NGO Benchmarking Model

NGO Benchmarking Model Evidence Guidelines 17 August 2017 Version 2.0

Contents 1 NGO Benchmarking Model 3 About the NGO Benchmarking Model 3 How to use the Benchmarking Model 3 How does the Benchmarking Model benefit NGOs? 3 How does the Benchmarking Model benefit NSW Government? 4 Interaction with existing accreditation systems 4 About these guidelines 5 2 Self-assessment principles 6 Review of your performance 6 Measure and analyse the findings 7 Enable continuous improvement 8 3 Customer standards 11 Standard 1: Services designed around customer experience 11 Standard 2: Customer engagement 14 Standard 3: Reporting back to the community 17 Standard 4: Collaborative work and partnerships 20 Standard 5: Innovation leading to adaptive change and better customer outcomes 23 Standard 6: Equity and cultural proficiency 26 4 Corporate governance standards 29 Standard 7: Leadership and strategic business planning 29 Standard 8: Governance and management 32 Standard 9: Continuous improvement 35 Standard 10: Data management 38 5 Templates 41 Policy 41 Process 42 Improvement plan 43 One-page strategic plan 44 6 Definitions 45 NGO Benchmarking Model: Evidence Guidelines Page 2 of 47

1 NGO Benchmarking Model About the NGO Benchmarking Model The non-government organisation (NGO) Benchmarking Model is a capability development tool that will allow your organisation to self-assess its performance against ten standards regarding customer focus and corporate governance. It is designed to embed robust, customer-centred principles into NGO operations to help deliver efficient, high quality and innovative programs and services. Each standard has three progressive levels of attainment: 1. Emerging 2. Mature 3. Excelling This tiered approach provides a clear pathway to continuous improvement by allowing your organisation to track its performance and easily identify opportunities to improve service delivery. You can use your organisation s benchmarking results to guide strategic planning, business operations and staff capability development programs. The model also includes accountability and assessment measures designed to give customers and funding bodies greater assurance that the services being provided by an organisation are high quality, value for money and outcomes-focussed. The Social Innovation Council developed the Benchmarking Model as a tool to support agencies and NGOs responding to increasing demands for human services. The tool demonstrates the NSW Government s commitment to building NGO capability and delivering better human services outcomes. How to use the Benchmarking Model An online self-assessment platform has been developed to allow you test your organisation s performance against the Benchmarking Model. It is a free, user-friendly tool that makes it easy for you to self-assess against the emerging, mature and excelling levels. You will need to upload to support your responses (see Section 3 for examples). It is important to remember that your organisation is on its own development journey; not every organisation wants or needs to be excelling. You will start self-assessment with the emerging level and can progress to further levels when you are ready. We encourage you to attempt a higher level each time to measure your organisation s improvement. How does the Benchmarking Model benefit NGOs? The Benchmarking Model is a capability development tool that will underpin the strategic direction and service delivery model of NGOs. Your organisation will benefit from: a clear understanding of the customer, and of government s service priorities increased transparency of your organisation s capability to customers, funding bodies, key stakeholders and the community NGO Benchmarking Model: Evidence Guidelines Page 3 of 47

attracting more diverse funding sources by demonstrating organisational capability for funding opportunities outside of the NSW Government a roadmap to improving service outcomes for customers by implementing initiatives to improve benchmarking scores accessing the free online platform with resources and guidance designed to help organisations further develop their performance capabilities comparing organisational capability against the broader not-for-profit human services sector building capability to support transition to outcomes-based contracting models. How does the Benchmarking Model benefit NSW Government? The NSW Government spent $2.5 billion (excluding disability services) on contracts with NGOs to deliver essential human services in 2015-16. It is paramount that this funding is delivered to organisations that are committed to continuous improvement and providing the best possible outcomes for their customers. Improving the customer-centric capabilities of NGOs will: increase the capacity of NGOs to deliver services that better meet the needs of customers create more effective services with improved customer outcomes increase the scope and accessibility of human services drive innovative service delivery increase data collection and sharing of data will inform planning, design and delivery for NGOs and agencies. Interaction with existing accreditation systems Agencies and NGOs are increasingly looking to adopt customer centric services as a key indicator of successful service provision. The Benchmarking Model has been designed to support all NGOs (regardless of the services they deliver) to do this. Many existing accreditations rely on organisational management indicators to determine an organisation s capacity to deliver quality services. These accreditation systems are often the primary means of driving continuous improvement. The Benchmarking Model complements and builds on existing NGO accreditation and certification schemes, while at the same time ensuring that NGOs operate to similar standards regardless of which scheme they are subject to. To reduce duplication, nine common accreditation systems have been mapped to the Benchmarking Model. This means that the online platform pre-fills data for NGOs that are accredited under the following systems: Disability Service Standards (DSS) Australian Service Excellence Standards (ASES) Certificate Level NGO Benchmarking Model: Evidence Guidelines Page 4 of 47

Home Care Common Standards (HCCS) Ageing, Disability and Homecare Standards (ADHC) Australian Council on Healthcare Standards (ACHS) Quality Improvement Council Health and Community Service Standards (QIC) International Organisation for Standardization AS/NZS ISO9001:2015 (ISO) About these guidelines These guidelines will help NGOs to: prepare for the online self-assessment process gather to demonstrate competence against the ten standards identify areas for targeted improvement understand what is needed to achieve progress to higher levels of attainment. We begin by looking at the principles you should follow when reviewing and measuring your organisation s performance. We then set out each standard and the types of policies, and activities you need for each level of attainment. However, we note that you might have other types of you can use to show you meet a standard. You will also find in this document: templates for policies,, improvements plans and strategies so you can develop resources for continuous improvement, if you need them definitions for key terms. NGO Benchmarking Model: Evidence Guidelines Page 5 of 47

