A systems approach to RTO self-assurance


There is an increasing demand from clients and others in the sector who are wanting to establish a system of self-assurance within their RTO. This interest is in response to messaging by ASQA encouraging providers to adopt a self-assurance approach to the management of their RTO operation. ASQA undertook consultation in August 2020 and released a paper in Nov 2020 summarising the feedback it received (click). This paper seemed to promote initiatives such as internal audits, collecting student feedback, and validation. This feedback seems to focus on what I consider are self-assurance related “activities” rather than proposing a model for holistic self-assurance that may have emerged from the consultation.

Almost 15 months after the conclusion of this consultation and the National VET Regulator has not yet published tools or guidance on how an RTO should approach self-assurance. In June 2021, ASQA promised to “share enhanced self-assurance tools” in the coming 12 months! Clearly work is happening but it seems to be taking a very long time for the regulator to provide it’s promised guidance. Meanwhile, the early adopters are just wanting to get on with it, hence, the reason for this article. My sincere hope for the sector is that, when ASQA do publish their “enhanced self-assurance tools”, I hope that this is more than just some type of enhanced self-assessment tool or validation tool or student survey tool. I hope it will provide a model for holistic self-assurance that supports all parts of the RTO operation.

Lets not forget the past

We are not re-inventing the wheel here. We are essentially talking about quality management which has been around since the 1930s and subsequently spread to the manufacturing industry and was particularly evolved by the Japanese motor production industry in the 1950s and 60s. I was introduced to Total Quality Management by my brother Paul in the context of the textiles and laundry industry and thanks to his infectious enthusiasm and belief, I had my “light-bulb moment”. Of course, these days we have a swag of “quality management systems” and standards out there such as the International Standards Organisation library of standards of most note the ISO 9001 “family” of quality management standards. We should also not leave out Six Sigma which is a well-accepted model for quality control informed by data collection and measurement.

We also should mention the VET sector’s previous attempts at introducing quality improvement which commenced in 2005 with the release of the AQTF standard at the time. The AQTF 2005 required RTOs to “collect and analyse stakeholder and client feedback and satisfaction data on the services it provides as the basis for improvement” and to “develop and implement written procedures relating to acting on opportunities for improvement” (Clause 1.9 and 1.10). This was expanded significantly in the AQTF 2007 standards (Clause 1.1, 2.1 and 3.1) by requiring the RTO to “collect, analyses and act on relevant data for continuous improvement of training and assessment and client services” as well as requiring the RTO to “use a systematic and continuous improvement approach to the management of operations”. This focus on the collection and analysis of data was then and is still critical to enabling continuous improvement. I find that some clients can get a little lost in this reference to “data” and I think moving forward we need to recognise that language is so important to either enabling or disabling adoption of policy. I explain that by “data” it simply means information or outcomes that can flow from various monitoring activities such as student surveys, assessment quality checks, spot audits, trainer feedback, assessment validation, to name just a few. These activities will often result in outcomes or findings which is the information we analyse to identify opportunities for improvement.

Those who have been in the sector from this time will recall how much focus was given to continuous improvement back in those days. When I undertook regulatory audits over these years, I would ask to see the RTOs continuous improvement policy and register of continuous improvement actions. I would then validate a sample of these improvements by requesting evidence of their implementation. When I think back about that time now, it all seems quite superficial but, maybe these were the necessary early steps to introduce the concept of continuous improvement and quality management to the sector. As a consultant in those days, I spent a significant amount of my time guiding clients in the establishment of their continuous improvement model. In the current standards released in 2015, there is clause 2.2 which is similar to previous standards which requires a systematic approach to continuously improve.

We need to acknowledge that clause 2.2 in the current standards has virtually not been included in an ASQA audit scope since 2016 when ASQA excluded this clause and many others from its much vaunted “student-centered audit model”. In 2016, the regulator’s focus on continuous improvement essentially disappeared. I know that in many RTOs the continuous improvement arrangements that were gradually developed through the period of 2005 – 2015 have now unfortunately fallen away. The regulator’s decision to exclude clause 2.2 from the student-centered audit model is likely to be a key barrier in moving forward with an even higher expectation of self-assurance. In many cases (not all), the key “sector wide” learnings about continuous improvement process forged over those years, the information systems to manage CI, the collection and analysis of information and the regular CI meetings have been discontinued. When a client says to me these days that they will enter a finding into their continuous improvement register and discuss at the next management meeting, my ears prick-up and I get a little burst of joy that the client still has these arrangements in place. It will be very challenging to regain this lost continuous improvement capability for many providers but, if we really want to move toward self-assurance, this is a good place to start.

