The review cycle has four stages within a three-year period. These stages are:
Internal Review Self-assessment
A 12-18 month period where designated people are trained in organising the internal assessment and review cycle process. During this stage, the organisation self-assesses against the Quality Standards, e.g. through team meetings every week or fortnight. The outcomes of the discussions are recorded in a workbook or Quality Journal. The Quality Standards and workbooks/Quality Journals are supplied by Te Wana. This period is like a “stock take” of the understanding and knowledge that people have of the organisation’s systems, policies and processes. It also provides an opportunity for identifying gaps and developing ideas for improvement. During this stage, essential or simple improvements can be made.
Planning and time are crucial. The organisation needs to prepare for the internal assessment, allow people time to participate and plan in advance which standards will be assessed, how and when. Te Wana can supply a template to use as a planning tool.
External Review
A team of 2 - 4 trained peer reviewers undertake an on-site external assessment (2 – 5 days) of your organisation against the Quality Standards. This includes reading your organisation’s self-assessment workbook/Quality Journal, policies and other documents, and conducting group interviews of a range of people involved with your organisation, including community networks.
Feedback
A written review report by the review team provides an overview of organisational context, strengths, areas for improvement and gives recommendations and commendations. The recommendations are used as the basis for the Quality Plan.
Taking Action Quality Workplan
The Quality Workplan is an action plan for working through the recommendations of the Review Report. Recommendations identify what needs to be done to meet the Quality Standards and to help an organisation make further improvements. Often many of the review recommendations simply affirm what the organisation has already self-identified in the internal review. The Quality Workplan phase is usually about 12 – 18 months, and prepares the organisation for the Accreditation Review if they choose this option. Progress reports are made every six months to Te Wana to show that the recommendations are being acted on.
Accreditation Review
The Accreditation Review is undertaken by a team of trained peer reviewers. This onsite review (2 – 5 days) uses the same processes as the Development Review (interviews, document assessment, facility visits). In addition, it looks at progress in meeting the recommendations of the Development Review. The self-assessment workbooks/Quality Journals are updated for any significant changes that have occurred since the Development Review. The review team provides a full written report on the achievement of the quality standards. If all requirements are met, then the review team will make a recommendation for accreditation that needs to be endorsed by the Quality Improvement Council. A Quality Workplan is again developed to act on recommendations from the review team after the accreditation review.
In some cases, an organisation may achieve the requirements for Accreditation at the time of the Development Review. On these occasions, the Development Review could become an Accreditation Review. This may be the case for well-established groups with comprehensive quality systems in place.