Revision: 0 - Web viewThe report can also be exported into a MS Word document although the latter format has reduced data editing options when compared to MS Excel

COMPANY-WIDEWI001 CONTINUOUS IMPROVEMENT (‘CAR SYSTEM’) PROCESS

1.0 Introduction

This work instruction explains how corrective action requests (CARs) and ideas for improvement (IFI’s) are created and managed as part of the Advent ManageR® risk management system that is a web-hosted application maintained and supported at an infrastructure level by Quality Award Partners®, Melbourne.

2.0 Quick-Find Index

Detailed instructions in this document may be found through the following hyperlinks:

Log into Advent Manager R® Navigate through Risk Registers Adding a risk into a risk register CARs

- Create - Attach files into CAR- Notify the person responsible - Find - Update - Close

System-generated reminder emails Reports

3.0 Scope

3.1System Access to Advent ManagerR®The Advent ManageR® (CAR) system is directly accessible on-line by people whose role has been identified as requiring access. Requests for access for employees other than this should be made by the relevant manager for the attention of ‘Business Improvement Manager’.

DSA people, who have not yet been authorised or given access into the CAR system, should discuss their corrective/preventive actions and ideas for improvement with their immediate supervisor who shall determine if the matter is appropriate to be dealt with at the local level or whether to enter into the CAR system. Local level resolution must be recorded and a traceable record retained.

3.2Application of the CAR SystemContinuous improvement shall be achieved in DSA by taking effective corrective and preventive action relating to customer service requests, workforce issues and service delivery performance;

These types of improvement are categorised as follows:

Customer Service: Raised either by ‘internal’ customers of a process or as a result of feedback received from external customers, regarding:

o Ideas for improvement in systems or in processes o Product complaints from external customerso Non conformances arising from audits or other review

Workforce Grievance or Disputes: o When dealing with workforce-related grievances and disputes refer first to the

Grievance & Dispute Handling Policy.

Commercial-in-Confidence © Disability Services Australia Limited 2010 WI001-03

When printed this becomes an uncontrolled document. Page 1 of 16


o ‘Workforce’ includes the ‘factory’ employees however the relevant manager must determine whether the issues is about their contract of employment or a service delivery responsibility.

o Where related systemic workforce issues are identified a CAR should be raised.

Quality of Service Delivery: Complaints regarding the quality of service delivery supplied by DSA to service recipients.

o The details regarding the particular complaint shall be recorded in a confidential area of the CAR system that is accessible only by authorised managers.

o Where related systemic service delivery issues are identified a CAR should be raised in the general CAR system.

4.0 Risk Management in Advent Manager R®

The automated ranking mechanisms built into each CAR help us to compare the various risks so that DSA can focus on managing the highest risks first.

Management of DSA’s identified risks – what action is to be taken about the risk - may include:

Acceptance: Some very low risks may be acceptable particularly if the known corrective actions are unacceptably difficult or costly.

Elimination: through corrective action involving engineering or process changes. Reduction: through corrective action such as training.

In Advent ManageR® the following terms are used: ‘Risk’ – this field describes the particular event that might happen e.g. ‘A helicopter crash damages

Condell Park’. The ‘Impact’ field describes what damage that event would cause (if it happened) e.g. Loss of

employees, closure of premises, loss of records. The ‘Likelihood’ describes how likely it is for the event to happen. The eight ‘Consequence’ fields rate the impact, by selecting from categorised ‘drop-down’ choices.

The latter method encourages a consistent rating framework to be applied across all risks.

5.0 How the CAR System is arranged

Each CAR is managed according to its risk – “Let’s fix the high risk CARs first!”

Similar sorts of CARs are grouped together under a description of whatever risk it is that they share in common. Then it is easier to review a set of related CARs in order to reduce a particular risk.

In turn, those risks are more easily managed if they are prioritised and put into groups that are ‘owned’ by the right part of DSA:

Some risks will be ‘owned’ at a company-wide level e.g. lack of disaster recovery plans wil be in the DSA company wide risk register..

Other risks are to do with part of the company e.g. missed medication in Lifestyle locations, would be in DSA Community Support Service’s Risk Register.

Consider each ‘owner’ as living in a discrete multi-storey car park called a ‘risk register’.




Each car park owner can see all their parked cars, grouped onto various floors. The car park owner knows that some floors are more risky than others – All cars parked on such floors have to be looked after with a higher priority in order to avoid impacts on the car park business.

Refer to the following example showing cars grouped onto floors in each of several car parks.




6.0 Risk Registers (‘Car Park’) security & confidentiality

DSA people can only enter the risk registers (‘car parks’) related to their job and their position.

