Editorial: A practical SQUARE Guide on quality service for boards of disability service providers for adults with intellectual disability in Australia

Citation

Wallace, R.A., Rimes, J. and Bitsika, V. (2023), "Editorial: A practical SQUARE Guide on quality service for boards of disability service providers for adults with intellectual disability in Australia", International Journal of Quality and Service Sciences, Vol. 15 No. 1, pp. 1-16. https://doi.org/10.1108/IJQSS-03-2023-189

Introduction

In Australia, disability service providers deliver disability supports to people with intellectual disability across a range of residential, personal support, employment, social and educational domains. Disability sector market analysis shows more than 80% of Australian disability service providers operate as companies or incorporations, called “organisations” for the purposes of this paper (National Disability Services, 2019). Section 198A of the Corporations Act 2001 (2023) regulations mandates that the business of such organisations, either for-profit or not-for-profit, must be under the direction of a board, composed of people appointed as directors. In addition, each state and territory has its own Associations Incorporations Act which has implications for organisational structure [Part 1.1A of Corporations Act 2001 (2023)]. The primary function of the board of directors is to direct, rather than operationally manage, the business of that organisation. Both consumers and management have important roles to play in aspects of service delivery, though it is the board as the most senior body within a disability service provider organisation that has ultimate responsibility for ensuring that practical, ethical, financial and regulatory viability including quality service is achieved [Australian Institute of Company Directors (AICD), 2016].

Despite the presence of boards within disability service provider organisations, evidence in contemporary and historical published literature (Brown and Radford, 2015), royal commissions (Royal Commission, 2020), public inquiries (Robertson, 2020) and government reports (World Health Organisation, 2011) reveals that many people with intellectual disability simply do not receive the quality of disability support services they require to lead a good life, with restrictions noted in accessing usual community, health and social goods and services. Such restrictions not only create participation barriers in activities and work but also adversely impact on individuals’ capacity to make meaningful life choices and achieve personal goals. For people with intellectual disabilities, insufficient service quality is not only associated with unfulfilled potential but also with personal harm. Inadequacy of service quality can lead to exhibition of behaviours of concern as a sign of dissatisfaction by adult users with intellectual disability (Hadaway and Brue, 2015), which in turn severely diminish the life opportunities and quality of living for that person (Felce et al., 2002). Observed lower levels of participation in education, training, employment, access to goods, services and facilities and experiences of ongoing discrimination among people with intellectual disability (Australian Institute of Health and Welfare, 2012; Emerson and Hatton, 2014; Emerson et al., 2011) are indicative of potentially inadequate service quality. Deficiencies in quality service by disability supports have also been identified as being implicated in poor physical health outcomes of people with intellectual disability in the hospital setting (NSW Ombudsman, 2018).

The Australian Institute of Company Directors (AICD, 2019b) stipulates that boards have a responsibility to monitor service quality with the same rigour and attention that they give to corporate and financial performance. This is backed up by royal commissions into banking (Royal Commission, 2019b), aged care (Royal Commission, 2019a) and disability (Royal Commission, 2020). Yet, board attention is often weighted towards financial matters and the many well-regarded resources for boards are relatively quiet when it comes to specific guidance on quality service (AICD, 2020a, 2020b, 2020c). In the present paper, it is postulated that several fundamental factors are related to a disability service provider board’s mismatch of board priorities with those of quality service delivery, amongst them few are:

• insufficient openings for the consumer voice of lived experience of intellectual disability on quality service at every level of board activity;

• board leadership insufficiently well organised with respect to structure, function, diversity, skill and industry knowledge, so it cannot carry out its duties on quality service;

• boards lacking a comprehensive vision of the importance and scope of quality service coupled with insufficiently allocated resources to attend to quality service; and

• boards having a deficiency of systems to obtain quality service data, assess and direct action on deficiencies and act to continuously improve service.

The SQUARE Guide, designed for evaluation of quality service by boards of disability service provider organisations for adults with intellectual disability in the Australian context, is offered as a practical approach for remediating these limitations. The acronym SQUARE provides a mnemonic of the active intellectual processes required by board members in looking at the service quality of their organisation, that is, understanding, appreciating, responding and enacting, when they are undertaking a six-step procedural process of quality service review, depicted in Figure 1. A detailed tabular description of what each of these steps entails is also presented in Supplementary Table 1. Material in Supplementary Table 2 provides a description of generic boards applied for disability service provider organisations, and Supplementary Table 3 lists a range of important regulations and legislation pertaining to quality of disability services and of particular relevance for boards when looking at quality service.

