Implementation guidelines for non-government community services

Implementation tools

Page last updated: 2010

What does quality mean for your organisation - how do you already demonstrate management and service quality?
Policies and procedures
Before you begin your baseline assessments for each standard
Who should conduct the baseline assessments?
Identify your existing evidence
Review your current state and additional evidence requirements
Complete the action sheet
Implement the actions and monitor progress
Sign off and move to the next standard


As noted in earlier sections, implementation requirements vary depending on state and territory arrangements, current organisational experience in working within a quality and continuous improvement service system, and other factors.

This section addresses some of the practical issues for service providers to consider as the implementation process begins: who needs to be involved, what will need to be done and how it might be done.

It includes some practical suggestions and tools to help organisations conduct a baseline assessment of current performance against each of the National Standards. It is not mandatory to use the tools.

This section also discusses how base line assessment can identify opportunities for service improvement, and be the basis for ongoing commitment to, and development of, a culture of continuous quality in service management and delivery, involving boards, staff, consumers, carers and funding bodies.

What does quality mean for your organisation - how do you already demonstrate management and service quality?

Section 2 noted that service delivery in the non-government community mental health sector (as in other parts of the mental health service system) is influenced by a number of different quality, safety and performance requirements.

The national standards are an important component of this environment, but not the only one. Embracing a continuous quality improvement culture involves more than complying with the national standards, and will not necessarily require the same actions from all organisations.

Practices which indicate that the service has a commitment to continuous improvement could include but are not limited to:
  • regular meetings to review, for example, complaints, processes that have gone wrong and communication breakdowns - resulting in changed processes to address the issue
  • operating programs that have a strong evidence base to support their efficacy
  • regular reviews of organisational risks and the strategies in place to mitigate them
  • regular (perhaps twice per year) forums with consumers and carers to discuss issues such as service provision and what is working well or less well for them
  • inviting experts to visit the agency or to attend staff meetings to talk on issues of interest or concern
  • processes for staff to provide suggestions for service improvement, and for rewarding good ideas
  • staff performance appraisal systems and acting on what they identify as needing to be addressed, such as staff training and development needs and succession planning
  • regular reviews and evaluations of services or elements of services and acting upon the findings
  • adopting and working within a documented quality framework or having external accreditation arrangements in place.
The size, type of service, service mix complexity, service locations, funding and financial arrangements and board and staffing structure and expertise, are all factors that will influence the organisation's approach to service quality and continuous quality improvement.

The following are questions which, at the start of the national standards implementation process, will help organisations to take a considered approach to what implementation will mean for them.
The questions will help to place the principles of recovery oriented mental health practice and the National standards for mental health services in the broader context of a quality system and a continuous quality improvement culture.

Answering the questions will also help you to identify what you already have in place and what you already do that will demonstrate compliance with the national standards.

Key questions to ask include:
  • What will our organisation look like, what will be the signs that it has a commitment to recovery practice and continuous quality improvement?
  • What are the core quality principles we want to embrace, and what for us will be the key processes of quality improvement?
  • What can we do ourselves with our existing resources and expertise, and who might be able to help us?
  • What resources, systems, structures do we already have in place that help us to demonstrate our compliance with the national standards and our commitment to continuous quality improvement?
  • What other resources and tools would be useful and how do we access them?
  • How do the Principles of recovery oriented mental health practice and the National standards for mental health services fit into this; how do they relate to and support what we want to do?
With a strong commitment from the board and staff, it is possible for even very small organisations to make significant achievements towards continuous quality improvement, and to integrate the recovery principles and the national standards into their daily operations to contribute to that outcome.

Once implemented, the national standards should not be an add-on or an additional work load on already hard working boards, managers and staff. They should simply be a part of how the organisation goes about the business of quality management and service delivery. Top of page

Policies and procedures

Clearly written and comprehensive policies and procedures are an important part of a well managed organisation that delivers quality services.

Some service providers will find as they implement the national standards that there are areas in which they need to review policies and procedures or develop new ones. Sometimes organisations get so involved in making sure that they have the 'right' policies and procedures in place that the policy and procedures manual becomes an end in itself, instead of the means to quality management and quality service delivery.

The purpose of having policies and procedures is to guide organisational practices and behaviours, not to meet a compliance requirement. Organisations can have excellent policies and procedures and still be poorly managed or providing services of less than optimal quality.

When reviewing existing policies and procedures or developing new ones as part of implementing the national standards, do not lose sight of:
  • Why you have the particular policy and procedure
  • Who has to act in ways that are set out in the policy and procedure
  • What the organisation needs to do to help those people to do what is required of them, for example through information, supervision and training.
The best policies and procedures are generally those in which the people who have to carry them out understand why they are necessary and have a say in their development. Top of page

Before you begin your baseline assessments for each standard

Before starting your assessment of where your service stands in relation to each standard and its criteria consider this: who in your network could you collaborate with in implementation, and who might be able to help you.