Simplification - This reduces information-clutter and enables a more focused approach. Your own ‘Car Park Key’ - You will use your own unique logon identification and password to enter

Advent ManageR®.

7.0 Log into Advent Manager R® To log in to the system:

Go to the link: https://www.adventmanager.com.au/login.aspx

Hint: Save the above address as an Internet Explorer favourite.

Enter your full email address in the ‘User Id’ field.

Example: [email protected]

Hint: If an attempt is made to use an incorrect ‘email’ format, a prompt will appear as a display warning ‘Invalid Email Address’.

For the first access occasion, enter the strong password already supplied to you by an email from the Advent ManageR® Administrator. Click the white ‘Login’ button.

An Entry Display Screen will be presented. Click on the logo:

Hint: There are three main tools provided within Advent ManageR®. The scope of this Work Instruction ignores ‘Incident Manager’ and ‘Compliance Manager’.

The 'Risk Register' page will appear; locate the brown drop-down bar (Home, Reports, System, and Help) at top of page.

Click on ‘System’, then ‘Change Password’. Follow the prompts to set your own secret ‘strong’ password which will work on the next occasion

you log in to Advent ManagerR®.

Hint: Strong passwords should appear to be a random string of 8 characters or longer and include a combination of uppercase and lowercase letters and numbers. This is essential to provide for effective security for DSA’s protection against malicious attack.

Hint: To help with forgotten passwords, the user can now save a password hint when setting up a new password. Alternatively, you can obtain a new password from the login screen.

Test your new password by clicking on ‘System’, then ‘Logout’ to log out, and then successfully log back in to the Advent ManageR® system. Contact the Administrator for any further guidance.



mailto:[email protected]

https://www.adventmanager.com.au/login.aspx


8.0 Navigate through Risk Registers

8.1 Go to the relevant Risk Register

Select the appropriate Risk Register for the relevant Division.

To allow for raising a CAR where a specific risk has not yet been defined in Advent ManageR®, DSA has provided a single company-wide risk (Risk number 2) located in the Corporate Risk Register - This risk register is open to every user of Advent ManagerR®. This contains the shared risks that affect all of DSA - for example regarding risk of loss of DSA’s ISO9001:2000 Quality System Certification.

To find this company-wide register known as ‘DSA Corporate’ risk register: Select ‘Home’ Select ‘Risk Register’ Under ‘Register for’, select ‘DSA Corporate'.

Within the selected risk register (‘car park’) select the applicable risk (‘floor’). If there is no suitable risk already defined, a new risk may be needed. (Refer: Adding a risk).

9.0 Adding a risk into a risk register

Only the Chief Executive, relevant Divisional Director or the Business Improvement Manager may approve the creation of a new risk.

Adding a new risk into a risk register is equivalent to building a new floor in a car park and will require formal management level consideration of the impact. Authorised requests for adding a new risk shall be made to the ‘Business Improvement Manager’.




10.0 Create a CAR

A new CAR is created as follows:

View the Risk to which the CAR will be assigned. Confirm it is appropriate to contain the intended new CAR.

Select the blue underlined number (e.g. 0)in the cell headed ‘CAR’ – That number indicates the current total number of CARS already attached to that Risk

Select the ‘Add/Create New CAR’ button – See the following screen-print:

Describe the CAR details: o Select 'Origin' (mandatory field). Refer to 3.2 Application of the CAR System.o Complete 'Reason for Action Request' (mandatory field).o Complete ‘Investigation & Improvement Plan' - This is an optional field when

raising a CAR – Typically this is used when a manager delegates the task to another person or area of DSA but wishes to provide recommendations.

o Complete ‘Responsibility’ (mandatory field) – select the name of the person that will be responsible for the action.

o Select a CAR Due Date (the automatic default is the same as the date on which you are raising the CAR i.e. is same as the automatically displayed field entitled ‘Report Date’); the due date may be changed later by the person responsible upon their consideration of the intended action.

Save the information – Refer to instruction for saving in 13.0 Update a CAR o This lodges the CAR into the system and assigns a unique CAR number in the

banner heading.

Upload Files into the CARo Browse to the document using the ‘Browse’ Button then click on ‘Upload File’ to

attach the file to the CAR. Repeat the ‘Browse’ and ‘Upload File’ actions as needed to make further attachments to the same CAR - Refer to the screen shot below:

o Re-save the CAR - This will ensure the attached files are available to other people that subsequently open the CAR.

o Note that you cannot save files unless they are in the server folders. The system does not allow for file saves from your C: drive.