Given the absence of literature specifically for boards of disability service providers on quality service, the guide recommendations derive from resourced, referenced and collated information from generic board documents (e.g. Australian Institute of Company Directors), published literature across a spectrum of papers on quality service in intellectual disability (Buntinx and Schalock, 2010) and consumer input significance (National People with Disabilities and Carer Council, 2009) must be considered as “a first draft”, for later testing for evidence base validation. Its recommendations are quite consistent with contemporary models of governance frameworks of quality and safety and comply with relevant disability commonwealth, state and territory legislation. A similar prescriptive tone and format, as apparent in prominent Australian quality service standard documents, for example, the National Disability Insurance Scheme Quality and Safeguards Commission (2021) and the Australian Commission on Safety and Quality in Health Care (2017, 2021a), has been adopted in the SQUARE Guide. In proposing the SQUARE Guide, the authors are additionally well credentialled to do so, having considerable experience in boards of disability service providers (xx), consumer group leadership (xx), provision of services for people with intellectual disability (xx education, xx autism and xx health), collective and individual lived experience of intellectual disability by way of family and friends, health clinical governance (xx) and research in intellectual disability (xx, xx, xx).

Importantly, the SQUARE Guide has been overall shaped by available literature, experience and pragmatism to make a practical, usable document for boards, able to be understood, used and refined by them, ultimately for the benefit of people with intellectual disability.

The first three steps fundamental to achieving a baseline infrastructure by which the board can pursue quality service are:

1. establishment of robust board structure, governance and composition;

2. assurance of adequate board resources dedicated to quality service; and

3. identification of the dimensions of quality service for the disability service provider organisation.

The next three steps are action focused and derived from Donabedian’s (1966) classic work on evaluation of quality service provision in human service organisations. Donabedian’s model broadly organises its consideration of human service by inputs, process and outcomes. Thus, the remaining steps become action focussed on:

1. inputs: collections of quality service data;

2. process: measurements, comparisons, weighing up and analysis; and

3. outputs: decisions, deliverables and directions on quality service.

As the SQUARE Guide makes clear, the board’s role in ensuring service quality is to understand their roles and its dimensions, appreciate what is required, respond to the findings and enact actions and outcomes as a means to ensure continuous quality service improvement of the disability service provider.

Consumer voice and quality service

At the heart of the SQUARE Guide's values and principles is the central role of the consumer. In the context of disability service provision for adults with intellectual disability, taking a person-centred approach with the focus on the consumer as an active participant in the determination of quality service is a core element of the Australian Government National Disability Standards (2013) and fundamental to the Convention of the Rights of People with Disabilities (2006). It is the view supported by people with intellectual disability too: “nothing about me without me” (United Nations, 2004; National People with Disabilities and Carer Council, 2009). Unacceptable gaps in boards’ roles in seeing consumer-reported needs as a priority has been acknowledged in numerous commissions with strong messages for boards to focus on consumer needs in dedicated and formalised ways that involve engagement with people with disability (AICD 2020a, 2020b). Such policy directives and ethical values highlight a central tenet of the SQUARE Guide that the views of people with lived experience of intellectual disability (themselves, family, close friends) must be, directly and transparently, a significant part of the quality service review as undertaken by the board. Each step of the SQUARE Guide explicitly addresses consumer involvement.

Attending to consumer perceptions and needs is also associated with considerable organisational marketing and cost benefits, in fact: “to keep customers, you have to delight them, exceed their expectations, and anticipate, discover, and fulfil their latent needs…boards need to be attuned to [marketing] research” (McGovern et al., 2004, p. 16). While some human service organisations may perceive difficulties in finding a “balance between the organisation’s client purpose and effective business acumen of the service provider” (National Disability Services, 2019, p. 42), data suggest that providing continuous high service quality is one of the primary ways a human service organisation can differentiate itself from competitors (Poor et al., 2013), and if nothing else, this appears to be a prerequisite for success, if not survival (Parasuraman et al., 1988). The cost effectiveness of this approach is supported by data on service quality research within charitable human service organisations by researchers such as Bennett and Barkensjo (2005).

