and they are in line with the NDIS philosophy and Code of Conduct
  • you have an appropriate governing body for the size of your organisation
  • you have a clear organisation structure and lines of reporting
  • you have formalised meetings that occur at set times
  • you document outcomes of meetings and save these appropriately

Next steps

  • DEVELOP your Company Profile and Structure
  • EDUCATE your team on this document
  • REVIEW annually

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Strategic Plan

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Why do I need this document?

A Strategic Plan is a document that outlines the direction and goals of your business over the next 2-5 years, how you will get there, and how you will know if you have been successful. Your plan can be a single page or fill up a folder, depending on the size and complexity of your business and work. A ‘SWOT analysis’ is one way to evaluate your organisation by identifying Strengths, Weakness, Opportunities and Threats.

The NDIS wants to know:

  • your business is focused and your team has direction i.e. they know what they are trying to achieve and how they will get there
  • your values and plans are in alignment with the NDIS Code of Conduct, NDIA Terms of Business and NDIS Commission Rules.

For smaller organisation of about 6 employees the main topics we suggest you include in your Strategic Plan are:

  • Mission or purpose – why are you doing this?
  • Goals – what do you want to achieve?
  • Plan – how will achieve your goals?
  • Key performance indicators (KPIs) – how will you know you have succeeded?

For larger organisations you will need to develop a more comprehensive Strategic Plan and a business plan to sit alongside it.

It is outside the scope of this project to provide you with a full strategic plan but there are many online resources to assist with this e.g. AICD Strategic Plan Development, Smart Sheet Strategic Plan Templates, Forbes Strategic Plan Template. There are also consultants who specialise in strategic planning that can help.

Why the auditors like it

They can see:

  • you have a plan that aligns with the Commission’s requirements
  • you have provided your team with clear goals and direction indicating good leadership
  • you have involved service users including people living with disability into the planning of your service delivery

Next steps

  • INVESTIGATE strategic planning and templates to suit your business if you do not already have one
  • DETERMINE who will be part of your strategic planning team, consider the skills and backgrounds of your team, consider including a service user or NDIS participant to get their views and input
  • UNDERTAKE a strategy session
  • DEVELOP your Strategic Plan
  • INFORM your team of the Strategic Plan so they have direction too
  • EVALUATE your performance and make any necessary changes to achieve your goals
  • ADD to your Compliance Calendar – Review of Strategic Plan by Governing Body
  • ADD to your Annual Training Plan – Overview of Strategic Plan for all staff.

Conflicts of Interest Policy

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Why do I need this document?

Conflicts of interest can exist in many forms when planning services for a participant. You need to make sure the needs of your NDIS participants and all of your clients come first. So it is important to recognise where conflicts exists and have ways to manage them.

Here are just some examples of conflicts of interest that may exist in your organisation:

  • offering participants services from your organisation when your organisation provides Support Coordination as well as a range of services.
  • creating a support plan when you know how much money a participant has to spend on services and your organisation provides a range of services.
  • prescribing supports where there is a close relationship with a supplier e.g. a member of your team prescribes wheelchairs and has a family member that owns a wheelchair supply company.

To manage these conflicts of interest you need to be transparent with participants and provide them with appropriate information so they can make informed choices. This may include informing participants about:

  • why you have recommended particular services in your support plan
  • any financial gains your organisation stands to make
  • any relationships between your organisation or a practitioner and suppliers
  • other service providers they could use instead of you.

You should also document your discussions with participants where any decisions/agreements are made about support plans.

The NDIS wants to see:

  • participants’ needs come before the needs of your organisation or any individual associated with your organisation
  • participants can make informed choices about their support plans based on unbiased information.

You can set up a register to document interests and how you intend to manage them. Not all of your organisation’s ‘interests’ will conflict with the needs of participants but they need to be acknowledged and managed.

