Community services
quality governance framework
Safe, effective, connected and person-centred
community services for everybody, every time
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Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services October 2018.
Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people.
Indigenous is retained when it is part of the title of a report, program or quotation.
ISBN/ISSN 978-1-76069-509-5 <Print>
ISBN 978-1-76069-510-1 <pdf/online/MS word>
(1807040).
3
Contents
Secretary’s foreword 5
Background and context 7
Quality governance goal and defnition 11
How to use this resource 12
Audience 12
Scope 12
Quality governance principles 13
Quality governance roles and responsibilities 14
Clients and families 14
Frontline staff and volunteers 15
Operational managers and team leaders 15
Executive 15
Boards, directors, committees of management 16
Department of Health and Human Services 17
Quality governance domains 18
Leadership and culture 19
Client and family partnerships 20
Workforce 21
Best practice 22
Risk management 23
Measures of success 24
Indicators of poor-quality governance 26
Support for quality governance 27
Monitoring and accountability 29
References 30
4 Community services quality governance framework
5
Secretary’s foreword
The Victorian Department of Health and Human Services delivers, funds
and regulates community services that have a real and tangible impact on
people’s lives.
We have a duty to keep the people who use our services safe from
preventable harm. This is, and must be, our non-negotiable starting point
when delivering positive outcomes for all Victorians.
The department, sector and service providers all have an important role to
play in collectively preventing harm, and delivering an evidence-informed
approach to meet the unique needs of our community.
Effective quality governance is fundamental to consistently delivering safe,
effective, connected and person-centred community services.
The implementation of this Community services quality governance
framework connects existing safeguards and approaches to quality and
safety. It shifts the focus from compliance, to continuous improvement and
reinforces the need to listen directly to the voices of people who use our
services.
It also places a spotlight on the leadership and culture of our organisations,
and on the importance of valuing the experience and expertise of our
workforce and volunteers who deliver community services every day.
I would like to acknowledge the many community services and departmental
staff and people who use community services who have contributed to
the delivery of this framework, through their ideas, collaboration and key
insights. In a time of increasing complexity we need to use our understanding
of systems to maximise the value we can bring.
We have an opportunity to learn from the experience of other sectors in
their successes and failings, to look at what we can apply and scale, such
as the aviation and health care systems approach to quality improvement.
We will also harness the unique characteristics and strengths of community
services, such as our investment in practice development. Implementation
will not happen overnight; it will require us to test, reflect and refne; to iterate
and evaluate as we go.
I am pleased to share this Community services quality governance
framework with you, and look forward to working together to continuously
improve our delivery across the entire community services system.
Kym Peake
Secretary
Department of Health and Human Services
6 Community services quality governance framework
7
Background and context
Community services in Victoria are undergoing considerable reform. This
reform supports people in getting the right services when they need them,
and provides an earlier, connected and coordinated response. It aims to
reduce service silos and recognises that people’s needs are not distinct but
overlap and change over time.
The reform will also see community services become more outcomes-driven,
where the focus is on the outcomes and experiences of service users.
Reform creates an opportunity to focus on what is at the centre of
community services – making a difference to ensure that people can
live their best possible life. We will only know if we are achieving this if we
measure it, listen to the people we support and to the people who provide
our services. Measurement will tell us about what is working well and what we
need to improve; it will help us track and share our progress.
Community services are complex. Our service system is complex. People’s
lives can be complex, particularly in times of vulnerability and stress.
Collectively our community services are charged with providing the right
support, at the right time, in the right way, for people who access our services
and for this to be delivered in a connected and coordinated way.
Everyone should expect to be safe in our community services. Unfortunately
there continues to be clear evidence from external reviews, internal reviews
and incidents that we do not always get it right. Preventable harm does
occur and this is not acceptable.
A recurring theme from the 2017 Royal Commission into Institutional Sexual
Abuse was of governance failings, ‘where poor practices, inadequate
governance structures, failures to record and report complaints or
understating the seriousness of complaints have been frequent’. These
failures highlight the need for accountable leadership, for effective
governance structures and practices, and for cultures that prioritise the best
interests and safety of every person receiving services.
Similar system failing themes can be identifed in the 2017 Victorian
Ombudsman’s Review of Autism Plus: ‘Lines of responsibility were unclear –
a point underlined by many of those subject to this investigation, who were
eager to deny responsibility or blame someone else for the failings identifed.
…[clients] have been failed in this case, by people and systems.’
The Community services quality governance framework sets
the objective of safe, effective, connected and person-centred
community services for everybody, every time.
It outlines the roles and responsibilities involved in delivering
on that objective, and the domains and systems which promote
and support its consistent delivery.