Embedding consumer input into core board business is facilitated by, but not limited to, board membership comprising people with lived experience of intellectual disability and by direct representations by people with lived experience of intellectual disability to the board individually or in groups. Consumer presence on a board has been recognised as being immensely beneficial through their provision of valuable resources, social capital, insights, customer orientation and knowledge and market insight that can be offered by no other board members (Kohli and Jaworski, 1990).

Scope for consumer input at a board level outside of board membership, such as by individual, family group or formal consumer advisory group representation, also needs to be planned and addressed. Consumers need to be able to present a variety of material to the board including stories, surveys, complaints, compliments, values, initiatives, consultative feedback on board proposals, priorities and strategy, as well as having the ability to participate in bi-directional communication with the board.

Formalising consumer-board communication pathways of any format can be modelled on existing, accepted methods used in other human service industries at a board level such as the “partnering with consumers” standard outlined in the Australian Commission on Safety and Quality in Health Care (2021a, 2021b). In this, boards are required to have formal policies and procedures that support partnering with consumers, opportunities for consumer input into sub-committees, considerations to consumer advisory body establishment, involvement of consumer engagement in decision-making, ensuring effective systems for consumer complaints and monitoring of performance (Australian Commission on Safety and Quality in Health Care, 2017, 2021a, 2021b).

Importantly, to effectively open such access and participation of people with lived experience of intellectual disability in quality service, material for discussion has to be physically and cognitively accessible, communication channels need to be optimised, board processes adjusted for access and there must be truly inclusive practice embedded within board membership and function. Specific communication-enhancing strategies start with understanding the communication needs of the individuals with intellectual disability and may accordingly take the form of words, gestures, braille, signing, pictures, electronic devices and easy read (see Supplementary Table 1). Individuals having their usual disability support staff and families present may be particularly helpful in facilitating effective communication (Bray, 2003). Credentialled resources for achieving such effective communication with people with intellectual disability may be used (Council for Intellectual Disability, 2017); board membership can be provided with specific training about communicating effectively with their consumers with intellectual disability and about other disability values (National Disability Insurance Scheme Quality and Safeguards Commission Training Module, 2021; Australian Commission on Safety and Quality in Health Care, 2021b), and consumers with intellectual disability should be offered educational materials on how to effectively provide information to the board (People with Disabilities Western Australia, 2019).

Six steps of the SQUARE Guide

Step 1: Ensuring a functional board

Effective superintendence of an organisation’s quality service requires an optimally functional board. All the usual categories for generic board roles and functions of an organisation are applicable for boards of disability service provider organisations: setting the strategy direction, ensuring corporate governance, obtaining data and responding to clients and the market, ensuring financial sustainability of the organisation, overseeing appropriate workforce capability, setting values, safeguarding, quality management and improvement, information and knowledge management (AICS, 2020). Supplementary Table 2 lists generic board roles and functions paired with contextual examples for boards specific to disability service provider organisations (AICD, 2020a, 2020b, 2020c; National Disability Services, 2017). The SQUARE Guide includes the additional role of quality service responsibility to this list.

A functional board ensures that there is a suitable and transparent corporate governance structure which outlines its own sub-committees, hierarchical lines of communication within the board sub-committees and with management and consumers. Such a board also requires that the distinct and complementary roles of boards, management and consumers in contributing to quality service are clarified. Importantly, sub-committees always report back to the whole of board for ratification of sub-committee analysis and recommendations. Board membership of disability service providers need to be prepared to learn about and keep up to date with relevant national and state or territory disability legislation and regulations, disability values, industry and particularly having specific knowledge of their liabilities (Supplementary Table 3).

An effective board requires appropriate board membership, which spans representation of the consumer voice, diversity, relevant professional skills, community standing and knowledge of the regulatory framework. Inclusion of board members with industry or functional experience in the field is considered to value add to the organisation in that field (McDonald et al., 2008).