2 Self-assessment principles Review of your performance You should internally review your organisation s performance against the standards to achieve meaningful self-assessment results. Sources of Your review should check that your organisation s for each standard is reliable, and the triangulation method will help you do this. It draws on documentation, observation and interviews, so some of the you supply will be numerical or quantitative (such as a statistic) and other will be descriptive or qualitative (such as interviews with patients). To best understand your organisation s performance, you should support the information you provide using at least two of the following sources: 2 Observation 1 Documentation 3 Interviews Evidence Source 1 Documentation Source 2 Observation Review documents. Examples include both electronic and paper versions of: these guidelines governance reports and other documents strategic and operational plans, policies and information supplied to customers, such as health information documentation of meetings with internal and external stakeholders reports from internal reviews, assessments, audits and evaluations customer feedback. Observe staff and organisational, and the environment. Do appropriate staff regularly meet with stakeholders? Do customer records show tailored plans have been developed to manage services, with the appropriate people involved? Are these plans regularly reviewed? Has scheduled maintenance of equipment been carried out, with repairs and replacements as needed? NGO Benchmarking Model: Evidence Guidelines Page 6 of 47

Source 3 Interviews Interview stakeholders using open questions. Can staff explain the policies, and systems applying to their roles? Do customers know how to navigate the service they are using? Are customers clear about what the service is, who will be delivering it and how they can seek change? Sample base Your sample base needs to reflect your cohort size. This means the information you provide, including the observations and interviews you conduct, will need to reflect the following sample base: Cohort size Sample base 1 9 50% of the cohort 10 100 10 100+ 10% of the cohort Try to sample randomly, so one individual or sample is as likely to be chosen as the next. If the is inconclusive, you should increase the number of samples until you are satisfied you can determine compliance. Measure and analyse the findings Measuring performance You can measure performance at various stages in the lifespan of a program, service or activity, and your findings may differ at each stage. To be comprehensive in your self-assessment, you should separately document: the process you followed the output of that process the outcome, impact or results. Supplier Input Action Output Customer Outcome Process Output Outcome, impact or results It is important to measure whether you have achieved the standards at all three stages and if so, to what extent. You should be able to demonstrate a strong and logical relationship between the organisation s activities and their outcome. While results show compliance, the process ensures they are achieved in a way that gives confidence about your future performance. Discussion of results When completing the online self-assessment, you should review, document and discuss the you use with other staff. You should then summarise the findings of the assessment and again discuss them broadly, including with management. NGO Benchmarking Model: Evidence Guidelines Page 7 of 47

Your discussion with management should cover the improvements needed to address the standard, and timeframes for adopting them based on: their importance for your customers and service delivery any regulatory and legal requirements. You should record the agreed timeframes in your improvement plan (see section 5 for a template). Enable continuous improvement A key principle under the Benchmarking Model relates to continuous quality improvement. You should create a systematic approach to ensure your organisation keeps reviewing, analysing and improving its performance. Here we outline two recognised methods. Plan Do Study Act The PDSA Cycle is the best-known method. You can enter this cycle at any of its four stages: Act Capture the knowledge Study Reflect on the theory and implementation results Plan Develop a new theory Do Implement the theory Approval to implement and accountability assigned Stage 1 Plan Stage 2 Do Stage 3 Study Plan what you are going to do and the data to collect. State the objective. Make predictions about what will happen, to who, when and why. Develop a plan to test the change. Gather performance (such as through audits and customer feedback) of the nature and size of the issue. Implement improvements you identify, such as corrective or proactive actions, preferably on a small scale. Implement improvements. Document issues and unexpected observations. Start analysing the data/. Study the results to see if the plan worked. Complete the data analysis. Compare the data to your predictions. Summarise and reflect on what you learned. NGO Benchmarking Model: Evidence Guidelines Page 8 of 47

Stage 4 Act Act on the results and try another plan if the first did not succeed. Decide what modifications should be made. Prepare a plan for the next issue. Approach Deployment Results Improvement Another quality cycle is the ADRI Cycle, which offers a method for critical assessment. Its main focus is ensuring that organisational success correlates to a planned, sustainable cycle of improvement. Approach Improvement Deployment Results Stage 1 Approach Stage 2 Deployment Stage 3 Results Stage 4 Improvement Think and plan. What is your intent for each indicator? What are you trying to achieve? What goals have you established? What strategies, structures and do you have to achieve the indicator, and why did you choose them? What quantitative and qualitative performance indicators will track progress? Implement and do. How have you implemented the planned strategies, structures and? Have they been implemented across the organisation? To what extent? How far have they been accepted and integrated as part of normal operations? Monitor and evaluate. How effective has the approach and its deployment been? What are the trends in the performance indicators for this criterion? How do these results compare with best practice? Learn and adapt. How do you review the appropriateness and effectiveness of the approach and its deployment? How do you use the results for the criterion to do this? What have you learned and how have you captured this? How have you used this learning to improve the approach and its deployment? NGO Benchmarking Model: Evidence Guidelines Page 9 of 47

Elements of successful continuous improvement A successful approach to continuous quality improvement includes: using customer perceptions of service to define quality promoting partnerships setting up effective, collaborative meetings engaging staff in the improvement process, and training managers to lead it incorporating strategic planning at the highest levels of management analysing systems rather than people or things using accurate data to analyse and measure improvement achieving improvement through incremental steps linking evaluation to planning. NGO Benchmarking Model: Evidence Guidelines Page 10 of 47

