Accreditation bodies, their processes, their theoretical constructs and their patterns of thinking, are all directed to supporting and helping providers. They of necessity, have close relations with aged care providers and draw staff and assessors from these providers. They teach processes which, if the providers are motivated, will improve care.
The slider sections below look at why it is not working and what can be done about it by using the proposed hub.
Problems with accreditation
The agency attempts to monitor compliance with these processes but importantly, do not collect, collate or publish objective data about failures or standards of care. They are consequently not able to prove that accreditation is effective (although it is likely that for motivated providers the processes taught are helpful).
"... Many people who contact Aged Care Crisis are shocked to learn that it is still possible for a home to breach its responsibilities as an approved provider under the Aged Care Act, have serious complaints substantiated against them, including assaults, and yet still manage a perfect accreditation score and avoid any public scrutiny whatsoever.
Family members wanting to make informed decisions about a residential aged-care placement for their loved ones, especially those with dementia, are often unable to do so.
Aged Care Crisis are concerned about the proposed extended scope of the Aged Care Standards and Accreditation Agency, renamed the Australian Aged Care Quality Agency from 1 January this year, with regard to regulatory powers previously vested in the Department of Health and Ageing.
The Quality Agency, as it is currently structured, has two conflicting roles: a regulatory function and an educative function. Such a conflict of interest cannot be sustained and acts against the wellbeing of frail people in residential care.
The critical roles of education and the establishment of exemplar processes and practices within aged-care homes must be separate from the roles of oversight and regulation. A body independent from the industry would better accomplish the latter roles. This would address a number of other conflict-of-interest situations ..."
Source: Ms Saltarelli from Aged Care Crisis to Senate Community Affairs References Committee, 14 Feb 2014
The Agency is not structured to measure standards and their marking system is so far off a bell curve that hardly anyone fails to get full marks so it is of little value to customers, whether these be potential residents, their families, the community or government. They create the illusion that all is well in aged care and allow rationalisations.
A market which fails to discriminate between good and bad, is a market that encourages universal mediocrity - the minimum that everyone can get away with. That costs less so is more profitable.
There was a review of the accreditation process in 2009 to which ACC and I both made submissions. We did not get any feedback and the report was never published. If the comment below relates to the same 2009 review then Alzheimer's Australia received a draft copy to comment on, which is what most reviews do.
Those who made critical submissions did not see either a draft copy or the final report. Perhaps what Alzheimer's Australia commented on was another internal review that the public were not invited to participate in --- but why would they do two within a year?
The CEO of Alzheimer's Australia's response to "the review of the Aged Care Accreditation Standards and Processes in 2010" voiced it's disappointment with the overall approach and the lack of consumer input.
... As we indicated in previous submissions (Ageing Consultative Committee on the Review of the Accreditation Process July 2009), the current accreditation process does not provide an indication of outcomes being achieved and as a consequence consumers have little information about how services are operating beyond minimum standards. Unfortunately, the proposed draft standards do not address this concern ...
... We need a new approach to the assessment of aged care in Australia that gives consumers greater input in to the process and results in outcomes that can then be reported to consumers in an accessible form. We should strive for an accreditation system that focuses not only on identifying facilities that have fallen below minimum standards, but also a system that provides incentives for continuous quality improvement and results in better quality of life for residents ..."
Source: Review of the Aged Care Accreditation Standards and Processes - Response from CEO Glen Rees, Alzheimer's Australia (29 Sep 2010)
In its submission to the Productivity Commission Inquiry - Caring for Older Australians, the Accreditation Agency itself protested that it is not structured to be a regulator and that this creates a conflict of interest for the agency:
"... The accreditation agency's responsibility is to support and encourage a quality environment that supports quality care and improvement in aged care while identifying where homes have failed to meet the standards. This approach is in the interests of the residents, who are usually frail, vulnerable and elderly. To do this role adequately requires a strongly collaborative approach with their stakeholders. This does not align with an inspectorial policing approach ..."
