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Birhan Social Development College

Community Service Work

NTQF Level I

Learning Guide #36

Unit of Competence: Apply Quality Standard

Module Title: Applying Quality Standard
LG Code: LSA CSWV1 M11 -36
TTLM Code: LSA CSWV1 TTLM 2019v1

Lo1. Assess own Work

Learning Instruction Sheet For All Learning Guides

Instruction Sheet
1. Read the specific objectives of all Learning Guides.
2. Follow the additional instructions if given by your trainer and follow the below listed
instructions from number 3-7.
3. Read the information written in the “Information Sheets”. Try to understand what are
being discussed. Ask you teacher for assistance if you have hard time understanding them.
4. Accomplish all the “Self-checks”
5. Ask from your teacher the key to correction (key answers) or you can request your teacher
to correct your work. (You are to get the key answer only after you finished answering
each Self-check).
6. If you earned a satisfactory evaluation proceed to the next “Information Sheet ”.
However, if your rating is unsatisfactory, see your teacher for further instructions or go
back to the previous information sheets.
7. Submit your accomplished Self-check. This will form part of your training portfolio.
 Instruction Sheet Learning Guide #36

This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –

1. Identify Ways of assessing work

2. Make policies and procedures of relevant quality standards,
3. Understand Characteristics of services
4. Examine Workplace procedures
 Information Sheet-1 Ways of assessing work

1.1. Ways of assessing work

Self-assessment, or “self-evaluation,” is the making of judgments about the quality an
organization provides autonomously and with full accountability. Evidence which is
referenced in the self-assessment report is used in self-assessment. The goal of self-
assessment is:
 Determining the current condition and making comparisons with examples of good
practice
 Determining improvement potential
 Systematic quality improvements
 Self-assessment is a cyclical process.
It is exceptionally important that service providers manage the quality of their working
process and continually improve it using defined quality criteria. As part of monitoring and
improving the quality of their work, service providers encourage their staff to analyze and
evaluate their own performance. The Quality Assurance Committee makes use of the results
of analysis to reach a view of the overall quality of the organization. The result of this self-
assessment process should be plans for improvement in all relevant areas and all relevant
levels.
There are, of course, a range of approaches to quality assurance and improvement. There is no
single model for self-assessment. Organizations which adopted the self-assessment process
have placed it under their own control and responsibility. Evidences must be collected and
analyzed in order to make judgments about their performance.
How are we doing? Asks providers to consider how their organization
is performing in relation to the VET provider
mission, targets, and objectives
How do we know? describes the use of performance indicators and
quality criteria to measure how the VET provider
is doing
What are we going to do now? An improvement plan is created based on the
current condition

 Through self-assessment a provider comes to know:

  what it is aiming to do
 whether it is meeting its aims successfully
 what needs to be maintained or improved
 whether changes are working If a service provider comes to know these things
through self-assessment and acts on them, it is well on the way to having an
efficient quality assurance system. Self-assessment is at the heart of quality
assurance.
 The process of self-assessment and continuous improvement should include:
 evaluation of performance
 annual self-assessment report
 annual improvement plan, improvement targets and action plans
 long-term (e.g. 3 to 5 years) development plans
 monitoring and reviewing the extent to which annual improvement, long-term
development, and other action plans are achieved and targets are met
 external evaluation
Effective self-assessment will enable organizations to identify their strengths and weaknesses,
to compare their performance with that of other service providers, and to plan for
improvement. This planning will involve:
 Identifying and prioritizing areas for improvement
 Setting objectives and determining the actions which need to be taken to bring about
improvement
 Agreeing targets, milestones and criteria which will be used to direct and control the
improvement process

Evaluation of performance

Monitoring and external evaluation Self assessment report

Improvement plan
In planning for self-assessment service providers should identify:
 why self-assessment is being carried out
 which areas and/or activities have been prioritized to be subject to self-assessment
 how the self-assessment will be carried out – systems for collecting, analyzing and
reporting on performance in key areas
 who will carry out the self-assessment
 when the stages in the process will be carried out
 how the results will be reported on, how they will be made available
Elements and Performance Criteria Pre-Content Elements describe the essential outcomes of a
unit of competency. Performance criteria describe the performance needed to demonstrate
achievement of the element. Where bold italicized text is used, further information is detailed
in the required skills and knowledge section and the range statement. Assessment of
performance is to be consistent with the evidence guide.
1.1.1. Self-Assessment Framework
Social work service providers should seek to develop a form of self-assessment that is
responsive to their own organisational needs and the needs of their stakeholders. However,
there are three basic requirements relating to the self-assessment framework that all service
providers must satisfy.
1. Self-assessment deals with all aspects of the service provider’s activity, but, in
particular the quality and standard of clients experience and achievement.
2. Self-assessment deals with all aspects of the service provider’s activity, but, in
particular the quality and standard of client’s interest.
3. Self-assessment must take into account relevant stakeholder interests, national
improvement strategies, and government policies.
1.1.2. Gathering and Generating Evidence
A further key principle of organizational self-assessment is that all of the judgments made
against the quality areas and criteria must be supported by evidence and that this evidence
must be valid, reliable, authentic, consistent, sufficient, and in other ways suitable for the
purpose.
In the self-assessment process, assessors make judgments based on various types of evidence.
Evidence must be drawn from the various sources of evidence available in order to make
judgments.
For example, quality area: “information systems” will require relatively simple as well as
more complex judgments. Most of the judgments about the information system to be made are
about accuracy, security, review cycles; and the evidence will come from the information
itself and the procedures associated with it. This should be quite straightforward.

It is necessary to always distinguish the actual evidence presented in support of a judgment

from the source of that evidence.
The source of the evidence is in itself not sufficient. The internal and external sources from
which the evidence is derived, must, however, be stated clearly. Self-Assessment Framework
gives suggestions of possible sources of evidence for each priority and/or quality area. Some
evidence sources are used for more than one quality area.

However, those engaged in self-assessment, as well as internal and external evaluators will all
have to make a judgment about the quality and robustness of the evidence quoted in self-
assessment reports. They have to decide whether the evidence provides adequate justification
for the strengths or weaknesses claimed. For evidence to be robust, it should be:
 valid: evidence is relevant to and supports the strength or weakness identified
The idea of validity applies to the relationship between the evidence, the source of evidence,
and the judgement drawn from it. The link must be logical. If the link between the evidence,
the source, and the judgment can be shown to be weak or ambiguous, then the evidence will
not be valid for the judgment, and the judgment itself will be invalid. It is important,
therefore, to ensure that these links between source, evidence and judgement are clearly
understood and thoroughly tested.
 quantifiable: internal and external performance measures are used, both figures and
percentages are used and are clear and unambiguous
 sufficient: evidence is complete and there is enough to cover all the criteria of one
area; evidence can be triangulated, e.g. there is evidence from three separate sources
and three different perspectives
There must be enough evidence to allow conclusions about strengths and weaknesses to be
drawn. In the example above there would have to be data about all of the learners, not a
sample. In most cases different evidence from different sources will be required, to give
sufficient evidence of different perspectives.
 current: evidence is recent enough to give an accurate position at the time of writing
the self-assessment report For most purposes this will mean using data from the same
year during which self-assessment takes place; but, for some purposes it will mean
using evidence from previous years where the data is stable enough.
 accurate: evidence is attributed to named and verifiable sources
1.1.3. Elements and Performance Criteria of self-Assessment
A. Assess own work
 Continuously check completed work against workplace standards relevant to the
operation being undertaken
 Demonstrate an understanding of how the work activities and completed work relate
to the next production process or processes and to the final products or services
concerned
 Identify and isolate faulty components, products or processes
 Record and/or report faults and any identified causes to the supervisor concerned,
where required, in accordance with workplace procedures
B. Assess quality of received components, parts or materials
 Continuously check received components, parts, materials, information, service or
final products against workplace standards and specifications for conformance
 Demonstrate an understanding of how the received components, parts or materials,
information or service relate to the current operation and how they contribute to the
final quality of the product or service
 Identify and isolate faulty components, parts, materials or information that relate to
the operator's work
 Record and/or report faults and any identified causes in accordance with workplace
procedures
 Identify causes of any identified faults and take corrective action as specified in
workplace procedures

1. Measure components, parts or materials

 Measure materials, component parts, information, service or products, as required,
using the appropriate measuring instruments in accordance with workplace
procedures
 Record information on production indicator
  Record basic information on quality and other indicators of process performance in
accordance with workplace procedures
2. Investigate causes of quality deviations
 Investigate and report causes of deviations from specified quality standards for
components
 Recommend suitable preventative action based on workplace quality standards and
the identified causes of deviations from specified quality standards of materials
1.1.4. Required Skills and Knowledge for Assessment
Required skills include:
 interpreting work instructions, specifications, standards and patterns appropriate to
own work
 carrying out relevant visual inspections of materials, component parts and final
products
 carrying out relevant physical/chemical measurements or tests
 maintaining accurate work records in accordance with procedures
 carrying out work in accordance with occupational health and safety (OHS) policies
and procedures
 meeting work specifications
 communicating effectively within defined workplace procedures
 interpreting and applying defined procedures
Required knowledge
Required knowledge includes:
 relevant quality standards, policies and procedures
 relevant production processes, materials and products
 basic characteristics of materials used in the relevant production processes
 safety and environmental aspects of relevant production processes
 relevant measurement techniques and quality checking procedures
 workplace procedures
 reporting procedures
 policies and procedures of relevant quality
Information Sheet-2
standards

2.1. policies and procedures of relevant quality standards

2.1.1. Social work policy
It is a system of interrelated principles and courses of action by a welfare agency to
 determine the nature and range of social work intervention,
 formulate programmes for service delivery,
 maintain and improve the expertise of social workers and other service workers, -
and
 Promote social work research. Social work policy is therefore applicable to a
specific welfare agency and those social workers involved.
Policy is usually proof of how a political system responds to the needs and problems made
known, in the form of demands, by the environment. These demands are called policy issues.
Various factors can give rise to policy issues, for example
 circumstances and societal trends such as population growth and violence; - the
policy of political leaders;
 personal viewpoints of office-bearers;
 research regarding societal opinions;
 social problems presented by the media and pressure groups.
Once policy issues have been raised, policy proposals are submitted for consideration by those
concerned. Policy can therefore be initiated at ground level or by the authorities. If the policy
is formulated and accepted it is usually issued in the form of a declaration, for example
through laws, regulations etcetera. The policy is ultimately executed by means of legislation,
the courts and interest groups.
2.1.2. Quality development approaches
 Policy- and strategy development
 Furthering employees’ professional qualityDeveloping of protocols & procedures
 Developing of quality sub-systems (e.g. interfraternel examination among
colleagues)
 Involvement of clients
 Coherence and chain-quality
As a basic model for a strategy of systematic quality improvement we may use a step-by-step
approach consisting of the following elements:
 Drawing up of criteria and norms to be met by the care provider; which is the
situation desired?
 Investigation of the situation in practice and registering, using measurable data as
much as possible;
 Planning of activities that should improve the situation;
 implementing improvements according to the planning and;
 Evaluating the results and re-start of improving activities if necessary.
The ‘circle of quality or cyclic approach indicates that quality improvement should be an
ongoing process of planning, action, check and feed-back, readjustment, etc. Now, if we apply
practice to the steps just mentioned, we may find
 Home care should be available 24 hours per day instead of the current 12 hours
maximum provision;
 investigation shows: most 24 hours home care is needed in a district where many old
people live;
 we make a plan for altered work-shifts for present social workers; we recruit
volunteers to help us by taking over some simpler tasks;
 we inform the clients involved, we instruct the volunteers and we start working
according to the altered scheme;
 we ask clients if they are satisfied, we ask the volunteers about their experiences and
we process our conclusions.
2.1.3. Overview of some methods and working procedures for quality improvement in
social care
Individual employee Collegial teams Worker & client Employees and
organization
self-assessment on-the-job Intervision , client handling complaints, assessment meetings ,
, coaching in-practice, discussion, panel of clients, career counseling,
counseling methodical job- feedback from visitation,
supervision, intervision coaching, clients, mystery client market research,
documentation and. interfraternal counselor , council of program ,
learning protocol examination among clients, council of evaluation ,data bases
colleagues , quality parents quality circle
circles care plan ,
team learning
 information Sheet-3 Characteristics of services

2.3. characteristics of services

2.3.1. Definition of services
 Service: is the work of dealing with customers. A service is any act or performance
that one party can offer to another that is essentially intangible and does not result in
the ownership of anything. It may or may not be tied to a physical product.
 A service is an act or performance offered by one party to another. Although the
process may be tied to a physical product, the performance is essentially intangible
and does not normally result in ownership of any of the factors of production.
 Services are economic activities that create value and provide benefits for customers at
specific times and places, as a result of bringing about a desired change in—or on
behalf of-—the recipient of the service.
 Service can be seen simply as those points of interaction between service providers,
normally the employees of an operation, and their customers. A broader description
would include all the elements that go to make up a complete service package or
experience, which might include, as in a hotel, a complete mixture of products and
services. The nature of the service act means that operations have a number of
particular characteristics that affect their management.