8 Community services quality governance framework
…..‘The report highlights the need for … a rigorous accountability and
oversight system that will hold organisations to account and adequately
protect people with disabilities.’
These fndings are not unique to Victorian community services and there are
opportunities to learn from the experience of other sectors and settings. An
alarming number of similar failings are available to review within our own
jurisdiction, within Australia and internationally. Tragedy lies in the service
system’s inability to learn from both its own and others’ failings.
Importantly, service failings happen in services that are accredited. This tells
us that accreditation cannot and does not tell the whole story, nor can it
provide complete assurance of quality and safety within an organisation.
Reviews of safety system failings such as Targeting Zero: The Review into
Hospital Safety and Quality Assurance have highlighted the importance of:
• culture
• setting clear expectations at all levels through an organisation of roles in
ensuring high-quality services are delivered
• strong and accountable leadership
• the need for the department to be clear on how it supports and holds
services to account
• the importance of using information to drive improvement and of the
need for the people who deliver and receive services to be partners in the
improvement effort.
The 2017 South Australian Independent Commissioner against Corruption’s
review into Oakden, a public older persons mental health service, found
‘salient lessons about identifying and properly dealing with complaints, the
consequences of attempting to “contain” issues of concern and withhold
information from senior persons and the extraordinary dangers associated
with poor oversight, poor systems, unacceptable work practices and poor
workplace culture. Above all it highlights what can occur when staff do not
step up and take action in the face of serious issues.’
Not only have system reviews highlighted the failures in listening to and
valuing the experiences of service users, they also note the importance of
organisational culture. Frontline staff who were unable to speak up about
safety concerns, or who were not listened to when they did, were not able
to protect clients and service users from harm. Just as the people using
community services should always be safe from preventable harm, so too
should our staff. This encompasses physical, psychological and cultural safety.
The department has a number of safeguarding mechanisms in place
including regulation, performance management processes for funded
organisations, external complaints and oversight bodies, and audit and
review of services by external bodies against standards.
Each of these safeguards plays an important role in protecting people who
access community services. Unfortunately, despite these safeguards, system
failings leading to preventable harm continue to take place and hurt some of
the most vulnerable members of our community. These safeguards, though
‘Complaints
from patients
and families …
is the smoke
under the door.’
Robert Francis
(author of the inquiry
into the failings in care at
Mid Staffordshire, NHS).
9
required and a critical component of the service system, are not enough to
prevent harm if they don’t work together in a connected and coordinated way.
This quality governance framework is designed to provide a basis from
which safeguarding functions are brought together and connected. It is
this connection that will move us from harm prevention to a coordinated
approach of continuous improvement and safety and service excellence.
Compliance with regulation such as the Child Safe Standards and Human
Service Standards are foundational and fundamental requirements for
quality and safety. To continuously strive for high-quality community
services requires more than compliance with regulations and standards.
Achieving this vision requires a whole-of-organisation approach where
everyone is focused on the same goal of excellent services and where there
are strong connections between all parts of the quality and safety system.
Quality governance is not about compliance. A recent study by Ham and
others found that high-performing services achieve great outcomes by
taking actions that go beyond compliance. These include:
• a vision for the future – clearly communicated, specifc and quantifable
goals for improving services
• client and family partnerships – the client is at the centre of services and
is viewed as a partner in design and delivery
• organisational culture – a ‘just’ culture* exists whereby staff are supported
and their wellbeing prioritised
• continual learning and improvement – staff are provided with
opportunities and encouragement to further their skill sets
• leadership – strong, transparent, supportive and accessible leadership
fosters a culture of learning, accountability and openness with strong
practice engagement
• teamwork – staff are supported at all levels of the organisation by skilled
management
• quality improvement – established methods and data are used to drive
and design actions to improve safety and quality.
*’Just’ culture recognises that individuals should not be held accountable
for system failings. It is a culture of trust, learning and accountability. It is a
culture where frontline staff are not punished for actions taken by them that
are proportionate to their experience, training and role, but where there is
accountability for reckless behaviour and an absence of care.
‘The people you
rely on are the
ones you don’t
feel safe with
– that’s the
conundrum.’
Client
10 Community services quality governance framework
The culture of learning from when things go wrong and taking a systems
approach to prevent future harm is well developed in other industries and
underpins a systems approach to improvement.
Quality governance will be a new concept for some community services.