You MUST advise the person nominated in the ‘Responsibility’ field that they now have your CAR to consider. This action is NOT automatic - you MUST send a message as described.


11.0 Notify the person responsible

This ‘step’ is mandatory – It must be done before exiting each newly created CAR:

Select the grey coloured ‘Send Email’ button near the bottom middle of the screen. Select the appropriate details e.g. for each occasion that you double click on a name in the mail

address list in the ‘left hand panel, the application will place that address in the right hand panel as a destination address.

A standard ‘default’ email body-text message is provided. You may delete, overwrite or add further explanatory text to the body of the email. For instance you may add a first-name greeting or some further background to aid in understanding the particular context surrounding the CAR.

You must have already saved the CAR before using the ‘Send Email’ function. If you have not already saved, you will get an error message. In that instance clear the error message dialog box and then save the CAR – That allocates a CAR ID number and the CAR can then be emailed as an advice.

12.0 Find a CARThere are two main ways of finding a particular CAR:

Either Clicking on the Hyperlink in a Sentinel email message and following the logon prompts,

Or

Using the search method described above. In the resulting report, find the description summarising the CAR of interest. Take note of (write down) the ‘Date Raised’ and the wording under the ‘Reason for Action

request’. Proceed to the CAR by clicking on the blue underlined number (in the example shown below it

is 2) under ‘Risk #’:

Click on the blue underlined number (in the example shown below it is 88) under ‘CAR’:




- Use the ‘Date Raised’ and the wording under the ‘Reason for Action request’ so as to locate the row relating to the particular CAR of interest. Refer to the example below:

Use the information recently noted down (the ‘Date Raised’ and the wording under the ‘Reason for Action request’). Use this to recognise and locate the CAR of interest.

Click on the ‘eye symbol’ to display the particular CAR’s detail.

13.0 Update a CAR Refer to section 12.0 Find a CAR.

Amend the details e.g. Change the due date or add some details into the action plan. All changes must be saved before exiting the CAR details screen; all changes will be lost if not saved prior to exiting the CAR details screen.

To save the changes made to the CAR detail then click on the grey coloured ‘Save’ button near the bottom left of the screen.

The system will automatically log a history describing ‘who changed what, and when it was done’. Click on the Email History button to view a summary of emails specific to the CAR:

To exit the CAR details screen, click on ‘Return to CAR Report’ button.




14.0 System-generated ‘reminder’ emails

14.1 Introduction to Sentinel Notification

There is an automated reminder called ‘Sentinel Notification’ built in to the CAR system. If a CAR’s ‘due date’ is exceeded then an emailed reminder will be sent to the person listed as ‘Responsibility’ who will then revise the due date and add a reason for that change.

Consider a fictitious example: Suppose an IFI was raised, and sent it to Mary Smith who made Fred Bloggs responsible for dealing with the action. The original due date had passed, and Fred received a reminder but had not updated the CAR with an explanation in the ensuing one week.

The Sentinel program in the Advent ManageR® system accordingly sends an escalation email to Mary Smith as shown in example shown overleaf:

The particular CAR can be opened from the actual Sentinel email by clicking on View Details. Updates can then be made such as to due date or intended actions; The system logs such activity including the Logon identity of the person doing the update.

14.2 Weekly EmailsThere is a weekly reminder cycle as follows:

Action If you are the person listed in the ‘Responsibility’ field for the corrective action for a CAR, then you will receive ONE consolidated email on each Monday morning for any CARs due:

Over the coming two weeks Due today Overdue

EscalationIn addition, all Managers of people responsible for the corrective action of CARs will receive ONE consolidated escalation email on each Monday morning relating to all their peoples’ CAR's that are by then at least a week overdue on being completed.

Each Monday any such CAR will continue to be listed in the Manager’s notification email until the due date has been revised into the future, or the CAR has been ticked as ‘Action Completed’.

14.3 Once-only EmailYou will receive an email when you are first nominated as the person assigned under the ‘Responsibility’ field. It is obligatory to send you an email if you are the person assigned the ‘Responsibility’ for corrective action. If you have been given such ‘Responsibility’, then you will receive an email advice.




15.0 Close a CAR The communication stages in closure of a CAR are:

15.1 Tick the Action Complete This Stops the automatic Sentinel notices. For sentinel notifications to cease being sent regarding the CAR, as the person responsible you are required to click the box ‘Action Complete’. Then emails will no longer be sent to you regarding the CAR.

AND15.2 Who can authorise closure?