View your RTO operation as a system

Self-assurance simply means to be confident. It means having confidence in your systems to ensure your compliance with regulatory requirements and having confidence in your service delivery and resilience. So, it’s not just about compliance. Being self-assured means that we can have confidence in the whole business with quality service delivery as the primary objective and compliance achieved as a consequence of systems working together. This focus on systems and taking a “systems approach” to viewing and managing your RTO is critical to enable self-assurance.

We need to shift the thinking from viewing the RTO operation as a lineal service delivery operation from marketing to completion, to view the RTO as a system of interacting components. We need to recognise that these components are team members performing their relevant tasks such as training, admin support, marketing, compliance, course design, et cetera. These team members all have points of interaction with each other. As an example, a course designer will interact with marketing, a trainer will interact with admin support. When the trainer submits an assessment to admin support for a quality check and the recording of results, this is an interaction of two components (internal customers) as part of the overall RTO system.

I identify the following three components to the RTO System:

  • Enrolment and Completion – Standard 4, 5 and 3
  • Training and Assessment – Standard 1
  • Governance and Administration – Standard 2, 6, 7, and 8

Viewing the RTO operation as a system enables systems thinking about how these components work together and are interconnected. This is very different from a more traditional view of the RTO operation as a lineal process along the student pathway. Applying systems thinking recognises that each team member within these components is relying on other team members from other components. It is not possible to work in isolation. We all depend on each other to ensure the system is working to achieve the best possible outcomes. Within the system everyone’s job is as equally important.

The points where the work intersects are critical production points where team members will need to regularly communicate to set local rules and expectations for the exchange of work with each other. This is often referred to as managing the internal customer. As an example, the trainer is a customer of the admin team. The trainer will deliver their completed assessment to the admin team. The admin team will review the assessment as part of a quality control process (hopefully). If the admin team find that the assessment is incomplete, they will return the assessment to the trainer for remediation. This wastes time and energy, can lead to friction, delays outcomes being reported, delays revenue being claimed, delays certificates being issued and of course is a potential non-compliance. This can be resolved by the trainer and the admin team communicating with each other about each other’s needs to make the process more efficient.

Hopefully this results in the trainer having a better understanding of how they need to better prepare their work for submission to the admin team to improve the process efficiency. It may also resolve any misinterpretations by the admin team that is leading to work being unnecessarily held up in assessment quality control. It is always a two way street. An important part of systems thinking is identifying these critical production points and getting those involved talking to identify ways to improve both the quality and efficiency. In systems thinking, we appreciate the critically important part that everyone performs in the system. If any of those components fall over, it will impact on the whole system. Everyone needs to be trained and informed about their duties and be accountable for their responsibilities. Everyone needs to consult with their internal customers to set and understand expectations. Everyone needs to view their role as an important part of the system as a whole.


An RTO self-assurance model

With an understanding of the RTO system, we can now move to build a self-assurance model to compliment the system. I identify three important mechanisms of an RTO self-assurance model. These include:

  • assurance coordination,
  • a calendar of assurance activities, and
  • local assurance actions.

Lets unpack these.

Assurance coordination.

Assurance coordination may occur during a management meeting or other regular coordination meeting. It may be conducted in any format but must be a regular meeting such as once per week or fortnight. Those responsible for assurance coordination will receive the information and reports of opportunities for improvement that are flowing from the assurance activities and actions and will consider these in a consultative way to decide on what action to take regarding improvement opportunities. I frame this as “coordination” because there does need to be management oversight and coordination of the self-assurance model. Some opportunities for improvement are simply not possible at the time due to resourcing constraints and management need to balance improvement activity with production activity.

Assurance coordination is ideally constituted by your regular management or team meeting attendees. Infact, I would strongly recommend that your self-assurance management be integrated with your regular management or team meeting. Particularly for small to medium sized RTOs, I do not advocate the establishment of separate committees or separate meeting arrangements. Try and keep it integrated with your usual meeting. For a large RTO, it may be best to establish a separate meeting or committee due to the more complex operational requirements and utilise a self-organising approach with assurance coordination at separate campuses or business units.

To coordinate self-assurance, you will need an information system to enter and manage the improvement actions which are agreed for implementation. Most of these improvements are not simple and many will stay open for many weeks and sometimes months while those responsible for implementation will report back about their progress. An “information system” may be as simple as a Word doc with a table to record improvement initiatives and actions. There are of course various software platforms that are available for this purpose at a cost. Your RTO student management system may also have an integrated quality management system build in like our own RTO Data Cloud. In the first instance, I recommend keeping it very simple and consider more sophisticated options once you have some runs on the board. I have seen some very successful continuous improvement systems using just a spreadsheet to record improvement initiatives and actions.