Implementing quality governance means change. Some organisations will
have begun exploring quality governance in their own settings. Others will
have incorporated components of this approach as they establish robust
quality and safety systems. Each service will be at a different place in the
change journey. The systems, structures and processes to support quality
governance will need to be tailored by each service to reflect the scale and
complexity of services delivered and should evolve as it learns and grows. It
will never be a ‘set and forget’ exercise – organisations must always ask what
they are aiming for and how they are measuring achievement towards this
goal. Continuous improvement will be a constant, and the focus will always
be on achieving the best possible outcome on what matters to the client.
The Community Services Quality and Safety Offce is a new part of the
department focussed on connecting systems and approaches to drive
continuous improvement in community services.
‘To err is human,
to cover up is
unforgiveable,
and to fail to learn
is inexcusable.’
Sir Liam Donaldson,
World Health
Organisation
Envoy for Patient Safety
Quality governance: the integrated systems, processes,
leadership and culture that are at the core of safe, effective,
connected, person-centred community services, underpinned
by continuous improvement.
Delivering safe, effective, connected, person-centred community
services is a shared goal of all community service providers.
Quality governance goal
and defnition
High-quality services require a commitment from all staff in pursuing and
maintaining excellence, especially in the face of complexity and adversity.
Fundamental to achieving excellence and providing quality person-centred
services are robust, integrated quality governance systems.
Quality governance provides a framework for organisations and individuals
to deliver safe, effective, connected, person-centred community services for
everybody, every time. Its purpose is to help organisations and their staff
achieve this goal through continuous monitoring, evaluating and improving.
11

person-centred
‘Quality
improvement
requires a focus
on data not
just trust.’
CRANAplus 2013
12 Community services quality governance framework
How to use this resource
This framework has been developed so that services can scale, adapt and
implement components to meet the needs and scope of their organisation.
Each service should use it to review, design and continuously improve its
own structures, systems and processes. It specifes that everyone, whether a
volunteer, manager, CEO or member of a governing body, has a role to play in
achieving the best possible experience and outcome for the people who use
community services. No-one can ignore this responsibility.
It is important that governance systems are regularly reviewed and evaluated
to meet local requirements and drive continuous improvement. The framework
is to be used to inform organisations’ planning, performance measuring and
benchmarking, and board activity and review. It should be used to support
clients and practitioners in amplifying their voices and promoting the goal of
safe, effective, connected, person-centred community services.
Data that reflects quality and safety should be collected, performancemonitored and connected to drive improvement. Using data to understand
and inform quality and safety in services supports systemic improvement.
Boards and their subcommittees should use this framework to drive their
organisation to ensure that it meets the needs of the people it supports through
formal arrangements and reporting but also through culture and leadership.
All community services should have formal quality governance functions
and structures in place that are proportionate to the needs and scope of the
organisation.
This framework has been deliberately crafted to align with Safer Care
Victoria’s Delivering high-quality healthcare: Victoria’s clinical governance
framework for organisations such as mental health community services,
community health services and alcohol and drug services where both
frameworks may apply.
Audience
This framework is designed for all organisations that deliver community
services, including the department and community service organisations.
Every person in an organisation has a responsibility to deliver on safety and
service excellence. For this reason, this framework is designed to be accessed
and used by everyone from frontline staff and volunteers, through to team
leaders, managers, executives and board members. The framework outlines
how these responsibilities differ, and how important it is that staff at every
level of an organisation understand their role in pursuing service excellence.
Scope
Community services span:
• department-delivered community services – child protection, disability
and housing services
• department-funded community services – child and family, community
housing, alcohol and drug, community mental health, disability, family
violence and community health services
• department-regulated community services such as NDIS services
• Family Safety Victoria and its funded/contracted services.
‘I’m not asking
for a lot, I’m just
trying to get a
basic service.’
Client
13
Quality governance principles
The principles listed in Table 1 guide effective, high-quality governance
systems. Common characteristics of high-performing services are reflected
in these principles.
Table 1: Quality governance principles

14 Community services quality governance framework
Quality governance roles
and responsibilities
High quality services and outcomes for every Victorian require everyone at
every level in community services to play a role. Everyone from support staff
to practice leaders, CEOs and department staff should focus on:
• partnering with clients, families and communities
• regular review, evaluation and identifying areas for improvement
• ownership and accountability for the quality of services provided.
Specifc roles are highlighted in Figure 1.
Figure 1: Quality governance roles and responsibilities
Clients and families
People are the central focus of quality governance. Their experiences of and
participation in community services are fundamental indicators of quality
and safety.
Clients and families:
• participate to their desired extent in the services they receive
• participate in system-wide service improvement
• advocate for safety to support the best possible outcomes for themselves
and other clients
• share their experience, provide feedback and offer suggestions to support
improvement.
