Continual Improvement Policy

1. PURPOSE

The purpose of this Policy is to outline DCIRS Community Care’s commitment to continual improvement in all aspects of our services and operations. This commitment aligns with the requirements of the National Disability Insurance Scheme (NDIS) and Aged Care Quality Standards ensuring the delivery of high-quality, safe and effective supports and services to our clients and participants. This Policy will commence from 2 September, 2025. It replaces all other continual improvement policies of DCIRS (whether written or not).

2. APPLICATION

This Policy applies to employees, volunteers, contractors and students of DCIRS. It also applies to clients & participants, external stakeholders, linked organisations and members of the general public.

3. DEFINITIONS

Continual Improvement – a systematic approach to enhancing the quality, effectiveness, and efficiency of services and operations.

SMART Goals – goals that are Specific, Measurable, Achievable, Relevant, Time-bound.

4. POLICY

4.1 Continual Improvement Overview

DCIRS Community Care believes that continual improvement is essential for:

• Enhancing the quality of life for clients & participants

• Meeting and exceeding the requirements of relevant standards and legislation

• Promoting a culture of learning and innovation

• Improving efficiency and effectiveness

• Ensuring sustainability

This policy covers all services and operations of DCIRS Community Care, including but not limited to:

• Client & Participant care

• Service Delivery

• Risk Management

• Workplace Health and Safety

• Governance

• Compliance

• Training and Development

• Administration

4.2 Guiding Principles

• Person-Centred: "All improvement activities will be focused on enhancing the well-being and outcomes of our clients/participants."

• Evidence-Based: "We will use data, feedback, and best practices to inform our improvement efforts."

• Collaborative: "We will actively involve clients/participants, families, staff, and other stakeholders in the improvement process."

• Systematic: "We will use a structured approach to identify, plan, implement, and evaluate improvements."

• Transparent: "We will communicate openly about our improvement activities and their outcomes."

• Accountable: "We will assign responsibility for implementing and monitoring improvements."

5. PROCEDURES

5.1 Data collection and Analysis

DCIRS Community Care may collect data from a variety of sources including client & participant feedback (surveys, interviews, complaints, compliments), Incident reports, audit findings, performance data and staff feedback. This data will be analysed to identify trends, patterns and areas for improvement.

5.2 Identifying Opportunities for Improvement

Opportunities for improvement may be identified through regular reviews of data and performance, feedback from clients, participants, families, external stakeholders, linked organisations and staff, internal and external audits, incident investigations and benchmarking against best practices. Opportunity to Improve (OTI) forms should be made available to all employees, clients and participants of DCIRS Community Care. OTI forms should be available upon request to external agencies and individuals. OT forms should be completed by the individual who has identified the improvement opportunity (front side of the form – blue accent) and the form should then be passed onto the managing director for review (back side of the form – green accent). For confidentiality purposes, the form should always be placed face down with the green manager’s side facing up.

5.3 Planning and Implementing Improvements

When an opportunity for improvement is identified, a plan should be developed that includes a clear description of the issue or opportunity, specific, measurable, achievable, relevant and timebound (SMART) goals, actions to be taken, resources required, responsibilities and timelines. The plan will be implemented in a timely and effective manner.

5.4 Monitoring and Evaluating Improvements

The effectiveness of implemented improvements will be monitored and evaluated to determine whether they have achieved the desired outcomes. This may involve collecting data to measure the impact of the changes, seeking feedback from clients, participants and staff, and reviewing relevant policies and procedures.

5.5 Continuous Improvement Tools and Techniques

DCIRS Community Care should use a range of tools and techniques to support continual improvement such as root cause analysis, SMART goals and SWOT analysis.

5.6 Documentation

All stages of the continual improvements process should be documented, including identification of the issue, planning of the improvement, implementation of the changes and monitoring and evaluation of the results.

5.7 Feedback Mechanisms

DCIRS Community Care has several feedback mechanisms, including suggestion boxes, regular staff meetings, client & participant surveys, external stakeholder & linked services surveys, opportunity to improve forms and incident reporting systems.

5.8 Training and Development

DCIRS Community Care provides training and development opportunities for staff to enhance their skills and knowledge in continual improvement practices.

6. RESPONSIBILITIES

Management: Responsible for leading, supporting and promoting continual improvement, providing resources, and ensuring the policy is implemented effectively.

Staff: Responsible for actively participating in continual improvement activities, identifying opportunities for improvement and providing feedback.

7. STANDARDS AND LEGISLATION

This policy is aligned with the following NDIS and Aged Care Quality Standards:

• NDIS Practice Standards

• NDIS Quality and Safeguards Commission

• Disability Act 2006

• National Standards for Disability Services

• Aged Care Quality Standards

• Aged Care Act 2005 (Aged Care Act 1997 until 1 November 2025)

• Aged Care Quality and Safeguards Commission • Charter of Aged Care Rights

• This policy also considers all relevant legislation and regulatory requirements.

8. ASSOCIATED DOCUMENTS

• Opportunity to Improve Form

• Feedback and Complaints Policy

• Risk Management Policy

• Incident Management Policy

9. VERSION AND REVIEW INFORMATION

DCIRS reserves the right to amend, replace, or terminate this policy from time to time.

Version 1.0: 2 September 2025 Review Date: 2 September 2028