Services are often described in contrast to goods. While the later are tangible items that can be
created and then sold or used later, a service is intangible and perishable. It is usually created
and consumed simultaneously.
2.3.2. A service package
Service package consists of four interrelated elements that must provide a consistent image to
the customer. First, facilitating goods are the materials purchased or consumed by the buyer
or the physical items that an operation uses during service delivery. Second, explicit services
are the readily observable or sensual benefits that the operation delivers. This includes the
speed of delivery, the accuracy of the order, the menu range and so on. Third, implicit
services are psychological benefits that derive to the customer from using a particular service.
For a restaurant, this would include the aesthetic appeal of the restaurant décor, the feeling of
care provided by the treatment from the service staff, the status derived from visiting a
prestigious operation and the like. Fourth, supporting facility is the physical environment
that must be in place before a service can be offered. For a restaurant, this would include the
physical structure of the building, the internal décor including all the furnishings and fittings
front and back of house as well as the car park and external landscaping for tour operator the
office contacts, and the one with the skills to perform. There are four basic characteristics of
services: intangibility, inseparability, variability, and perishability.
Intangibility: Unlike physical products, services cannot be seen, tasted, felt, heard or smelled
before they are purchased.
“Someone who purchase a service may go away empty-handed but they do not go away
empty-headed… they have memories that can be shared with others”.
To reduce uncertainty caused by service intangibility, buyers look tangible evidences that will
provide information and confidence about the service, for example in the decor and
surroundings of the office , or from the qualifications and professional standing of the
employees. Tangbailing the product- promotional materials, employee appearance, and
service firms physical environment all keep tangbailing the service.

Inseparability
In most services industry, both the service provider and the customer must be present for the
transaction to occur. Customer-contact employees are part of the product. Inseparability also
implies that customers are also part of the product.

Services are produced and consumed at the same time, unlike goods which may be
manufactured, then stored for later distribution. This means that the service provider becomes
an integral part of the service itself. The guide in the tour of specified destinations inseparable
part of the service offering. Taxi operator drives taxi, and the passenger uses it. The presence
of taxi driver is essential to provide the service. The services cannot be produced now for
consumption at a later stage / time. The client also participates to some extent in the service,
and can affect the outcome of the service. People can be part of the service itself, and this can
be an advantage for services marketers.
In tourism, the customer participates in the production of the service. Organized sightseeing
offers a good example. Provision of guide services and consumption of the sightseeing occurs
simultaneously. The greater the interaction between the tour guide and the visitor, the more
pleasurable the service will be.
Variability
Services are highly variable. Their quality depends on who provides them and when and
where they are provided.
There are several causes for service variability:
a) Services are produced and consumed simultaneously, which limits quality control.

b) Fluctuating demand makes it difficult to deliver consistent products during periods of

peak demand.

c) It depends on the service provider’s skill/experience.

d) Time/length of service/tiredness.

e) Lack of communication and heterogeneity of guest expectation.

Because a service is produced and consumed simultaneously, and because individual people
make up part of the service offering, it can be argued that a service is always unique; it only
exists once, and is never exactly repeated. This can give rise to concern about service
qualityand uniformity issues. Personnel training and careful monitoring of customer
satisfaction and feedback can help to maintain high standards.
Perishability
Service cannot be stored. If service providers are to maximize the revenue, they must manage
capacity and demand because they can’t carry forward unsold inventory. Therefore,an
airplane that leaves the airport with empty seats will never be able to sell those specific seats
on that specific flight, and that income is lost forever.
Perishability does not pose too much of a problem when demand for a service is steady, but in
times of unusually high or low demand service organizations can have severe difficulties.

The inability of the service sector to regulate supply with the change in demand poses many
quality management problems. This is a challenge for a service marketer. Therefore, a
marketer should effectively utilize the capacity without deteriorating the quality to meet the
demand. The above characteristics are generally referred to in many texts as being what
makes services marketing so different.The special characteristics of service operations mean
that their management should be treated differently from that of other production systems.
 information Sheet-4 Workplace procedures

2.4. Workplace procedures

2.4.1. What is procedure?

A procedure is the way something is done, e.g. the forms that need to be filled out for
requesting leave. procedures support employment agreements by providing detail on matters
that might not be negotiated as part of an employment agreement. You’ll often (but not
always) have both a policy and a procedure for a particular topic. For example, your health
and safety (H&S) policy might be linked to your accident reporting procedure. The policy
might cover

 the principles of keeping people safe

 taking time off for illness
 striving for a good work-life balance

Procedure is designed to enable a workplace that:

 Is safe;
 takes an informal and early intervention approach in resolving workplace issues;
 is free from harassment, bullying, occupational violence and discrimination,
vilification and victimization;
 ensures equal opportunity and alignment with the Charter of Human Rights and
Responsibilities and Public Sector employment and practice principles;
 aligns behavior and conduct with RCH values, policies and procedures, and relevant
Legislation; and
 compliments our commitment to the Senior Medical Staff/Executive and RCH
Compacts for all professional craft groups in relation to personal accountability, not
walking past bad behavior, and treating others the way they wish to be treated.
2.4.2. Common policies and procedures

Your business might benefit from a number of different policies and procedures. Although not
all of them will be relevant to your business, you could consider what your house rules might
be on:

 code of conduct — this should also cover privacy and conflicts of interest
  discipline, misconduct and employment investigations
 health and safety
 holidays and leave
 hours of work and overtime, including time in lieu and flexible work arrangements
 information security
 internet, e-mail and social media use
 leaving the business
 performance appraisals
 recruitment, including reference checking
 resolving employment issues
 training and development
 travel
 use of company equipment
 how to handle customer complaints.

The best way to prevent injuries in the workplace is to implement a rigorous safety program
that will educate and empower your team to avoid injuries. With the right structure, your team
will be happy to enforce those standards because, after all, nobody wants to get hurt at work.
Implementing safety standards is a meaningful way to let your employees know that you are
looking out for them. More often than not, injuries occur due to lack of education and
enforcement around the various hazards present at their worksite. Offering simple safety
procedures to address those hazards is the first step to develop a healthy work environment.
2.4.3. What exactly are Safety Procedures?
If you think about it, safety procedures are all around us. From simple reminders on the wall
that remind employees to wash their hands, to construction workers being required to wear ear
protection when loud equipment is used on-site.
Safety procedures can be defined as standardized methods that describe how to conduct
tasks to minimize risks to people, environment, processes, and materials.
For better or worse, any good safety manager adheres to Murphy’s law — “anything that can
go wrong will go wrong.” When it comes to protecting your business and employees, it’s
critical to minimize the opportunities for things to go wrong.
And that’s why I’m are here today: to help you to craft your company’s safety procedures and
ensure your employees will be safe from work-related injuries. Here are some examples of the
most common workplace hazards, their corresponding safety procedures, and why they are
essential:
Safety Procedure: Pre-Operational Checklist
If you do not have a pre-operational checklist already established, it is time to create one.
These are the most common aspects that you should include in your list:
 Check for leaks, and other visible defects everywhere on the forklift;

 Evaluate the tire pressure and overall condition;

 Test the brakes and the steering controls;

 Check if the seat belt is functioning correctly;

 Verify the forks’ status, including the top clip retaining pin and heel;

 Check all fluid levels (including hydraulic, transmission and brake);

 Ensure the manual compartment is clean of debris;

 Check functionality of finger guards;

 Check hydraulic hoses and mast chains (visually);

 Ensure load backrest extension functionality;

Keep in mind that forklift manufacturers provide customers with inspection details specific to
each model.
Another point to take into consideration, besides checking the forklift functionality, is to
ensure the balance of the materials stacked up in the fork. Tip-overs are one of the most
dangerous accidents that a forklift can cause.
Safety Procedure: Fire Prevention Checklist
It is essential to implement daily or weekly inspections to prevent workplace fires. These are
the most critical aspects that you should include in your checklist:
 Verify if there is any obstruction in escape routes;

 Check if the extinguishers are in good condition;

 Check if fireman lift sign is legible;

 Ensure that the fire hydrants and hose reels system are functioning correctly;
  Ensure that loads on racks are not over-stacked (this might bring them too close to a
sprinkler head and limit the sprinkler’s efficiency in an emergency situation);

 Inspect the building ventilating system at least once per year;

 Ensure cords are not daisy-chained (daisy-chained cords can overdraw electricity from
the circuits and cause the wires to heat up and potentially result in a fire);

 Ensure that the circuits are not overloaded;

 Turn off electrical appliances at the end of the work-day;

 Maintain machines that produce heat away from any inflammable material;

 Remove every waste paper, trash, and materials that can easily catch fire.

Safety Procedure: Workplace Safety Review

There are many details in the workplace environment that you can proactively manage to
lower the risk of injury. If you do not have a workplace safety review established, these are
some of the details to include on it:
 Cover cords and cables in walkways;

 Clean up spills immediately;

 Place a “wet floor” signs when you cannot dry it;

 Encourage employees to use closed shoes;

 Ensure cabinets and drawers are shut when nobody is using it;

 Check if there is proper lighting everywhere in the building;

 Watch for potential hazard areas such as unexpected steps or uneven ground and use
signage to increase attentiveness;

 Ensure stairs handrails are securely placed

Even though slips and trips happen are common, oftentimes, they are entirely preventable.
Implementing rigorous inspections to monitor workplace environmental hazards is critical to
preventing these types of injuries. While most trips and falls do not lead to severe injuries,
they can cost businesses significant amounts of cash in worker’s compensation claims.
Remember, most of these incidents are preventable with proactive inspection plans in place.
Safety Procedure: Lockout/”Tagout” (LOTO) Checklist
Machinery such as mills, lathes, and grinders offer high risk for workers if they are not
properly locked out during a service. That’s because an unexpected restart can catch the
operator by surprise and lead to a serious accident.
A lockout/tag-out procedure should include at least these following steps:
1. Investigate the primary energy sources (hazards) that will need to be controlled;

2. Inform supervisor and every employee related to the machine;

3. Isolate the machine from any type of energy source ( for instance, turning off the
power or shutting a valve);

4. Assign one worker to be responsible for the lockout;

5. Attach a lockout device to each energy-isolating device;

6. Attach “tag-out” device (tag with assigned worker name) to each energy-isolating
device;

7. Check for residual energy still stored within the machine;

8. Verify if the machine has been properly isolated and de-energized.

Safety Procedure: Chemical Control System

When employees are handling chemicals in the workplace, it is critical to make them aware of
the company’s chemical control system. Safety procedures must be made for each unique
chemical to prevent the unique hazards they bring to the worksite.
These are some essential steps to be listed in your chemical control system:
 List every chemical (and its characteristics) in an accessible report;

 Store chemicals away from inflammable material and gas cylinders;

 Ensure chemicals are stored with closed lids when not in use;

 Secure combustible material in fireproof cupboards;

 Refrain from storing chemicals in a package that it is not its original package;

 Label every chemical with all its components’ information;

 Use personal protection equipment (PPE) when necessary;

 Ensure First Aid Kit is always stocked and ready to be used;

  Check for chemical spills on a regular basis;

 Read the material safety data sheet (MSDS) before using any chemical.