Clients
and
families
The
department
Operational
managers and
team leaders
Boards,
directors,
committees of
management
Executive
Clients
and
families
Frontline
staff and
volunteers
Safe, effective,
connected,
person-centred
community
services
15
Frontline staff and volunteers
The people who have direct contact with, and deliver services to, our clients
are the face of service quality. Frontline staff and volunteers:
• support clients to share their experience
• work within relevant standards, protocols and guidelines
• speak up and raise concerns about quality and safety for their colleagues
and clients
• share information and learnings regarding safety
• monitor and review their services and focus on continuous improvement
• work collaboratively as part of coordinated teams and services
• work with and support clients to exercise their voice, recognising clients
may be hesitant to do this for a range of reasons
• go beyond the bare minimum to pursue excellence for clients
• regularly update their skills and knowledge to provide the best
service possible.
Operational managers and team leaders
Operational managers and team leaders:
• provide a safe environment for staff and clients that supports a culture of
collaboration, teamwork and transparency
• ensure that staff and volunteers are clear about their roles and
responsibilities
• support and develop staff and volunteers to deliver the best possible service
• proactively identify and manages risks
• lead and model behaviour that supports continuous learning and
speaking up about quality and safety concerns
• promote a culture of continuous improvement through sharing
information and supporting and enabling staff and clients to contribute to
and lead improvement efforts
• support staff to seek out client voices in a way that responds to power
imbalances.
Executive
The executive and CEO:
• provides visible leadership and demonstrates a commitment to delivering
the organisation’s strategic direction
• creates and promotes a safe and open culture that empowers staff to
speak up and raise quality and safety concerns
• fosters a ‘just’ culture of safety, fairness, transparency, learning and
improvement in which staff are empowered and supported to deliver their
roles and responsibilities
• proactively seeks information from qualitative and quantitative sources
including staff and clients to test and understand the quality of all areas of
service delivery
• drives a culture that is committed to supporting clients to exercise their voice
• maintains focus on the quality of services, ensuring that listening to
and acting on the client voice is at the centre of the business and the
organisation remains focused on continuous improvement
• regularly reports to the board or committee of management on risks,
outcomes, areas for improvement and progress on achieving the best
service across all areas of service delivery.
Frontline
staff and
volunteers
Operational
managers and
team leaders
Executive
16 Community services quality governance framework
Boards, directors, committees of management
Governance bodies have specifc responsibilities for quality and safety in
their service. These should be specifed in their constitution, strategic plan or
other governing charter.
Governing bodies have ultimate responsibility to ensure the services
delivered within their organisation are safe and of a high quality. Governing
bodies must also take the necessary steps to assure themselves that the
services within their organisations are safe. Governing bodies must ensure
they have appropriate subcommittees with suitably skilled members,
including a subcommittee dedicated to quality and safety.
Governing bodies:
• set a clear vision, strategic direction and ‘just’ organisational culture to
drive consistently high-quality services and to facilitate effective employee
and client engagement and participation
• ensure they have clear and regular reporting on the quality and safety of
their service via a dedicated subcommittee
• stay engaged, visible and accessible to staff
• ensure they have the necessary skill set, composition, knowledge and
training to actively lead and pursue quality and excellence in service
delivery
• understand key risks and ensure controls and strategies are in place to
mitigate them
• monitor and evaluate all aspects of services provided through regular and
rigorous reviews of benchmarked performance data and information
• ensure robust quality governance structures and systems across the
service effectively support and empower staff to provide high-quality
services and are designed in collaboration with staff expectations
• delegate responsibility for the implementation, monitoring, evaluation of
improvement to their executive
• regularly seek information from the executive, staff and clients about the
status of quality and safety in all areas of service delivery.
Boards,
directors,
committees of
management
It is crucial that community service organisation boards and departmental divisions
develop and maintain robust relationships.
The Community Services Quality and Safety Offce will develop tools to support this,
with particular focus on ensuring the delivery of safe, effective, connected, personcentred community services.
17
The department
The department has a number of key quality governance functions including to:
• set the expectations and accountability requirements for quality and safety
• ensure community services have the relevant data and information to
support and oversee quality and safety
• provide leadership, support and direction to community services
• monitor quality governance implementation by regularly reviewing key
quality and safety data
• monitor the quality governance system to identify concerns early and to
take appropriate, timely action to address system failings.
Defnitions of key roles
The department as service provider: Provides direct service delivery
to clients and families. The department will apply this framework to its
operations (in relation to expectations of executive, operational managers
and frontline staff.)
The department also has specifc functions as system steward, funder,
regulator, contractor, capacity builder, as defned below.
