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Defence Estate Quality Management System (DEQMS) BSI Certification


Stage 2: Assess Continuous Improvement (CI) Opportunity and Register as a NC or OFI


Activity 1 - DEQMS team conduct a quick assessment of the CI and escalate as required.

  • discuss the CI and check to make sure a similar CI has not already been registered.  If we have seen this problem/opportunity before and there is a significant concern then the CI will be escalated via the CI Escalation Process, a risk assessment will be conducted as required; and
  • does the CI have Work Health Safety WHS implications? It's automatically deemed to be severe and must be addressed urgently in accordance with Work Health Safety Act.

Activity 2 - DEQMS team record the CI as a Non Conformance (NC) or Opportunity for Improvement (OFI) and advise originator.

  • record the NC / OFI on the Register;
  • create an objective folder as per the agreed file structure;
  • complete Stage 1 of the CI Registration and Tracking Form and save it in the Stage 1 objective folder; and
  • email the originator with a NC / OFI number to confirm it’s been received and recorded.

Activity 3 - DEQMS team organise the CI Stage 2 Assessment meeting to discuss the NC / OFI.

The DEQMS team lead the CI Stage 2 Assessment meeting using the CI Stage 2 Assessment Meeting template with the identified internal and external SME’s/stakeholders.
The meeting will discuss the following:

  • overview of the DEQMS CI Process and way forward for the NC / OFI;
  • outcomes of the DEQMS quick assessment;
  • PRAP outcomes, if relevant;
  • does this relate to legislation, policy, process, template or product;
  • identify the possible approach to progress the problem/opportunity;
    • process mapping, facilitating workshops;
    • analysing existing policy or process guidance or the need to address a new Australian Government obligation;
  • discuss who the appropriate stakeholders/directorate responsible for addressing CI including if it relates to other areas in Defence i.e. contractor, Group or Service; and
  • is there a quick fix to the CI, what is the risk of doing nothing;
  • do we need to do a Continuous Improvement Risk Assessment;
  • is a CI plan required, who will be the SME Lead assigned the responsibility to develop the CI Plan and date it will be provided; and
  • what are our next steps and agreed timeframe's.

If agreement cannot be reached between the SME’s/stakeholders, the CI should be escalated using the CI Escalation Process.

Activity 4 - DEQMS team update the NC / OFI record with the outcomes of the meeting.

  • schedule the next meeting;
  • complete the CI Meeting Minutes;
  • update the CI Registration and Tracking Form with the endorsed CI Meeting outcomes, including the agreed timeframe's and way forward;
  • send the SME Lead the updated CI registration and Tracking Form;
  • update the NC / OFI Register; and
  • save/update records in Objective.

Activity 5 - If required, DEQMS team coordinate detailed assessment.

DEQMS Team will undertake a more detailed assessment of the CI, looking at other data sources as shown below to gather existing information about the CI and assess the frequency of the problem/opportunity.

Data sources include (but are not limited to)

Liaison / engagement / meeting / committees

  • Liaison between DEQMS Team members and internal and external stakeholders (verbal and written) regarding CI;
  • Senior management feedback during monthly DEQMS management meeting; and
  • past decisions format Committees and Forums.


  • Formal DEQMS survey responses regarding completeness and accuracy of DEQMS policies, processes, procedures and templates.


  • Quality Management Reporting Trends - includes all audit program findings, current/past/closed non-conformances and opportunities for improvement;
  • DEQMS Audit & Review Program and associated results; and
  • Other audit reports e.g. formal reports provided by third parties documenting audit/review findings.


  • First Assistance Secretary - Infrastructure
  • First Assistance Secretary - Service Delivery
  • Sponsor
  • Technical Authority (TA)
  • Subject Matter Expert (SME)
  • Company Quality Manager