3 Customer standards This section outlines the types of for demonstrating achievement under the six customer-focused standards. Our list is not exhaustive as we recognise that NGOs may have other of the requirements and we encourage you to use it. Each level of attainment builds on the one before. To progress from Emerging to Mature, and from Mature to Excelling, the organisation must meet the indicators and of the previous level. Standard 1: Services designed around customer experience The organisation understands the needs of its customers and deliberately designs its services to address their needs. It recognises customers as key stakeholders in planning, developing, delivering and evaluating services. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation knows who its customers are and what their service needs are. has documented policies and for learning what customers need asks customers or their representatives for input when planning, developing, delivering and evaluating its services engages with customers, including target groups and the community, when managing its services. People Business planning policy and Feedback management policy Customer feedback Records of discussions with customers and key community groups or people, such as meeting minutes, focus group reports or surveys Targeting services to address customer needs, including complex needs or hard-to-reach customers Aligning service delivery with funding and service agreements Identifying gaps in service delivery Customers give feedback NGO Benchmarking Model: Evidence Guidelines Page 11 of 47

Mature The organisation systematically seeks and uses input from customers to ensure its services meet their needs. monitors and improves its outcomes by learning about its customers needs and what they think is important uses input from customers to set its outcomes and performance measures uses reporting on the customer base for strategic and business planning monitors the profile and needs of the community in which it operates, and applies this information to its planning and development responds to changing community needs, within contractual obligations and service or funding agreements. Strategic plan Business plans that address issues from customer feedback, meetings and consultations Results of customer surveys, forums and other data collection, where priorities are identified, actions taken and directions documented and followed up Records of networks or links with other service providers, such as interagency meetings Up-to-date community profile Reports to the board, management committee or senior managers Monitoring the community profile and using it to inform services NGO Benchmarking Model: Evidence Guidelines Page 12 of 47

Excelling The organisation proactively draws on independent information and customer needs when designing services and their underlying. has a strategic plan and related business plan (or similar) that reflect deep knowledge of the customer base and the potential for growth or change in its services and locations consistently uses customer information to make resourcing decisions, identify service improvements and improve sustainability consistently meets the needs of customers, including target groups and the community, and responds to changing needs actively suggests service changes to funding bodies before, during and after contracts to achieve better outcomes for customers and the community. Customers or their representatives actively participate in evaluations and the organisation informs them of the outcomes in a timely way. Strategic plan and business plans that demonstrate a deep understanding of the customer base Annual reports Consultations and meeting minutes showing the organisation engaging with funding bodies Contracts or memorandums of understanding with community partners Using results from customer surveys, forums and other data collection to design services within funding agreements Collaborating with other community providers to meet the needs of identified groups in the community Proactively engaging with funding bodies based on information about the community and customer needs NGO Benchmarking Model: Evidence Guidelines Page 13 of 47

Standard 2: Customer engagement Customers can access the most appropriate services for their needs and are actively involved in decisions about service delivery where it affects them. Note that each of the following levels of attainment builds on the previous one. Emerging Customers can access information about the services the organisation provides. They have a voice in decision-making about their service needs. The organisation has defined for customers accessing its services and customers (including prospective ones) are aware of these. Customers or their representatives can discuss how their needs are identified and assessed, if appropriate. Examples of Access to services policy Eligibility and prioritisation of admission policy Feedback management policy Service assessment and planning policy Referrals, including for ineligible prospective customers Waiting list management Complaints and appeals Assessment of customer needs Customer forums, meetings, files and records Identifying eligibility criteria, target groups, prioritised needs and the requirements of the funding program Informing the community and potential customers of the services, eligibility and access Recognising customers from different backgrounds and vulnerable or marginalised groups, including people: from culturally diverse backgrounds, such as Aboriginal or Torres Strait Islander peoples with disabilities in out-of-home care from gender and sexual minorities (LGBTIQA) NGO Benchmarking Model: Evidence Guidelines Page 14 of 47

Mature The organisation systematically communicates with, and responds to, customers about accessing the services that meet their needs. Customers can choose services that best suit them from available options. The organisation gives all customers information in an appropriate format to help them understand the options, make their choice and know their rights and responsibilities. regularly communicates with customers about its services and responds promptly and carefully to customer communications enables customers to access services in line with the funding guidelines and their assessed needs gives customers the chance to discuss the service type, approach and level that best meets their needs communicates in a way that ensures customers understand. Examples of People Business plans relating to customer engagement Admission and access policy and Assessment policy and Case management policy and Feedback management policy and Service delivery policy and Results of community surveys and other data collection Records of networking with other service providers, such as meeting minutes, focus group reports or customer files Records of discussions with customers and key community groups or people, such as meeting minutes, focus group reports or surveys Records of response times to customers Communications with customers that meet different literacy and language needs, such as versions in plain English, braille or other languages (including use of a translator where needed) Ensuring information about the services is in a form that is easy and accessible for all customers, including children Using a variety of channels to engage with customers from different situations and backgrounds Giving customers a voice in service planning through forums like youth advisory groups or councils Ensuring timely customer interactions, including assessments, intake and services Staff have training and knowledge about service access and eligibility in line with funding guidelines Customers show knowledge of the services available and NGO Benchmarking Model: Evidence Guidelines Page 15 of 47

eligibility requirements to meet funding guidelines Excelling Person-centred approaches that provide quality outcomes are at the heart of the organisation's operations. It engages with customers through different channels that cater to diverse needs. ensures all customers can access the available services they need delivers appropriate services that are planned, delivered and evaluated with customers or their representatives plans its service based on the needs of customers and target groups actively reviews and updates its feedback mechanisms to ensure they remain current, relevant and effective for customers and stakeholders. Examples of Strategic plan and business plans that demonstrate quality improvements with the customer at the centre Improvement plan that defines how to manage opportunities for customer engagement Annual and other reports Customer files and records, including needs assessments, meetings, case management, evaluations and service plans Results of periodic customer surveys Results of periodic reviews of feedback management and the actions taken Considering the requirements of funding programs and guidelines, including the number and type of services the organisation is funded to provide Offering customers a range of opportunities to be actively involved and encouraging them to contribute to service decisions Creating channels for feedback and engagement through social media, websites, surveys, informal group discussions (such as service outreach and pop-up services), or reaching customers through trusted organisations or stakeholders Actioning, monitoring and evaluating the results of customer feedback Monitoring the response time to customer feedback NGO Benchmarking Model: Evidence Guidelines Page 16 of 47