Tied into considerations on board membership and crucial to diversity is consumer representation. This has been recognised as an important concern in community groups (Milner and Kelly, 2009), and so it should be for boards of disability service providers. Rhode and Packel (2010) warned that board diversity with respect to gender, race and ethnicity does not convincingly lead to better financial management of organisations and highlighted the potential damage of token diversity membership, postulating that a critical number of minorities must be included in boards to authenticate diversity. Overall, they concluded that well-managed diversity in board membership could enhance an organisation’s public image by conveying commitments to equal opportunity and inclusion. It is sensibly estimated that up to 25% (i.e. two to three people) of board membership should comprise people with lived experience of intellectual disability and industry experience as part of board diversity considerations (People with Disabilities Western Australia, 2019). Appropriate diversity should also enable the board to consider issues in terms of type and level of intellectual and physical disability age, gender, culture, heritage, language, faith, sexual identity, relationship status for example (National Disability Standards, 2019, p. 16).

Step 2: Ensuring adequacy of board resources and infrastructure for quality service

Both the Australian Institute of Company Directors (AICD, 2019b) and the interim Disability Royal Commission (AICD, 2019b, 2020c) stipulate that boards have a responsibility to monitor service quality with the same rigour and attention that they give to corporate and financial performance. This has resourcing and infrastructure implications for, and comprise, the substance of step 2 of the SQUARE Guide (Supplementary Table 1). Just as boards frequently have dedicated sub-committees to ensure financial solvency and other key risk areas, then so too a sub-committee dedicated to quality service is proposed in this step. Importantly, such a sub-committee needs to have the resources and capability to undertake quality service review. The SQUARE Guide proposes that this involves preparatory work gaining a sound appreciation of the lived experience of intellectual disability, of appropriate regulatory, ethical, industry standards, of practical aspects of disability service provision in the light of the organisations mission and of the relevance and influence of quality service in other board roles and functions as outlined in Supplementary Table 2.

Resourcing for quality service board infrastructure entails establishment of the terms of reference of the sub-committee. These include: need to address internal governance including membership stipulations, frequency and location of meetings, meeting budget, deliverables, identification of dimensions of quality service, responsibilities for community voice access and inclusion, making arrangements on how quality service data are collected and provided by management or consumers, response to deficiencies in quality service and overseeing enactment of measures addressing breaches and ensuring continuous improvement, education of the main board, urgency of response, determination of means of assigning a grade of quality service to particular services and goods it offers, mechanisms for reporting to the main board.

The quality service sub-committee may also be particularly charged with educating the larger board on the lived experience of intellectual disability, ethical, regulatory and legislative issues of quality standards, making them aware of special reports, significant local incidents and proposing anticipatory maintenance and urgent adjustments of quality service during environmental or situational crises. Resourcing for educational materials and training should be extended to board members on how to communicate with people with intellectual disability, to consumers on disability-industry mandates and about how the board works and to making quality service material cognitively and physically accessible to consumers with intellectual disability.

Just as the annual reports by the board of the disability service provider encompasses a transparent financial statement, the board should also be able to present an annual quality service statement on material received, directions made, resultant outcomes and ongoing goals.

Step 3: Dimensions of quality service to be considered by the board

In step 3 of the SQUARE Guide, the board sub-committee on quality service must define both the dimensions of quality service relevant for disability service providers for adults with intellectual disability and the means by which to measure them. The first part is about building a structure for quality service which entails specification of its dimensions for enactment and evaluation and the second is about ensuring inclusive data collection from consumers and other sources. The scope of dimensions span generic features of quality service such as consumer service perspective, consumer stories, mandatory industry compliance issues, significant public reports, quality of life and data collection methods can include qualitative and quantitative measures of those elements of quality service.

Generic consumer perceptions, surveys and quality service.

Poor et al. (2013) proposed consideration of five factors of service quality relevant for any organisation: process quality, product quality, physical quality, interactive quality and organisation quality. Further to this they concluded that the desirable underpinning attributes of these factors comprised service availability, communications, competencies, humility, reliability, trust, responsiveness, security, understanding and tangibles dimensions. Parasuraman et al. (1988) developed a survey-like multiple item scale for measuring consumer perceptions of service quality called SERVQUAL with ultimately only five distinct dimensions: tangibles (physical facilities, equipment, appearance of personnel), reliability (ability to perform the promised service dependably and accurately), responsiveness (willingness to help customers and provide prompt service), assurance (knowledge and courtesy to employees and their ability to inspire trust and confidence) and empathy (caring, individualised attention the organisation provides its customers). SERVQUAL data potentially provide consumer perspectives of warmth and empathy of workers, elements of service delivery such as “front desk” experience, not necessarily captured by other external standards of quality service as described below. These elements are acknowledged as important parts of quality service provision in the disability sector (Summers, 2015). Though limitations are acknowledged, versions of this instrument have been used widely across service industries for years (E-QUAL, 1998; Ladhari, 2009) and more recently incorporated in website survey services.