For example, it could be another non-government mental health service provider or a public mental health service with which you have a collaborative relationship.

Two collaborative strategies worth considering are:
  • implementation partnerships, in which two or more organisations work on the implementation of a particular standard at the same time
  • mentoring partnerships, in which a larger, more established organisation mentors and supports a smaller, newer organisation during implementation.
If you identify a need to purchase training, perhaps other services also have a similar need. Consider sharing the costs and resources.

Plan to implement incrementally. Organisations are strongly encouraged to work on one standard at a time.

Initially, especially for smaller organisations, the task might seem daunting. It is important to remember that:
  • Your service probably already has a number of things in place that you have simply not thought of as evidence or indicators in relation to the national standards - things that are part of your existing quality arrangements, or just part of the way you do business.

  • Now is the time to go through your agency and service documentation in a planned way to see what might relate to one or more of the national standards. This includes your strategic and operational plans, policies and procedures, consumer and carer information sheets, fact sheets, training records and memoranda of understanding.

  • Peer non-government community mental health service providers might have information and resources that will help you, and you might have something that might help them in return - for example, relating to the standard under consideration or another standard.

  • There are a lot of resources (including templates and model policies and procedures) developed not only for non-government community mental health services but also for other service sectors such as alcohol and other drug services, disability services and home and community care services. Much of the material developed in other sectors is very relevant to the national standards. You might be able to access these through your local networks, but the internet is also a rich source. Top of page

Who should conduct the baseline assessments?

Who should conduct the baseline assessment for each standard will vary according to the standard, but it will always be easier and produce a more comprehensive picture if more than one person is involved. For example, board members and senior managers should be involved in assessing Standard 8. Governance, leadership and management.

Consumers should be involved in assessing standards 3 and 6, and carers standard 7, but they could also make a useful contribution to others. Occupational health and safety representatives should be involved in standard 2. Regardless of who is involved, a relevant senior person in the organisation should have a leadership role in relation to each assessment.

Identify your existing evidence

Responding to the questions about what quality means for your organisation and how you already demonstrate service quality and management will help to establish your organisation's baseline status as you begin the implementation process.

A current state assessment template is provided at the end of this section to help you to decide where you currently are in relation to each standard before you begin work on it. You are not obliged to use this template if your organisation has other tools or resources that will work better for you.

Remember, not all criteria for each standard are relevant to the non-government community mental health sector, and you don't necessarily have to meet all of the applicable criteria to demonstrate that you are meeting a particular standard.

Try to collect all the evidence you have in relation to the standard and its criteria, remembering to consider what is already contained in your existing policies and procedures, fact sheets, training records, et cetera. Remember also that one piece of evidence might be relevant to multiple standards and multiple criteria. Top of page

Review your current state and additional evidence requirements

When you have completed the current state assessment for a standard, step back and look at what it tells you:
  • What are you already doing well? As part of your commitment to continuous quality improvement, what are your opportunities for further service improvement?
  • Are you able to take action for further improvement now, or should you wait until other areas are at a level with which you are satisfied?
  • In what areas do you have evidence of progress, but still need to do further work?
  • What will it take, what evidence will be required to demonstrate that you have reached the level you think you need to reach for baseline compliance in these areas?
  • Who needs to do the work and who will monitor progress?
  • Are there any significant gaps - where you have no evidence - and are some of these gaps more critical than others?
  • What do you need to do, what evidence must be collected to address the gaps?
  • Are there other organisations that might have some of what you need, that you can approach for assistance? Now is the time to use your networks.

Complete the action sheet

Use the action worksheet to set out what you need to do - based on the assessment you have made - and who needs to do it. Set realistic deadlines.

Implement the actions and monitor progress

Begin work on the identified areas. Use the review form to review the progress you have made and the evidence you now have in place for this standard. Remember that the best approach is one of continuous quality improvement. You don't have to do everything up front. You might identify opportunities for service improvement that you will not act upon until the following year.

Sign off and move to the next standard

When you are satisfied that you have done all that you planned to do at the implementation stage for this standard, move on to the next one. Top of page


Current state assessment form

Sample form for Standard 1: rights and responsibilities. This table has three columns:
  • indicator (indicators 1.1 to 1.17 are listed)
  • relevance to service (yes/ no)
  • current performance in relation to this indicator (we are satisfied that we meet this criterion (evidence); we partially meet this criterion (evidence); criterion not yet met)

Action form

Sample form for Standard 1: rights and responsibilities. This table has four columns:
  • indicator (indicators 1.1 to 1.17 are listed)
  • action required (to be completed)
  • by whom? (to be completed)
  • by when? (to be completed)

Review form

Sample form for Standard 1: rights and responsibilities. This table has three columns:
  • indicator (indicators 1.1 to 1.17 are listed)
  • progress made and date
  • action still to be completed by when