In our consumer-driven environment, meeting the needs of the consumer is now the focal point for defining effectiveness. Unless this is achieved, systems are merely giving us a false sense of security and exposure to non-compliance risk. In our experience the issue is not whether you have systems, the question is whether they’re working as intended and effective in ensuring consumer satisfaction and compliance.

In this insight, we explore some common challenges to implementing and maintaining effective systems and give you recommendations to ensure that your systems work.

Partner – Quality & Clinical Governance

The challenge

While the focus is rightly on meeting consumer expectations, a facility is ultimately accountable to the regulator. This can lead to a “systems approach” of “yes we have a system that deals with that”. While this may be true, all too often we encounter the following challenges:

A proliferation of systems, many of which don’t talk to each other – this often causes duplication and inefficiency or gaps in information.
The perception that the systems are ineffective – this leads to the development of shadow systems or an abandonment of the systems at the front line.
User error and lack of training – with high staff turnover it’s easy to forget the the many new staff since you last ran that training refresher course. Over time your workforce is simply unaware of how the systems operate.

Consumers and the clinical governance standards demand that providers can independently attest that their systems are appropriate, effective and in use.

When there is a system failure, the key task is to undertake a root cause analysis to determine the source of the failure.

Our recommendations

Based on our non-compliance analysis from January – June 2020, Standard 8 (3c); effective organisation-wide governace system, is 5th on the top 10 unmet requirements. In instances of non-compliance, either the system is missing or it doesn’t work.

From our work conducting root cause analysis, we have found the leading pointers of system breakdown are:

  • unresolved issues
  • consumer dissatisfaction and
  • workforce non-conformance.

As we all shift our focus to the new year we’d like to share five (5) tips that will help you maintain or restore compliance in a sustainable way:

1. Understanding the problemProviders need to understand the root cause of their problems; a Band-Aid approach will never provide an appropriate sustainable solution; it will only treat the symptoms.

A common misconception is that software (clinical management, hospitality management, medication management) will be a solution to address systemic gaps. However, without truly understanding the core issue of poor care delivery or poor staff practice, this is a road to nowhere. Digital transformation should occur as a result of innovation rather than a band-aid solution to the problem.
2. Understand the dataAsk yourself, where audits are completed at 100% outcome, does this mean that the gaps have not been identified correctly? Where a facility has lower than average incidents, e.g. falls and incidents, is there underreporting occurring?

"Data without facts gives you a two-dimensional; black and white view of the world facts without data give you colour and texture but not the insight to solve the issue" Markovitz 2020. A two prong approach is required; this is where an external, independent view is also helpful to provide fresh understanding of the data.
3. Who is monitoring?The system is as good as the user. If no one is monitoring the systems to confirm its effectiveness, it may well already be broken.
4. Simulate a mock testWar gaming a scenario is a great way to test the effectiveness of your systems. If you do this, make sure the information is available during an assessment contact as evidence.
5. Seek feedbackTo truly understand how well your systems are performing, providers must embrace open and honest feedback from their consumers. Seeking unbiased feedback from a consumer's perspective is critical for demonstrating effectiveness.

With the introduction of Standard 8, providers must ensure there is a focus on consumer collaboration, effective organisation-wide systems, effective risk management systems and a clinical governance framework.

Effectiveness goes beyond having the system in place – it’s ensuring it’s working to specification!

An independent perspective

When you are part of the system, it can be hard to pull back and see clearly. Our team at Pride, led by Kaye Mann and Katrina Ong, are trusted by both the largest and smallest aged care providers in Australia.  

Whether you are looking for an independent voice to look at your data, test the effectiveness of your systems or provide you confidence in your compliance, our internal review and root cause analysis (ISO 9001 certified) will meet your needs.

Below is some feedback we received from a recent project.

…Her [Katrina’s] experience and expertise assisted by the broader team at Pride Living meant the advice we received was wise and timely which allowed us to make decisions with confidence. I would recommend Pride Living and Katrina to any organisation that finds itself in a compromised compliance situation

…As appropriate she [Katrina] conveyed information and advice to enable the Governance Committee to make decisions with confidence…

To find out more on how we can help you, contact Katrina Ong on 0499 016 867 or email