Stories from consumers and their families and quality service.

Anecdotal stories from consumers and their families, like case studies in medicine, may facilitate in-depth, multi-faceted explorations of complex issues in their real-life settings (Crowe et al., 2011). Listening to stories, comments and reports from consumers and their families provides real-life context and perspective to an organisation’s services in ways that statistics cannot, and in these ways, they are valid factors in quality service deliberations by boards. Stories can encompass details of service delivery that are important to consumers but not necessarily captured in the regulatory surveys. Consumer perceptions of disability support workers who provide services to them are valuable in that they may provide information about worker culture and stimulate board consideration of the broader picture of organisational culture. Furthermore, the act of listening provides a ready access for board–consumer engagement about those matters and others which may arise. An individual story may lead to further qualitative or quantitative evaluation with individual or more global action. For example, the consequences of personal narratives have been profound in improving health services for people with intellectual disability (Mencap, 2007). In considering personal stories, some form of factor analysis undertaken by management for the board may draw connections between seemingly different factors of relevance in quality service.

Regulatory standards and quality service.

To maintain accreditation, disability service providers must comply with numerous commonwealth, state or territory regulations and legislation, for example, relating to anti-discrimination, workforce issues, disability services acts, not-for-profit status and service standards. Two crucial sets of regulatory documents related to quality service, with which boards must be familiar, are the National Standards for Disability Services (Australian Government Department of Social Services, 2013) and standards set by the National Disability Insurance Scheme Quality and Safeguards Commission (2021). These standards, framed by human rights principles such as the United Nations (2006) Convention on the Rights of People with Disability, embed quality management principles and person-centred approaches in service delivery with respect to rights, participation and inclusion, individual outcomes, feedback and complaints, service access and service management. The National Disability Services Standards (2013) outline six service standards (rights, participation and inclusion, individual outcomes, feedback and complaints, service access, service management) and their specific (and measurable) implications for achieving rights for people, outcomes for people and standards for services. Documents within the NDIS practice standards and quality indicators (2021) set out participant outcomes with respect to person-centred supports, individual values and beliefs, privacy and dignity, independence and informed choice, violence abuse neglect exploitation and discrimination, governance and operational management, risk management, quality management, information management, feedback and complaints management, incident management paired with responsibilities of the provider in delivering supports and services to consumers are fundamental to establishing quality service of a disability service provider organisation. Codes of conduct for workers and providers outlined by the NDIS Commission (National Disability Insurance Scheme Quality and Safeguards Commission, 2019a) are additional necessary considerations in relation to quality service considerations at a board level (see Supplementary Tables 1 and 3).

Royal commissions, inquiries, special reports, safeguarding gaps, important consumer reports and quality service.

Time and time again, a particular inquiry of a sentinel event (Robertson, 2020), a coronial report on deaths of people with disability (NSW Ombudsman, 2018), consumer groups (National People with Disabilities and Carer Council, 2009) and Aged Care and Disability Royal Commission (2019a, 2020) provide detailed analysis of particular elements of the missing quality service provision. The stories behind the conduct of these reviews are often related to dramatic and terrible experiences for people with disability. The outcomes of such reviews often describe “must-dos” for disability service providers and are extremely relevant for boards in their roles of direction of quality service. The recommendations can be quite diverse, and boards must be vigilant about, and have an appetite for, the sourcing and consideration of contemporary reports on disability quality service aspects, outside of the usual sources.

Quality of life and quality service.

Quality service for adults with intellectual disability is viewed as being inherently linked with their quality of life. Hogg and Moss (1990) indicated that application of quality of life as a component of quality service was critical to successful ageing among people with intellectual disabilities. Hogg and Lambe (1997) found that quality service planning fundamentally required quality-of-life considerations. Schalock and Buntinx (2010) proposed that knowledge of quality-of-life concepts and measurements regarding recipients of disability services was a pre-requisite for enhancing supports and evaluating personal outcomes of individuals with intellectual disabilities. They define quality of life “as a multidimensional phenomenon composed of core domains influenced by personal characteristics and environmental factors,” these being the same for all people but varying in relative value and importance among individuals (Buntinx and Schalock, 2010, p. 285).