`’Safety Procedures’ Bottom Line You can prevent the majority of unsafe conditions
before they result in injury or in an emergency.’
Taking care of employees’ safety is an enormous responsibility. Once you’ve identified the
necessary procedures, the next step will be to implement them. Communication, education,
and compliance are vital components to execute when it comes to implementation.
Even the most rigorous safety manager can’t be everywhere at once. It is crucial to empower
your employees to identify unsafe behaviors and hazards so they can report issues that need
repair. Successful workplace safety procedures can be measured by how well people adhere to
the safety standards on a daily basis.
So keep in mind, safety first.
Because at the end of the day, it is always better to be safe than sorry.

Self-Check one Learning Guide 36

Direction II; multiple choices
1. One of the following is not characteristic of service
A. Inseparability,
B. variability
C. Perishability.
D. Tangibility
2. Choose the correct sequential order of Social work assessment process steps
A. Assessment, Planning, Intervention, Review/evaluation
B. Assessment, Planning, Review/evaluation, Intervention
C. Assessment, Review/evaluation, planning, intervention
D. Assessment, intervention, review/evaluation, planning
3. Choose the wrong definition regarding service package
A. Facilitating goods -are the physical items that an operation uses during service
delivery.
B. Explicit services are the readily observable or sensual benefits that the operation
delivers.
 C. Implicit services are psychological benefits that derive to the customer from using a
particular service.
D. supporting facility are the materials purchased or consumed by the buyer
4. to maximize benefits ,service providers have to store their services
A. True
B. False
5. Self-assessment deals with all aspects of the service provider’s activity, but, in particular
the quality and standard of client’s interest.
A. True
B. False
6. Inseparability also implies that customers are also part of the product.
A. False
B. True
Direction II. Short answer
7. List the 10 principles of service delivery

8. List out the major knowledge required for self-assessment

 Answer Sheet Score = ___________
Rating: ____________

Name: _________________________ Date: _______________

Short Answer Questions

1. _________________

2. _________________

3. _________________

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Birhan Social Development College

Community Service Work

NTQF Level I

Learning Guide #37

Unit of Competence: Apply Quality Standard

Module Title: Applying Quality Standard
LG Code: LSA CSWV1 M11 -42
TTLM Code: LSA CSWV1 TTLM 2019v1

Lo2. Assess quality of service rendered

 Instruction Sheet Learning Guide #37

This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –

 Understand Quality check standards

 Examine Causes of faults
 Examine Methods of identifying and reporting faults
 Demonstrate Parameters of evaluating services

Information Sheet-1 Quality check standards

1.1. Quality check standards

1.1.1. What are standards?
This is a more complex question than it might at first appear. They are certainly ‘clear and
explicit statements about key elements of a given service’; they say ‘this is how things should
be in this service’ and ‘this is what the customers have the right to expect’. They can be
expressed as statements of how much, how well, how often or how quickly something
happens and can be percentages, numbers, frequencies or cost.

In practice, we have few standards expressed as numbers or other quantities, because we

intend above all that standards should be focused on outcomes for customers, usually
expressed at the individual level.

1.1.2. Why to set standards?

As the saying goes, “You cannot manage what you can’t measure”. Setting measurable
standards is a vital part of the quality assurance process. They specify how things should be.
It is important to set quality service standards in order to establish a target upon which the
operation’s teams can work towards. Setting quality service standards provides a sense of
purpose and direction and establishes the extent of the standard that is required by an
operation, organization or department. It communicates expectations so that everyone is aware
of what is expected and required. It is important to ensure that quality standards are clear and
concise, attainable, observable and realistic. Setting standards of service defines the service
image.

Standards show the agreed requirements for a service and help build in quality by enabling us
to:
 provide a clear direction for services and products
 promote a shared vision and common understanding
 provide a basis for monitoring, inspection, evaluation and future planning.

1.1.3. The process of setting standards

The standards to be established should set out key expectations of services. The standards
should be:
 as explicit and precise as possible;
 practicable;
 written in plain language-clear
 effective and efficient;
 based on the needs of customers;
 flexible, sensitive and responsive to the changing needs of customers;
 reliable and consistent, with continuity of delivery;
 Compatible with the overall strategies and goal of the organization.
 continuously improved and developed by monitoring, evaluation and inspection;
 provided by people with a high standard of professional knowledge and practical
skills;

Having measurable standards for physical setting and for customer service ensure consistency,
communicate performance expectations and set product specifications for procurement.They
also serve as the measurement benchmark for measuring achievement of standards and for
identifying gaps (both in physical product and in service).
It is vitally important, however, that standards are based on customer expectations and needs.
Often there is a gap between what management perceives the customer needs to be, and what
the customer actually wants. Therefore, it is important to identify your market mix and the needs
of each respective market, and develop your physical and service quality standards based on
the markets you are provided for.
1.1.4. How do you set standards?
Form a team to develop your customer service quality standards. If you have a small
organization includes everyone. If your organization is large, ask for representatives from
each area to form the team. To get the team started, use the following questions to prompt
discussion:

 What are our desired results?

 What does success look like?
 What is important to us?
 What do we want to be known for?
 What do our customers need? What can we deliver?
 What can we do to focus on our customers?
 What measures can we put in place to ensure consistency?

Physical Quality Standards

Physical standards should be set for facilities and products. Standards for facilities are usually
general descriptor statements –Examples:
 Demarcated Reception Area
 Computerized clients history to be maintained
 Secure storage facilities available for left luggage

Service Quality Standards

Standards for s e r v i c e s are usually availability statements –:
 All clients offered an escort to the bedroom by a member of staff with excellent
skills.
 Clients informed of important hotel and bedroom facilities by the escort.
Service quality standards specify what the clients should experience, during any “moment of
truth”. A “Moment of Truth” is any point of interaction that a customer has with an
organization and through their experience of that interaction, gain an impression of the
organization. Service quality standards try and quantify the client’s expectations (based on
client’s feedback and Industry norms).Service quality standards also set actions for ensuring
that we can anticipate, meet and exceed client’s expectations. Every time a client has contact
with an employee of the establishment, they should have a service experience as described in
the service quality standard. Example:
 Our assurance is that the phone will be answered within 3 rings.

The Service Quality Standards also state what the employee should know and be able to doing
order to be able to meet the Service Quality Standard.

Information Sheet-2 Causes of faults

1.2. Causes of faults

A service performance that surprises and delights customers by falling above their desired
service levels will be seen as superior in quality. If service delivery falls within their zone of
tolerance, they will feel that it's adequate. But if perceived quality falls below the adequate
service level expected by customers, a discrepancy—or quality gap—has occurred between
the service provider's performance and customer expectations.

The model has been used by many companies as an assessment or service audit tool because it
is comprehensive and offers a way for companies to examine all the factors that influence
service quality.

Why do quality failures occur? Gaps can occur at different points;

1. in the design,
2. production, and
3. Delivery of services.
The service gap is the most critical, because it involves the customer's overall assessment of
the service, comparing what was expected against perceptions of what was received. The
ultimate goal in improving service quality is to narrow this gap as much as possible. To do so,
service providers may have to reduce or close the six other gaps.

Gap1: Customers’ expectations versus management perceptions:-It is variation between

actual expectations of customers and the way how the management understands their
expectations (management does not understand what customers expect from a service).It
occurs as a result of the lack of a marketing research orientation, inadequate upward
communication and too many layers of management.

Gap 1 represents the general incompatibility between company management and customers.
The basic reason of its appearance is failing to understand the real customers’ expectations.
The important reason for the emergence of this Gap is the existence of too many levels of
organization which restrain and alter certain levels of information about the expectations and
demands of customers. Moreover, not understanding the customers’ expectations can be as
well the result of a bad management of customers’ complaints.

Reasons for provider gap I (Customer’s expectations and Company’s perceptions of

customer expectations)
 Inadequate marketing research orientation
 Lack of upward communication
 Insufficient relationship focus
 Inadequate service recovery-failing to manage customer complaints
  Lack of information about any feedback between the company and the consumers
directed to the management;
 Too many organizational layers that hinder or modify parts of information in their
upward movement from those involved in contact with the consumers.
Closing gap 1:-Learn what customers expect
 Use research (collect data on customer expectations), complaint analysis, customer
panels
 Increase direct interactions between managers and customers
 Improve upward communications
 Act on information and insights
 Listen to customers

This gap can reduce for example if the general manager has maximum level of contact with
the guests and the hotel also appears to have the most employee input in the decision making
process.

Gap2: Management perceptions versus service specifications:-It represents variation

between perceptions of the management about theexpectations of customers and specification
of service quality, i.e. management of a company realized the actual customers’ expectations
but has not developed a system of measures which will enable the delivery of a desired
quality. It occursas a result of inadequatecommitment to service quality, a perception of
unfeasibility, inadequate task standardization and anabsence of goal setting.

Reasons that cause Gap 2, i.e. variation between perceptions of the management about the
expectations of customers and specifications of service quality are the following:
Badly designed services

 Unclear, undefined service design/specification;

 Insufficient support of the top management to service quality planning.
Lack of standards defined from the aspect of customers:
 Standards are not defined respecting customers’ demands;
Inadequate service ambience and physical elements:
  The company’s physical facilities, equipment, and other tangibles not appropriate
to the service offering
 The company’s physical facilities, equipment, and other tangibles not attractive
and effective
Moreover, problems can be caused by the lack of resources, too growing demand and
inadequate engagement of company management.
Closing gap 2: Establish the right service quality standards
 Top management commitment to providing service quality
 Set, communicate, and reinforce customer-oriented service standards
 Train managers to be service quality leaders
 Be receptive to new ways to deliver service quality
 Standardise repetitive tasks
 Prioritise tasks
 Gain employee acceptance of goals and priorities
 Measure performance of service standards and provide regular feedback
 Reward managers and employees for achievement of quality goals

Gap3: Service specifications versus service delivery: It represents difference between

specification of service quality and attributes of the process of service production and
delivery, i.e. difference between what managers have defined as standard of service quality
and the way how a service was actually delivered. It happens as a result of role ambiguity and
conflict, poor employee-job fit and poor technology-job fit, inappropriate supervisory control
systems, lack of perceived control and lack of teamwork.
The reasons for the emergence of Gap 3 are the following:
Oversights in the human resources management:
 Unclear roles and conflict of interests-e.g. one doing another job/2 or more roles
 Poor system of evaluation and praising;
 Lack of team work
 Poor employee-job fit
 Poor technology-job fit

Poor cooperation of customers:

  Customers do not understand or do not know what their role and responsibility in
the service process are;
 Customers make a negative influence among themselves.
Badly harmonized offer and demand:
 Poor choice of customers/segments;

Managers are able to define specifications of services based upon the customers’ demands.
However, what can happen is that the employees are not able to deliver the service in an
adequate way. For example, management of a restaurant orders that a specific dish needs to be
delivered within 20 minutes while the waiter delivers the same dish after the period
demanded. Possible reasons for that are: conflicts between the staff, poor intersectional
cooperation between the kitchen and the restaurant, conflict with management and customers,
unskilled staff, inadequate system of motivation, old-fashioned kitchen equipment, too many
crowd in the restaurant, etc.
Closing gap 3: Ensure that service performance meets standards
 Attract the best employees
 Select the right employees
 Develop and support employees
• train employees
• provide appropriate technology & equipment
• encourage and build teamwork
• empower employees
• internal marketing
Internal marketing- means that the service firm must effectively train and motivate its
customer-contact employees and all the supporting service people to work as a team to
provide customer satisfaction.
 Retain good employees
• measure and reward service quality achievements
• develop equitable and simple reward systems

The service performance gap is evident in many of the hotels as often the wrong employee is
assigned to the wrong job or function. Staff appraisals are important for the management to
communicate with their staff on their progress and what is expected of them. At the interview
stage, what is expected of employees must be clearly stated and during the training and
induction, meeting the expectations of the customer has to be strongly emphasized.