System steward: Oversees and manages system policies, institutions,
infrastructure, policy and planning.
Regulator: Regulates human service providers and enforces specifc
regulatory schemes that are designed to protect vulnerable people.
Funder and purchaser of services: Sets funding models, outcomes,
targets and funding program guidelines and leads reform of funding
approaches.
Contractor: Monitors inputs, outputs and outcomes and identifes assesses
and responds to performance issues.
Capacity builder: Supports learning, innovation and improvement
systems as well as workforce sector development, research partnerships
and networks. It shares knowledge, information and data, builds capacity
to measure outcomes and use data, and supports practitioner and client
engagement.
The purposeful interconnection of these functions, each of which contributes
to quality and safety, will be articulated in a community services system
quality and safety architecture and operating model (under development).
The
department
18 Community services quality governance framework
Quality governance domains
Quality governance exists within the system of a community service
organisation’s broader governance, oversight, strategy and assurance
arrangements. This ensures both a future and accountability focus, and
that the appropriate corporate governance arrangements such as fnancial,
risk and business mechanisms are in place and are aligned to support the
delivery of safe, effective, connected, person-centred community services
for everybody, every time.
The framework identifes the systems of focus that are required to develop and
maintain a high-performing organisation.
The systems are organised into fve domains of quality governance that are
underpinned by continuous monitoring, evaluation and improvement:
• leadership and culture
• client and family partnerships
• workforce
• best practice
• risk management.
Quality governance requires a focus on all domains. These domains are
inter-connected and interdependent. Quality governance is achieved through a
whole-of-organisation approach and is supported by systems and processes that
are proportionate to the risk, size and complexity of the organisation. Continuous
monitoring, evaluation and improvement underpin quality governance.
Figure 2: Quality governance domains
evaluatin
g
monitorin
g
improvin
g
Leadership
and
culture
Risk
management
Workforce
Best
practice
Client
and family
partnerships
Safe, effective,
connected,
person-centred
community
services
19
Leadership
and
culture
Leadership and culture
Visible, accountable and purposeful leadership at all levels of the service
system is required to cultivate an inclusive and ‘just’ culture and facilitate the
delivery of high-quality services.
Leaders set the tone on the way organisations do their business. An engaged
workforce requires strong inclusive leadership. Engaged staff and clients who
are enabled to actively participate in organisational strategy, planning and
delivery are the foundations of quality.
There is strong evidence from analysis of high performing services that
leadership styles and processes and organisational cultures affect the
outcomes of people receiving services.
The culture of an organisation is shaped, fostered and enhanced by its
leaders. A strong organisational culture is required to support staff and
leaders to deliver their best in supporting the best outcomes.
Conversely, leaders who aren’t open to learning about problems or listening
to feedback from staff or clients set themselves and their organisations up
for failure. They also place the safety of their staff and clients at risk.
An organisation’s culture must be one of fairness, respectfulness and
transparency. It should be based on natural justice and should value learning
from when things go wrong. It should foster accountability for decisions and
actions.
Culture is not static; it requires effort from the whole organisation. It is
supported by systems that promote productive working relationships
between all levels and across the organisation.
Systems should be in place that ensure:
• a clear vision for improving the quality of services is communicated
throughout the organisation
• organisational alignment in strategic goals and priorities for providing
high-quality services and experience for every client in a way that is
seamless and integrated
• a supportive, transparent culture that is set and led by the governance
body that assists all staff to provide high-quality services and to
continuously improve
• clear accountability for planning, monitoring and improving the quality of
each service or program
• the CEO, governance body and leaders regularly review their performance
and seek external ideas and knowledge on how best to strive for the best
service
• the governance body and executive visibly engage with and support
clients and staff in their roles
• appropriate governance structures, including committee and reporting
structures, are in place to effectively monitor and improve quality
performance
• the development and support at all levels of the organisation of leaders
who promote and drive high-quality services
• the development of staff skills and systems for achieving high-quality
services, managing change and improvement across the organisation
• effective supports are in place for staff who identify quality and safety issues
• regular and rigorous evaluation of the effectiveness of systems for
developing and supporting positive organisational leadership and culture.
20
Client and
family
partnerships
Client and family partnerships
Effective client, family and carer partnerships are crucial for improving clients’
experiences and outcomes, and for designing services that meet people’s needs.
Partnerships require tailored listening and proactive engagement, and
support participation.
People are at the heart of community services. People’s experience of
and participation in services are basic indicators of quality and safety.
Participation and partnership does not happen on its own – it requires
action. The foundation of participation is that voices are proactively sought
out, listened to and responded to.