Standard 3: Reporting back to the community The organisation collects and analyses customer outcomes, reporting back to them in aggregate. It draws links showing how these outcomes contribute to community wellbeing. It also shows where services are making a positive difference with qualitative and quantitative data. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation actively helps its customers or their representatives to contribute to the data it collects to improve its service outcomes. The organisation regularly: seeks customer feedback on its services reviews feedback with customers or their representatives as part of its continuous quality improvement records, monitors and analyses customer input to identify trends reports complaints to the board, management committee or senior executives, informing them of the response, including service changes. Continuous improvement policy Feedback management policy Quality policy Complaints register capturing forms, actions, the timeliness of responses and customer satisfaction Reports to customers and other stakeholders Reports focused on: service results and outcomes for customers, such as the number of children successfully moved away from out-of-home care for more than 12 months communicating the impact the organisation is making Giving customers continuous and easy access to meaningful and culturally relevant information about the policies and Capturing and managing feedback with timely responses to customers Responding to diverse customer groups Analysing feedback, including trends, and reporting to customers Giving customers and staff information about feedback through documents, forums and meetings Including feedback management as a meeting agenda item, with trends presented and implications discussed Notifying the regulatory authority of any: relevant changes to the way the services operate serious incidents NGO Benchmarking Model: Evidence Guidelines Page 17 of 47

complaints that allege a legal breach Mature The organisation uses customer information to measure, benchmark and improve its internal and services so it can deliver increasing value for all stakeholders. It designs tailored for building and managing customer relationships to ensure its services meet current and future needs. develops a culture of continuous improvement using customer input to plan, deliver and review services has a clear approach to collecting information and reporting back to customers, focusing on key needs and expectations measures all indicators of customer satisfaction against identified needs and expectations designs and manages its relationships with customers to promote trust and confidence gives clear contact points and mechanisms for reporting to customers. People Reports to the board, management committee or senior staff on changes in the design and tailoring of Showing how complaints data has informed planning and strategies to address issues Helping each customer to take part in developing and reviewing complaint handling policies and, and reporting outcomes to them and their representatives Reviewing customer satisfaction with referrals to other organisations Collating staff and customer feedback on their satisfaction Analysing trends in feedback to: improve customer outcomes, relationship management, policies and, and products and services report to customers and stakeholders drive continuous improvement Staff have training and knowledge about feedback and reporting that is relevant to their positions Staff show understanding and capacity to continuously improve customer outcomes NGO Benchmarking Model: Evidence Guidelines Page 18 of 47

Excelling The organisation has effective systems and to determine: what data it should collect (such as business KPIs) how it handles, stores, analyses and interprets this data to create information and knowledge. It then uses this information and knowledge to increase its understanding of the customer environment. has for determining what data should and should not be collected, showing clear links with its purpose, strategy and health and safety as well as customer needs and outcomes has effective communication systems to share relevant information with customers and make it generally accessible to them regularly reviews and improves the effectiveness of its communication with customers to meet changing customer and business needs compares its results with other organisations, where relevant, to improve its customer outcomes. Strategic plan Business plans Improvement plan that shows opportunities identified through engagement with other organisations where program results can be compared Annual reports Records of networking with other service providers, such as meeting minutes, focus group reports or customer files Protocols between organisations, including the review of communication to ensure effectiveness and efficiency Demonstrating the use of data to identify opportunities to improve services for better outcomes, in line with the organisation s purpose, strategy and work health and safety Monitoring the effectiveness of the opportunities in the improvement plan and evaluating results NGO Benchmarking Model: Evidence Guidelines Page 19 of 47

Standard 4: Collaborative work and partnerships The organisation s culture supports collaborative work. Peer relationships are nurtured and partnerships maintained to improve customer outcomes. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation works with other service providers to help customers access the services they need. It has agreed protocols for referring customers between providers. refers customers to other providers so they can participate in the services they need works with these providers to coordinate service delivery and improve outcomes complies with any relevant referral and coordination under state and federal laws sources information from relevant community and support organisations to aid customer choice. People Referrals policy and Customer consent policy and, including for referrals and information sharing Case management and coordination policy and Referral forms or other referral information from customer files Communications with customers that meet different literacy and language needs, such as versions in plain English, braille or other languages (including use of a translator where needed) Customer perceptions and feedback on the referral process Brochures and other information about relevant service providers Establishing effective relationships and actively engaging with the community Complying with referral and coordination under law, where they apply Ensuring information about the services is: current and comprehensive in a form that is easy and accessible for all customers Staff have training and knowledge in referral Customers have opportunities to be involved in the NGO Benchmarking Model: Evidence Guidelines Page 20 of 47

organisation and contribute to service decisions Mature The organisation always refers customers to the services they need. It invests time and resources in strategic partnerships, and has strong collaborative work, leading to better outcomes for customers. establishes and maintains links with relevant service providers ensures its customers have access to services from other providers that address their identified needs builds relationships with organisations that share its values and engages with the community to promote its services, improve delivery and connect with prospective customers monitors collaborative work to ensure improved outcomes shares appropriate information and clarifies responsibilities with other organisations providing services to its customers to ensure continuity. People Coordination between agencies that ensure customer needs are met, including: networks, where established information-sharing (with consent from customers) regular case conferencing customer care records showing responsibilities Memorandums of understanding and regular communications showing links with community and partner organisations Other protocols between organisations covering referrals and complementary services Customer feedback showing their satisfaction that another provider can offer services that meet their needs Monitoring customer feedback to ensure the organisation meets expectations Supporting customers so they can seamlessly transition between providers through collaboration Staff have training and knowledge in collaborative work NGO Benchmarking Model: Evidence Guidelines Page 21 of 47