Why the auditors like it

They can see:

  • you have considered potential and real conflicts of interest
  • you have thought about ways to manage these conflicts to prevent them from negatively impacting on the services you provide NDIS participants
  • you have processes in place to educate your team on conflict of interest
  • participants are kept informed if there is any potential conflict of interest
  • you have a policy that is accessible to your participants

Next steps

  • ADAPT the Conflict of Interest Policy to your organisation
  • FILL IN the Register of Interest
  • ADD upcoming training dates on Conflict of Interest to your Annual Training Plan
  • ENSURE registering any interests for new staff happens at induction

Downloads

Delegation Policy and Procedures

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Why do I need this document?

You need to be able to demonstrate you have processes in place to delegate authority and responsibility to another person in the event someone is away. You will need to have a system in place for planned and unplanned leave to ensure management roles and clinical roles continue as smoothly as possible.

Anyone covering the roles and responsibilities of a person on planned leave must:

  • receive formal notification in writing of the role and responsibilities they will be covering and for what period of time
  • have the opportunity to undertake induction and training.

You can use your job descriptions to outline the roles and responsibilities that need to be covered.

Unplanned leave is much harder to cover. You need to consider and have processes in place for how your organisation will cover unexpected absences in the short and longer term.

If you are a sole trader or sole director you will likely need to consider external relief and have someone who can take over management of your practice in the event of your unplanned absence. The purpose of this document is not to tell you what to do but to encourage you to think and plan and then document your plan.

Note: if a clinical practitioner is going on leave you must also obtain consent from participants to receive services from an alternative allied health provider.

Why the auditors like it

They can see:

  • you have considered how you will manage planned and unplanned leave
  • you have thought about covering management, clinical and administrative roles in the event of absence
  • you have considered the rights of the participants when managing leave
  • you have provided appropriate training to the person covering the roles and responsibilities

Next steps

  • ADAPT the Delegation Policy to your organisation
  • EDUCATE your team and ensure they know who steps into what roles in the event of unplanned leave

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Meeting Agendas and Minutes

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Why do I need these documents?

You need a system to keep track of meetings and meeting agendas. You also need to have a clear history of the decisions and actions made at meetings. This is not just for the purpose of NDIS registration – these records become important management resources and even more important if something goes wrong and you need to identify how this happened.

It is also important to have a system to track progress of actions and if/when they have been completed. You may want to use a ‘traffic light’ system or have a column indicating completion date.

Some sample documents have been provided for you to use if you don’t already have a standard template for agendas and minutes. In these samples, the same document has been used for the agenda and for minutes.

The sample meeting agendas included are for a three-tier level of management.

  1. Governing body meeting
  2. Senior management meeting
  3. Team meeting

Smaller organisations may only have two levels of management and so only need the Governing Body Meeting and the Team Meeting Agendas.

It’s a good idea to do a Quality Improvement Activity auditing the number of actions planned vs the number of actions completed. This may be an area where you can put processes in place to improve.

Why the auditors like it

They can see:

  • you have a system for reporting and reviewing important information with the appropriate decision makers at the appropriate meetings
  • you have a system for disseminating and discussing information
  • you have a system to track decisions, actions and the dissemination of information
  • you have a process for reporting certain things to specific meetings

Next steps

  • OPEN the Sample Agendas and review
  • ADOPT a system to keep track of meetings, their agendas, discussions and actions
  • ADD the forms you decide to use to your Document Control Register

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About Risk Management

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Why do we have to do this?

The NDIS wants to know:

  • you identify and prioritise potential and actual risks to participants, yourself, anyone you have working with you and your business
  • you think about and act on ways to eliminate or manage risks
  • you document these systems for managing risks.

The Code of Conduct also requires providers to “respect the privacy of people with a disability” and “provide supports and services in a safe and competent manner”.

A common risk, but one that may not seem immediately obvious, is a participant giving ‘limited consent’. In a busy practice it is easy to forget who has given consent for what and you may unintentionally breach the consent given. Make sure you use participants’ Support Plans to record any participant-related risks so they are easily recognised by those working directly with the participant.

What auditors are looking for

They want to to see:

  • you regularly identify and prioritise a wide range of risks relevant to your business. These need to include risk relating to:
    • incident management
    • complaints management
    • work health and safety
    • human resource management
    • financial management
    • information management
    • governance
  • you have strategies to adequately manage these identified risks with a particular focus on high-priority risks
  • you have a documented system and can demonstrate that risk management strategies are implemented and regularly reviewed by senior management and the governing body
  • evidence that your insurances are appropriate, up to date and you have a system to ensure they are renewed on time.