Empowering participation in services and decision making helps
organisations to deliver services that are better tailored to the person’s
needs, preferences and values, and leads to better outcomes.
Client feedback (both positive and negative) is a valuable resource that
should be encouraged throughout all aspects and phases of the service.
It should be proactively sought in ways that are appropriate to the client’s
needs and preferences and be used to drive improvement for individuals and
the service system.
Failure to seek and respond to the voice of clients results in a compromised
understanding of service quality and safety. Services may be delivered
dangerously or excellently, without understanding the experiences of people
accessing the service. Organisations may not fully appreciate this.
In seeking out client voices, services should remind themselves of the
inherent power imbalance present in many provider–client relationships, and
how this might affect how clients express themselves and their concerns.
Services must be mindful of the complexities of seeking the voice of children,
and accommodate this in their work. Complaints should be responded
to compassionately, reflect best practice standards and be used to drive
improvement.
Systems should be in place to ensure:
• clients and their unique needs are key organisational priorities
• clients are actively invited and supported to provide feedback on their
experiences
• clients are provided with the relevant skills and knowledge to participate
fully in their service provision to the extent they wish
• clients are provided with the opportunity, information and training to
fully participate in organisational processes for planning, monitoring and
improving services
• clear, open and respectful communication exists between clients and staff
at all levels of the service
• services respond to the diverse needs of clients and the community
• services learn from and act on client feedback on service delivery to make
improvements
• client participation processes are monitored for their effectiveness
• complaints are responded to compassionately, competently and in a
timely fashion, with feedback provided to all parties about the action
resulting from their input
• issues arising from complaints are analysed, reported and used to improve
services
• clients’ rights and responsibilities are respected and promoted
• clients are made aware of oversight bodies available to assist and
advocate for them.
‘Look for problems
but also look
for solutions
– and ask us
because we might
have the answers.’
Client
21
Workforce
Staff must have the appropriate skills and knowledge to effectively fulfl their
roles and responsibilities. Systems must support a skilled, competent and
proactive workforce.
A skilled, competent and proactive workforce is the backbone of community
services. It requires a comprehensive approach to recruiting, allocating,
developing, engaging and retaining staff.
An informed workforce approach will enable services to have the right people
in the right place with the right skills to deliver the right service.
Ensuring that an organisation seeks and responds to the experience of its
staff enables the organisation to clearly understand its workforce’s strengths
and weaknesses.
Providing a workplace that is physically and psychologically safe for all is
non-negotiable. Organisational planning must include a focus on building a
culture that tackles discrimination, bullying and promotes staff engagement.
All staff require access to information and training on effective approaches
to continuous service improvement and how they can contribute to delivering
high-quality services. Human resource systems support staff to develop and
consolidate their skills, work within their roles and responsibilities and, where
appropriate, manage performance.
Systems should be in place to ensure:
• planning, allocation and management of the workforce provides the
appropriate personnel and skills to deliver high-quality services and to
meet changing client needs
• the community services workforce has the appropriate qualifcations and
experience to provide high-quality services and ongoing professional
development to maintain and improve skills
• a safe and fair workplace based on a ‘just’ culture and mutual respect
is provided, with systems in place to address issues with culture such as
workplace bullying, unconscious bias and discrimination
• staff feedback is sought and used in a visible way to improve services
• promotion and support of teamwork is the basis of providing high-quality
services
• clear communication of role expectations, responsibilities and standards
of performance is provided to all staff, and employees are supported and
held accountable for meeting these expectations
• mentoring and supervision is used to support, monitor and develop staff
• training and tools are provided so staff can monitor and improve their own
practice and organisational processes more broadly
• innovation in workforce practice supports the development and
maintenance of workforce excellence
• there is a just process for addressing individual performance that
prioritises client safety
• a defned system for managing complaints or concerns about a staff
member is in place and is regularly reviewed for its effectiveness
• the systems for developing and supporting the workforce are regularly and
rigorously evaluated to ensure their effectiveness.
Workforce
22 Community services quality governance framework
Best
practice
Best practice
Staff must be effectively supported to continuously improve the safety and
appropriateness of the support they provide through evidence-informed
best practice.
Best practice requires systems that support staff to provide safe and
appropriate services that deliver the best possible outcome, working within
the scope of the service’s funding and service agreement.
Research, evidence and guidelines should form the basis of service provision,
and staff should be supported to access and integrate this into service
delivery.
Systems to support best practice include staff having the required skills and
knowledge, support and guidance, and evidence (where available) to deliver
high-quality services.
