QA_POL_25 Continuous Improvement Policy

1. Purpose

Lumify Learn, are committed to service excellence and continual improvement of its day-to-day practices. This Policy and Procedure ensures that Lumify Learn: 

provide quality training and assessment across all of their operations consistently

adhere to principles of access and equity and maximises outcomes for all its students, and 

have management systems that allow for systematic monitoring of internal systems, strategies and practices that enable Lumify Learn to quickly respond to changes in the marketplace or to stakeholder expectations. 

2. Scope

This Policy and Procedure covers all of Lumify Learn’s training and assessment services across all campuses and all training/academic, student services, and governance staff members.

3. Responsibilities

The RTO Manager is responsible for ensuring this Policy and Procedure is implemented. The Compliance Coordinator is responsible for ensuring this Policy and Procedure is maintained and up to date in line with scheduled revisions. Managerial staff are responsible for ensuring their teams are up-to-date with this Policy and Procedure.

4. Policy and Procedure

It is the policy of Lumify Learn to develop, maintain and continuously improve its systems and procedures, including training resources to meet the needs and expectations of stakeholders, staff and learners.

Lumify Learn aim to maintain and continuously improve its services using a systemic approach in all areas of activity to ensure high quality outcomes. It has established procedures and processes for identifying and managing improvement activities and opportunities with its Continual Improvement Register its primary working tool for the monitoring of activities and actions to be taken to address continual improvement.

The key principles of continuous improvement revolve around creating a culture of:

  • continuously understanding customer needs.

  • customer focus

  • optimizing organizational performance

  • focusing on means to an end

  • continuous learning on mistakes

  • continuously improving systems and processes

  • fixing root cause of problems.

Lumify Learn acknowledge its investment in its continuous improvement program however also understands the benefits to the RTO and overall student experience with:

  • improved team morale

  • team member “buy-in”

  • reduced waste through improved processes

  • improved quality delivery

  • reduced rework time

  • faster response times, giving customers improved satisfaction

  • becoming more competitive by driving down costs, and

  • retaining/gaining customers through innovative products and services.

Lumify Learn have a systematic approach to assuring quality in all aspects of the business – in training and assessment services, client services and the management of its operations. The RTOs’ quality assurance and continuous improvement approach is based on the ISO Quality Management System 9001:2015 principles of Plan, Do, Check, Act methodology. The key components to this methodology are: 

  • the requirements of regulatory bodies, industry and customers are first understood and an approach is developed by the organisation to meet those requirements 

  • the plans are implemented and services are provided 

  • feedback and results are collected and analysed 

  • improvements are made based on the outcomes of the results 

  • the cycle is then repeated to implement improvements (refer to diagram representation).

The following mechanisms are in place to ensure quality within: 

a total quality management system including documented policies, procedures, systems and plans on which all staff are trained and given access to. This is built on a Student Experience Framework, with the following elements:

  • Plan

  • Foundation

  • Build

  • Accomplish, supported by a Quality Framework.

  • an RTO Delegation Register that informs of the key accountabilities across the RTO embedded.

  • regular staff Quality Bulletins on any changes and new policies, procedures and related documentation.

  • scheduling of internal staff training on updated Policies and Procedures and regular refresher training.

  • monthly Quality & Compliance meetings, chaired by an independent VET Consultant, which discuss both quality and compliance matters, based on the outcome of internal audits, validation of assessment activities and feedback from all stakeholders in the prior month.

  • a Master List: policies & procedures, documents and audit plan, risk schedule which maintains a record of the latest version of all policies, procedures, templates, forms and supporting documents, with an archival and retrieval system for all previous versions.

  • business processes that ensure feedback is collected from a wide range of stakeholders on a regular basis. Feedback is collated and analysed to measure performance and identify areas for improvement. This practice is encouraged throughout the RTO and is formalised through Lumify Learn ’s monthly Town Hall staff meetings.

  • an internal audit cycle that ensures Lumify Learn systematically checks that its RTO meets the requirements of legislation, regulatory frameworks, client service expectations based on identified RTO risks (refer to Master List: policies & procedures, documents and audit plan, risk schedule for internal audit schedule).