Next steps

  • WATCH the Webinar (Note: The webinar on risk management focuses on Verification and more work is required for Certification, but it will provide a good basis.)
  • GO TO the list of Documents
  • READ and UNDERSTAND the Spiel
  • READ the Intro to each document (where available)
  • CUSTOMISE each document to reflect your practice
  • ADOPT the documents

Risk Management Policy

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Why do I need this document?

The Risk Management Policy documents the rules and systems your business uses to identify and manage risks to your participants, yourself as the provider and anyone you have working for you. These include:

  • clinical risks e.g. participant injury, breach of privacy
  • compliance risks e.g. practising without AHPRA registration (for registered professions), worker checks, tax-related omissions
  • business risks e.g. financial oversight and viability, reputational damage
  • risks to workers, visitors and contractors.

The Risk Management Policy demonstrates that your business is operating in line with the NDIS Code of Conduct in particular to “Provide supports and services in a safe and competent manner with care and skill”.

Why the auditors like it

They can:

  • see you have a documented system that guides your risk management.

Next steps

  • OPEN the Risk Management Policy – read it carefully and only adopt this policy if you can do what it says.
  • REMEMBER to review your Risk Management Policy annually

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Safe Practice and Environment Policy

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Why do I need this document?

A Safe Practice and Environment Policy outlines the system and processes you have in place to protect participants, yourself and those you have working for you from injury. For those of you working in the community, you need to recognise the extra challenges of providing a safe environment and managing the risks.

This policy will need more customisation than others. In the provided policy, the highlighted areas are those that will likely need your attention and adaptation. These will depend on where you deliver services e.g. in rooms or in the community, and the type of services you provide.

Why the auditors like it

They can see:

  • you have a documented system for providing a safe environment for your participants, self and others you may have working with you
  • your practices are in line with the Risk Management Practice Standard and the NDIS Code of Conduct.

Next steps

  • OPEN the Safe Practice and Environment Policy – read it carefully
  • OPEN the two associated checklists when you are reviewing this document – Community and Safety Checklist and In-Rooms Safety Checklist
  • MAKE SURE anyone working for you understands this policy and the related forms and can comply with it
  • INCLUDE this policy in your induction package for new staff
  • CONDUCT refresher training
  • UPDATE policies and forms as required.

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Risk Management Register

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About Risk Management

We all manage risks every day (wear a seatbelt, safeguard client privacy, watch for traffic, reduce risk of falls for our clients). This document is about showing you have more formally assessed risks and put in place strategies to adequately minimise these risks.

To assist with risk management it is useful to use a risk matrix (a sample is at the end of the Risk Management Register). Matrixes allow you to assess the consequence and probability of any given risk and thereby give a rating of how high or low the risk is. You can also use the matrix to assess the level of risk if you had NO strategies in place (Initial Risk Rating) and then assess the RESIDUAL risk with your current strategies in place. This will indicate if you have sufficient strategies in place or if you need to do more to adequately manage the risk.

Depending on the size of your organisation and your meeting structure, you may find it easier to divide the register into different categories and / or to insert into an Excel spreadsheet with tabs for these different categories.

Why do I need this document?

This will provide you with one spot to record any risk you identify in your business and outline how you manage the risk. It helps you demonstrate you are providing services in line with the NDIS Code of Conduct, specifically “provide supports and services in a safe and competent manner with care and skill”

This register includes risks to participants, financial risks, work health and safety risks, and risks associated with the provision of supports. Risks are identified and analysed; management strategies are formulated and recorded on the register. More detailed strategies on how many risks are managed are also included in XXX’s policies & procedures (e.g. Incident Management, Safe Practice & Environment, Dignity of Risk and Duty of Care). However, this is a summary that is useful for managing operations, staff training and for when you do not (yet) have more detailed policies.
The risks & associated strategies provided are SUGGESTED only. You need to work with your governing body and, if applicable, your team to develop your own. Your governing body will then need to ‘approve’ the register (record in minutes of meetings).
As the Register is used to guide operations you will need to nominate someone to be responsible for managing the register including ensuring the management strategies are being implemented, the risks remain relevant, the register is reviewed at meetings, training on the contents is being conducted and formal review of the register is undertaken by the governing body to ensure risks and strategies remain relevant / are up-to-date.

