How to Write NDIS Policies That Reflect Your Practice

For a registered NDIS provider, policies and procedures are the written record of how your organisation meets the NDIS Practice Standards that apply to it. To write your own, work out which standards are on your scope, describe how your service handles each area, then check what you've written against the standards for gaps.

If you're not sure which documents you need, start with our guide to NDIS policies and procedures, which lists them by audit pathway and module.

Writing them yourself takes time, but you're the person who knows how your service works, so the result should describe your practice closely. That matters at audit, and it matters more for your workers and participants, who rely on the documents being right.

Work out your scope

Your registration groups set your audit pathway, and your pathway sets what you need to write.

• Verification covers four areas: incident management, complaints management, risk management and human resource management.
• Certification covers every outcome in the Core Module, plus any supplementary modules that apply to the supports you deliver.

Your Initial Scope of Audit, generated when you submit your application, states your pathway and lists the modules you'll be assessed against. Write to that list. If you haven't applied yet, Certification vs Verification explains how the pathway is decided.

Policy, procedure and records

These three do different jobs, and each area you cover needs all of them.

Policy. What your organisation commits to and why, tied to the Practice Standard it answers.

Procedure. The steps that carry the policy out: who does what, when, and what gets recorded.

Forms and registers. Where the record lands. These are how you show the procedure is being followed.

The Practice Standards don't set a format or a template for any of these. You can combine a policy and its procedure in one document or keep them separate, whichever your workers will find easier to use.

Start with how your service operates

Write the procedure before you look at the standard. For each area, describe what happens in your service now.

Taking incident management as an example, answer these in order:

1. Who notices that something has gone wrong?
2. Who do they tell, and how quickly?
3. What gets recorded, and where?
4. Who reviews it?
5. What happens afterwards to reduce the chance of it happening again?

Your answers are the first draft of your procedure. Do the same for each area on your scope.

Write steps a new worker could follow. "Incidents will be managed in line with best practice" doesn't tell anyone what to do. "The worker who witnesses an incident phones the manager the same day and completes the incident form before the end of their shift" does.

If you don't have a process for something yet, decide what it will be, then write it down. Don't write a process you don't intend to follow.

What to include in each document

The standards don't prescribe contents. As a practical structure, I'd suggest each document covers:

• The purpose, and the Practice Standard it relates to
• Who it applies to (all workers, managers only, contractors)
• The policy statement
• The procedure, as steps, with who is responsible for each
• The forms and registers used, by name
• A version number, approval date and review date

Name the roles as they exist in your organisation. If you're a sole trader, the document should say that you do each step, not refer to a quality manager or a board you don't have.

Review against the Practice Standards

Once the draft describes your practice, go through each outcome that applies to you, along with its quality indicators, and check for gaps.

Where the standard asks for something your document doesn't cover, one of two things is true:

• You do it, but haven't written it down. Add it to the procedure.
• You don't do it yet. Change the process first, then document it.

Do this check after you've described your practice, not before. That way the document describes your service first, and the standard is used to find what's missing.

Our free Practice Standards Gap Analysis lets you pick your modules, tick the evidence you hold and download a report of what's missing.

Keep it proportionate

The length and detail of your documents should match the size and risk of your service. A sole trader delivering therapeutic supports doesn't need a 200-page manual. A provider with several sites and a large workforce will need more detail on delegation, supervision and reporting lines.

Leave out anything that doesn't apply to you, such as procedures for supports you don't deliver.

Check it with your workers

Before you finalise a procedure, ask the people who carry it out to read it and tell you where it differs from what they do. Where there's a difference, change the document or change the practice, and make sure everyone knows which.

This isn't a requirement of the standards, but a Certification audit includes interviews with workers and participants, and it looks at whether what they describe is consistent with what your documents say. What to expect from your Certification audit covers how those interviews work.

Keeping documents current

Update a document when the process it describes changes. A new service type, a new role, new software for incident recording or a change to the standards are all reasons to revise.

The Practice Standards don't set a review frequency. I'd suggest reviewing each document at least once a year, and recording the review even when nothing changes.

If you'd rather not start from a blank page

Writing your own suits providers who know the standards well and have the time. If that isn't you, how to get NDIS policies and procedures compares the other options: template packs, guided builders and consultants.

If you use a template pack, the method above still applies. See why policy templates sometimes aren't sufficient for what to check before you submit.