  • Lumify Learn systematically monitors the RTO’s training and assessment strategies and practices to ensure ongoing currency and efficacy of the qualifications and courses on its scope of registration. The training and assessment strategies (TAS) and related curriculum and material are reviewed at least annually. 

  • Lumify Learn has sufficient strategies and resources to systematically monitor any services delivered on its behalf and uses these to ensure that the services delivered comply with the requirements of legislation, regulatory frameworks and client service expectations and has formal Agreements with each party, which outlines both parties’ responsibilities and the manner in which the RTO monitors the third party

  • regular assessment validation sessions against the Validation of Assessment Schedule that ensure the training and assessment practices used by Lumify Learn are of high quality, meet the needs of industry and regulatory requirements against the cycle specified within the Standards for RTOs (2015). 

All staff are responsible for the communication and promotion of this Policy and Procedure and for working in an accountable and transparent manner with others, which includes identifying and working in collaboration on solutions to improve service delivery and business activities.

Lumify Learn strive for excellence and considers continuous improvement processes integral to its ongoing success for its RTO. The organisation considers all business outcomes and processes to be an opportunity to learn, reflect and improve. Self-reflection and evaluation play a key role in the organisation’s quality assurance system and all managers and staff are encouraged to regularly reflect and evaluate performance and make recommendations for improvement through both informal and formal strategies, such as the Feedback Form and Validation of Assessment activities. Lumify Learn’s management teams will consider all recommendations for improvement made by any stakeholder. Recommendations, or an alternative strategy for improving the business area, will be implemented if the improvement is considered viable and where the recommendation is considered to be an improvement to current practices or outcomes. 

A detailed Continuous Improvement Register of the organisation’s continuous improvement suggestions, plans and achievements is maintained. This is aligned to Lumify Learn’s Student Experience Framework and enables Lumify Learn to target, improve and analysis areas of improvement which are client centred. The

Continuous Improvement Register records the following information for each issue:

  • date

  • cause

  • improvement activity: how this will be achieved, resources required, person responsible, timeline, progress, any approval required, implementation date and notes/comments

  • closed off date and follow up date of review as a comment (where high risk).

Stakeholder Feedback

The following groups are considered key stakeholders of Lumify Learn’s business: 

  • students and persons seeking to enrol. 

  • employers of students.

  • employers/companies.

  • clients or prospective clients of students. 

  • staff, both permanent and contractors. 

  • partner organisations.

Lumify Learn collect formal and informal feedback in the following ways and uses findings to gauge performance and identify opportunities for improvement:

  • evaluation surveys about a student or stakeholder’s experience of their course, workplace visit or with the organisation in general. 

  • satisfaction surveys are used to gauge student engagement and client satisfaction using the VET Quality Framework and AQTF quality indicator (QI) surveys, for students and industry.

  • discussions held during interviews, focus groups and meetings with students, clients and industry organisations – both service providers and peak bodies. 

  • outcomes and drivers of complaints and appeals. 

  • findings of internal and external audits. 

  • feedback provided by staff during staff performance appraisals, reviews and exit interviews. 

  • discussions held during internal staff meetings, including the monthly Town Hall meetings and daily huddles.

  • discussions held during moderation and validation activities. 

  • discussions held during industry meetings. 

  • informal discussions with other stakeholders. 

All stakeholders are invited to provide their feedback on any aspect of the organisation’s products and services at any time.  Feedback can be provided in person, over the phone or in writing using the Feedback Form available on the website. All feedback received will be used in Lumify Learn’s continuous improvement cycle. 

Feedback provided by staff plays an integral role in organisational self-assessment and performance evaluation. Trainers and assessors are likely to receive formal and informal feedback during their regular face-to-face interactions with students and other stakeholders. Trainer and assessors are also expected to provide their own feedback to the organisation on a regular basis so that their experiences can provide valuable input to the business decisions and operations of Lumify Learn. 

Staff are provided with the following opportunities to provide their feedback or pass on feedback received from others: 

  • meetings with their supervisor

  • (informal) Feedback Form

  • performance reviews

  • moderation and validation sessions,

  • fortnightly Compliance meetings, and

  • monthly Town Hall staff meetings.

