Last week’s hearings at the aged care royal commission in Brisbane looked at regulation in aged care. While rules and regulations are designed to safeguard residents, bureaucratic “red tape” also contributes to the failings in aged care.
The fear among nursing home staff of failing a review visit by an Aged Care Quality and Safety Commission surveyor has been known to shift the focus from care for residents to meeting paper trail requirements.
The best outcome for aged care residents and their families would be new reporting requirements centred on outcomes rather than processes. Their primary focus should be on the mediation of critical incidents – that is, looking at what caused them and how they could be prevented in future – and the maintenance of health.
How did we get here?
The crisis in the aged care sector has emerged over time. At least in part, systemic problems in organisations arise from interactions among its key players. These interactions must be aligned to achieve its common goals.
But the key players in the aged care system pursue divergent agendas. Regulators focus on process adherence, while staff struggle with their limited capacity to manage the complex needs of residents. Meanwhile, proprietors focus on economic viability.
The prevailing approach of dealing with the problem of a particular key player in isolation will not solve the problems of aged care as a whole.
Governance and accountability
Our research suggests the need for a major culture shift in the aged care system.
Peter Drucker, a well-known management consultant, educator and author, once said “management is doing things right; leadership is doing the right things”.
Ticking the boxes of a protocol to demonstrate “regulatory compliance” – that is, doing things right – is no longer an option on its own. Residents and their families expect staff to be attentive to residents’ changing physical, emotional, social and cognitive needs; that is, doing the right things.
These insights tell us the aged care system needs to be redesigned.
What would this look like in practice?
Let’s consider two common aged care problems – falls and diabetes – whose management is significantly influenced by the chosen accountability framework. The differences between an outcomes-based approach (that is, adapting care to problems in their context) and a process-based approach (adhering to a protocol) are stark.From shutterstock.com
The first example: a resident has a fall. Rather than only assessing her for injuries and vital signs (as per protocol), staff would also assess potential reasons for the fall – for example, lack of mobility, pain, low blood pressure, or polypharmacy (taking multiple prescription medications at once) – and involve allied health professionals in preventive and rehabilitative care. This could include muscle strengthening exercises, gait and balance retraining, pain management and medication review. These are measures that could reduce the likelihood of the patient falling again, thereby improving her outcomes.
And let’s take a resident with normally stable diabetes, who one day records an elevated blood sugar reading. Rather than just giving him more insulin, staff would also assess potential underlying reasons for the elevated reading. These could include loss of appetite, an infection, or an episode of delirium.
The royal commission should do many things, but adding red tape isn’t one of them
Increasing frailty and/or significant memory decline are the main reasons for admission to an aged care facility. These people are particularly vulnerable as their health changes frequently and rapidly.
Being bogged down by regulatory ritualism reduces the time staff have available to spend on residents’ physical, social, emotional and cognitive needs.
True accountability in aged care is achieved by demonstrating how the provided care has impacted a resident’s well-being. In that regard, the Aged Care Quality and Safety Commission should provide leadership and primarily act as an educator, helping facilities to become learning organisations. If an aged care facility fails to “learn and improve”, then sanctions and penalties become necessary.
More bureaucracy would only serve to perpetuate the current crisis, and would fail those residents and families who have suffered from the current failings in the sector.
Len Gainsford, a former adjunct research fellow in accounting & governance at Swinburne University of Technology, contributed to this article.
Joachim Sturmberg is Foundation President of the International Society for Systems and Complexity Sciences for Health (ISSCSH).
Authors: Joachim Sturmberg, Conjoint Associate Professor of General Practice, University of Newcastle