I do suggest that you adjust your meeting agenda to include self-assurance as a key meeting agenda item. This should include a sub-agenda item to review and discuss all new opportunities for improvement that have been submitted. Deal with these one at a time unless there is a common theme. Discuss the options and consider the need for more information prior to making a decision. Once a decision is made, be very clear in your direction. If the improvement is not identified for action, then provide the feedback to those who suggested it. If the improvement is agreed for action, then allocate a champion as the person responsible, allocate resources, agree on a timeframe and reporting arrangements, identify any coordination that is required across your “system”. This is particularly important to implement improvement actions in consultation with the relevant internal customers to achieve the maximum benefit. I might just make the point here that, it often occurs that new improvement opportunities may link or overlap with current improvement actions that are already underway, so you may consider linking these or merging these for more efficient coordination.

After you have considered all new opportunities for improvement, you can then move to the next sub-agenda item which should be to systematically review all open improvement initiative that are underway. It is important to work through these and consider their progress, give advice to those responsible, adjust resourcing if required, agree on revised timelines and reporting arrangements if necessary. The goal eventually is to close these actions and appreciate the impact of the improvement on the system. But sometimes this takes time, resources and coordination and it is the job of assurance coordination to provide that. This is also a great opportunity for recognition. We should recognise those that have carried through with the actions and have achieved the improvement. These people are the champions of self-assurance.

Calendar of Assurance Activities.

A calendar of assurance activities is a very basic concept that can have a massive impact on your overall management and coordination of the RTO system. This is simply a list of activities or events that need to occur throughout the year to meet quality assurance objectives. By this I mean everything from mandatory obligations that are part of the VET quality framework to the assurance monitoring activities and even the operational events that need to regularly occur. Basically, anything that can be scheduled into a calendar at the organisational level should be to recognise its importance and necessity. In many ways, you can think of this like the self-assurance engine that is ticking along in the background keeping everything else moving.

The following is just a snippet of the type of events that you may consider for your calendar of assurance activities:

  • Professional development activities,
  • Assessment validation events,
  • Mandatory reporting,
  • Policy and procedure review,
  • Third party monitoring activities,
  • Internal audits and spot checks,
  • Assessment moderation activities,
  • Training and assessment strategy review
  • Delivery site inspections and audits,
  • Industry consultation events and activities,
  • Management and team meetings,
  • Annual trainer survey,
  • Information systems review,
  • Trainer competency and currency audit
  • Marketing and enrolment review,
  • Regulatory information review,
  • Fees and payment review, and
  • Financial reporting

Clearly this is not an exhaustive list, and these assurance activities will be different for every RTO depending on its size and operating context. It is also the case that many of these activities will be reoccurring. As an example, I usually recommend that a client schedule staff professional development at lease three times per year. Management team meeting will be a regular occurrence in the calendar and things like “third party monitoring” is a broad description for a whole bunch of activities that will be scheduled throughout the year. You need to adapt your calendar of assurance activities to suit your business. Putting these important events into a calendar and planning the year ahead is an awesome way of getting organised to ensure these things happen. Not sure who coined the saying “if you fail to plan, you plan to fail” but this is completely true when it comes to a compliant and efficient RTO operation. Put it in the calendar and make the time and resources to ensure these activities occur.

The key point to conducting assurance activities is this, there will be outcomes that result from these activities that are valuable sources of information and potential opportunities for improvement. As an example, assessment validation may result in findings in relation to assessment practices that need to be improved or a delivery site audit may identify deficiencies in equipment availability at the site. These outcomes will feed into the forum for assurance coordination to be considered as opportunities for improvement. If this is undertaken properly and with purpose, there will be a steady stream of improvement opportunities to consider and act on as appropriate as the year progresses.

Local Assurance Actions.

Local assurance actions are the individual tasks that compliment self-assurance and are performed by individual team members in the normal course of their work. An example of this is the trainer participating in professional development to maintain evidence of their ongoing development of their training and assessment skills or a member of the admin team undertaking a quality check on completed assessment tools as part of the assessment quality control. Everyone has an important job to perform in an RTO from the newest team member to senior management. There are certain aspects of these jobs that have a direct relationship to compliance and self-assurance. It is important to note, that these actions should not be confused with Calendar Assurance Activities. Assurance activities are more organisation directed or collective activities, where assurance actions are the individual responsibility of each person during their work.

It is valuable to recognise these tasks as having an important relationship to self-assurance and compliance. Doing so, deepens each individual’s responsibility for compliance and reinforces the concept that compliance is everyone’s responsibility. It is not expected that significant opportunities for improvement will result from local assurance action, although each team member is certainly encouraged to report opportunities for improvement if these are identified during the normal performance of work.