Gap4: Service delivery versus external communication: It represents variation between

delivered service and what customer was actually told about the service itself. It occurs as a
result of inadequate horizontal communications and propensity to over-promise.

Promises and delivery depend on the communication and efficiency of the hotel departments.
How does this relate to service quality? If the organization fails to deliver what is being
promised to the customer, then they will measure poorly against reliability, assurance and
responsiveness.
Reasons for Gap 4

1. Lack of integrated service marketing communications:

 Custom that each external communication is observed independently;
 Interactive marketing (buyer-seller interaction marketing) is not part of
communication plan
 Lack of a developed programmed of internal marketing.

2. Inefficient or inadequate management of customers’ expectations:

 Lack of the management of customers’ expectations through all forms of
communication;
 Customers are not educated in an adequate way.

3. Unreasonable promises:
 Unreasonable promises in marketing activities, personal sale, etc.

Unreasonable promises and inadequate management of customers’ expectations lead to the

appearance of too demanding expectations. The result is offering services below the expected
level and negative perception of the quality by customers.

4. Inadequate horizontal communication:

 Poor communication between people responsible for promotional campaign and
people responsible for operational activities;
Closing gap 4: Ensure that service delivery matches promises
 Seek input from operations personnel on what can be done
 ‘Reality’ advertising
 real employees, real customers, real situations
 Seek input from employees on advertising
 Gain communications between sales, operations and customers
 Internal marketing programs
 In advertising, focus on service characteristics that are important to
customers
 Manage customer’s expectations

Gap5: the discrepancy between customer expectations and their perceptions of the
service delivered: It represents difference between customers’ expectations regarding the
service and their perception about the specific service. It happens as a result of the influences
exerted from the customer side and the shortfalls (gaps) on the part of the service provider. In
this case, customer expectations are influenced by the extent of personal needs, word of
mouth recommendation and past service experiences.

Expected Service - Perceived Service Gap

• This gap is the result of the other gaps

• This is the gap the customer notices
• Feedback on this gap (complaints) is diagnostic of the other gaps
• Here is where we obtain information that provides the imperative for improvement.
• Proactively seeking feedback here is essential to improvement

If any of the mentioned gaps or the combination of the same occurs, then Gap 5orthe “gap of
customers” will inevitably occur. It appears as the difference between the expectationsof
customers concerning the services and their perception of the service received inthe company
itself.
Reasons for Customer Gap 5 (Customer expectations and Customer perceptions)
 Not knowing what customers expect
  Not selecting the right service standards and designs
 Not delivering to service standards
 Not matching performance to promised

Top 10 reasons for poor quality customer service and their solutions

Customer service, the interaction between the client and the supplier is an integral part of the
purchasing and user experience, and as such, is the key to continued success in business.

1. People are not trainee:-  When an organization does not spend the time to fully train
their people the consequence is poor service.
 Solution:-  Dedicate resources (time and money) for training and reinforcement.  
Employees should be fully informed about company goals, the products and services. 
Emphasis and training should be focused upon the importance of listening and
responding to the customer’s requests.  People can only do the job if they are given the
right tools and objectives.  It costs money to train people.  It will cost more if you decide
not to train them.
2. People don’t care:-  Selecting the correct personality is crucial for your business
success.  Apathetic or self-centered personality types have no place in a business that
requires customer contact.
 Solution:-  Focus the selection and evaluation process to identify personalities that do not
fit the required profile.  Get the wrong people out immediately, it also sends a clear
message to everyone.
3. Sabotage:- Angry or frustrated employees can actively work to sabotage and try to
destroy the company.
 Solution:  Keep honest and open communications with employees.  Informally and
formally review performance, goals, objectives and feelings to stop potential problems
before they reach the customers.  Get these people out of the front lines immediately.
4. Employees don’t believe in the company, product or service.  If the image,
marketing and promotion of the company are quite different from the reality, workers
will not be able to sustain a positive attitude in the face of problems they know exist.
 Solution:  Be honest.  Work closely with customer service, marketing and quality control
to identify real problems and fix them.  Don’t let marketing advertise over problems,
solve them.
 5. Personal problems reflected in work.  When an employee’s personal life is in crisis
or out of control, they may exercise control, aggression and negativism toward
customers in an attempt to put some part of their life in order.
 Solution:  Clear communications with employees:  If their personal life is affecting work
performance, talk about it.  Time off, access to counseling or just listening may prevent
more serious problems.
6. Burnt out.  Too much negative, too many complaints can lower a person’s level of
commitment and move their positive and helpful attitude to an apathetic one.
 Solution:  Constant communication helps to identify who is burning out and why.  Get
customer service people together to talk of success and how to deal with the frustrations. 
Provide recognition or incentives for excellence in dealing with problems.
7. Not providing the correct solutions to customers, lack of empowerment.    There is
nothing worse than dealing with an employee who listens to a problem, then shrugs
and says they have to ask someone else in the company to intervene and provide a
solution.
8. Don’t see the benefits – don’t understand their role in the company. 
 Solution:  Employees project an image of the company.  They are the company.  They
should be reminded of their importance and value to the customer and to the company. 
Incentives, recognition, training and constant reinforcement are important.
9. Apathetic from hearing the same problems over and over.  A fundamental role of
the customer service division is to provide constant feedback on how customers view
the company, the products and the service.  If this feedback is not analyzed and acted
upon by upper management a feeling of apathy and frustration is created.
 Solution:  Set up a model and procedure for the accumulation, analysis and
implementation of solutions for the problems identified by customer service.
10.  Incentives/salary not tied to results.
 Solution:  If you insist that the company depends upon people, and that people are the
key to success, implement compensation packages, evaluations and incentives that
support and reinforce this.
 Information Sheet-3 Methods of identifying and reporting faults

1.3. Methods of identifying and reporting faults

1.3.1. Fault Reporting
 When power goes off, make sure all electrical appliances are switched off.
 Check the Main switch or Circuit Breaker in your Distribution Board and make sure it is
ON...
 If only part of your installation, e.g. Lights or socket outlets are not working check your
distribution board.
 Circuit breakers supplying the circuits may have tripped and should that be the case, ensure
that all appliances connected to the circuit are switched off.
 Attempt to reset the breaker, if it remains ON switch all appliances ON that were in use
one at a time, observing the effect on the supply.

1.3.2. Fault report system

A new fault reporting and data base system has become operational as of the 1st of April. The
main aim of the system is to allow a better way of keeping track of problems and their
solution by relying less on person-to-person communication and individual memories. This
should be more efficient as there is less need to talk to the `right' person, while this might also
avoid time loss when a problems recurs. The system also provides a simple way to do more
detailed statistics of the fault report, which will make reporting easier and more complete,
with the potential of giving us a better inside in what is required to let the telescope operate in
an optimal way.

1.3.3. Fault reporting service

We operate a fault reporting process to deal with all problems at both a network and a site
level, as quickly and efficiently as possible. However, this process can only work if all Janet-
connected organizations are familiar with the correct reporting routes.

1.3.4. Reporting problems

All members who wish to report a problem with their connection to Janet should follow the
route set out in their fault reporting letter. Contact information is sent to the management and
technical contacts by email on an annual basis and includes the current telephone, fax and
email address of the appropriate fault reporting contacts.

Information Sheet-4 Parameters of evaluating services

1.4. Parameters of evaluating services

Measuring service quality is absolutely crucial. Although it's not the same as customer
satisfaction — which has its own methods — there’s a strong and positive correlation between
the two . Here are 9 practical techniques and metrics for measuring your service quality.

1. Servqual

This is the most common method for measuring the subjective elements of service quality.
Through a survey, you ask your customers to rate the delivered service compared to their
expectations.

Its questions cover what SERVQUAL claims are the 5 elements of service quality : RATER.

 Reliability - the ability to deliver the promised service in a consistent and

accurate manner.
 Assurance - the knowledge level and politeness of the employees and to what
extend they create trust and confidence.
 Tangibles - the appearance; of e.g. the building, website, equipment and
employees.
 Empathy - to what extend the employees care and give individual attention.
 Responsiveness - how willing the employees are to offer a speedy service.

2. Mystery Shopping

This is a popular technique used for retail stores, hotels, and restaurants, but works for any
other service as well. It consists of hiring an "undercover customer" to test your service
quality – or putting on a fake moustache and going yourself, of course. The undercover agent
then assesses the service based on a number of criteria, for example those provided by
SERVQUAL. This offers more insights than simply observing how your employees work.
Which will probably be outstanding — as long as their boss is around.
 3. Post Service Rating

This is the practice of asking customers to rate the service right after it’s been delivered. With
Userlike’s live chat , for example, you can set the chat window to change into a service rating
view once it closes. The customers make their rating, perhaps share some explanatory
feedback, and close the chat.

It’s also done in phone support. The service rep asks whether you’re satisfied with her service
delivery, or you’re asked to stay on the line to complete an automatic survey. The latter
version is so annoying, though, that it kind of destroys the entire service experience.

Different scales can be used for the post service rating. Many make use of a number rating
from 1 – 10. There’s possible ambiguity here, though, because cultures differ in how they rate
their experiences .

People from individualistic cultures, for example, tend to choose the extreme sides of the
scale much more often than those from collectivistic cultures. In line with stereotypes,
Americans are more likely to rate a service as “amazing” or "terrible," while the Japanese will
hardly ever go beyond “fine” or "not so good." It's important to be aware of when you have an
international audience. Simpler scales are more robust to cultural differences and more suited
for capturing service quality. Customers don’t generally make a sophisticated estimation of
service quality. “Was it a 7 or an 8...? Well... I did get my answer quickly... On the other
hand, the service agent did sound a bit hurried…” No. They think the service was “Fine,”
“Great!” or “Crap!” That’s why at User like we make use of a 5-star system in our live chat
rating, why Help Scout makes use of three options (great – okay – not good), and use of four
smileys (angry – disappointed – fine – great). Easy does it.

4. Customer Effort Score (CES)

This metric was proposed in an influential Harvard Business Review article. In it, they argue
that while many companies aim to "delight" the customer – to exceed service expectations –
it’s more likely for a customer to punish companies for bad service than it is for them to
reward companies for good service.
While the costs of exceeding service expectations are high, they show that the payoffs are
marginal. Instead of delighting our customers, so the authors argue, we should make it as easy
as possible for them to have their problems solved.

5. Follow-Up Survey

With this method you ask your customers to rate your service quality through an email survey
– for example via Google Forms . It has a couple advantages over the post-service rating.For
one, it gives your customer the time and space for more detailed responses. You can send a
SERVQUAL type of survey, with multiple questions instead of one. That’d be terribly
annoying in a post-service rating.

It also provides a more holistic overview of your service. Instead of a case-by-case

assessment, the follow-up survey measures your customers’ overall opinion of your service.
It’s also a useful technique if you didn’t have the post service rating in place yet and want a
quick overview of the state of your service quality.

But there are plenty of downsides as well. Such as the fact that the average inbox already
looks more like a jungle than a French garden. Nobody’s waiting for more emails – especially
those that demand your time. With a follow-up survey, the service experience will also be less
fresh. Your customers might have forgotten about it entirely, or they could confuse it with
another experience. And last but not least: To send an email survey, you must first know their
emails.

6. In-App Survey

With an in-app survey, the questions are asked while the visitor is on the website or in the
app, instead of after the service or via email. It can be one simple question – e.g. "how would
you rate our service" – or it could be a couple of questions.

7. Customer Effort Score (CES)

. In it, they argue that while many companies aim to "delight" the customer – to exceed
service expectations – it’s more likely for a customer to punish companies for bad service
than it is for them to reward companies for good service .
While the costs of exceeding service expectations are high, they show that the payoffs are
marginal. Instead of delighting our customers, so the authors argue, we should make it as easy
as possible for them to have their problems solved. That’s what they found had the biggest
positive impact on the customer experience , and what they propose measuring.

8. Objective Service Metrics

These stats deliver the objective, quantitative analysis of your service. These metrics aren’t
enough to judge the quality of your service by themselves, but they play a crucial role in
showing you the areas you should improve in.