Why the auditors like it

They can:

  • see you have taken a proactive approach to risk management
  • ascertain you understand the risks to your participants, yourself and anyone you have working for you
  • review the strategies you have in place to effectively manage your risks and comment on their suitability

Next Steps

  • OPEN the Risk Management Register – read it carefully – delete those risks that are not pertinent to your business
  • Have a BRAIN STORMING SESSION with your team or peers to identify risks and mitigation strategies then add them to the Risk Management Register
  • COMPLETE the annual review of the Risk Management Register – it currently is listed on both the Compliance Calendar and the Annual Training Plan. If you are a solo AHP you will only need to do the Compliance Calendar action with your Governing Body. If you have others working for you, you can decide if you will also review the register with your team as you conduct refresher training.

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Community Safety Checklist

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Why do I need this document?

Working in the community and working in isolation poses risks to you and your workers. This checklist provides you with a list of things to consider to assist with your safety when working in the community. It should be read and used in conjunction with the Safe Practice and Environment Policy.

Why the auditors like it

They can see:

  • you have given thought and put procedures in place to assist with your safety when working in the community

Next steps

  • OPEN the Community and Safety Checklist – read it carefully and adjust to suit your business
  • REVIEW the Checklist – consider having a team meeting or meet up with a colleague if you work alone to customise it to your service
  • CONSIDER if you now need to further ADAPT your Safe Practice and Environment Policy.

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In-Rooms Safety Checklist

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Why do I need this document?

This is a checklist to enable you to conduct your own safety inspections. It provides you with a list of things to consider to help make your working environment safe for you, your participants, anyone working for you, and visitors.

This is an important document to have if something goes wrong. In that case you will be able to show your insurer you had a system in place and undertook regular safety inspections.

Why the auditors like it

They can see:

  • you have given thought and put procedures in place to assist with maintaining the safety of NDIS participants, yourself, and anyone working for you
  • you have documented any follow up required from safety inspections and that this has been completed.

Next steps

  • OPEN the In-Rooms Safety Checklist – read it carefully and adapt to suit your business
  • CUSTOMISE it to your service – consider having a team meeting to get everyone’s input
  • CONSIDER if you now need to further ADAPT your Safe Practice and Environment Policy.

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Insurance Documents Form

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Why do I need this document?

The NDIS needs to know you have appropriate insurances in place, including:

  • professional indemnity
  • public liability
  • accident insurance
  • workers compensation (for a Pty Ltd company).

Why the auditors like it

They can see:

  • you have appropriate insurances for your business and they are current

Next steps

  • OPEN the Insurance Document Form
  • CUSTOMISE the list of insurances to reflect your business
  • FIND all your insurance certificates and insert into the document

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About Quality Management

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We all try to deliver high quality services – to our participants, to their families, to referrers and to funding bodies. But how do you know you are providing high quality services without formally monitoring and measuring what you do and the outcomes you achieve? A quality management system is designed to provide answers and identify if there are opportunities for improvement.

Why do we have to do this?

The NDIS wants to know:

  • you have systems in place that allow you to meet the relevant NDIS Practice Standards and legislative requirements
  • you conduct internal audits to show you are delivering high-quality supports to your participants
  • your systems show you use outcomes, data, feedback and evidence-based practice to improve your service.

The Code of Conduct requires providers to “promptly take steps to raise and act on concerns about matters that might have an impact on the quality and safety of supports provided”.  Your quality management system helps you meet this.

What auditors are looking for

They want to see:

  • a documented system in place that effectively helps you assess the quality of your services
  • you regularly review services through conducting audits and surveys
  • evidence that you monitor your quality plan and strategies to keep quality on track
  • you seek feedback on quality from participants, families and your workers
  • you close the ‘quality loop’ and actually make improvements to your services.