Using quality of life as a proxy monitor of quality service provision is consistent with a person-centred human rights approach, has value for the disability service provider in directing focus on the implementation of quality improvement strategies that result in valued outcomes, provides material evidence that the measures are working or not (Schalock et al., 2018) and provides a measurable means to test congruence between and organisation’s systems, policies and practices and the individual quality of life (Schalock and Verdugo, 2012; Schippers et al., 2015). Such quality-of-life measures complement the perspective of service quality gained from stories from people with intellectual disability and their families who use targeted services of the organisation.

The next three steps described in the SQUARE Guide address matters of quality service data availability, mechanisms for analysis of the data, formulation of adequate response when there are concerns and oversight of the enactment of actions which address breaches of quality service.

Step 4: Arranging quality service data input for the board

Specifically, step 4 of the SQUARE Guide, the “input” phase of Donabedian’s (1966) framework, captures the need for gathering trustworthy and meaningful measurements of the dimensions of quality service for adults with intellectual disability. The quality service board sub-committee must take responsibility for specifying the way they receive input data, level of detail and apply a triage system of priority to input data addressing all the dimensions of quality service (e.g. SERVQUAL, quality of life scales, stories) and including update data on previous quality service recommendations. Data collections are prepared by management, provided to the sub-committee on quality service for their analysis and listed for reporting to the main board. Consumers with intellectual disability and their families also can contribute data via management, directly to the board sub-committee or as members of the board sub-committee.

Input data on the various dimensions of quality service may be viewed routinely each meeting, scheduled for interval review as set out in an annual timetable, or evaluated on an urgent basis, even out of session. Data may be grouped by regulatory and non-regulatory aspects, qualitative and quantitative to generate multiple themes for evaluation and review (AICD, 2019a) (Supplementary Table 1). In establishing the procedures for continuous data collection, board members must understand the time implications that these have on management (AICD, 2019a) and must respect the operational roles of management as distinct from their own. Company director educational resources suggest that characteristics of good information include being relevant, integrated, in perspective, timely, frequent, reliable, comparable, clear and from a credible source (AICD, 2019a).

Step 5: Processing and analysing quality service data by the board 300

Using Donabedian’s(1966) framework of human service quality testing, step 5 of the SQUARE Guide involves analysis and processing of the data collections by testing if a particular disability service addresses the three standards of: meeting specified outcomes, demonstrating alignment between inputs, processes and outputs and attending to continuous quality improvement.

In applying the SQUARE Guide, undertaking such processing of quality service data means that board members are required to understand the data, appreciate their significance for consumers and the organisation, respond to deficiencies and oversee enactment of continuous improvements. For example, when the board sub-committee membership considers results of application of toolkits of regulatory compliance or reviews the measurements quality of life scores on particular individuals or groups of consumers with intellectual disability receiving particular services from the organisation, it must weigh up what data mean for both the individual and the organisation mission, consider organisational consequences for service delivery improvement, balance competing organisational goals and limited resources, apply a triage system to addressing urgency of malalignments of input and outputs and seek the views and interpretations of people with intellectual disability and their families. AICD (2019a) furthermore suggests that board members should undertake their analysis of quality service data in the light of topical key board strategy, industry standards, board policy, organisation media releases, other industry updates and releases, general environmental, industry and economic updates.

For some non-regulatory dimensions of quality service, the sub-committee may need to formulate an a priori view of what specified outcomes for what services and for which consumers can be deemed satisfactory, unsatisfactory and assign a tag of urgency for action. Such assignments should necessarily involve the view of people with intellectual disability and their families, as discussed earlier, either as board sub-committee members or invited guests. Though there is a diverse range of quality data inputs on various topics of quality service requiring individual analysis, it may be that on some occasions a common “culprit lesion” such as poor organisational culture is uncovered as responsible for a whole cluster of quality service inadequacies. Such an analysis goes through the larger board before management is directed for particular action.