In line with the requirements of the VET Quality Framework and Clause 7.5 of the Standards for RTOs (2015), Lumify Learn collect and use data obtained through Quality Indicators to gauge its own performance.  Relevant (previous calendar year) indicator data is reported to the ASQA by the 30th June each year. These indicators are: 

  • student Engagement 

  • employer Satisfaction.

Reports from the Quality Indicator feedback collection tools is used by Lumify Learn to monitor and benchmark its performance at regular intervals.  This allows identification of: 

  • areas that need improvement 

  • areas where performance is getting weaker 

  • improvement targets, and 

  • whether the improvement plan is working. 

Collect Continuous Improvement (CI) Records

Staff, students and other stakeholders are invited to provide informal feedback and suggestions for improvement to any part of the organisation through a Feedback Form, available on Lumify Learn’s websites.  These Forms are reviewed regularly and form the basis of the review of the organisation’s performance.  Feedback analysis is shared by the Compliance Coordinator at quarterly Town Hall meeting.

Summarise each Continuous Improvement Record on Continuous Improvement Register

As they are received, the Compliance Coordinator logs the details of each Continuous Improvement suggestion on the Continuous Improvement Register

Record recommended improvements on the Continuous Improvement Register, without the need for a Feedback Form 

From time-to-time, Lumify Learn may make decisions about improvements from a management level.  These improvements are often not the result of a form or suggestion but rather from a managerial direction or response to operational events, achievements or issues.  These improvements are recorded on the Continuous Improvement Register without a Feedback Form as these changes are made. 

Implement the Improvements and Record Outcomes 

The RTO Manager ensures those responsible for implementing improvements are aware of their responsibilities and the agreed timeframe. Once implemented, the person responsible must report the outcome and completion date, which are recorded on the Continuous Improvement Register, by the Compliance Coordinator. 

The RTO Manager monitors the Register regularly to ensure it is up to date, timelines are adhered to and records of implementing improvements are kept accurately. An improvement is not closed until the improvement is evaluated, that is it has been checked that the improvement achieved what is expected and that there were no unintended consequences. The extent to which improvements are evaluated depends on the level and complexity of improvement and are at the discretion of the management team.

Collecting and Collating Student’s Feedback from Students

Lumify Learn uses formal surveys to collect feedback from students at course commencement (2/3 weeks from enrolment), using its own Student Commencement Surveys and at completion, using the ASQA prescribed Learner Quality Indicator Questionnaire at completion (refer Feedback Policy & Procedure). Lumify Learn endeavours to collect data for the Quality Indicators from all students who are enrolled in a program and the Compliance Coordinator monitors the number of returned surveys received to ensure that at least 80% of the student population completes a survey.

Responses are collated and reported to ASQA annually. Data is due in each year (for the calendar year before) on 30 June. The Compliance Coordinator is responsible for reporting this data to ASQA and must receive approval of the final report from the RTO Manager prior to submission.

Collecting and Collating Employer Feedback

Lumify Learn endeavour to collect data from all employers and workplaces who have students enrolled in a program. The ASQA prescribed Employer Quality Indicator Questionnaire is distributed to all employers by Lumify Learn’s Compliance Coordinator and trainers and assessors where delegated. The Compliance Coordinator monitors the number of returned surveys received to ensure that at least 80% of the relevant employer/ workplace population return a completed survey. The feedback is used in Training and Assessment Strategy and training product reviews.

Responses are collated and reported to ASQA annually. Data is due in each year (for the calendar year before) on 30 June. The Compliance Coordinator is responsible for reporting this data to ASQA and must receive approval of the final report from the RTO Manager prior to submission.

Internal Audits & Continuous Improvement

This procedure outlines the approaches taken by Lumify Learn to ensure quality and compliance against the standards and quality frameworks with which the organisation is required to adhere to. 

The RTO Manager schedules audits annually, by adding them to the risk management schedule, with timing over the year based on the level of identified risk to the RTO (refer to the Master List: policies & procedures, documents and audit plan, risk schedule) and the RTO risk matrix (Attachment A).