Source: Aged Care Standards and Accreditation Agency (Response to Draft Report)
Submission[Page 5] (21 Mar, 2011) - Productivity Commission Inquiry: Caring for Older Australians
Accreditation failed as a regulator in the USA and there is much to suggest that it has failed in aged care in Australia. Both the Productivity Commission and government ignored the agency's protest. Accreditation remains a central plank of the regulation of aged care in Australia.
All reports published by the agency are the result of planned cyclical three-yearly visits - the majority are "Site Audits" which are planned at the request of the nursing home, at a convenient time. The home has often spent months preparing. They are a costly and wasteful exercise if it is intended to measure standards.
Such reports tell us that the management of the aged-care home knows what it is supposed to do but gives no information about what happens on the other 1,093 days of the cycle. They tell us nothing about the ordinary day-to-day provision of services, or whether processes are being regularly followed.
Even yearly "Unannounced visits" by the agency or the department tell very little about the remaining 365 days. These findings are never made publicly available. The community are left to ponder over reports that are not a true measure of performance and may be up to three years old.
Individual residents' views may not be assessed while they are alive to benefit from any improvement made as a result of the assessment. It is hit and miss as to whether the assessors pick a good or bad day. Regular on-site surveillance and regular contact is required and this is what I am proposing with the hub.
The current limited system of late release and early removal of adverse reports from the agency website is unsatisfactory. Consumers are entitled to disclosure of all past, as well as current, reports. Information needs to be presented in a digestible format and not the current long and indigestable format.
Information should be presented in a readily comparable way. Frail older people are one of the most vulnerable groups in society and their protection should outweigh all other considerations. The current process for their protection fails on multiple counts.
Update - January 2015: Documents released under Freedom of Information show that nearly one in five new nursing homes failed to meet quality standards last financial year. The revelation comes as the Federal Government looks to cut red tape in aged care, including reducing the aged care complaints system. These changes are being promoted as part of an "Innovation Hub" in South Australia. The changes include:
- Reduction of audits: Less frequent audits (eg, site audits reduced from once every three years to five years);
- Self-regulation of complaints: Complaints by residents or family member to the Aged Care Complaints Scheme will be referred back to the home in question for resolution, including those that identify serious risk to resident health and safety
- Reduction of ACFI reviews: reduced Aged Care Funding Instrument reviews by the department
Update - May 2015 (Budget): Announcements include aged care accreditation will be privatised and providers will be allowed to shop around for a private accreditation service. A review of the NZ system found that providers would seek out more lenient accreditors to pass accreditation and care standards dropped as a result.
Source: Documents relating to the South Australian Innovation Hub released under FOI - [Disclosure log: 14/15 – 065 (19 Dec 2014)];
Source: Budget 2015 (CPSA media release, 1 Jun 2015)
What role for accreditation with a community hub?
Accreditation has a role to play in teaching and promoting good practice and ensuring that sound practices and processes are learned. Whether they are followed depends on other factors. These include the motivation and the pressures, including commercial pressures, on the organisation. Also important are the pressures placed on staff by the organisation.
Accreditation’s primary role should be educational and it should play only a supportive role in monitoring to ensure that the independent staff who monitor know what to do. Much needless paper work and wasted staff time could be eliminated.
With proper ongoing local monitoring of standards and outcomes it will be possible to assess accreditation's success, and see whether processes are actually being followed. Facilities will be far more motivated to adhere to processes, staff their facilities effectively and have trained staff supervise care if this is being reinforced by the local community representatives.
Proposed activities for accreditation
- Teaching facilities the processes needed for good care and ensuring that they are learned.
- Teaching the community surveillance staff about these processes so that they can monitor their implementation in an ongoing manner and assess whether they have been followed when failures occur.
- Local surveillance staff and the hub would report back on failures in process and might encourage the facility to call in accreditation trainers for remediation. Government agencies might insist on this.
- Accreditation visits would be conducted in consultation with surveillance staff, whose findings during the period since the previous accreditation would be critical in deciding on accreditation status.
- Surveillance staff would be accountable to the community and government - not the accreditation agency
Funding: The accreditation process benefits providers and it should be largely funded by them.