Excelling The organisation is strongly involved in shaping the sector by responding to reforms in partnership with stakeholders. The shared goals of partnerships are agreed, clear, realistic and wellunderstood by each partner organisation. The organisation shares the outcomes of partnerships with other organisations. maintains well-established links with relevant organisations systematically promotes continuity of services by sharing relevant information (including the outcomes of partnerships), clarifying responsibilities and building collaborative strategies with stakeholders has effective relationships with organisations that share its values and actively engages with the broader community so it can respond to sector reforms. Community engagement policy Records of networking with other service providers, such as meeting minutes, focus group reports or customer files Contracts with partnering organisations, covering: information-sharing responsibilities collaborative strategies regular communication Sharing relevant information, clarifying responsibilities and building collaborative strategies with stakeholders Building relationships with organisations who share its values, including through sophisticated partnership models like consortia or joint ventures Engaging with the community to support sector reforms NGO Benchmarking Model: Evidence Guidelines Page 22 of 47

Standard 5: Innovation leading to adaptive change and better customer outcomes The organisation nurtures and supports innovation. It draws ideas, perspectives and inspiration from various sources and dedicates resources to exploring new ideas and approaches. Innovation means the organisation is responsive to opportunities to improve its services with an out of the box culture embedded in the way it is run. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation uses ideas, perspectives and inspiration from a mix of sources to enhance its work. recognises the need to learn from others and uses techniques such as benchmarking, comparison and networking to enable continuous improvement recognises the value all staff contribute to its objectives and encourages their widespread participation has a culture that encourages staff to share ideas and explore approaches that can lead to better customer outcomes. People Strategic plan Business plans Improvement plan Feedback management policy Risk management policy and Complaints and compliments Continuous improvement policy and Risk assessment Meeting minutes showing staff participation Encouraging staff to be innovative and creative Enabling staff participation in innovative improvement activities Staff have training and knowledge in continuous improvement Staff contribute to the improvement process, leading to innovative service delivery and better outcomes NGO Benchmarking Model: Evidence Guidelines Page 23 of 47

Mature The organisation continually tests and adapts its core services to enhance delivery, and finds new ways to achieve results where traditional methods are not working. applies structured approaches to promote creativity, adopt innovative ideas (both internal and external), and achieve breakthrough performance uses creativity and innovation strategically and operationally increases the efficiency and effectiveness of its supports risk-taking within appropriate parameters. Strategic plan that shows creative and innovative programs being supported and promoted, strategically and operationally Business and improvement plans that document innovative ideas so knowledge is captured and shared Risk assessments and a risk register that show the organisation supports risk-taking within defined parameters Improvement process flowcharts, such as for deployment Documenting and measuring so everyone can contribute to improvement Effectively prioritising and converting opportunities into actions to improve customer outcomes Identifying and adopting innovative ideas Encouraging innovation and flexibility through improvement systems that respond to the organisation s needs Trialling, adopting and evaluating innovative ideas NGO Benchmarking Model: Evidence Guidelines Page 24 of 47

Excelling The organisation uses structured methods to improve its and achieve efficiency and effectiveness for all stakeholders. It prepares for change and maintains the agility needed to meet new challenges as they arise. It also invests in capacity building for staff to support innovation. The organisation has leaders who: drive continuous improvement under a suitable model include improvement in business plans and resource improvement projects appropriately monitor and recognise the achievements of teams delivering innovation. The organisation also: maintains its capacity to resource improvement projects through ongoing professional development, giving staff the skills they need resources innovation programs to increase the value of its services to customers adapts and responds quickly to opportunities. People Records of staff professional development relating to process improvement projects Meeting minutes, reports and plans showing opportunities for innovation and response rates Recognising the need to learn from others and using techniques such as benchmarking, comparison and networking to enable breakthrough improvement Reviewing and evaluating innovation programs Considering systems thinking in improving Showing timely responses to change Staff commonly and consistently use the PDSA Cycle or another relevant improvement method NGO Benchmarking Model: Evidence Guidelines Page 25 of 47

Standard 6: Equity and cultural proficiency The organisation recognises the cultural and social diversity of its customers and the community, incorporating diversity into its service design and delivery as needed. It sees individual wellbeing as closely linked to the strength of the community Note that each of the following levels of attainment builds on the previous one. Emerging The organisation is inclusive and respects all cultures and communities. It values the diverse skills and experiences of its customers. It is committed to giving them equal access and ensuring its staff are culturally proficient. knows the diversity of its customers and understands their needs recognises, respects and embraces cultural and social diversity enables each customer to take part in an appropriate assessment, bearing in mind their cultural and linguistic diversity recognises and promotes freedom of expression, as do its staff has preventative measures to ensure that people do not face discrimination, exploitation, abuse, harm, neglect or violence ensures an inclusive and welcoming environment, fair access for all customers, and the cultural proficiency of all staff provides cultural awareness training for all staff. People HR policy and Staff induction Assessment Plans identifying access and equity strategies Purpose, vision and values Regularly reviewing information, policies and about access with customers and their representatives to identify and minimise barriers to fair and equal access Staff have cultural awareness training and knowledge Leaders show a commitment to equal opportunities and act as a model of good practice for staff, customers and the community Customers have access to information and support so they can understand and exercise their rights, both human and legal Customers receive a service: that maximises their choices for social participation and cultural inclusion that reflects their right to privacy and ethical treatment in an environment free from discrimination, abuse, neglect and exploitation NGO Benchmarking Model: Evidence Guidelines Page 26 of 47