Examples of local assurance actions are:

  • Training and Assessment (Clause 1):
    • Delivery of a sufficient amount of training
    • Delivery in accordance with the training package
    • Sufficient resourcing of training and assessment
    • Engagement with industry
    • Monitor and support learners
    • Collection and recording of sufficient assessment evidence
    • Accurate reporting of assessment outcomes
    • Participating in assessment validation and moderation
    • Verification of trainer competency and currency
    • Maintenance of trainer industry currency
    • Participating in professional development on VET
    • Accurate transitioning of training products
  • Enrolment and Completion (Clauses 3, 4, 5):
    • Preparation and maintenance of marketing material
    • Review and approval of marketing material
    • Preparation and maintenance of pre enrolment information
    • Review and approval of pre enrolment information
    • Engagement with learners to determine their needs
    • Administering applications for credit transfer
    • Verifying unique student identifiers
    • Post commencement survey of learners
    • Conducting assessment quality control
    • Quality control of AQF certificate issuance
    • Post completion survey of learners
  • Governance and administration (Clauses 2, 6, 7, 8):
    • Coordination of self-assurance activities and meetings
    • Administration of third party arrangements
    • Monitoring of third party delivery of services
    • Administration of complaints and appeals
    • Management of organisational financial performance
    • Management of VET data collection and reporting
    • Management of organisation insurance protection
    • Keeping the NVR informed of material changes
    • Responding to requests from the NVR
    • Administer any mandatory reports or declaration
    • Maintain legislative compliance arrangements

Implementing self-assurance

The following steps should be taken to implement this system of self-assurance:

  • Present the concepts of this article to your team in a workshop and brainstorm how you might adapt this system of self-assurance to your unique organisation.
  • Identify a forum for assurance coordination and make the appropriate changes to the meeting structure, agenda and put in place the supporting information systems. This can be as simple as a spreadsheet.
  • Draft a calendar of self-assurance activities for commencement in January 2022. Use some of the activities I have suggested in this article where appropriate. Give yourself the next four months to educate team members and put in place the arrangements to undertake self-assurance activities. Put in place reporting arrangements to capture the valuable outcomes from these activities.
  • Provide a program of professional development to your organisation over the next four months on your self-assurance approach. Place a lot of emphasis on the local self-assurance actions that they are all responsible for. Reinforce individual responsibility in the context of a shared goal. Introduce the basics of quality management principles and systems thinking. Keep this fairly light and you will be amazed at how this can empower individuals. Watch the champions emerge.
  • Kick off your system of self-assurance with a little event. You want people to recognise that this is the start of something special that they are part of. Be realistic that there will be challenges and interruptions but reaffirm the organisation’s commitment to stay on task with this.
  • Schedule quarterly team meetings to bring everyone together to talk about how things are going and to discuss how the implementation can be improved. Keep in mind that this system is owned by everyone, so everyone has a voice. Reinforce the shared goals of the organisation.
  • Don’t be afraid to step back and allow your champions to step forward. One of the most amazing things about quality management and systems thinking is that is can be a light-bulb moment for some people. Suddenly they see the organisation as an interconnected system and they can see where the choke points are and the inefficiencies.
  • Give yourself one year of running your self-assurance system and then conduct a review with the team. Take note of everything that has been achieved over the year but also take note at how the team are now more engaged in the organisation, how they have an ownership in achieving continuous improvement.

In conclusion

In this article, we have recognised the multiple layers to self-assurance within the RTO System. We have our self-assurance engine ticking along with our calendar of self-assurance activities (macro layer). This helps us to meet our compliance obligations and to schedule and conduct the monitoring activities needed to identify opportunities for improvement. We have every team member focusing on the performance of their own local self-assurance actions during the normal performance of their work. Each team member acutely aware of their responsibility to perform these actions to promote quality and efficiency and to manage the exchange of work with internal customers (micro level). In the middle of our system, we have assurance coordination reviewing the emerging opportunities for improvement and providing the direction to act on these where appropriate and coordinating the conduct of the calendar of assurance activities.

Lets be clear, this stuff is not easy, but nothing that pushes us to improve ever is. You will stumble at first and make mistakes that are valuable lessons to improve as you move forward. Remember that, self-assurance means having confidence in your service delivery and your resilience. Being self-assured means that we can have confidence in the whole business with quality service delivery as the primary objective and compliance achieved as a consequence of working together. Give yourself this opportunity.


Good training,

Joe Newbery

Published: 13th August 2021

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