Next steps

  • GO TO the list of Documents
  • READ and UNDERSTAND the Spiel
  • CUSTOMISE each document to reflect your practice
  • ADOPT the documents

Document Control Register

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About Feedback and Complaints Management

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Why do we have to do this?

You need to have a Feedback and Complaints Management system that is in line with the:

This system must enable participants and their families, your workers and other providers (i.e. everyone) to give feedback and or make a complaint directly or via an external avenue.

Some of your staff complaints may be better handled via your Human Resource Management procedures. This will depend on the nature of the complaint or grievance.

The NDIS wants to know:

  • everyone is encouraged to provide feedback or make a complaint
  • everyone is informed how to make a complaint or give feedback
  • everyone has multiple options for giving feedback or making a complaint and feels supported through the complaints process
  • you take note of feedback appropriately and use it to improve your service
  • everyone is satisfied with the outcome of the feedback/complaint.

What auditors are looking for

They want to see:

  • you have a feedback and complaints management system appropriate for the size of your business and the services you provide
  • everyone knows how to make a complaint and feels supported through the process
  • the system is maintained and current and that it is reviewed and improved, with input from participants, workers and others where appropriate
  • the system complies with the requirements under the above documents
  • you have learnt from any complaint that has occurred and used these ‘learnings’ to improve your services.

Next steps

  • WATCH the Webinar
  • OPEN the list of Documents
  • LOOK at the Spiel
  • CUSTOMISE the Documents to reflect your practice
  • ADOPT the documents

Feedback and Complaints Management Policy and Procedures

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Incident and Complaint Report Form

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Why do I need this document?

The Incident and Complaint Report is the form you will fill in to formally acknowledge any incident or complaint. This is a good place to record the nature of the incident or complaint and your intended follow-up actions.

If an incident or complaint involves a participant you should also make a record in the participant’s progress notes referring to this report.

An example for use with a complaint has been provided.

Why the auditors like it

They can see:

  • you have a way to record incidents and complaints
  • what follow up action you planned
  • the outcome once you have implemented those actions
  • you have considered who this incident/complaint should be reported to
  • that you made system changes when and if required.

Next steps

  • REVIEW the Incident and Complaint Report Form – SAMPLE
  • OPEN the Incident and Complaint Report Form
  • TRIAL the report and determine if it will work for you
  • CUSTOMISE the report if required
  • ADOPT the form
  • EDUCATE your team on the purpose and use of the form
  • FOLLOW the process and actively seek feedback

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Incidents and Complaints Register

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Why do I need this document?

The Incident and Complaint Register maintains a history of:

  • all incidents and complaints you have acknowledged
  • how they have been managed
  • the outcomes.

The register provides you with a tool to ensure all incidents and complaints are managed effectively and you are actually following up with your intended actions. This document helps you to demonstrate you are following the NDIS (Incident Management and Reportable Incidents) Rules 2018.

At your next audit, auditors will particularly want to see that the register has been actively used and the policy has been followed.

The provided register is an Excel document. You may want to add a separate page for incidents, complaints and reportable incidents.

Why the auditors like it

They can see:

  • you have a way to record and manage incidents and complaints
  • you have involved participants and workers in the investigation of incidents and determining actions and outcomes
  • what follow up actions have been planned and completed
  • the effectiveness of the actions, in particular the participant’s response
  • you have learnt from the incidents and made improvements to systems as a result.

These actions and system changes need to be included in the minutes of relevant meetings.

Next steps

  • OPEN the Incident and Complaint Register
  • DETERMINE a start date and insert into register
  • INSERT data into the register for current incidents and complaints
  • REVIEW and UPDATE register regularly

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About Incident Management

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Why do we have to do this?

The NDIS wants to know:

  • participants are safeguarded by your incident management system
  • you acknowledge incidents when they occur
  • you respond appropriately to incidents
  • you learn from any incident that does happen
  • your system complies with the
    • NDIS (Incident Management and Reportable Incidents) Rules 2018
    • NDIS Commission Incident Management Systems: Detailed Guidance for Registered NDIS Providers June 2019

What are auditors looking for?