Mature The organisation minimises the barriers that can prevent some customers participating fully, and recognises the support networks and socioeconomic factors that affect wellbeing and resilience. It has strong links to diverse communities and seeks input from all customer groups. addresses barriers to full participation for individual customers engages with all relevant communities and seeks input from diverse customer groups in setting its direction and planning services. People Communication strategies that enable every customer, including those with cognitive or sensory needs and diverse backgrounds, to fully engage in the services Processes that are easy to understand, consistent and transparent so each customer is treated fairly and according to their assessed needs Memorandums of understanding with other service providers Actively and consistently supporting every customer to engage in the services Working with relevant community leaders and other organisations to address barriers to services and set directions Leaders model behaviour that is aligned with the organisation s values NGO Benchmarking Model: Evidence Guidelines Page 27 of 47

Excelling The organisation regularly monitors and assesses the effectiveness of its services for customers from diverse cultural and social backgrounds, and adapts them as needed. Its services are responsive to the cultural and social needs of customers. monitors systemic, widespread barriers to full participation for its customers (including potential customers) where required, seeks approval to amend its services under program or funding agreements to address these barriers consistently supports the empowerment and self-determination of its customers. Governance framework covering cultural proficiency Fostering equal opportunity, the environment, education and the health and wellbeing of customers and potential customers Monitoring barriers that prevent customers and potential customers participating in services, within the program or funding agreements Ensuring services are effectively managed with wellestablished governance arrangements that are regularly reviewed NGO Benchmarking Model: Evidence Guidelines Page 28 of 47

4 Corporate governance standards This section outlines the for the four governance standards. As with the customer standards, our list is not exhaustive and each level of attainment builds on the one before. To progress, the organisation must meet the indicators and of the previous level. Standard 7: Leadership and strategic business planning Leadership and strategic business planning align with the organisation s purpose, focusing on customer-centred service design and business development. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation uses systems and to establish and communicate its purpose, vision, values and goals. It understands how to plan for sustainable success, what the core business strategies are and how to align the whole organisation to its purpose. The organisation regularly reflects on progress towards strategic goals, adjusting strategy when the external environment changes. has a clearly stated vision, purpose and strategic plan that define the outcomes sought for sustainable success communicates its purpose, vision, principles, strategies, goals and objectives for organisational success communicates the ethics, values, beliefs and behaviours that underpin its strategic direction has for developing, reviewing and adapting strategy is working towards ensuring it has appropriate leadership arrangements. People Strategic plan Business plans Management commitment policy Contingency planning Staff induction Purpose, vision, values and goals Reviews of the strategic plan and business plans Staff records, such as induction files Periodically reviewing policies and Developing services to meet customer needs within program guidelines Working towards a governance framework Staff receive training, education and knowledge on the values, beliefs, purpose, principles, strategic direction, goals and objectives NGO Benchmarking Model: Evidence Guidelines Page 29 of 47

Mature The organisation creates an environment that promotes a system of leadership at all levels. Its management structures also promote leadership and the allocation of effective accountabilities. Senior leaders model the desired behaviour. has effective and visible systems and for leadership at all levels has leaders that actively engage with staff and customers, ensuring the vision, purpose and values are relevant and well understood by all stakeholders involves people at all levels when developing plans that reflect its vision allocates accountability for executing and communicating the plans, and uses team and individual measures to track achievement has a detailed business plan that identifies proposed activities and costs, considerations and risks for each activity group, and ways to address these. People Business plans that reflect the organisation s vision, activities, resources and risk management Governance policy and Monitoring regulatory compliance and sharing information on new or updated requirements Managing information systems Communicating the purpose, vision, values and goals to staff and customers Maximising opportunities for all stakeholders to be involved in operational planning Periodically reviewing the business plans, including KPIs, accountability, monitoring and reporting on achievements Staff help develop the purpose, vision, values and strategies Leaders ensure staff and customers understand the purpose, vision and values Leaders role model behaviours in line with the values Everyone holds themselves and others accountable to the values NGO Benchmarking Model: Evidence Guidelines Page 30 of 47

Excelling The organisation has clearly defined outcomes, with explicit, quantifiable and meaningful performance measures. Customers contribute to developing the strategic plan, which includes contingency and predictive planning. has systems and to turn strategic decisions and imperatives into actionable plans and programs to achieve its goals actively includes customers when developing its strategic plan measures its performance against the strategic plan, business plans and intended outcomes makes improvements and corrections as needed, and periodically reviews what it has learnt is agile and adjusts its strategic direction by predicting change, managing uncertainty, planning for contingencies, managing strategic risk and responding rapidly to significant external changes assesses and predicts the technology, knowledge, skills, resources and competencies it will need to be successful in the future. Contingency plans Business continuity plans Annual reports Transforming strategic decisions into business plans, such as governance arrangements and HR Researching and analysing markets to ensure services match core capabilities Assessing the results of planning against intended outcomes Maximising opportunities for customers to be involved in strategic planning Periodically reviewing the organisation s strategic direction and updating it in response to significant external events Reviewing business plans to ensure they align with strategic decisions being adopted through programs and other activities Reviewing business and actions plans to evaluate progress Capturing the lessons learnt and ensuring these lessons aid continuous improvement Assessing future needs, such as technology, skills and resources NGO Benchmarking Model: Evidence Guidelines Page 31 of 47

Standard 8: Governance and management The organisation is governed effectively and efficiently so it can deliver quality services. Accountable and transparent governance arrangements maximise outcomes for stakeholders and ensure compliance with relevant laws and contracts. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation s culture supports behaviours that are consistent with its values and helps it to achieve its objectives. Its governance defines the it uses to manage its business. It complies with all regulatory and legal requirements that apply. has appropriate governance arrangements to manage its operations and ensure all legal obligations are met has a management philosophy that embodies its values in the way the values are communicated, adopted, reviewed, reinforced and incorporated in the workplace and documents like policies defines behaviours that show and promote its values, recognising and rewarding these behaviours has a system of policies,, controls, risk management and relationships to meet its legal, financial and ethical obligations supports professional development with governance that define roles, powers and responsibilities and the links with its owners, stakeholders and management structure. Financial management policy and Governance policy and Management commitment policy Risk management policy and Workforce planning and recruitment strategy for a skilled, engaged and responsive workforce Professional registrations Records of staff inductions, professional development, performance reviews and management Records of compliance with contracts and funding agreements Records of the board, management committee or senior executives being involved in business decision-making, such as minutes or reports Operational reports relating to the services, such as budgets Monitoring regulatory and legal requirements NGO Benchmarking Model: Evidence Guidelines Page 32 of 47