Using the ‘Send Email’ button, an email describing or referencing ‘real’ evidence, must be sent to the next level of manager responsible for the area covered by the risk register in which the CAR is parked. When the manager has verified that there is sufficient evidence that the action has been taken the manager shall email the Administrator to request closure. Where appropriate, the manager responsible for the area may request through the Business Improvement Manager for an internal auditor to validate the evidence.

15.3 VerificationThe ‘Follow Up Date’ is an optional ‘reminder’ facility for the Internal Audit team to verify the corrective action at some time later in order to confirm it is effectively in place. Such verification may be included in the next scheduled internal audit or conducted specifically to close the CAR.

16.0 Reports

16.1 Selecting your report

In the Advent ManageR® application, there are flexible reporting options may be selected to create Advent ManageR® on-line reports regarding a specific CAR or related sets of CARs as follows:

All Open CARs Click on the ‘Reports’ option on the Advent ManagerR® ‘Toolbar’. Select ‘CAR, MAP & Incident Report’ in the drop down menu:

The remainder of the search fields should be completed to suit the particular reporting needs. Fields may be left ‘blank’ – Not all fields have to be filled in. The more fields that are defined, then the smaller and more focused will be the report.

16.2 Exporting CAR reports to an Excel spreadsheet

The Advent ManagerR® report can be exported from Advent ManageR® into a spreadsheet held externally to the Advent ManageR® system. It may then be subsequently edited, formatted and sorted at up by the MS Excel ‘Data Sort’ functions. The report can also be exported into a MS Word document although the latter format has reduced data editing options when compared to MS Excel.

For a more detailed Instruction, refer to Appendix 1. Create an ‘OPEN CARS SUMMARY REPORT’ .




17.0 Continuous Improvement

Email to the Administrator for any further advice or 'Help' - Please do NOT contact the Quality Award Partners' phone number shown on the Welcome to Advent ManageR® log-on screen. Contacting the DSA Quality support team will allow DSA the opportunity to continuously improve this work instruction or take other appropriate corrective/ preventive actions.

All contact with Quality Award Partners® shall be made ONLY via the Administrator.

18.0 ReferencesRefer to the Corrective and Preventative Action’ procedure for a general background relating to requirements for this process.

For further detail on the Advent ManageR® application, check the Help Screens, or go to the Quality Award Partners® Document Managenment System (accessible from the Advent ManageR® home page)

Advent ManageR® site: https://www.adventmanager.com.au/login.aspx



https://www.adventmanager.com.au/login.aspx


Appendix 1. Compile an ‘OPEN CARS SUMMARY REPORT’

IntroductionPurposeThe following instruction describes how to create an MS Excel spreadsheet describing CARs that are open (uncompleted). The resulting spreadsheet may then be edited, formatted and sorted to display a view pertinent to a Division, date etc. Although the export facility also allows exporting to a MS Word document, this Appendix assumes that Excel will typically be the format of choice due to flexibility of data presentation .The rest of this Appendix describes only exporting data to MS Excel.

SecurityThe Advent ManageR® log-on process allocates access rights to each individual.

The Business Improvement Manager has oversight of these access arrangements and their ongoing review.

Quality Team members have been delegated administrative rights to the Advent ManageR® system and can access all Risk Registers.

Non-administrative system-users (the typical normal user) are only able to read and write to CARs that are related to Risk Registers within their own Division or a formally agreed specific part of the organisation.

The above access rights define the boundary for the scope of the Open CARs Summary Report generated by this instruction.

Confidential Information – Grievances & ComplaintsThere are some risk registers specifically related to grievances &/or complaints that contain CARs with information that is of a confidential and private nature. Access to those risk registers is controlled through the logon identity. The Advent ManageR® application also maintains a log of detail actions.

It is important to recognise that if the person, who creates such an Open CARs Summary Report, has been granted log-on access to a confidential register, then that report will contain confidential information requiring either appropriate deletion or formally controlled distribution.

The privacy and confidentiality of those data must be maintained and protected throughout the reporting process.

Work InstructionData is extracted from an Advent ManageR® report and placed into an Excel spreadsheet as follows:

1. Prepare a Blank Spreadsheet from a special template

If you use a special template, then first open it Click on the ‘Read Only’ button. Click the Windows button at the top left of the Excel task bar Select ‘Save As…’ to save as a renamed file at a location of your choice. Your choice of location must avoid creating confidentiality and privacy issues concerning the data

that you intend to copy across from Advent ManagerR®.