 Volume per channel. This tracks the amount of inquiries per channel. When
combined with other metrics, like those covering efficiency or customer satisfaction, it
allows you to decide which channels to promote or cut down.
 First response time. This metric tracks how quickly a customer receives a response
on her inquiry. This doesn’t mean their issue are solved, but it’s the first sign of life –
notifying them that they’ve been heard.
 Response time. This is the total average of time between responses. So let’s say your
email ticket was resolved with 4 responses, with respective response times of 10, 20,
5, and 7 minutes. Your response time is 10.5 minutes. Concerning reply times , most
people reaching out via email expect a response within 24 hours; for social channels
it’s 60 minutes. Phone and live chat require an immediate response, under two
minutes.
 First contact resolution ratio. Divide the number of issues that's resolved through a
single response by the number that required more responses. Forrester research
showed that first contact resolutions are an important customer satisfaction factor for
73% of customers.
 Replies per ticket. This shows how many replies your service team needs on average
to close a ticket. It’s a measure of efficiency and customer effort.
 Backlog Inflow/Outflow. This is the number of cases submitted compared to the
number of cases closed. A growing number indicates that you’ll have to expand your
service team.
 Customer Success Ratio. A good service doesn’t mean your customers always finds
what they want. But keeping track of the number that found what they looked for
 versus those that didn’t, can show whether your customers have the right ideas about
your offerings.
 "Handovers" per issue. This tracks how many different service reps are involved per
issue. Especially in phone support, where repeating the issue is necessary, customers
hate handovers. There are four most common service complaints.
 Things Gone Wrong. The number of complaints/failures per customer inquiry. It
helps you identify products, departments or service agents that need some "fixing."
 Instant Service/Queueing Ratio. Nobody likes to wait. Instant service is the best
service. This metric keeps track of the ratio of customers that were served instantly
versus those that had to wait. The higher the ratio, the better your service.
 Average Queueing Waiting Time. The average time that queued customers have to
wait to be served.
 Queuing Hang-ups. How many customers quit the queuing process. These count as a
lost service opportunity.
 Problem Resolution Time. The average time before an issue is resolved.
 Minutes Spent Per Call. This can give you insight on who are your most efficient
operators.

Some of these measures are also financial metrics, such as the minutes spent per call and
number of handovers. You can use them to calculate your service costs per service contact.
Winning the award for the world’s best service won’t get you anywhere if the costs eat up
your profits.

Some service tools keep track of these sort of metrics automatically, like Talk desk for phone
and User like for live chat support. If you make use of communication tools that aren’t
dedicated to service, tracking them will be a bit more work.

Self-Check two Learning Guide 37

Direction one; Short answer

1. Outline the five elements of service quality which is listed out by SERVQUAL
2. Outline the major service gaps
 Answer Sheet Score = ___________
Rating: ____________

Name: _________________________ Date: _______________

Short Answer Questions

1. _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________

2. _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________________________
 Logo
Birhan Social Development College

Community Service Work

NTQF Level I

Learning Guide #38

Unit of Competence: Apply Quality Standard

Module Title: Applying Quality Standard
LG Code: LSA CSWV1 M11 -42
TTLM Code: LSA CSWV1 TTLM 2019v1
Lo3. Record information

Instruction Sheet Learning Guide #38

This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –

 Understand Basic information on the quality performance

 Recognize Recording performance information
 Information Sheet-1 Basic information on the quality performance

3.1. basic information on the quality performance

A quality management system (QMS) is a formalized system that documents processes,
procedures, and responsibilities for achieving quality policies and objectives and thus
consistently delivering a quality product or service to the customer.  A QMS helps to
coordinate and direct an organization’s activities to meet customer and regulatory
requirements and continually improve its effectiveness and efficiency.  The QMS
documentation must accurately and succinctly document the organisation’s structure,
procedures, processes and resources.

A well designed documented system has many benefits, it ensures quality standards are
routinely met, minimizes the potential for error, reduces downtime when deviations occur due
to being able to quickly access relevant data, and allows for easy monitoring of the processes
such that process outputs are analyzed and appropriate adjustments are made.  QMS
documentation fulfills many functions such as communication of information, providing
evidence of conformity and sharing knowledge and as such many different types and levels of
documents are needed, for example a quality manual, quality policy, documented procedures
and work instructions.

A one size fits all approach won’t work, each document type must be fit for purpose such that
it is readily understood by relevant personnel and can be effectively implemented.
Documentation must also be lean, as too many documents will result in the processes and
respective QMS being harder to both use and maintain while also being bureaucratic.
Documentation is also required for regulatory purposes and must demonstrate the effective
planning, operation and control of the organisation’s processes and the implementation and
continual improvement of the effectiveness of its QMS.  It is evident that good documentation
is critical to a functioning QMS, in fact it forms the foundation of the organisation’s QMS as
it gives effect to the QMS for the life-cycle of the product/service being delivered.

Is your QMS documentation fit for purpose?

Fit for purpose QMS documentation ensures that all processes are understood and consistently
executed by employees such that a quality product/service is delivered to the customer each
and every time.  If your organisation’s documentation doesn’t meet this standard it will result
in regulatory non-compliance, significant costs to your organisation in terms of resources to
rectify issues, and may impact your organisation’s reputation for example as a result of delays
in processing customer orders or failing to deliver a quality product or service to your
customer.

RRL can help your organisation achieve fit for purpose QMS documentation whether you are
a start-up company embarking on designing a QMS and documentation of same and need to
get it right first time or QMS documentation in place isn’t fit for purpose and is thereby
hindering effective and efficient operation of the QMS.

What does fit for purpose QMS documentation look like and how can you achieve it?

Realization of fit for purpose documentation is based on PDCA (Plan-do-Check-Act) cycle

and can be achieved in 5 steps which are detailed below.  Fit for purpose documentation must
be lean to facilitate implementation and maintenance while the documents must clearly
describe all QMS processes using simple, concise unambiguous language to ensure that
processes are understood and can be easily implemented.

To achieve fit for purpose documentation you must first identify the documentation that your
organisation needs for implementation of its QMS and the medium you want to use either
hard copy or electronic media.  The amount of documentation needed depends on the size of
the organisation and its business, the complexity of the processes and their interactions and
the competence of the personnel.  Many organisations find it useful to use a process map to
document the processes and their interactions and use this as a tool to decide on what
documents are needed, good planning at this stage will save time and effort later.

The next step is to decide on the structure of the QMS documentation, which usually follows
the organisation’s processes or the structure of the applicable quality standard or a
combination of both.  The structure or hierarchy of the documentation facilitates distribution,
maintenance and understanding of the documentation.  Following the identification and
structure of the documents needed Step 3 is where you generate the required documents, this
is the most difficult part of the realisation process as the documents themselves will determine
employees understanding of the processes such that they can implement and document them
accordingly as quality records.  Implementation of the documentation system is the next phase
and is documented in the document control procedure which must be robust and stringently
followed.

The final step is maintenance and improvement of the QMS documentation throughout the
lifecycle of the product or service. Maintenance is performed by ensuring that QMS
documents are controlled as per document control procedure and improvement is achieved via
analysis of QMS outputs and taking appropriate action to continuously improve effectiveness
and efficiency of the QMS.

Step 1:   Identify documentation

Identify all your processes and the interaction between them using a Process Map, analysis of
the processes should then be used to determine the amount of documentation needed for the
QMS. QMS standards will determine mandatory documents, for example ISO13485:2016 lists
Quality Manual, Quality Policy, Quality Objectives, Quality Records and six procedures as
listed below as mandatory documentation:

1. Control of Documents
2. Control of Records
3. Internal Audit
4. Control of Nonconforming Product
5. Corrective Action
6. Preventive Action

Thereafter you only require procedures to cover each section of the standard that applies to
your business and the complexity of the business will dictate the amount of documentation
and level of detail needed.

Step 2:   Identify structure of documentation.

This structure is applicable to all organisations regardless of its size or complexity and we
would recommend that this structure is adopted for your organisation.

Figure 1 describes a typical QMS documentation hierarchy with different document types at
each level as follows:

Quality Manual

Describes both the QMS in place and what you are going to do as an organization to
implement the QMS.  The Quality Manual should include the scope of the QMS, details of
and justification for any exclusion, references to documented procedures and a description of
the processes of the QMS and their interactions which is usually presented as a diagram.

Quality procedures

Describes how the organization implements the QMS by documenting the applicable
processes. Format can include text, flowcharts, tables, a combination of the above as best
meets the needs of the organization. Procedures usually cross reference work instructions.

Work Instructions

Describe an activity within a process and provide detailed descriptions of how to perform and
record tasks. The structure, format and level of detail required depends on the complexity of
the work, methods used, training undertaken and competence of personnel who execute the
work instructions.

Quality Records
Serve as evidence that the organisation has done the work documenting the actions of an
activity or process.

Step 3:   Generate QMS documents

QMS documents detail the organisation’s structure, procedures, processes and resources and
when followed result in a quality product or service being consistently delivered to the
customer.  Good documentation will determine employees understanding of the processes
such that they can implement and document them accordingly as quality records, thus
documents need to be easy to read, have a natural logical flow, use simple & clear language
and be concise.  These attributes will ensure an understanding of the content and information
being conveyed. If time and effort is employed at this stage in getting the documents to
required standard it will avoid time and effort later in revision of documents.

Documents should be generated by the process owners as they are the people who best
understand the processes.  The first documents that need to be generated are the quality
procedures of which the document control procedure should be drafted first. The document
control procedure describes the structure of all document types within the QMS and so is the
first building block in the design of QMS documentation.  The document control procedure
addresses the following:

 Review and approval of documents for adequacy prior to issue

 Review of documents and update as necessary and re-approval
 Ensures correct revision status of and changes to documents are identified
 Ensures relevant versions of applicable documents are available at points of use
 Ensures documents remain legible and readily identifiable
 Ensures documents of external origin are identified and their distribution controlled
 Prevents deterioration or loss of documents
 Prevents unintended use of obsolete documents and application of suitable
identification to them.

The next quality procedure documents to be generated should be those mandated by the
quality standard your organisation is following and as you draft these documents you can start
generating the Quality Manual which will reference these documents.
The last documents to be generated are those required to cover each section of the standard
that applies to your business.  Once all the quality procedures are generated you can start
drafting the work instructions, and once all the procedures and work instructions are generated
cross check them against your Quality Manual to ensure the Quality Manual gives an accurate
overview of your QMS.

Step 4:   Implement documentation system

Document control procedure details the documentation system in place and how it is to be
implemented.  The system in place must ensure that all documents are controlled, legible,
readily identifiable, retrievable, available at points of use and reviewed regularly for ongoing
suitability throughout product/service lifecycle.  This procedure must be followed for all
controlled documents.  Documents detail the organisation’s structure, procedures, processes
and resources and are needed as objective evidence for regulatory compliance and are
auditable thus document control procedure is critical as if it isn’t operating properly you will
very quickly run into compliance problems and will have to apply costly resources to address
problems.

Step 5:   Maintenance and Improvement

Maintenance and continuous improvement of documentation is very important.

Documentation needs to be maintained in line with document control procedure such that the
organisation is in compliance with QMS and regulations.  Documentation needs to be
regularly reviewed and data from QMS processes evaluated to identify any changes required.
Updates and improvements are identified because of changes in processes, non-conformances,
audits, training, identified improvements and changes to standards.
 Information Sheet-2 Recording performance information

3.2. Recording performance information

3.1. Standards of recording

Standard 1: Documentation in social work practice is grounded in the values, ethics and
principles of the social work profession.

Documentation is an integral part of social work practice. It is therefore important that social
workers document all interventions in an ethical and competent manner. The CASW Code of
Ethics (2005) outlines the values and principles that guide professional social work practice.
These values include:

a. Respect for the Inherent Dignity and Worth of Persons

b. Pursuit of Social Justice
c. Service to Humanity
d. Integrity in Professional Practice
e. Confidentiality in Professional Practice
f. Competence in Professional Practice
Social work documentation standards pertain to all areas of social work practice including
clinical, community development, management and supervision, research, education and
policy development.