They want to see:

  • you have an incident management system appropriate for the size of your business and the services you provide
  • the system is maintained and up to date
  • the system complies with the requirements under the above documents
  • incidents are managed appropriately and planned intervention is followed up
  • you have learnt from any incidents that have occurred.

This means you need to be able to show the auditors examples of implementing your incident reporting, recording and resolution.

Next steps

  • WATCH the Webinar
  • GO TO Documents below
  • LOOK at the Spiel
  • CUSTOMISE the documents to reflect your practice
  • ADOPT the documents
  • PROVIDE examples, including what happened and outcomes

Incident Management Policy and Procedures

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Why do I need this document?

The Incident Management Policy outlines the system your organisation has in place to acknowledge, record and manage any incidents.

Take your time to read this policy. It is quite complex as some incidents need to managed in a different way to others and reported to different authorities. These vary between states and territories, so you need to make sure you have the correct details for your jurisdiction. Links for key areas e.g. mandatory reporting, WorkSafe, have been supplied.

As many practitioners see a variety of clients and age groups, guidance on incident reporting beyond NDIS participants has been included (although this does not necessarily cover every situation for your client groups or funding bodies). You can delete any sections that are not relevant to your business e.g. if you do not provide services to children or older people.

The NDIS wants to know that you are very clear about what needs to be done for different types of incidents. This does not mean you and your team need to be able to recite the policy. Instead, you should be aware:

  • of exactly what events trigger a review of the requirements and hence what needs to be reported
  • that you have a readily accessible and complete policy document and forms you can refer to for answers so you can respond accordingly.

You may need to report where harm could have potentially, as well actually, occurred through:

  • acts, omissions, events or circumstances that occur in connection with providing NDIS supports or services to a person with disability
  • acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person.

Why the auditors like it

They can see you:

  • have an Incident Management System that demonstrates you meet the relevant NDIS Rules and Guidelines (In this case National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018 and the NDIS Commission Incident Management Systems: Detailed Guidance for Registered NDIS Providers June 2019)
  • and your team know your reporting obligations of serious incidents
  • keep a register of all incidents and are maintaining it to ensure incidents are reported, managed and resolved appropriately – including with your governing body. This means you need to be able to show the auditors examples of implementing your incident reporting, recording and resolution.

Next Steps

  • WATCH the Webinar
  • OPEN the Incident Management Policy
  • READ the policy carefully
  • CUSTOMISE the policy to your business – add as appropriate and delete sections that are not relevant to your business. Note that you will need to investigate your state or territory requirements.
  • ADOPT the policy
  • TRAIN any workers you have in the policy and the associated procedures
  • PROVIDE evidence that you are following the policy and procedures and provide examples, including what happened and outcomes, plus minutes of meetings

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Incident Investigation Form

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Why do I need this document?

The Incident Investigation Form helps you demonstrate your understanding of the need to investigate more serious incidents to prevent recurrence and possible harm to NDIS participants and others.

This form needs to be used if you feel there is any chance of litigation or if it is a notifiable incident.

As the policy and procedures document states, if police need to be involved providers are NOT to conduct their own investigations until the police give clearance to do so. If you do need to undertake an in-depth investigation of an incident, the best practice is to engage a third party to avoid conflict of interest.

Workplace Health and Safety Queensland has a useful fact sheet called ‘Tips for investigating workplace incidents’. While this is focused on worker injury, it also provides a great structure for investigating ‘root causes’.

Why the auditors like it

They can see:

  • you recognise the need to investigate more serious incidents
  • you have a means to record formal investigations
  • what follow up action you planned and the outcomes

Next Steps

  • OPEN the Incident Investigation Report Form
  • TRIAL the form and understand what each field is asking for
  • CUSTOMISE the form if required
  • ADOPT the form
  • EDUCATE your team, if applicable, on the purpose and use of the form

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About Human Resource Management

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The NDIS wants to know:

  • you have systems in place to ensure participants receive supports from people who have appropriate qualifications and are competent in their role
  • the people providing participant supports are experienced in providing person-centred supports and are meeting the NDIS Code of Conduct
  • you meet your legislative requirements and industry standards
  • workers’ pre-employment checks, qualifications and experience are completed and maintained
  • orientation and induction processes, including the mandatory NDIS worker orientation program, are in place and completed by workers
  • workers are effectively trained to meet the needs of each participant
  • timely supervision, support and resources are available to workers relevant to the scope and complexity of supports delivered.
  • the performance of workers is managed, developed and documented, including through providing feedback and development opportunities.