2. Open a Web Browser - Log in to Advent Manager R®

3. Extract the Raw Data - Follow the detailed instructions commencing on the next Page.




Open the path: ‘Reports\’CAR, MAP & Incident Report’. Set the search criteria in the ‘drop-down’ displayed fields - Leave all fields ‘blank’ except as follows:

Select Complete/ Uncomplete as: ‘Uncompleted’

Select Display Report as: ‘CAR Report’.

Select the highest level of ‘Register’ that your report needs to cover.For instance this may be your specific Division, your specific department within one Division or be

left blank for ‘DSA All’:

If you want to include Registers for those parts of the organisation that are ‘lower’ down in the DSA organisational tree than the Register you have selected, then tick the box against ‘Include Sub Directories’.

Click on ‘Retrieve Result’:




Select ‘Export’, leaving the drop-down setting as ‘Excel’. Click ‘Save’.

Save in a temporary directory as a renamed file e.g.

Open the file that you have just saved. Select ‘Yes’ to a security question:

Hint: Do not log out of Advent ManageR® yet – You may need to repeat the operation.Hint: There is an auto-time out in Advent ManageR® – If you are ‘away’ too long you may have to log in

again.

Use the left mouse button to click once on the shaded cell in the spreadsheet’s corner where the Alpha and Numeric scales meet:




Reset the font size to 10:

Click Ctrl+A to select ‘All’ the spreadsheet’s data. Click Ctrl+C to copy the data from the temporary file. Open the spreadsheet that you created per Appendix1, 1. Prepare a Blank Spreadsheet. Position the mouse cursor so as to highlight cell A1. Click Ctrl+V to paste the data. Click Ctrl+S to save the data. Inspect the data to confirm that the data appears to be relevant to the column headings; if

acceptable you should now log out of Advent ManagerR®. If the data appears corrupted, delete the data rows from the spreadsheet and repeat the above

operations. Reports containing data describing grievances and complaints shall not be released or emailed

without the approval of least the relevant Divisional Director. This means that normally the following process applies:

o Manually delete the confidential data on all rows that relate to ‘Grievances’ and ‘Complaints’ by right-clicking on the row numbers and selecting ‘delete’.

o Re-save the spreadsheet file. Where so specifically approved by at least the relevant Divisional Director, reports containing data

describing grievances and complaints shall be:o At all times be stored in a confidential manner.o Communicated under a controlled distribution protocol.

You may need to edit (overwrite words, format columns or letters etc.) in the various Headings or Title data to make the report more meaningful or look better aesthetically.




Sort the dataThe spreadsheet may be data-sorted e.g. ‘days old’, ‘risk level’ etc. as follows:

Before sorting the data it is essential to populate data into any blank cells that have appeared in columns A, B, C where data appears in any other of the columns.

Copy the relevant cell data for Columns A, B and C into their relevant rows that lie below. Hint: Inspect your sets of pasted data to ensure they are identical for each of the relevant rows.

Position the mouse cursor at the lowest right populated cell, hold down the left mouse button and ‘swipe’ diagonally up to include cell A1; This operation should select all the cells; If not all cells are highlighted, then repeat until successful.

In the spreadsheet task main task bar, select the path: ‘Data\ Sort’ In the resultant drop-down dialogue box enter the desired criteria for the sorting operation and

select OK. Repeat as needed. Column J (‘Divn.’) may (optionally) be populated to clarify DSA-wide reports for distribution at

CEO and Divisional Director level. If the report is to be printed in black & white (not on a coloured) printer, Select Ctrl+A and

change the text colour to black.

Apply Auto-FiltersAuto-filters may be used in Microsoft Excel to facilitate selection of specifically tailored views of a common set of data. To enable this feature, the spreadsheet must first be edited to ensure all blank cells have been populated so as to allow the filters to recognise useful data; This IMPORTANT – Failure to comply will render the data corrupted.

Either write ‘n/a’ into blank cells or populate with common data as follows: Inspect data in columns A (‘Risk #’), B (Register’) and C (‘Risk Level’) – For each column in turn,

if blank cells exist, copy the data from whatever is displayed in the most adjacent populated cell that resides above within the same column.

When copying, ensure that the data does not inadvertently automatically increment on each successive row. For example, Risk 2 must not become incorrectly copied as 2,3,4,5 etc on successive rows down the sheet.

Leave Column J (‘Divn.’) blank at this stage. Refer below under ‘Sorting’ regarding any (optional) further population of this column J.

In the ‘Data’ toolbar, select ‘Filter’, then ‘AutoFilter’. Reset the filters to their ‘All’ position immediately before saving and closing the spreadsheet.

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Documents

Revision: 0 - Web viewThe report can also be exported into a MS Word document although the latter format has reduced data editing options when compared to MS Excel