Standard 2: Social workers maintain records of social work intervention(s).

Social workers have an ethical and legal responsibility to maintain social work records.
Documentation of social work interventions with clients should be contained in one file. The
records may be electronic, paper or both. Social workers should not maintain client
information that is not relevant to the service delivery. Social work documentation should
only include information that addresses the clients’ needs and meets legislative, ethical and
organizational requirements.
Standard 3: Social workers ensure records are in a format that facilitates monitoring
and evaluation of the social work intervention (s).

Social work documentation is completed in a timely and chronological order to ensure

accuracy, clarity and credibility of the information. Recordings should be completed
following the intervention or as soon as reasonably possible afterwards. Social workers use
professional judgment to determine if records need to be completed more expeditiously. The
need to document a record more immediately may depend on the complexity of the case,
degree of risk, impact on service delivery, and/or legislative requirements. Where
organizational standards exist, social workers should be aware of and adhere to policies and
timelines for documentation to be completed.

Social work records should contain all information that is clinically relevant and significant to
the service delivery. At a minimum, records should include the following:

 Client’s name and contact information

 Presenting issue and description of professional service requested
 Client’s informed consent
 Copy of relevant documents (e.g., referrals, letters, court documents, etc.)
 Professional assessment, goals, interventions, and outcomes
 Progress notes
 Communication with other professionals and collateral contacts
 Clear statement of when and why the professional relationship is terminated
 Fee for service agreements (for those in private practice)
Records that are not clinically focused should contain at the minimum contact information for
relevant partners and stakeholders, assessments, planning and implementation notes, records
of meetings and communication with stakeholders, appropriate consent forms, pertinent
research, and evaluations.

Social work records should be free from jargon and emotive or derogatory language.
Abbreviations should only be used after the term is explained the first time it is used in the
record. This is important to avoid misunderstandings. Errors must not be erased or deleted.
If corrections need to be made, they should be noted as such and dated and initialed by the
social worker. To ensure the credibility of the note, social workers should also ensure that
they use accurate spelling and grammar.
Consultations with a supervisor, colleague, or consultant that is relevant to the service
delivery should be documented in the client’s record. Clients should be informed that
information may be shared with a supervisor or internal consultant as part of the social work
service delivery when appropriate. Informed consent is necessary when client information is
released to an outside consultant.

Standard 4: Social work documentation shall include a clear assessment, intervention

strategy and termination plan. Documentation and assessment skills are interrelated. As noted
by Leon & Pepe (2010), “how one interviews and assesses a client will determine how
informative the client contact will be and consequently how much essential content one can
include in the client documentation” (p. 365). Incomplete or inaccurate records can lead to
inadequate services for the client.

Standard 5: Social workers protect client confidentiality and ensure that clients are aware of
the limits of the confidentiality of social work documentation before initiating the social work
relationship and throughout the relationship as needed.

When social workers provide services to more than one individual in a client system (e.g.,
families, couples and groups), it is important that all parties are informed of each person’s
right to confidentiality and the confidentiality of information shared by others, and how
records are being maintained. This information should be clearly documented in the client
file. Clients being seen individually, in addition to the family, group or couple’s work, should
have their own social work record.

The disclosure of client information and records to persons or organizations is permitted:

 With the informed consent of clients. This consent, written or verbal, should be
documented in the client record.
 When disclosure is necessary to prevent serious, foreseeable, and imminent harm of
the client or others. Social workers use their professional judgment to determine how
much client information needs to be disclosed to prevent harm.
 When required by federal and provincial laws or regulations.
When disclosure of social work records is required by a court order or subpoena, social
workers should be familiar with the nature of the request, seek consultation, take care not
to release more information than is required, inform the client where appropriate, and
strive to protect confidential client information from unreasonable public exposure. This
 may involve applying to the court for some client information to be withheld from the
public record; however consultation with a supervisor or manager would be prudent in this
situation.

Standard 6: Social workers are familiar with best practice guidelines pertaining to
Technology use and documentation.

Within the current context of technological advances, it is important that social workers take
precautions to ensure and maintain the confidentiality of information transmitted to other
parties through any form of electronic communication. Social workers should be aware of
and inform clients of the limits to confidentiality that may apply to these forms of
communication.

The following are some areas for consideration:

 E-mail, phone and text messages from clients that have clinical or therapeutic
significance should be documented in the clinical file.
 When electronic modes of communication are used in practice, it is important that
social workers include policies around documentation of electronic communications
within the informed consent process.
 When using electronic forms of documentation or information collection (e.g.,
laptops), it is important that social workers develop risk management strategies (e.g.,
computer passwords, appropriate storage).
 When social workers communicate with clients via e-mail/text, social workers discuss
with clients the type of information appropriate for e-mail/text in keeping with
organizational policies, the Code of Ethics and best practice guidelines. This
information should be clearly documented in the client file.
Standard 7: Social workers are familiar with best practice guidelines for completing
social work documentation and engage in continuing professional education.

As part of on-going professional development, social workers continue to assess their

knowledge of social work documentation through self-reflection and consultation with peers,
managers and/or supervisors and to engage in professional development opportunities to
foster continued learning and competency.
Social workers engaged in supervision, including those involved in the provision of field
instruction to students, ensure that social workers and students are familiar with the standards
for social work recording and best practice guidelines for documentation and writing, while
seeking opportunities to enhance the competency of supervisees and students in social work
documentation.

Standard 8: Documentation of community development processes, project planning,

policy development, and research is grounded in the values, ethics, and philosophy of the
profession.

Social workers employed in community organizations and consulting work, document their
work with clients, families, groups, communities, employers and stakeholders in accordance
with the standards set forth in this document and the CASW Code of Ethics.

Self-Check Three Learning Guide

Direction one; short answer

1. Outline the major prerequisites to disclosure of client information and records to

persons or organizations is permitted:
2. List out the six procedures listed by ISO13485:2016 mandatory documentation:

Answer Sheet Score = ___________

Rating: ____________

Name: _________________________ Date: _______________

Short Answer Questions

1._______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______

2._______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________
 Logo
Birhan Social Development College

Community Service Work

NTQF Level I

Learning Guide #39

Unit of Competence: Apply Quality Standard

Module Title: Applying Quality Standard
LG Code: LSA CSWV1 M10 -39
TTLM Code: LSA CSWV1 TTLM 2019v1

Lo4.Study causes of quality deviations

 Instruction Sheet Learning Guide #39

This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –

1. Recognize Quality deviations

2. Understand Causes of Quality deviations
3. Recognize Preventing quality deviations

Information Sheet-1 Quality deviations

4.1. Quality deviations

Quality: has a direct impact on product or service performance. Thus, it is closely linked to
customer value and satisfaction. Satisfaction is regarded as one of the key judgments that
consumers make regarding a tourism service and is always a focal point for marketer
attention. Quality service helps a company maximize benefits and minimize non-price
burdens for its customers. American society… defines quality as the totality feature and
characteristics of a product /service that bear on its ability to satisfy customer needs.
This definition implies that the customer becomes eventually the quality referee. The process
by which customers understand quality is often regarded as a comparison of the service
standards expected when purchasing a service, compared to their perceptions of service
experiences. So, customers can be dissatisfied, satisfied or delighted depending on the balance
between expectations and perceptions. “The seeds of consumer satisfaction are planted during
the pre-purchase of the consumer decision process.” It is against this individual benchmarking
that tourists measure the quality of their service experiences. Satisfaction is defined as a post
consumption evaluation that the chosen alternative is consistent with prior beliefs and
expectations (with respect to it). Dissatisfaction, of course, is the outcome when this
confirmation does not take place.
Customer focused definitions suggest that quality begins with customer needs and ends with
customer satisfaction. Researchers have defined quality in different ways and there is no
agreed definition of service quality. It has been variously defined as value, conformance to
requirements, and fitness for use and meeting customers’ expectations.

Quality is determined by the expectations and perceived delivery level for each of a bundle of
factors for each customer. It has been defined from various views as:
 Customer: ‘The totality of features and characteristics of a product or service
that bear on its ability to satisfy stated or implied needs’ (ISO 8042, 1989).
Quality is the opinion of the totality of goods and service provision as
determined by the customer. Quality is affected by the concept of value.
 External (marketing): Quality is a set of expectations and perceptions which we
have a role in managing.
 Internal (operations): Quality is conformance to internal procedures. Quality is
not making any mistakes and maximizing internal efficiency.

However, within the service sector, quality is often defined from a customer’s perspective and
should aim to meet customers’ expectations.

The creation of memorable, positive customer service—service so good, so unique, so

different, that it takes the customer by surprise and leaves him with a smile on his face and a
story to tell—is often strikingly parallel in structure and outcome to fine stage magic. Just as
the skilled stage magician is a master of audience enchantment, the service magician brings a
touch of charm and delight to his or her customer’s day, life, and world . . . even if just for a
moment.

Quality Risk Management(QRM) was mainly designed to be used prospectively when

manufacturing operations are defined and validated. Therefore, potential deviations are
identified and avoided by implementing risk control measures and preventive actions. QRM is
based on the identification of product attributes and operational parameters which are critical
to manufacturing operations in order to identify in advance their associated risks. This
guidance document describes how this information may be used as criteria for the
categorization and treatment of events, and eventually, deviations. The application of risk
management in dealing with deviations is not only practical but provides a framework for a
decision-making process based on a scientifically sound and objective approach, while also
enabling decisions to be confidently upheld before the regulatory authorities. Under this
approach, a sequence of steps may be identified when handling events and possible
deviations:

i. Event detection:
The manner on how personnel react when in presence of an event is the first challenge to the
system, and it largely depends on their level of training, qualification, commitment, and
support form upper management.

As a basic requirement, personnel are expected to be alert and aware of possible undesirable
events and clearly know what to do in terms of documenting and communicating them. The
way personnel react and make decisions can be systemized and improved by the use of a
decision tree to initially screen events based on their risk and impact on the product in order to
categorize, record, and investigate them as needed.

ii. Deviation Categorization

The decision tree simplified risk assessment that answers the following questions when an
event is encountered:

 Can the event affect a product attribute, manufacturing operational parameter or the
product’s quality?
 Does the event contradict or omit a requirement or instruction contemplated in any
kind of approved written procedure or specification?
A. Minor Deviations When the deviation does not affect any quality attribute, a critical
process parameter, or an equipment or instrument critical for process or control; it would be
categorized as Minor, and treated as such by the applicable procedure. Possible examples of
minor deviations are given below:

- Skip of FEFO principle (first expired-first out) in raw material handling.

- Balance out of tolerance used to determine gross weight of raw materials upon
reception.
- Pressure differential out of established limits in class D washing area.
 - Inadequately trained personnel to perform warehouse cleaning activities.
B. Major Deviations

When the deviation affects a quality attribute, a critical process parameter, an equipment or
instrument critical for process or control, of which the impact to patients (or
personnel/environment) is unlikely, the deviation is categorized as Major requiring immediate
action, investigation, and documented as such by the appropriate SOP. Possible examples of
major deviations are given below:

 Use of unapproved reference standard to test an API or drug product.

 Inadequately trained personnel to perform sterility tests. - Production started
without line clearance.
 Filter integrity test has been carried out using equipment with no documented
installation qualification completed.
 Gross misbehavior of staff in a critical aseptic process.
 Pressure differential out of established limits in aseptic fill areas. - Operational
parameter out of range for a parameter defined as non-critical.
 Untrained personnel responsible for segregating the approved and rejected raw
material in the warehouse
C. Critical Deviations

When the deviation affects a quality attribute, a critical process parameter, an equipment or
instrument critical for process or control, of which the impact to patients (or personnel or
environment) is highly probable, including life threatening situation, the deviation is
categorized as Critical requiring immediate action, investigated, and documented as such by
the appropriate SOP. Possible examples of critical deviations are given below:

- Expired or rejected API component used.

