With more than 40 sanctions and 229 notices of non-compliance in 2018, it seems like the rules have changed. Our clients tell us that quality assessors are no longer coming in with a mindset of ‘innocent till proven guilty’ rather the onus is on Providers proving they are compliant.
This shift in approach can be seen in the trend of notices of non-compliance and sanctions over the last 10 years as shown in Figures 1 and 2.
Unless providers adapt to this change it will have far-reaching negative consequences .
Source: Data on residential aged care quality, Cumpston & Bail (2019)
There is much talk of this at present, in simple terms it’s the systems and processes that highlight deficiencies or risks in care and services and the mechanisms to manage these.
Clinical governance starts with the Board. When we facilitate Board workshops, the question we ask is: “are you confident that the organisation has systems and processes which highlight deficiencies in areas of risk and more importantly is management proactively managing them?”.
Just as the Board relies on a financial audit to verify financial reports, our view is that it should rely on external clinical audits to verify the robustness of clinical governance.
Failure in clinical governance will inevitably lead to non-compliance.
Your right of review
If you receive a notice of non-compliance you are entitled to have the Commission reconsider and review certain decisions including serious risk. When we assist clients in their response, we take the following approach;
- Comprehensive – addressing more than just the identified issues of non-compliance, rather detailing how the overall system will ensure compliance and the adequate provision of care.
- Actionable – clear details on each remedial action including intended result, responsible person and relevant comments
- Timely – the dates for planned actions should be reasonable and appropriately prioritise improvements
At PrideLiving we call this the CAT approach! Using a CAT approach, we have successfully had a number of initial negative findings revised in favour of our clients.
Managing a non-compliant facility
If you are found to be non-compliant, the Commission will direct you to revise your plan for continuous improvement and set a timetable for improvement (TFI). Depending on the level of non-compliance, it is often wise to appoint a project manager whose entire focus is on implementing the TFI. Where resourcing or skills are an issue within the organisation appointing someone external, a Nurse Advisor and/or an Administrator may be prudent.
The key risks we see where facilities have non-compliances are;
- Management and staff turnover: It is common where there is a failure that there are staff changes. Providers often fall into the trap of finding the next candidate, rather than the most qualified candidate.
- Systems break down: Generally, the systems are not the problem it’s staff practices. Lack of monitoring of care delivery in areas of non-compliance can result in recurring failures.
- Change management: the changes required to address the failures need to be sustainable, this means they must be embedded in the culture of the facility. Putting out the fire only solves the immediate. Your service will be on the Commission’s radar until they are satisfied sustainable systems and processes are in place.
As Nurse Advisors and Administrators, we have assisted facilities achieve full and sustained compliance. We do this by:
- diagnosing and treating the root cause of system breakdown
- training staff to ensure they have skills for the future
- be change agents to shift practices and culture
An action plan that works
Accreditation and review visits are part of life in aged care, so we developed the following action plan to assist providers;
- Ensure your governance framework has a clear clinical governance element to it. One that addresses key risks, and appropriate monitoring and reporting by your board and executive
- External quality and compliance audit to provide third party confirmation that your governance systems are operating effectively
- In the event of non-compliance be CAT like in your response
- Allocate appropriate dedicated resources to addressing any non compliance, serious risks or sanctions
If you require assistance in ensuring the robustness of your clinical governance or have been issued with a non-compliance notice, contact me at firstname.lastname@example.org for a free initial consultation.