In close liaison with the General Manager, the Compliance Coordinator nominates person/s to carry out audit (internal or external). The staff member/external person carrying out each audit is confirmed as conversant with the policy, procedures and external legislative requirements and quality frameworks that affect the environment the Lumify Learn operates in and/or the area being audited.

The Compliance Coordinator will manage the collection of evidence to demonstrate practices against each audited standard. When auditing, the sample size of activity evidence (e.g. student assessments) is selected to be statistically valid, as well as support the audit process.

The audit report includes identification of the evidence used to conduct the audit, an overall finding against each standard, recommendations for improvement and required rectifications. The Compliance Coordinator ensures that all documentation of the internal audit is complete and accurate and show transparency in the documents and evidence used to form a decision.

The RTO Manager reviews and endorses all audit reports and present findings to the next Town Hall meeting. The risk rating is also reviewed and adjusted according to the findings, which may result in an agreed decrease or increase of risk to Lumify Learn – this decision will impact on the cycle of internal auditing of this activity with the risk management schedule also adjusted accordingly. Any improvement strategies agreed to as a result of the audit are recorded in the Continuous Improvement Register: these strategies are monitored by the Compliance Coordinator through to completion and approval by the General Manager. A copy of a signed, dated and endorsed audit report by the RTO Manager or his authorised delegate is kept on file.

5. Related Documents

QA_REG_01_01 Master Register: policies & procedures, documents and audit plan, risk schedule

QA_REG_01 RTO Delegations Register

QA_REG_25 Continuous Improvement Register 

QA_POL_08 Complaints and Appeals Register

QA_FRM_25_01 Quality and Compliance meeting Standing Agenda template

QA_FRM_25_02 Quality and Compliance meeting Standing Minutes and Action List template

QA_FRM_15 Validation Assessment Recording Tool

QA_FRM_20_03 Initial experience feedback form (domestic)

QA_FRM_20_06 Student Exit Survey (Learner Quality Indicator Questionnaire) 

QA_FRM_20_07 Employer Survey (Employer Quality Indicator Questionnaire)

QA_FRM_023 Industry Engagement and Feedback Form

QA_FRM_20_01 Feedback Form

Quality Bulletin hard copy template


RTO Risk Matrix

Lumify Learn identify and mitigate its VET practice risks through analysis against the risk framework below. Lumify Learn’s Internal Audit Schedule, as outlined within the Master List, supports the monitoring of the risks as well as ensuring mitigating circumstances are identified and controlled.


Potential Impact/Consequence (within an RTO environment)

Unlikely/Rare – where systems are consistently followed

Low/Insignificant – minimal foreseen impact on business

Likely/Possible – where systems are not always followed

Medium/Moderate – failure to initially pass external audit

Highly Likely/Almost Certain – where systems are rarely followed

High/Major – suspension of RTO licence or government funded contract

Extreme/Catastrophic – cancellation of RTO licence and/or government funded contract

Potential Impact/Consequence from an external Audit





Likelihood of Staff Adherence











Highly Likely/Almost Certain





Risks which are assessed as being in one of the following categories are assessed as ‘Very High’ and will be proactively managed:

  • High/Major consequences which are Almost Certain to occur

  • Extreme/Catastrophic consequences which are Possible, Likely or Almost Certain to occur.

Very low risks are categorised as Insignificant with at best only the possibility of occurrence or are rated as Minor/Rare.

Internal auditing is established to provide independent and objective advice which supports Lumify Learn in achieving their goals by assisting it to achieve sound managerial review and control over all of its operations.

As such, Lumify Learn administer the following internal audit regime:

  • Extreme Risks will attract an audit undertaken by an external Consultant every 6 month

  • High Risks will attract an audit undertaken by an external Consultant every 12 month, or at the very least, a validation of an audit undertaken internally

  • Medium Risks will attract at least an internal audit every 12 month by an internal staff member, usually the Compliance Coordinator, and

  • Low Risks will attract at least an internal audit every 2 years by an internal staff member, usually the Compliance Coordinator.