The safety, effectiveness, impact and outcome of services should be regularly
monitored, reviewed and improved using relevant measures and reporting
processes.
Best practice is continuously evolving. It requires regular review and
refnement to reflect and respond to changing client needs, technology and
service system arrangements.
Systems should be in place to ensure:
• evidence-informed services are provided within the scope of funding and
service agreements
• service standards and protocols are clearly articulated, communicated
and adhered to across the organisation
• practitioners regularly review and improve their service
• clearly defned roles, scope of practice and supervision processes support
practitioners to work safely and effectively
• active partnerships are developed with clients and include a shared
understanding of the plan
• clients experience smooth, connected transitions across settings and
services
• staff participate in the design and review of service systems and
processes, and support innovation
• data on the safety, effectiveness and person-centeredness of services is
collected, analysed and shared for the purposes of both accountability
and improvement
• staff regularly review their own performance.
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Risk management
Services must have a broad-based risk management system that integrates
organisational, fnancial, occupational health and safety and practice risk.
Both safeguarding and minimising risks to clients requires structured
approaches to safety that are both reactive and proactive – that both repair
and prevent harm. Safe services rely on staff and their awareness of systems
that prioritise safety for all. Safe services are supported by mechanisms that
identify issues early and respond when things go wrong.
Risk management for clients should be approached systematically
and integrated within broader risk management systems that scan for,
monitor, review and manage risk. This includes early identifcation of
risks and defned escalation processes with clear pathways, processes,
accountabilities and oversight.
Where safety is compromised, leadership and management risk systems
must support staff to respond appropriately through escalation,
management and corrective action.
It is essential that issues relating to risk are analysed and shared to improve
safety and inform future work.
Systems should be in place to ensure:
• a planned, proactive, systematic and ongoing evidence-based approach
to creating safety for clients and staff is in place
• the organisational culture supports staff to pursue safe practice and to
speak up for safety
• risk considerations and data inform goal and priority setting and the
development of business and strategic plans
• risks are proactively identifed, monitored and managed through an
effective register with clearly understood, integrated risk data
• known client risks are proactively addressed and all services are regularly
scanned to identify risks as they emerge
• the identifcation and reporting of client incidents is consistent with the
department’s incident management policy and is tracked over time to
monitor and identify safety issues
• client incidents are investigated to identify underlying systems issues and
root causes, and this information is used to improve safety
• the service complies and adheres with risk-related legislation and relevant
Australian standards
• systems and datasets for developing and supporting client risk
management are regularly and rigorously evaluated to ensure their
effectiveness.
Risk
management
24 Community services quality governance framework
Measures of success
All community service providers collect and report large amounts of data,
but it is not always used to its full potential or synthesised in an intelligent
way. Community services should review their data and identify ways that it
can be connected to give enhanced insights into issues and trends within
their service.
Monitoring processes help assess the effectiveness of approaches, identify
areas of risk and support continuous improvement.
Measures should be set to reflect the organisation’s goals for service
excellence and encompass safety, effectiveness, person centredness and
connectedness dimensions.
These should span the nature and breadth of service delivery, be sought from
all the quality governance domains and, where possible, span qualitative
and quantitative data sources. A focus should be on improvement targets
rather than merely meeting funding or other administrative, regulatory or set
performance targets.
Services should consider both lead and lag indicators.
• Data may be held by the department or held locally by service providers.
• Data should align with the department’s community services quality and
safety data suite (under development).
• Data should be benchmarked and support comparison across time and
with peer organisations.
• Data should identify risks and strengths.
Table 2 suggests ways to measure success against the quality governance
domains.
25
Table 2: Quality governance domains – potential measures of success

Risk
management
Best practice
Workforce
Client and family
partnerships
Leadership
and culture
26 Community services quality governance framework
Indicators of poor-quality governance
Common themes can be found in the literature and in service reviews related
to quality and safety governance failings. These include:
• a system that is purely focused on compliance with standards and little to
no focus on high-quality services and improvement
• an isolated, inward-looking organisational culture and leadership that
does not support learning and/or cultivates a fear of speaking up
• a disengaged board, CEO and executive who are unwilling to hear bad news
• management and leaders disconnected from oversight systems
• substandard practice leadership, staff engagement and teamwork to
support best practice
• weak data reporting (in both form and content); passive monitoring actions
• tolerance of substandard care – problems are well known and entrenched
but not actively addressed; acceptance of ‘the way things are’
• absence of client and family voice and participation, and limited support
and interest in clients and families
• lack of practice review and poor clarity of accountability for service
improvement
• lack of data benchmarking and review
• evidence not considered in practice or system improvement.