Mature The organisation s policies and are reflected in its practice. It has well-established governance arrangements, which are regularly reviewed and ensure the services are effectively managed. It also has a risk management strategy that continually identifies risks and defines strategies to minimise or address them. knows its responsibilities to stakeholders and has an effective system of leadership, accountability and controls to fulfil those responsibilities shows staff fully understand and adhere to policies and procedures ensures these reflect current good practice through regular reviews encourages staff to show leadership under a management system that defines roles and responsibilities within a risk management strategy. Delegation and decision-making policies Accountability and reporting Planning Financial management and reporting policy and Compliance management Roles and responsibilities Policies and that reflect a current approach to laws, standards, funding requirements and sector policy, and are accessible to all stakeholders Documented governance arrangements Insurance certificates Risk management plans or other documents covering risks to customers, staff and the organisation Documents showing ongoing risk monitoring, including identification, reporting and mitigation strategies Funding agreements and related program guidelines Professional standards Meeting minutes Audits, reports and plans for the board, management committee or senior executives Monitoring compliance with laws, funding agreements and policies to continuously improve performance Performing services in line with contractual obligations Recruiting, supporting and monitoring senior management positions in line with the organisation s vision and values, and probity requirements Protecting the integrity of accounting and financial reporting systems Managing risks and financial and operational controls, including fire safety and insurance Periodically reviewing and updating policies and NGO Benchmarking Model: Evidence Guidelines Page 33 of 47

to ensure they reflect good practice Excelling The organisation supports society and its smaller communities by taking part in activities to build capacity. It adjusts its professional development priorities based on evaluation outcomes, new opportunities, challenges and service requirements. shows its commitment to its community and the wider society, for example by sharing information and holding community consultations contributes to community wellbeing by fostering equal opportunity, the environment, education and health shows its commitment to equal opportunity and acts as a model of best practice for employers and the community is environmentally responsible, for example by recycling and reducing waste encourages wellbeing among community stakeholders by minimising any adverse effects of its services and operations regularly reviews its professional development priorities to respond to evaluation outcomes and feedback, and build the skills and capability to manage existing and future service needs. Environmental policy, committing to minimise the negative impacts of products, services, systems and on the environment Contributing to equal opportunity, the environment, education and the health and wellbeing of community stakeholders Making decisions that take into account community interests Evaluating professional development priorities NGO Benchmarking Model: Evidence Guidelines Page 34 of 47

Standard 9: Continuous improvement The organisation has an established and supported culture of continuous improvement at all levels. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation identifies documents and manages its value-creating, support and leadership to achieve its objectives. It maps and understands the interdependencies in its for service delivery. It optimises all its systems and, and regularly reviews their relevance and suitability against its objectives. uses ongoing discussions with customers and other stakeholders to inform its services and and create the best outcomes monitors its to assess effectiveness and areas to improve identifies links within its improves performance by measuring both in-process achievements and final results for all its controls process quality by monitoring variation in performance, checking results, determining causes and making corrections uses trends and patterns of variation (both stability and capability) to determine if its changes have led to better performance. Continuous improvement policy Feedback management policy and Incident or accident management policy and Quality policy Risk management policy and Improvement planning Self-assessment or audit Meeting minutes and reports, such as those relating to management, customers or focus groups Results from self-assessments and audits Records of service changes in response to feedback Customer feedback covering different situations and backgrounds Effectively completing self-assessments and identifying opportunities for improvement Actively addressing, investigating, resolving and documenting grievances and complaints Implementing reactive and corrective actions, and ensuring these contribute to continuous improvement Understanding the effect of varying a process on other parts of the same process or another one NGO Benchmarking Model: Evidence Guidelines Page 35 of 47

Mature The organisation uses structured methods to improve its and achieve efficiency and effectiveness for all stakeholders. It prepares for change and maintains the agility needed to meet challenges as they arise. The organisation s leaders: drive and encourage continuous improvement monitor improvement projects and recognise the achievements of staff delivering improvements. ensures sustainability with a suitable and consistent improvement method incorporates planning for improvement in business plans and improvement projects. People Business plans that cover improvement Action plans Improvement plan Identifying and adopting innovative ideas Effectively prioritising and converting opportunities into actions, to improve customer outcomes Encouraging staff to be creative and innovative Staff commonly and consistently use the PDSA Cycle or another relevant improvement method Staff understand that all have variances and work to reduce these NGO Benchmarking Model: Evidence Guidelines Page 36 of 47

Excelling The organisation continuously improves its services, based on how they perform against required standards, customer expectations and similar organisations. uses measures and monitoring methods to confirm that its services will meet customer expectations uses both quantitative and qualitative measures for products and services to determine their level of excellence continually compares itself with similar organisations and independent information to understand how it can improve or adapt its performance and outcomes. Annual and other reports Contracts with partner services Ensuring policies and are: effectively documented readily available reviewed and evaluated regularly with staff and customers and their representatives Ensuring the services operate effectively and contribute to continuous improvement Monitoring variation in service performance, including determining causes, taking corrective action and evaluating the results to improve customer outcomes Defining internal and external partnerships Developing and managing partner relationships in line with performance requirements Learning from others to increase process effectiveness and efficiency NGO Benchmarking Model: Evidence Guidelines Page 37 of 47