- Sterilization record of product-contact material used in aseptic filling process
not available or unacceptable.
- Incomplete inactivation stage of fermentation.
Temperature out of control limit during detoxification stage
 Information Sheet Causes of Quality deviations

4.2. Causes of Quality deviations

A. Quantity of work (untimely completion, limited production)
 Poor prioritizing, timing, scheduling
 Lost time
 Tardiness, absenteeism, leaving without permission
 Excessive visiting, phone use, break time, use of the Internet
 Misuse of sick leave
 Slow response to work requests, untimely completion of assignments
 Preventable accidents
B. Quality of work (failure to meet quality standards)
1. Inaccuracies, errors
2. Failure to meet expectations for product quality, cost or service
3. Customer/client dissatisfaction
4. Spoilage and/or waste of materials
5. Inappropriate or poor work methods
C. Work Behavior Which Result in Performance Problems
Inappropriate behavior (often referred to as "poor attitude")
• Negativism, lack of cooperation, hostility
• Failure or refusal to follow instructions
• Unwillingness to take responsibility ("passing the buck")
• Insubordination
• Power games
• Resistance to change
• Unwillingness, refusal or inability to update skills
• Resistance to policy, procedure, work method changes
• Lack of flexibility in response to problems
D. Inappropriate interpersonal relations
 • Inappropriate communication style: over-aggressive, passive
• Impatient, inconsiderate, argumentative
• Destructive humor, sarcasm, horseplay, fighting
• Inappropriate conflict with others, customers, co-workers, supervisors
E. Inappropriate physical behavior
• Smoking, eating, drinking in inappropriate places
• Sleeping on the job
• Alcohol or drug use
• Problems with personal hygiene
• Threatening, hostile, or intimidating behavior

Information Sheet Preventing quality deviations

4.3. Preventing quality deviations

A pre-existent QRM will contribute to determine the categorization of the deviation. If QRM
has not been performed, it may be carried out at this time as part of the impact assessment in
order to determine the criticality of the process parameters involved, and the risk to the
patient.

A. Minor Deviations
Minor Deviations may be treated as follows:

 Description
 Correction
 Efficacy and Conclusion
 Data base record
An adequate description of the deviation requires documented objective evidence written in a
concise and clear way stating time, location and person that found the deviation when
possible. Minor deviations are normally addressed by Corrections which are taken to correct
and contain the problem (including immediate actions), based on sufficient documented
evidence.

Corrections are immediate actions taken based on a simplified analysis of the deviation. They
should be QA (quality Assurance)approved before implemented if possible, and if this is not
feasible, the authorized and qualified responsible personnel may approve and carry out the
correction, and approved by QA as soon as possible. Corrections associated to manufacturing
lots need to be QA approved before release. Minor deviations do not necessarily require an
investigation aimed at identifying the root causes of the problem as major and critical
deviations do. Some corrections could require a change control.

Efficacy of the corrections is normally verified based on the immediate outcome of the
actions, and this should be documented. The result of the documented evaluation of the
correction/s has to be stated under Conclusions.

The information may be recorded in any form of data base (a simple matrix suffices, given the
case) where it can be retrieved later during quality reviews or investigations.

B. Major or Critical Deviations

Major or Critical Deviations may be treated as follows:

 Description
 Correction
 Efficacy of Correction
 Batch Disposition, if applicable
 Root Cause Investigation
 Efficacy of Corrective Action
 Conclusion
 Data base record
Major or critical deviations usually require an enhanced, thorough and objective description
which needs to be documented. An adequate description associated to the deviation is
essential in order to perform a meaningful investigation. Major or critical deviations would be
typically first addressed by corrections, which would need QA approval as mentioned above.
An investigation is then initiated on the root causes of the deviation, followed by the
corresponding corrective actions.

If a minor deviation is repeated a significant number of times, it could turn into a major
deviation, and must be treated as such. The investigation of the deviation should also
determine the reason why the implemented corrective actions were not successful. Based on
the same rationale, repetitions of one same incident can turn it into a minor deviation.
Root cause investigation
Root Cause Investigation is a powerful tool used for quality improvement. Among the
different tools available for Root Cause Investigation, the “5 Whys” and “Ishikawa Fish Bone
Diagram” are the simplest and most used ones.

The “5 Whys” refers to a series of sequential questions (i.e. each response given is asked
“why”, normally from 3 up to 5 times). This exercise allows a thorough understanding of the
underlying or root causes of the deviation, which may be related to a systemic problem. The
Fish bone diagram is a cause-effect type of analysis where the product / process is the main
spine, the effect is the actual nonconformance, and the secondary spines are the different
factors or causes that could have affected or “caused” the deviation (i.e., materials, controls,
personnel, equipment, procedures, etc.).

The impact on the affected process, equipment, system or product should be assessed
regarding other similar situations that could be taking place or will occur. A “vertical”
analysis to identify the root cause should always be accompanied by a “horizontal” analysis
on the possible events that could be avoided in the future by extending the scope of the
investigation to evaluate the possible impact of the deviation on other lots of the same product
or on other similar manufacturing processes.

It is reasonable to assume that often there will be deviations for which the root cause cannot
be readily and clearly determined, and that a probable cause will not be determined. Also, in
certain cases, the deviation will be attributed to unpredictable circumstances beyond control.
In any case, conclusions and rationale should always be well supported and well documented.

It is fundamental that investigations on root causes of deviations be carried out in a systematic

and professional manner following an approved procedure, and conducted by adequately
trained personnel. When well-managed, it provides an excellent opportunity to have
departments communicate between them and to improve process understanding.
Investigations should be based on historical data and accumulated knowledge. For further
reading and training on the matter see “Quality management system –Medical Devices –
Guidance on corrective action and preventive action and related QMS processes”.

iv. Corrective and Preventive Actions (CAPA)

The root cause investigation process is a key step in handling major and critical deviations as
it will provide objective evidence to implement corrective and possibly preventive actions as
 part of the CAPA system. Corrective Actions are taken to eliminate the root causes of
deviations, and should be based on good quality investigations. Corrective actions should be
QA approved before implemented and their efficacy verified in a documented manner,
activity that could require a significant period of time. Corrective actions could be transferred
to an independent CAPA system to avoid unnecessary delay for deviation closure. This
independent CAPA system should include tracking of all actions required by a pre-approved
CAPA plan and effectiveness check.

Not all corrective actions will have associated preventive actions. Corrective actions are
“reactive” in nature and are triggered in response to detected deviations and could generate
preventive actions as well. These preventive actions (linked originally to nonconformities)
will act on similar processes, manufacturing lines or different sites, where there has not been
yet a deviation. The following diagram (Diagram 3) could be considered part of the general
CAPA strategy:

Investigate Identify Root Cause

Determine Effectiveness of Implemented Actions Identify

Actions

Implement Actions

Approve identified Actions Verify

identified
Actions (e.g.
need
for change
control, revalidation

v. Risk Control.
Risk Control is a decision making process to reduce the risk to an acceptable level. It includes:

Risk reduction: mitigation or elimination of the risk when it exceeds a specified level (not
acceptable), in terms of severity and probability of harm. “Processes that improve the
detectability of hazards and quality risks might also be used as part of a risk control strategy.
The implementation of risk reduction measures can introduce new risks into the system or
 increase the significance of other existing risks. Hence, it might be appropriate to revisit the
risk assessment to identify and evaluate any possible change in risk after implementing a risk
reduction process”. Any implementation of risk reduction measures should follow the
established change control system.
Risk acceptance is a formal decision to accept the residual risk or it can be a passive decision
in which residual risks are not specified.

vi. Risk Review

The effectiveness of the risk management process should be reviewed periodically based on
meaningful information “(e.g., results of product review, inspections, audits, change control)
or unplanned (e.g., root cause from failure investigations, recalls). Risk review could include
reconsideration of risk acceptance decisions”. Risk Review is an essential QMS activity which
is incorporated in the overall lifecycle and continuous improvement approach. New
information related to the occurrence of deviations should be incorporated as part of the Risk
Review process.

Self-Check four Learning Guide 39

Direction one; short answer

1. List out the sequence of steps which is necessary for handling events and possible
deviations.
2. Outline the major or Critical Deviations may be treatment mechanisms.
 Answer Sheet Score = ___________
Rating: ____________

Name: _________________________ Date: _______________

Short Answer Questions

1. _______________________________________________________________________
_______________________________________________________________________
_______________________________________________
2. _______________________________________________________________________
_______________________________________________________________________
___________________________________________________________
 Logo
Birhan Social Development College

Community Service Work

NTQF Level I

Learning Guide #40

Unit of Competence: Apply Quality Standard
Module Title: Applying Quality Standard
LG Code: LSA CSWV1 M11 -42
TTLM Code: LSA CSWV1 TTLM 2019v1

Lo5. Complete documentation

 Instruction Sheet Learning Guide #40
This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –

1. Recognize Quality parameters

2. Examine Indicators of service performance
3. Understand Reporting procedures

Information Sheet Quality parameters

5.1. Quality parameters

Quality assurance involved all techniques and activities aimed at eliminating causes of
unsatisfactory performance at all relevant stages – from the identification of needs to the
assessment of whether these needs have been met.
Hence a quality assurance process which would cover the following steps:
 identifying priority areas which need to be monitored
 setting targets, standards, or required levels of performance for these priority areas
 developing and implementing a system for collecting, analysing and reporting on
performance in priority areas
 identifying what action should follow if performance falls below targets, standards, or
required levels
 implementing and monitoring action for change
In the first instance, quality assured provision means that service provision is in line with the
needs of employee, employers, the local community, and the economy.

Information Sheet Indicators of service performance

5.2. Indicators of service performance

Performance management is a set of management processes that analyze and enable a

company to achieve set objectives. The purpose of performance management is to improve
work performance and encourage individual productivity in organizations, as well as to
identify and eliminate ineffective performers as well as recognize strong performers. When a
performance initiative is successful, it helps the organization achieve its desired results with
the resources the company has on site. Performance management has three main activities:

 Selection of goals: Goal setting improves work motivation. Goal acceptance is

necessary and so is moderation of goal setting efforts as well as the progression from
setting to attainment.
 Consolidation of measurement information:  Measurement information collected
and analyzed has to be relevant to the organization’s progress as compared to the goal.
There is no use, for example, in measuring what sales tactics are accomplishing if the
company objective is to become more customer-oriented.
 Interventions made by managers: As with any other goal, there are times when
strategies will not align with tactics, and as such, business managers can intervene to
ensure the performance is in line with the goals and objectives decided on by the
company.

5.2.1. Performance Measurement Process

A company’s performance measurement process is vital to the decision-making process. you

cannot control what you cannot measure and you cannot change what you cannot control. So
deficiencies and outdated systems can only be corrected and updated if they are examined and
measured against the company’s objectives and desired standards. Measurements then are
used by a company for assessment of the processes, reduce variations and control methods,
continuously improve the systems in place and manage assessment to ensure goals are being
met with efficiency and effectiveness. Companies implementing a solid performance
measurement system should follow these principles:

 Measure what is important, and customer satisfaction is always important.

 Be customer oriented and focus on meeting those needs. Customers give great
feedback, and this can help the firm decide what to measure.
 Involve your workers in designing and setting up a measurement system, this will help
them to feel involved and they will more likely want to uphold the standards and aim
to accomplish the goals you set together.
There is a cyclical approach to performance measurement that starts with the management of
expectations by outlining the process and defining the expected outcomes. Next, steps should
be taken to outline what is important to be measured, what will be impacted and the desired
outputs. Following that the managers should continue with the collection of data and develop
a strategy that will follow and link levels of performance to the set goals. And once those
steps are taken the final part of the cycle is to create an image of what the performance looks
like and what is being done whether for maintenance or improvement. Broken down below is
the cycle in the form of steps. Once a company follows this route, it will be easier to see how
daily acts performed by the company are either adding to the process or deviating from the
important objectives. 

1. Outline the direction the process will take

Identifying the direction of the process will offer an understanding of what you are about to
measure. Select the processes that impact the business and the customers and start there.