Step 6: Producing output/outcomes/directions on quality service

The outputs of analysis of quality service data by the sub-committee should include a summary by dimension plus assessment outcomes since the last meeting, an interpretation of severity of any quality service breach for the individual consumer and the organisation, an assessment of causal factors, implications and actions for management to address, a triaging of urgency for amendment, commentary on continuous improvement, consumers views and an overall scoring of quality service. Given the status of quality service, the quality service sub-committee chair should deliver a report at each main board meeting. Reports must be cognitively and easily accessible by people with lived experience of intellectual disability and their input received for output completion.

The whole board’s task is to discuss the report and make final directions for management, possibly with timelines for achieving the tasks. At this level, robust discussion within board membership might be expected as recommendations for service improvement must be balanced against a reality of limited resources. The ongoing presence of the consumer voice is essential at this last stage to ensure authenticity of responses to breaches in quality service. All board members need to uphold the SQUARE Guide conceptual functions of understanding the importance of the evaluations, appreciating the consumer voice and eventually responding in a unified way with specific actions and directing the enactment of specific changes through management. In directing actioning of quality service items, the board may decide to evaluate the implementation phase of the action plans by management and request timely updates.

Some outcomes of quality service review may be designated as “lessons to be learned” with presentation of strategies on how to implement the necessary changes to avoid future errors. Such strategies would be discussed within the board and final directions passed on to management. Evidence of implementation and changes would, in the future, be presented as input data for the quality service sub-committee. Boards may direct management to undertake a specific project to research ways to address quality service problems. For appropriate focus of auctioning, it is helpful to identify whether outcomes of the quality service review have implications for the organisation as a whole, for particular sections of the workforce, for a particular disability support service or for particular consumers or groups of consumers of the organisation. Such considerations also assist in approximating resources allocation required to make amendments in light of the organisation mission and overall strategy.

It is important that, like the input data, output recommendations of the sub-committee deliberations contain measurable outcomes and if implemented provide evidence of continuous improvement as described in Donabedian’s (1966) framework for human service evaluation. Board education may be an important output and recommendation.

Conclusion

This paper describes a proposal for a pathway for boards of disability service providers for adults with intellectual disability in Australia to conduct and carry out their responsibilities of ensuring the provision of the best possible quality service is delivered by their organisation to their consumers with intellectual disability. Quality service has been traditionally undervalued as an important element of disability service provider organisations. Relatively recent implementation of the NDIS and the NDIS Quality and Safeguards Commission in Australia has elevated quality of service provision to a priority level among boards of organisations, many of which until now have not had any, or very few, dedicated resources on quality service.

Using the acronym, the SQUARE Guide, the six steps of the pathway, all of which include representation of people with lived experience of intellectual disability, are:

1. ensure a functional board;

2. establish resources for quality service review;

3. set the dimensions of quality service;

4. obtain input data on quality service;

5. process and analyse the data; and

6. provide outcomes and outputs and embed a strong commitment to continuous quality improvement (Figure 1, Supplementary Table 1).

Following these steps of service quality evaluation in conjunction with use of purposeful, dedicated intellectual and critical thinking functions of understanding, appreciation, responding and enacting at each step of the SQUARE Guide greatly facilitates board member capacity to fulfil their obligations and privilege of board membership with respect to quality service.

It is conceded that the SQUARE Guide proposal is novel and its development has been an ambitious goal. To date, little in the published literature has attempted to specifically, wholly and comprehensively focus on the roles of and mechanisms by which boards of disability service providers for adults with intellectual disability extend their oversight to quality service. On each of the separate six steps, on the topic of consumer voice in quality service there is adequate literature, but little exists of the whole proposal. The unique contribution of this document has been to present a cohesive complete framework for boards. The approach has been unapologetically pragmatic. The six steps comprise recommendations derived from published literature, robustly valued web material, information and knowledge of the Australian disability sector and relevant legal issues and presented in an experiential, pragmatic and teachable way to boards. Furthermore, all steps comply with Commonwealth, state and territory mandatory legislation. In these senses, however, a limitation of the proposal is that it has not been rigorously tested and assessed for usefulness and effectiveness in ensuring that adults with intellectual disability receive quality service from their disability provider organisation. The SQUARE Guide as presented is considered an open invitation and opportunity for scrutiny, testing for effectiveness and revisions as guided by research evidence, experience, legislation and consumer input.

Figures

Figure 1.

Six steps of the SQUARE Guide on quality service for boards of disability service providers for adults with intellectual disability

Supplementary data

Supplementary data for this article can be found online.