Standard 10: Data management The systems that collect and use data are effective, with appropriate controls over privacy and security. Note that each of the following levels of attainment builds on the previous one. Emerging The organisation has effective information management systems that maintain privacy and confidentiality. has to define the knowledge required for its success and sustainability updates and refines the information it holds has for protecting privacy and confidentiality. People management policy and Knowledge management Privacy and confidentiality policy and Customer packs that include the privacy and confidentiality policy Capturing the organisation s knowledge, including: determining what information it should collect (such as business KPIs) setting out how it is handled and stored, and how it is analysed and interpreted to create knowledge Managing information systems, including elements like common terminology and a clear path to increasing capabilities Storing records, such as staff and customer files, covering security, confidentiality, retrieval, archiving and destruction, in line with privacy laws Collecting customer feedback on their access to personal information and on confidentiality Staff are trained in the organisation s policies and, and there are strategies for informing them about updates or changes Customers can access their information and it is kept up to date NGO Benchmarking Model: Evidence Guidelines Page 38 of 47

Mature The organisation has an information management system that allows all staff to work effectively and efficiently. has data and information sharing policies and to ensure a continuous focus on improving the data available uses its data and information to underpin decision-making gives all staff access to the technology they need to do their work effectively and efficiently regularly reviews its IT needs keeps its IT up to date. People Capturing data and using a diverse range of existing and potential knowledge sources, both internal and external Regularly updating and refining data and information, continually improving the type and quality available Maximising the organisation s capability to access and use information for decision-making Aligning its data and information to decision-making with: a user-friendly repository, ideally linked to the IT system and generally accessible a back-up store of current information in case of an emergency or disaster strategies that ensure data and knowledge remains secure and confidential Ensuring that data is shared among those who can use it to improve performance Defining and regularly reviewing data collection needs and methods Maintaining advanced information systems and regularly reviewing IT Staff demonstrate knowledge of information management Staff have access to the technology they need to complete their work effectively and efficiently NGO Benchmarking Model: Evidence Guidelines Page 39 of 47

Excelling The organisation embraces new technologies to adapt, innovate and thrive in complex, challenging and uncertain environments. continuously improves its data management strategy, underpinned by data quality, governance, platforms, architecture and operations maximises its strategic advantage by harnessing the knowledge and expertise its people and systems hold regularly investigates and assesses new technology makes good use of current technology to adapt, innovate and thrive. Valid, reliable, relevant, timely, secure and sound data Decisions based on current information, knowledge and fact Defining the knowledge needed for success and sustainability Capturing and sharing knowledge Encouraging staff to access, discuss and build on data, information and knowledge Analysing and interpreting data to continually improve and inform short and long-term decision-making Using analysis to support the organisation s understanding of the nature and impact of variation on, outputs, outcomes and measurement systems Using data as the basis for training and innovation Ensuring continual learning is a fundamental element of the organisation s culture NGO Benchmarking Model: Evidence Guidelines Page 40 of 47

5 Templates Policy A policy is a framework of principles, usually set by a board or senior governance body, that guides decision-making and activity. It outlines an organisation s intent on a topic. When developing a policy, you should consider: who it applies to and whether there are any exceptions (scope) what the policy is trying to achieve (objective) what it covers (description). You should then review it regularly to make sure it remains current and relevant. We recommend using a template similar to this one, where we have added some example text: Quality Improvement Policy Scope Objective Description Responsibilities Policy owner The Quality Improvement Policy applies to all staff and contractors at [NGO]. This policy will embed a culture of continual improvement to ensure that we deliver high quality products and services that meet our customers expectations. [NGO] has adopted a framework for quality improvement, which gives us a systematic way to continuously improve our performance All staff must adhere to this policy. As an employer, [NGO] must ensure we comply with relevant laws. Senior Executive Officer Key dates Created: May 2016 Review due: May 2018 or as needed Related documents Strategic Plan Quality Improvement Guidelines Improvement Log Process Definitions The following terms apply to this policy: Term Definition Continuous quality improvement (CQI) NGO Benchmarking Model: Evidence Guidelines Page 41 of 47

Process A process describes the steps needed to implement a policy and achieve an outcome. Processes are usually developed and adopted by senior executive officers. When developing a process, we recommend using a template similar to this one, where we have added some example text: Improvement Log Process Scope Objective Description Responsibilities Process owner The Improvement Log Process applies to all staff and contractors at [NGO]. This process will ensure we capture, prioritise, action and evaluate opportunities for improvement relating to customers, staff and other stakeholders. When staff identify an opportunity for improvement, such as through client feedback, they should fill in the Opportunity for Improvement Form and submit it to the Quality Coordinator. The Quality Coordinator will: complete the form by entering the next available OFI number from the register and update the request until it is completed advise the form originator as action is taken report each month to the Senior Executive Officer. The Quality Coordinator must: assess the impact of escalated issues/actions on the Quality System and report these to the Senior Executive Officer maintain the Improvement Register acknowledge, action, review and evaluate opportunities for improvement in a timely manner, and ensure follow-up actions are implemented report on the status of opportunities, including trending and analysis. The Senior Executive Officer must encourage continuous quality improvement, supporting budgeted resources. Quality Coordinator Key dates Created: May 2016 Review due: May 2018 or as needed Forms and records The following forms relate to this process. On completion, they become records: Form Title Copy Location QR 01 Quality Report Electronic Quality folder on X drive Related documents Strategic Plan Quality Improvement Policy Quality Improvement Guidelines Definitions The following terms apply to this process: Term Definition Quality report (QR) NGO Benchmarking Model: Evidence Guidelines Page 42 of 47

Improvement plan Your improvement plan should track any issues you identify and your response to them. It should align with your Strategic Plan and Business Plan. NGO Benchmarking Model: Evidence Guidelines Page 43 of 47

One-page strategic plan NGO Benchmarking Model: Evidence Guidelines Page 44 of 47