2. Identify the important activity and measure it

The focus should be on key areas and business components, not people. This needs to be
controlled because of the impact on productivity, efficiency and quality of other units of
measurement

3. Establish company’s performance goals, objectives or standards

Goals and standards need to be established to be able to compare logically what is being
accomplished. They should be established for various aspects of the company and measured
based on the standards set.  They should also be attainable, economic, applicable, consistent,
cover all interrelated department activities, understood by those trying to reach them, stable
and established, and most of all adaptable so if need arises they can be added to or subtracted
from, based on what is required by the customers.

4. Establish ways in which to measure performance

Each measurement system should contain a unit of measurement, a sensor (evaluation of

actual performance) and a consistent frequency (number of times measured).
5. Name the key department managers involved

In this step, the decision makers must be labeled and put into place. Various decisions should
be made such as how and what data will be collected, who will analyze and report the
performance, how to compare the goals and performance and what needs to be done if
corrective action is needed.

6. Collect relevant information

In order to support the goals and have cohesive information, useful, and relevant data must be
collected. Once collected, however, the leader in charge of data retrieval will need to extract
all the necessary information to find all the answers to the questions that will lead to
performance measurements. There are two types of data to be collected in this particular
process: (1) variable or measured and (2) attributed or counted data.

Measured data takes on different values and shows a numeric picture of the business’ process.
An example would be the number of hours spent working on a problem.

But counted data on the other hand does not necessarily present in numeric form. An example
of this type of data would be the answer to the question was the solution to the problem found,
yes/no?

7. Examine and report performance

The point, of collecting the data, is to gather new insights and draw conclusions. But before
this happens the data has to meet the following criteria:

 ensure data collected answered original questions,

 locate and remove any bias in the collection process,
 ensure the correct number of observations were accumulated, and
 finally ensure the data is enough to come to meaningful conclusions.

The next part of this step is to analyze. Remember, collected data is not necessarily a true
reflection of actual performance, so there will likely need to be more than one raw data input
to get the true picture. Once the raw data is put into the analytic system, it needs to be grouped
into a simple readable and understandable form, either tabular, statistical, graph or in a
singular chart as the data needs to be easy to draw conclusions from. Then finally the
information and conclusions will be developed into a report.

8. Compare goals and performance measured

In this step, the responsible party has to compare the report to the goals outlined from the
start. Are there variances to be corrected? If so, the leader will create his or her report and
send it on to the person in charge of making the changes.

9. Ensure corrective measures are taken

This step has to do with making a decision; does the leader take action, toss out the
recognized variance or make a new set of standards?  The leader can either change the
objectives or change the process taken to get to the objectives. A root cause analysis will help
to determine what the best possible solution is whether the process is redundant or the goals
unrealistic.

10. Bring process and goals in line with each other

This cycle is also known as the feedback loop, and it will close off once the goals and the
steps taken are in sync. There is a number of actions that can be taken to ensure the two are
working together to bring about the best results. The desired result is always to remove
defects and improve the process to achieve the main objective.

11. Establish new goals if needed

The step is pretty self-explanatory; if it doesn’t work then it needs to be adjusted. Keep these
three features in mind when designing new performance measurement goals.

 The degree of success in previous attempts.

 The changes applied to the process.
 The ability to adequately communicate improvement relative to the work process.
 Information Sheet Reporting procedures
5.3. Reporting procedures
5.3.1. Performance Reporting Components

Performance reporting is the process of collecting raw data, deciphering the coherence
between the goals and process and creating and distributing performance information to
stakeholders. There is an added aspect of reporting and that is the clarification of the use of
resources to obtain the goals that have been set. In a performance report clarification should
be done alongside the information provided on scope, cost, schedule quality and procurement,
as well as the following inputs should be taken into consideration.

 Data on work performance: This information outlines the work that is being
performed, completed recently and what the follow up steps will be.

 Units of Performance measurement: These measurements include schedule

variances, cost variance, cost performance index, schedule performance index and
planned value among others. These values help with reporting unbiased and relevant
quantifiable information, thus making better reports.

 Completed forecast: This measure is the predictor of future roadblocks in the process.
Forecast completion, or completed forecast is often expressed using two factors:
estimate at completion and estimate to complete, which gives time and amount
predictions for completing a project.

 Measures for quality control: Activities that compare results to quality standards and
processes are called quality control measures. These are put in place to ensure the
product provided is of the highest quality.

 Project Management Plan: This contains the performance measurement baseline,

which is the basis for approved management control.
  Requested changes approval: In the change request approval input, any changes that
have been approved are ready to be put in place. After project changes have been
approved, they need to be placed in front of stakeholders so these changes can be
communicated and implemented.

 Produced actions: These refer to all the actions, results, products associated with
producing and completing the task.

5.3.2. Benefits of Performance Reporting

Performances reports help companies to define, set and achieve better performance goals and
helps stakeholders manage the risk in investing in this company. The technology-driven
processes that can be put to analyze the raw data collected and turn it into actionable strategies
to help companies with their decision-making process. It comes with a lot more benefits, but it
needs to be a main focus of the company that wishes to improve its process.  The report
should cover every aspect of the company’s operation from concept to distribution and cover
the lifecycle of the business. Various studies that should be included in the report are
employee health and safety, social and environmental responsibility, safety of the processes
being undertaken and quality and security practices of the company.  By focusing on those
areas and including the fundamental components of leadership, risk management,
improvement and implementation, while involving the elements of an established structure, an
overview of each section of the report, a statement of purpose and set of expected outcomes,
business will benefit greatly from their performance reports. Listed below are just a few of the
immediate benefits that businesses with continuous performance management and
performance measurement, evaluation and reporting can expect to experience.

 Getting the most out of business practices internally

 Improved decision-making process
 Operational facility improvements due to changes
 Allows the team to analyze the status of the schedule and budget
 Continuous feedback to team members and managers
 Encourage effective communication with upper management and customers
 Early identification of variances to be addressed
 Quick implementation of corrective measures
 Access to new business and, therefore, new revenue
  Beating out the competition
 Spotting problems that need to be addressed

Self-Check five Learning Guide #40

1. List out the three main activities of Performance management

2. Outline the steps of a quality assurance process

Answer Sheet Score = ___________

Rating: ____________

Name: _________________________ Date: _______________

Short Answer Questions

1. _______________________________________________________________________
_______________________________________________________________________
__________________________________________________
2. _______________________________________________________________________
_______________________________________________________________________
___________________________________________
 FOR TRAINERS/TEACHERS USE

I. ANSWERS FOR SELF CHECK

ANSWER SELFCHECK ONE

Answer key
1. D
2. A
3. D
4. False (because we can’t store service)
5. True
6. True (In most services industry, both the service provider and the customer must be
present for the transaction to occur.
7.
1) Supply strong leadership
2) Integrate marketing throughout the company

3) Understand the customer

4) Understand the business

5) Apply operational fundamentals

6) Leverage the freedom factor

7) Use appropriate technology –

8) Practice good human resources management

9) Set standards, measure performance and establish incentives

10) Feedback the results to employees

 8.

i. relevant quality standards, policies and procedures

ii. relevant production processes, materials and products
iii. basic characteristics of materials used in the relevant production processes
iv. safety and environmental aspects of relevant production processes
v. relevant measurement techniques and quality checking procedures
vi. workplace procedures
vii. reporting procedures

ANSWER SELFCHECK TWO

1.
• This gap is the result of the other gaps
• This is the gap the customer notices
• Feedback on this gap (complaints) is diagnostic of the other gaps
• Here is where we obtain information that provides the imperative for
improvement.
• Proactively seeking feedback here is essential to improvement
2.

 Reliability - the ability to deliver the promised service in a consistent and accurate
manner.
 Assurance - the knowledge level and politeness of the employees and to what
extend they create trust and confidence.
 Tangibles - the appearance; of e.g. the building, website, equipment and
employees.
 Empathy - to what extend the employees care and give individual attention.
 Responsiveness - how willing the employees are to offer a speedy service.

ANSWER SELF CHECK THREE

1.

 With the informed consent of clients.

  When disclosure is necessary to prevent serious, foreseeable, and imminent harm of
the client or others.
 When required by federal and provincial laws or regulations.

2.
 Control of Documents
 Control of Records
 Internal Audit
 Control of Nonconforming Product
 Corrective Action
 Preventive Action

ANSWER SELF CHECK FOUR

1.

 Event detection
 Deviation Categorization
2.

 Description
 Correction
 Efficacy of Correction
 Batch Disposition, if applicable
 Root Cause Investigation
 Efficacy of Corrective Action
 Conclusion
 Data base record
ANSWER SELF CHECK FIVE
1.

 Selection of goals
 Consolidation of measurement information
 Interventions made by managers

3.

 identifying priority areas which need to be monitored

  setting targets, standards, or required levels of performance for these priority areas
 developing and implementing a system for collecting, analysing and reporting on
performance in priority areas
 identifying what action should follow if performance falls below targets, standards, or
required levels
 implementing and monitoring action for change
II. SESSION PLANS

Session Plan-1
Unit of Competence Apply Quality Standard
Module Title Applying Quality Standard
Assess own work
LO 1

Session Objectives: At the end of this session the trainees shall be able to –
 Understand Ways of assessing work
 Identify policies and procedures of relevant quality
standards,
 Identify Characteristics of services
 Employ Workplace procedures

Nominal
Activities Contents Methods
Duration
Sessions 40min Ways of assessing work Orientation
policies and procedures of relevant quality Lecture-
50min
standards, discussion
Characteristics of services Lecture-
45min
discussion
Workplace procedures Lecture-
50min
discussion
Individual
Evaluation Written exam
Activity
Summary Summarize the daily lesson Discussion
Resources  Learning Guide #36
 Session Plan-2
Apply Quality Standard
Unit of Competence
Module Title Applying Quality Standard
LO 2 Assess quality of service rendered
Session Objectives: At the end of this session the trainees shall be able to –
 Understand Quality check standards
 Examine Causes of faults
 Employ Methods of identifying and reporting faults
 Understand Parameters of evaluating services

Nominal
Activities Contents Methods
Duration
Sessions  Quality check standards
45 min Discussion
 Causes of faults Lecture-
45min.
discussion
 Methods of identifying and Lecture-
50 min
reporting faults discussion
 Parameters of evaluating services Lecture-
50min
discussion
Individual
Evaluation 2 hrs. Oral questions
Activity
Question and
Summary 5 mins Summarize the daily lesson
Answer
Resources  Learning Guide #37
 Session Plan-3
Apply Quality Standard
Unit of Competence
Module Title Applying Quality Standard
LO 3 Record information
Session Objectives: At the end of this session the trainees shall be able to –
 Basic information on the quality performance
 Recording performance information
Nominal
Activities Contents Methods
Duration
Sessions Define The concept of workplace
30 mins Discussion
relationship
Understand Importance of workplace Lecture-
45 min.
relationship discussion
Individual
Evaluation 2 hrs. Written exam
Activity
Question and
Summary 5 mins Recall the discussion
Answer
Resources  Learning Guide #38

Session Plan-4
Unit of Competence Apply Quality Standard
Module Title Applying Quality Standard
LO 4 Study causes of quality deviations
Session Objectives: At the end of this session the trainees shall be able to –
 Understand Quality deviations
 Identify Causes of Quality deviations
 Prevent quality deviations

Nominal
Activities Contents Methods
Duration
Recognize Quality deviations Lecture-
45 min
discussion
Understand Causes of Quality deviations Lecture-
90 min
discussion
1 hr Recognize Preventing quality deviations Lecture
Individual
Evaluation 1:30hr Written exam
Activity
Summary Discussion
Resources  Learning Guide #39

Session Plan-5
Unit of Competence
Apply Quality Standard

Module Title Applying Quality Standard

LO 5 Complete documentation
Session Objectives: At the end of this session the trainees shall be able to –
 Understand Quality parameters
 Identify Indicators of service performance
 Report procedures
Nominal
Activities Contents Methods
Duration
Sessions 45 Quality parameters
Discussion
Mins.
Indicators of service performance Lecture-
45Min.
discussion
Reporting procedures Lecture-
45Min.
discussion
Individual
Evaluation 5 min. Oral questions
Activity
Question and
Summary 15 mins Summarize the daily lesson
Answer
Resources  Learning Guide #40