NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-008
Document Control
This table shows a record of significant changes to the document.
| Legal Name: | Holistic Healthcare Management Services |
| ABN: | 20695058096 |
| ACN: | 695058096 |
| Primary address/head office: | 15 Agasse Way, Tapping WA 6065 |
| Document Name: | NDIS Policies and Procedures Manual – Core Module |
| Document Number: | CM-POL-008 |
| Approved by: | Director |
| Date Approved: | February 2026 |
| Version No: | 1.0 |
| Comments: | Initial Release of the Policies and Procedures Manual |
| Next Review Date: | May 2026 |
Introduction and Purpose
Holistic Healthcare Management Services is dedicated to maintaining a robust and effective quality management system that ensures the delivery of safe, high-quality, and participant-centred supports. This system is proportionate to the organisation’s size, scale, and complexity of services and is aligned with relevant legislation and standards.
The purpose of this policy is to establish a framework for continuous improvement by leveraging data, participant and worker feedback, evidence-informed practices, and risk-related insights to enhance the quality of supports delivered.
This policy underpins Holistic Healthcare Management Services’s commitment to fostering a culture of excellence, accountability, and innovation, ensuring that participants consistently benefit from high-quality supports tailored to their individual needs and preferences.
Scope
This policy applies to all aspects of Holistic Healthcare Management Services’s operations, including but not limited to:
- Support delivery.
- Participant care and outcomes.
- Internal systems and processes.
- Compliance with legislative and regulatory standards.
It encompasses all employees, contractors, consultants, volunteers, and third-party providers involved in the organisation’s activities.
The policy is applicable to all settings, including residential care, community-based supports, and administrative operations.
Definition
| Term | Description |
|---|---|
| Quality Management System (QMS) | A structured framework of policies, procedures, processes, and practices aimed at delivering consistent, high-quality services. |
| Continuous Improvement | An ongoing effort to improve processes, systems, and outcomes based on feedback, data, and evidence. |
| Internal Audit | A systematic review of organisational processes and practices to ensure compliance with policies, standards, and regulations. |
| Evidence-Informed Practice | Decision-making based on a combination of research, participant preferences, and organisational insights to achieve the best outcomes. |
| Feedback Mechanisms | Tools and processes for collecting input from participants, staff, and stakeholders to inform improvements. |
| Risk-Related Data | Information derived from risk assessments, incident reports, and monitoring activities used to identify areas for quality enhancement. |
Outcomes and Indicators
| Term | Description |
|---|---|
| Each participant benefits from a quality management system relevant and proportionate to the size and scale of the provider, which promotes continuous improvement of support delivery. |
|
Guiding Principles
- Participant-Focused Quality: The QMS is designed to prioritise participant needs, preferences, and outcomes, ensuring supports align with individual requirements (Indicator 1).
- Evidence-Based Decision-Making: Quality improvements are informed by data, risk analysis, participant feedback, and evidence-based practices (Indicator 3).
- Proportionality and Scalability: The QMS is proportionate to the organisation’s size, scope, and complexity, ensuring practicality and effectiveness (Indicator 1).
- Continuous Improvement Culture: A culture of learning, innovation, and adaptability is promoted across the organisation to drive ongoing enhancements in support delivery (Indicator 3).
- Accountability and Transparency: Clear roles, responsibilities, and processes ensure accountability at all levels, fostering trust and confidence among stakeholders.
Policy
Holistic Healthcare Management Services will implement and maintain a quality management system (QMS). The organisation will adopt a comprehensive quality management system that is dynamic, scalable, and tailored to its unique operational requirements. This system will be integrated into every aspect of daily operations, ensuring quality is not just an outcome but a core value embedded in all activities. The QMS will be designed to facilitate systematic monitoring, rigorous evaluation, and the fostering of a culture of continuous improvement.
The organisation commits to:
- Establishing and documenting a QMS tailored to its size, scale, and scope of support, ensuring compliance with legislation and standards (Indicator 1): The QMS will include a detailed framework outlining policies, procedures, and processes that align with regulatory requirements and industry best practices. It will account for the complexity of support delivered, ensuring that every service, regardless of size or scale, adheres to consistent quality standards. Documentation will include governance structures, responsibilities, and escalation processes to address issues effectively and ensure accountability.
- Conducting regular internal audits to evaluate processes, identify gaps, and ensure adherence to the QMS (Indicator 2): Internal audits will form the cornerstone of the QMS, enabling the organisation to identify compliance issues, inefficiencies, and potential risks. These audits will be structured and proportionate to the size and complexity of the organisation. Findings will be used to implement corrective actions and improve processes, ensuring that quality standards are maintained or exceeded.
- Using data, feedback, and risk insights to inform continuous improvement initiatives and enhance participant outcomes (Indicator 3): A robust data management system will be implemented to collect, analyse, and utilise participant feedback, staff input, and operational data. Insights derived from this data will inform targeted improvements to service delivery, policies, and staff training. This feedback loop will ensure that the QMS evolves in response to real-world challenges and opportunities.
- Providing training and resources to ensure staff are equipped to contribute to quality improvement processes: The organisation will invest in comprehensive training programs to build staff capacity in understanding, implementing, and sustaining quality management practices. Resources such as workshops, e-learning modules, and on-the-job mentoring will be made available to ensure staff are well-equipped to uphold quality standards in their roles.
- Regularly reviewing and updating the QMS to reflect changes in regulatory requirements, participant needs, and organisational objectives: The QMS will be subject to periodic review to ensure it remains aligned with current laws, regulations, and best practices. The review process will also incorporate feedback from participants, workers, and external stakeholders, ensuring that the system remains relevant and effective.