There are also times of greater risk for quality governance including when
there is:
• very rapid organisational growth and systems have not kept up with the
size, scale or complexity of the demand or organisational needs
• a transition between oversight systems or a focus on new developments at
the expense of existing service delivery
• a change in the CEO, signifcant changes in executive leadership or
governing body.
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Support for quality governance
Tailored quality governance questions can be used by governing bodies and
leaders to critically examine their own service. Suggested questions include:
• Are we pursuing specifc goals for excellent services?
• When was the last time we heard the client perspective?
• When was the last time we heard from staff?
• What does safety look like around here?
• What is my role in quality and safety?
• Do we know what the red flags are?
• How will we fx what we know isn’t working?
• What evidence do we have to show we are delivering the best services?
• Do we know what our quality and safety problem areas are?
• How do we evaluate our services?
• What must we do to improve the effectiveness of our systems?
• What are we aiming to improve and how will we know we are getting there?
• How do we support and speak up for safety in our service?
• Do staff feel supported to create consistently safe, person-centred and
effective services?
• Are our staff adequately skilled, engaged and empowered to provide safe,
high-quality, person-centred services?
• Do we have a ‘just’ culture and, if not, what are we doing about it?
• What actions are we taking to ensure that inappropriate behaviour is not
tolerated?
• How do we support listening to clients and families?
• What actions do we take to empower clients to meaningfully partner in
service delivery and design?
• How do we support and promote service improvement in partnership with
clients?
• How do we share our quality and safety learnings?
• What is the evidence that we are delivering positive outcomes?
• Do we have a shared understanding of success?
28 Community services quality governance framework
The Community Services Quality and Safety Offce will develop further
supports to assist providers in implementing quality governance. These may
include the following:
Training and tools
• Online and in-person training, capacity building and seminars
• A toolkit and associated implementation support for boards
• Leadership development – particularly on quality improvement
methodologies
• Data literacy – tools to help use data more effectively such as using the
correct measures and reporting and analysing data in a way that is
meaningful and purposeful
• A self-audit tool for services to monitor key components of local structure
and processes
• Examples of quality governance instruments, documents and tools that
are able to be modifed to meet organisational needs
Implementation support
• Improvement capability – tools and processes that support effective and
sustainable improvement efforts
• Guidance on structures and processes that can support quality
governance
• Support for implementing evidence-based practice
Local area networks
• Supporting networks of community service leaders to focus on collective
improvement efforts
Client voice
• Tools to better capture and use client voices and to support client
participation
• Promotion of the client voice / client voice framework
The quality governance framework and tools will be regularly reviewed and
evaluated to ensure they evolve to reflect and respond to need and evidence.
29
Monitoring and accountability
Initially, organisations will be supported to adapt to quality governance
systems, ensuring that formal quality governance functions and structures
are in place and are proportionate to the needs and scope of the
organisation. A quality and safety subcommittee of the governance group
should be established.
In future, organisational data reporting on a suite of measures will be
required to enable analysis, benchmarking and comparison. This will give
clarity on systemic strengths and risks; it will help track and share progress
across the entire service system.
Public accountability for in-scope organisations will be determined for their
quality and safety planning and performance.
An initial focus will be on supporting boards and governing bodies to
promote their understanding of accountabilities and responsibilities in
relation to quality governance. This focus raises the awareness and supports
the intent for all in-scope organisations to report on their performance
against quality and safety.
These requirements, following consultation and phasing, will be specifed in
policy and performance monitoring requirements.
30 Community services quality governance framework
References
CRANAplus, 2013, Clinical governance guide for remote and isolated services
in Australia. CRANAplus. Alice Springs.
Duckett S, Cuddihy M, Newnham H, 2016, Targeting Zero: Report of the
Review of Hospital Safety and Quality Assurance in Victoria, Victoria.
State Government of Victoria, Melbourne.
Ham C, Berwick D, Dixon J, 2016, Improving quality in the English NHS: a
strategy for action, The Kings Fund, London.
Lander B, 2018, Oakden a shameful chapter in South Australia’s History.
Independent Commissioner Against Corruption, Adelaide.
Royal commission into institutional responses to child sexual abuses,
2017, Final report Royal Commission into Institutional Sexual Abuse,
Commonwealth of Australia, ACT.
Safer Care Victoria, 2017, Delivering high- quality health care – Victorian clinical
governance framework. Victoria. State Government of Victoria, Melbourne.
Victorian Ombudsman, 2017, Investigation into the management and
protection of disability group home residents by the Department of Health
and Human Services and Austism Plus. Melbourne.
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32 Community services quality governance framework