The Royal Commission’s Interim Report – A reflection on the findings and where to focus transformation efforts
You don’t need to read far into the Royal Commission’s Aged Care interim report to get a sense of the issues Aged Care is facing in Australia. In fact, all you need is the title – ‘neglect’.
This is a report that doesn’t pull any punches:
- ‘The aged care system fails to meet the needs of its older, vulnerable, citizens.’
- ‘It is designed around transactions, not relationships or care or the new narrative of a meaningful lived experience co-designed by consumers for consumers’.
- ‘It does not deliver uniformly safe and quality care, is unkind and uncaring towards older people and, in too many instances, it neglects them.’
It shouldn’t come as a shock. But, it is a fork in the road – a new path must be crafted.
The report clearly signifies the much-needed change heading for our industry. I myself, together with colleagues John Engeler and Dr Maggie Haertsch spoke in detail during the Hobart hearing. We expressed our views relating to governance and how our work supports providers on their compliance transformation journeys. We have had great success working through and with providers of all sizes and types.
In essence, what we believe Aged Care needs, is the very reason Anchor Excellence exists.
- Strong and responsive leadership from board through to resident lived experience
- A capable workforce that engage with elders achieving their goals needs and preferences
- Quality systems that prevent harm, particularly with a focus on high impact risk and that address information needs and flow both up and down the organisation eg Board to Consumer and vice versa.
- Leaders at every level that are engaged, inspired and enabled to do what is essential in delivering quality and safe care.
We know the actionable, achievable recommendations that can make a difference to residents in aged care, and we’re here to help organisations implement them.
Not every organisation involved in Aged Care should be painted with the same brush of neglect. We know many leaders who are acting now to better support their staff and residents and transforming their organisations into the new narrative. But, in order to bring about a real difference, not only to residents but also to public opinion, we shouldn’t kid ourselves.
The change required has only just begun. As a starting point, here is our go to list for you to cross-check.
Key Safety and Quality Issues
Responses and solutions
1. Unsafe Care
The attitude, aptitude and skills of direct care staff are paramount to the consumer experience of care.
A workforce that understands its relationship with the organisation, management and ultimately with the consumers to whom they are delivering care and service.
This is Registered Nurses, AiNs, PCA’s, ancillary staff, maintenance staff, allied health staff, catering and cleaning staff.
2. Immature quality management & measurement methodologies
A quality management system that enables compliance for outcome-based standards must include the following key elements:
- Clear segregation of duties, the role and responsibility of incumbents must demonstrate practical application of policy and procedure, into practice and following the companies organisational structure.
- A well-functioning document management system that provides for current policies, procedures or work instructions.
- A responsive training and development plan that provides for capability assessment with training plans that redress the specifics arising from the quality management systems and consumer experience.
- There needs to be periodic assessment of risk and in the new standards, a comprehensive assessment for high impact and high prevalent risks. Post assessment of the risks for both individual consumers and collective communities of consumers are then addressed through a risk management approach.
- Risk minimisation strategies including comprehensive plans of care and risk registers with articulated controls clearly identified.
- A clear pathway of enabling consumer co-design and feedback across each of the previous features to deliver a strong consumer centric and responsive organisation.
- A structured oversight by the governing body over all of the elements listed, enabling and supporting strong leadership of the organising performance both as an Approved Provider and in its pursuits of its own strategic objectives.
3. Consumer engagement and health literacy for consumer risk
Consumers that understand their care and their risks are better placed to engage with service providers and can actively participate in decisions about their care.
Health literacy of aged consumers and their representatives (be that supported or substitute decision makers) is generally lacking. More effort to inform consumers about clinical risk, the risks associated with their co-morbidities and how strategies translate into well informed plans of care is critical for a genuine ‘partnering-in-care’ approach and for consumers to make informed decisions about risk as it applies to themselves.
4. Immature clinical governance systems
Organisations that do not have a clear understanding of the principles of clinical governance are unable to ensure a structured way of going about delivering quality and safe care. This understanding and capability needs to be evidenced across all key personnel in the organisation’s delegation schedule; and within the organisations structure for committees and decision making forums. The organisation structure needs to be deployed with enough clarity in position descriptions so that the assigned incumbents are supervised for alignment against the combination of systems, processes and practices. Organisational reporting systems must enable the information flow of key measures, audits and consumer feedback in a way that gives rise to clear performance measurement with the communication systems enabling feedback on progress.
Boards that do not have a skills-based mix may not then have the requisite ability to review data or measurement and over rely on management as the ‘experts’.
5. Inadequate management capability
The General Manager/ Director of Nursing / Facility manager (whichever term applies) is the integral leader of the ‘management team’ at the service level. It is a lead indicator for success that the Leader role models inclusive, responsive and engaging traits that help enable the adherence to organisations systems and to lead the culture of safety and quality, encouraging a ‘high performing team’ approach.
When the leader disconnects or does not role model ideal behaviours – culture, teamwork, communications systems and responsiveness are all negatively impacted. Symptoms of this can be low reporting of complaints, high staff turnover at the reporting level, staff grievances and high levels of staff disengagement.
Regional or Senior oversight of Homes (for stand alone this may be a board; in multisite this may be a regional structure) must also include leaders that enable the organisations systems, processes and people. Siloed approaches do not support cross collaboration and sharing of information that then informs higher level of management. The number of homes in a region needs to be manageable and span of control over a workable workload is essential.
Performance of a Home is dependent on the synergy between Home level leadership and regional or senior level leadership
6. Inadequate Clinical leadership
Highly engaged and skilled registered nurses are essential to the aged care system.
It is true, that residents in aged care today present with more co-morbidities and more complex health care needs. The rise of chronic disease means that the clinical oversight and leadership is more important than ever.
The Care Manager is the key leader of the clinical team. Retention of experienced Care Managers is reported, as a challenge across the industry.
The Registered Nurse’s ability to lead the team, including supervision and leadership of the direct care team; manage the robust handover processes and deployment of the organisations document management systems are essential for safe and quality care delivery.
In each case a sanctioned home has needed to redress RN capability including increased focus and supervision to ensure oversight of the clinical governance outcomes for the resident experience of care.
7. Inadequate roster management- delivering right people, right time, right skills
Roster management is a specialty function in its own right, but it is often under resourced or placed in the hands of individuals ill-equipped to manage the complexity.
Rosters that are relationship based, have regard for consumer needs and preferences, and have a proportionate mix of full-time and part-time staff enable consumers to have carers who get to know them. The staff are across the needs in care plans and alert to any changes in condition, emotional state or behaviour.
It is a lead indicator for poor outcomes for consumers if a service has high Agency use (unless there are risk minimisation strategies deployed); shifts not replaced regularly or staff without enough understanding of the systems in the home (i.e. insufficient onboarding and orientation).
In Australia there is no training course available that delivers a best practice approach to rostering in aged care.