Department of Health

Healthy Workers Initiative

Quality Framework  for the  Healthy Workers Initiative

Self Assessment

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Undertaking the self assessment will provide a useful opportunity for the organisation to reflect on what it does, what it should do, what it does well and where there are areas in need of improvement. Teams often report that this part of the process is very satisfying and useful.

The steps in undertaking a self assessment4 are:

1. Allocate a self assessment coordinator. The self assessment coordinator should be a person who is familiar with all components of the organisation and preferably has some understanding of quality improvement.

2. Select the self assessment team. Ideally the team will comprise approximately 3–5 members (depending on the size of your organisation) and comprise representatives who provide direct service delivery, program oversight, organisational management, or other key stakeholder positions e.g. partners, consumers representation. Sole providers can establish a team by engaging external support such as partners and clients as part of the self assessment team.

3. Assign each team member a domain5. for which they will assume an overall coordination role. The domains allocated should be those with which the person is not intimately familiar as this will promote a higher level of assessment. Assessing components that members are more familiar with creates a tendency to make assessments based on their personal knowledge and does not encourage them to explore actual evidence of performance.

4. Disseminate information. Provide all team members with a copy of this Healthy Lifestyle Program Provider Registration Implementation Guide.

5. Explain the assessment and registration process to all your staff. It will be useful to explain the aim of obtaining Healthy Lifestyle Program Provider Registration using the Framework. Provide advice to the whole organisation and client group about the registration process so they understand what is to happen, and that they may be asked questions about the way the organisation operates. This will promote transparency about the registration process and assist in implementing changes that may arise as a result of the process. In this step, sole providers might engage only with the client group, if at all.

6. Identify evidence against each rating item. Instruct members to identify evidence for each criteria of their allocated domain/s. They need to suggest at least one piece of evidence (electronic or hard copy) that can be submitted for each element.


    Minimum evidence for each criterion is listed later in this guide. While team members need to identify and adhere to this minimum, they may wish to include additional evidence to ensure they have comprehensively demonstrated the attainment of domain criteria. Remember each organisation will be different and the extent of evidence available in organisations will very much be determined by the size and type of programs.

    Information sources to inform self assessment and identification of evidence include:

    • interviews with key staff
    • review of policy and program documentation
    • review of brochures and client information
    • interviews with clients
    • organisational data.

    One document may serve as evidence against several different performance criteria — for example, your business plan. This is quite acceptable and just needs to be referenced accordingly in the On-line Self Assessment for Healthy Lifestyle Program Provider Registration.

    In some cases your team may decide that a performance criterion is not appropriate or relevant because of the way your organisation is structured. Where this is the case, please rate that element as ’Not Applicable’ and describe why in the comment box.


7. Conduct team discussion. Bring together the self assessment team for a pre-allocated time. Ensure that there is a comfortable venue and that each member brings the relevant evidence for the domain they coordinate.

    Discuss each domain until a consensus is reached on the self assessed level of performance. The options for performance levels include ‘Yes’, ‘In progress’ or ‘No’. It is important to remember that a consensus agreement is not necessarily unanimous agreement or a majority vote, but rather when all members can agree to accept the final decision. The levels note performance at a particular point in time and do not need to be absolute. The self assessment should be based on a ‘most of the time’ judgement.

    Each criterion also has a series of questions that seek a ‘Yes’, ‘No’, or ‘Not Applicable’ option to be ticked. These questions are intended to highlight current practice along with identification of areas for improvement.


8. Disseminate findings to management group. The findings should be presented to the management group (however comprised) for discussion. This is an ideal time to identify gaps against the strategic intent of the organisation and areas requiring improvement. Improvement activities can then be planned and incorporated into the business planning/quality improvement planning for the organisation.

9. Disseminate findings to organisation. It is important that the whole organisation can see the outcomes of the assessment and the resulting planned improvement activities. Sole providers may choose to disseminate findings to key stakeholders.

10. Develop an Action Plan. An action plan should be developed to harness the areas identified in need of improvement into a plan for action that is prioritised, targeted, time limited and resourced. Do not try to address every deficit. Identify the key items that when addressed will significantly enhance the quality of the business. It is important not to plan to do more than is practically possible.

11. Complete and submit the On-line Self Assessment report, Action Plan and associated evidence.

12. Plan a repeat assessment. It is recommended that the self assessment be repeated at least annually and scheduled in advance to ensure it occurs at an appropriate time that can best feed into other planning and / or accreditation type processes.


4 Adapted from the Dual Diagnosis Capability in Addiction Assessment Tool Guidelines 2008
5 A domain comprises one standard and associated performance criteria. There are eight domains in the HCI Framework including Safety & Risk

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Published date: July 2012