Next steps

  • WATCH the Verification Human Resource Webinar
  • READ and UNDERSTAND the Spiel
  • REVIEW the relevant Documents already provided in Standard 1:
    • HR Register
    • Compliance Calendar
    • NDIS Induction Checklist
    • NDIS Employment Checklist
    • Annual Training Plan
    • Training Attendance Sheet
    • Participant Survey (and related forms)
    • Goal Attainment QI Activity
    • Support Plan Audit
    • Incident and Complaints Register
  • REVIEW your current HR documents and ensure they meet the above requirements
  • SOURCE other documents as discussed above
  • CUSTOMISE each document to reflect your practice
  • ADOPT the documents
  • MONITOR on-going adherence to completing plans / registers

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Human Resources Policies

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About Continuity of Supports

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The processes outlined below will need to be specific to your business processes and anything you use as part of your those processes e.g. client management software.

The NDIS wants to know:

  • each participant has access to timely and appropriate support without interruption. You will need to have evidence of standard operating procedures (SOPs) for the following:
    • administrative procedures
    • managing unexpected and planned staff absences
    • new referrals

Administrative Procedure Manual or Standard Operating Procedures 

You need to have a documented system to guide your administration team and minimise disruption in the event relief staff are required. This is a big job if you don’t already have SOPs in place. If you are a small business you may consider joining forces with a colleague and working on these together.

You can start by identifying what SOPs would be useful e.g.

  • taking a new referral (using the New Participant Intake Checklist provided in Rights and Responsibilities as a starting point)
  • billing procedure for an NDIS-managed participant.

Being diligent with documenting incidents on your Incident Register will help you identify and prioritise what SOPs are required. For example, if you are having incidents or complaints related to billing procedures, developing a SOP for that will be a priority. Prioritise the SOPs you need and make a plan to complete them over the coming year.

It is often good to get the person who is responsible for the task to develop the draft SOP. This gives them ownership and they will be more likely to comply with it and update it if changes occur.

SOPs will need to be reviewed at least annually to ensure they remain current. You will also need to show the auditor you have a system in place for reviewing SOPs.

SOP for Managing Unexpected Staff Absence and Planned Staff Absence

Participants are generally seen by the same practitioner within an organisation i.e. the person who conducts the initial assessment is the person who implements the Support Plan. You will need to be able to show the auditors how you manage staff absences, planned and unplanned.

This SOP must include keeping the participant informed and giving them choice e.g. wait for their usual provider to return or agree to work with someone else. It also needs to include:

  • how you will match the relief provider to the participant’s:
    • needs, through clinical skills and qualifications (see HR Register)
    • preferences
  • how the provider will be able to learn about the participant so they can effectively provide the required supports.

Refer to the sample SOP1: Participant Management in Case of AHP Unplanned Leave as a starting point.

While many support services are not time-critical, you do need to identify any critical supports your business delivers and determine how these would be provided in the event of staff leave or unexpected emergencies (refer also to the Risk Management Register). This would be flagged as a ‘risk’ in the participant’s Support Plan with appropriate management strategies outlined.

SOP for New Referrals

It’s important to have a procedure for taking a new referral which includes understanding the participant’s preferences e.g. place and time of service and who they want present at their appointments. A New Participant Intake Checklist has been provided to help you get started. Evidence of meeting a participant’s preferences shows you listened and responded appropriately and the participant’s experience was consistent with their expressed preference. If, for some reason, you cannot meet the participant’s expectations, document conversations to show you communicated with them and gave them a choice of using another service provider or accepting what you can realistically do.

Next steps

  • WATCH the Webinar
  • GO TO additional Document below
  • READ and UNDERSTAND the Spiel
  • CUSTOMISE the document to reflect your practice
  • ADOPT the document

SOP Participant Management in Case of Unplanned Leave

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