Quality Management Process
The Quality Management Process encompasses the following components:
Quality Planning: The quality planning process begins with identifying organisational objectives, participant needs, and regulatory requirements. These objectives will be outlined in a quality strategy document, which serves as a roadmap for achieving excellence. Plans will include detailed action steps, timelines, resource allocations, and performance benchmarks. Stakeholder engagement is critical in this process; input from participants, workers, and external experts will ensure that plans are both practical and inclusive. The focus will be on balancing strategic goals with operational feasibility, ensuring that quality improvements are sustainable.
Quality Assurance: Quality assurance activities aim to ensure that service delivery consistently meets predefined standards. This includes the standardisation of policies, procedures, and operational workflows to reduce variability and improve reliability. Compliance with legislative requirements is systematically monitored through annual reviews and ad-hoc audits. Documentation and tracking mechanisms will capture quality assurance activities, allowing the organisation to identify recurring issues and address them proactively.
Internal Audits: A systematic internal audit program will be developed to evaluate the effectiveness of the QMS. These audits will follow a structured schedule, ensuring that all key areas of operation are reviewed regularly. The scope of audits will include compliance with regulations, alignment with participant outcomes, and adherence to internal policies. Audit findings will be categorised by severity and prioritised for action. Management will receive detailed audit reports, and follow-up actions will be tracked to ensure resolution.
Continuous Improvement: Continuous improvement is a dynamic process that integrates findings from audits, feedback, and performance reviews into actionable initiatives. Improvement projects will be prioritised based on their potential impact on participant outcomes and organisational efficiency. These initiatives may include redesigning processes, introducing new technologies, or enhancing staff training programs. The organisation will also create forums for sharing best practices and lessons learned to drive a culture of innovation and excellence.
Monitoring and Evaluation: A robust monitoring and evaluation framework will track the effectiveness of the QMS. Metrics such as participant satisfaction, service quality, and compliance rates will be reviewed regularly. Evaluation results will be shared with key stakeholders, fostering transparency and accountability. The framework will also include mechanisms for identifying emerging risks and trends, enabling the organisation to adapt proactively.
Procedure
Incident Management
The organisation will maintain a detailed incident management system to document, investigate, and resolve quality-related issues. Each incident will be logged with comprehensive details, including the time, nature of the incident, and actions taken. Investigations will focus on identifying root causes and implementing corrective measures. Lessons learned will be incorporated into training programs and policy updates, ensuring that similar incidents do not recur.
Feedback Mechanisms
Participants and workers will be encouraged to provide feedback through multiple channels, such as surveys, suggestion boxes, and regular check-ins. This feedback will be systematically collected, categorised, and analysed to identify trends and inform improvements. Actions taken in response to feedback will be documented and communicated to stakeholders to demonstrate accountability and responsiveness.
Staff Training and Competency
Comprehensive training programs will cover quality management principles, compliance requirements, and participant-focused practices. Training will be tailored to different roles, ensuring relevance and effectiveness. Competency assessments will be conducted periodically to validate staff understanding and application of quality standards. Refresher courses and advanced training opportunities will be offered to foster continuous learning.
Risk and Quality Integration
Risk management data will be seamlessly integrated into quality management processes. This includes using risk assessments to identify quality risks and developing targeted mitigation strategies. Collaboration between quality and risk teams will ensure a holistic approach to addressing organisational challenges. Regular reviews will assess the effectiveness of these integrated processes, fostering resilience and adaptability.
Roles and Responsibilities
| Ref No | Roles | Responsibilities |
|---|---|---|
| 1 | Board and Senior Management | The board and senior management will oversee the implementation and effectiveness of the QMS, ensuring alignment with organisational goals and regulatory requirements. They will allocate resources for quality improvement initiatives and provide strategic direction for continuous improvement efforts. |
| 2 | Workers | All workers will adhere to quality policies and procedures in their daily activities. They will report quality-related concerns and incidents promptly and participate in training and improvement initiatives. |
| 3 | Quality Coordinator | The Quality Coordinator will maintain the QMS, coordinate audits, and facilitate the implementation of corrective actions. This role will also involve analysing data, preparing reports for management, and driving improvement initiatives. |
Record Keeping
Quality Audit Records
Detailed documentation of audit plans, findings, corrective actions, and follow-up activities will be maintained. These records will be reviewed periodically to monitor progress and ensure accountability.
Participant Feedback Records
Feedback will be systematically collected, categorised, and analysed. Documentation will include responses to feedback and actions taken.
Continuous Improvement Logs
Comprehensive records of improvement initiatives, including objectives, timelines, outcomes, and lessons learned, will be maintained.
Training Records
Documentation of all staff training sessions, attendance, and competency assessments will be kept to ensure compliance and readiness.
Risk Integration Records
Data from risk assessments and monitoring activities will be recorded and used to inform quality improvements.
Related Documents
- Participant Handbook
- Participant Satisfaction Survey
- Participant Exit Form
- Staff Handbook
- Legal Requirements Register
- Strategic Plan
- Business Plan
- Internal Audit Program
- Internal Audit Report
- Management Review Report
- Continuous Improvement Plan
- Continuous Improvement Form
- Continuous Improvement Register
- Document Control Register
References
- ISO 9001:2015 Quality Management Systems – Requirements
- NDIS Practice Standards and Quality Indicators
- Australian Guidelines for Quality Management in Human Services
- Continuous Improvement Frameworks – Best Practice Guidelines
Policy Review
This policy will be reviewed annually to ensure alignment with best practices, legislative requirements, and feedback from participants, staff, and advocates. Updates will be made as needed to enhance its effectiveness and relevance.
