The yearly and three-yearly visits that are being done cannot possibly give a reasonable or fair assessment of what is happening in a facility or the community. Government is moving to provide more and more care in the community. It is therefore critically important that there be oversight staff in the community who visit the facilities and those receiving care at home on a regular basis, and who can respond immediately to issues when they arise.
The two slider sections below, look at the problems and then what can be done about them.
Aged Care hamstrung by lack of real information
The absence of any attempt to correlate standards of care and quality of life with cost and type of provider has been referred to on multiple occasions in a variety of reviews and inquiries. Total reliance on a deeply-flawed accreditation system to collect data has made this impossible.
Even the industry is now acknowledging the problem. Aged and Community Services Australia (ACSA), the body representing not-for-profit aged care providers addressed it in a report in 2013.
Issue 12 - balancing quality and financial performance
The available data on performance and sustainably of the sector appears to be based entirely on an assessment of financial metrics. There is no attempt in any of the reports reviewed to balance financial performance, financial viability or system sustainability with quality of care and outcomes for residents, or with community expectations or objectives. These financial estimates appear to make the assumption, but it is not explicitly stated, that all operating RAC (Residential Aged Care) service are of equal and acceptable quality.
There appears to be a significant gap in our knowledge of the relationship between financial performance and of quality and between staffing levels and quality. For example, it is sometimes suggested that not-for-profit entities enjoy greater staffing ratios than for-profit entities and that this does contribute to higher quality. How do we strike a sensible balance between the measures of financial performance with the measures of quality so that we can judge the cost of quality and variation in quality between provider types?
Source: The financial viability and sustainability of the aged care sector - ACSA White Paper 2013, Pg 5)
The Aged Care Crisis Centre has been particularly critical of the inability of:
- researchers to compare staffing and other factors with standards of care and quality of life, and
- potential customers to evaluate different types of provider, let alone individual facilities in their local area.
The aged care system seems to be trapped in mediocrity, simply because there is no information about what is happening in the sector. This is disgraceful. A market cannot work if customers don't have the information they need to be effective.
Proposed changes
The local aged care hub would source suitable local people in a position to take on the surveillance work. They would be jointly appointed. Ideally these would be people with some experience in caring or in health care - and failing that would have a local advisor with expertise to mentor and guide them.
There should be at least two people allocated to each facility and area so that they can support each other, resist intimidation and cover when one is on leave. They could work for or be shared by adjacent localities. They would visit the facility informally, talk to residents and nurses and check medical and nursing records.
They would also be responsible for complaint handling and for observing and monitoring the processes and procedures taught by the accreditation agency. They would collect data for the provider and the community and put it into a database.
Responsibility of the department
The department would be responsible for training the surveillance staff and for supervising them. The employees would have a central government mentor with whom they discuss issues and problems and who would visit as needed to see what is being done and assess the performance of the surveillance staff.
It is important that the data collected is comparable with other facilities and the mentor would work with the staff to ensure this. The chairperson of the hub or a deputy would support these staff locally and help them with any difficulties they have. These staff would be given training in surveillance, data collection, complaints handling and accreditation processes.
Responsibility for data collection
No facility or organisation can effectively provide care unless it monitors what it does and keeps accurate records, including complications and failures. This is the responsibility of the provider and in the 21st century records should wherever possible be digital. Tablets or phones should be used to collect it.
Monitoring of standards and records
Whatever system of record keeping is used, the responsibility of the surveillance staff is to talk to patients and their relatives, talk to nurses, watch procedures and see how care is being delivered so that they know what is happening and can check this against the records. They will keep track of the medical records, checking that they are timely, accurate and that information documenting complications or failures in care is not omitted.
When facilities fail to keep proper records of care there should be a fine sufficiently large to be a major deterrent, particularly if failures or complications are not recorded. If there are major failings or a complaint about care then the record should be printed or copied by the surveillance staff for secure documentation.
Surveillance staff would assist the provider by collating the data in the records so that the incidence of failures, and measures of wellbeing, such as weight loss, are collated. They will assess and record the numbers of staff on duty, the time taken to answer call bells, whether residents are soiled or well tended, toileting practices and the quality of food and assistance with feeding.
They will brief the managers on their findings in an ongoing manner, assisting them to get things right. Their role is to be supportive and helpful. They will be in a good position to make an assessment of the quality of life offered. They will assist with local and multi-hub research directed to assessing needs and answering problems that would facilitate decision making.
The surveillance staff would work with the chairperson or a deputy to generate reports on the performance of the services provided in the area and share these with the department. Where there are concerns about standards, they would have input into the process of responding and sanctioning.
Staff would be mentored by a mentor in the department and supported locally by the chairperson or deputy. But they are part of the team comprising the hub including the provider, all working for better outcomes.
While the staff would be responsible to the mentor and the local community, they should be working with facility staff and management, helping them to improve their performance and gather accurate information to help them do so. While there is an element of policing, this only becomes so when there are important issues that need addressing or that are not attended to.
Funding
It is likely that staff would be part-time. The department would fund their salaries. The frequency and depth of surveillance would depend on the standards of care found. Problem facilities would require more frequent surveillance and the chairperson would negotiate this with the departmental officer acting as mentor for the section. Remote facilities that find it more difficult to maintain standards would need more help.
As indicated earlier, the hope would be that regulations would rest lightly and formal enforcement would seldom be needed, but it needs to be decisive and effective when it is needed.