Governance for aged care boards

Boards need to beef up their clinical governance standards and business models ahead of the Royal Commission into Aged Care Quality and Safety final report on 26 February.

More than 10,000 people made submissions to the Royal Commission into Aged Care Quality and Safety. A total of 641 witnesses, including a 105-year-old recipient of aged care services, gave evidence. For many, it was the first time they’d had the opportunity to tell their stories.

Yet listening to feedback from consumers and their families, and providing effective complaints and incidents systems are essential clinical governance tools, says Rosina Hislop FAICD, chair of ECH Inc, a provider of integrated retirement living accommodation and ageing care services. “Boards should monitor consumer complaints and incidents, and seek to understand the key themes and issues,” she says.

In her role with ECH Inc, Hislop and other board directors go out on site visits with in-home care providers. “We want to understand what it’s like to spend time walking in their shoes,” she says. “It’s not about us interfering in what our people do, or making operational decisions, but observing and learning — so when we’re back in the boardroom making strategic decisions, we understand the context.”

Although the final report of the Royal Commission is not due until 26 February, it’s unlikely to contain any surprises. Stories of widespread neglect and abuse in aged care — followed by the spread of COVID-19 through some facilities — exposed systemic problems. This prompted the 475-page Counsel Assisting’s Final Submissions, released on 22 October 2020, to foreshadow the need for boards to beef up their clinical governance standards. “Deficiencies in the governance and leadership of approved providers have resulted in serious shortfalls in the quality and safety of care,” the document states. “Some boards and governing bodies lack professional knowledge about the delivery of aged care including clinical expertise [and] there is a risk that governing bodies may focus on financial risks and performance, without a commensurate focus on the quality and safety of care.”

Clinical governance is core board business, but is sometimes conflated with accreditation, resulting in a “compliance mindset”, says Dr Julie Phillips GAICD, owner and principal of The South Face Consulting. “What you risk is adopting a rollercoaster approach, where there’s a mad scramble and a focus on clinical quality and safety when an audit occurs,” she says. “Everyone goes, ‘Thank goodness, the auditors have gone’. And it falls off the radar again, until the next time something happens.”

Clinical governance must be given the same level of attention as financial oversight, says Hislop. “When things go wrong, clinical governance has often been delegated to the operational side of the business, without quality and safety metrics set and monitored by the board,” she says. “But making sure we have that oversight is critical, because at the end of the day, boards are accountable for promoting a culture of safety, inclusivity and quality of care.”

Phillips points out that there’s no one-size-fits-all for clinical governance because organisations face different risks, depending on their consumer demographics and service delivery model. Boards must understand their clinical risk exposure and what their risk appetite or risk tolerance is — and the effectiveness of their controls.

“Traditional definitions of harm and clinical governance have really focused on physical harm — the classic ‘operating on the wrong limb in hospital’ scenario,” says Phillips. “But modern definitions of harm have moved on from just considering physical harm, to incorporate psychological harm, socio-behavioural harm, broader harm to the community, the impacts on clinical staff and volunteers — and burnout.”

Culture matters

Cultivating strong leadership and a “no surprises” culture where staff feel safe to flag potential problems, is another important element of clinical governance, says Dr Cherrell Hirst AO FAICD, a director of independent living services and residential aged care provider Bolton Clarke.

“It’s a philosophy that has to be reiterated: ‘Bring us the bad news, tell us what’s wrong, tell us what you’re worried about.’ But that culture must be developed, you can’t just assume that it’s there,” says Hirst. “That comes back to the relationship between the board and the executive, which largely depends on the relationship between chair and CEO.”

Pandemic-related challenges were either magnified or minimised by workplace culture, says Hislop. “A client of mine, which operates residential aged care facilities, in Victoria had staff who tested positive to COVID-19 — but not a single resident.

I asked them: ‘Why do you think that is?’” she says. “It came down to the culture they’d built over years. They were very clear: ‘If you have any symptoms, stay home, get tested. Don’t worry about your sick leave.’ Very early on, the organisation had audited its personal protective equipment and ordered additional supplies because they place safety and quality at the core of what they do. All the subsequent decisions flowed from that.”

In comparison, some aged care facilities are now facing class actions due to poor infection prevention and control measures. According to medical journal The Lancet, three-quarters of deaths from COVID-19 in Australia have been in aged care homes.

The Counsel Assisting’s final submissions state that each governing body will have a “care governance committee” chaired by “a member of the governing body with appropriate expertise in care provision”.

That doesn’t mean you must have a gerontologist on your board, or that everyone must have clinical qualifications, notes Hislop. “But your board must have appropriate clinical literacy and the required skills and composition to ask the right questions. When I talk to boards that have had things go badly wrong in their organisations, they’re often genuinely shocked and upset. They say, ‘We didn’t know.’ The key consideration is, ‘Were you asking the right questions?’”

Aligning executive KPIs with the delivery of safe care is crucial, as is asking whether financial or operational output metrics, such as a focus on short-term cost control, may be inadvertently undermining this objective, says Phillips. “What boards choose to measure will send a really strong message throughout the organisation.”

Maintaining oversight through effective monitoring of clinical “lag” indicators such as incidents and “lead” indicators such as staff turnover and staff safety culture surveys is also important. For instance, despite the inherent challenges associated with current and projected workforce shortages, boards needed to consider what high use of agency staff, or high turnover among clinical leaders, says about the organisation’s workplace culture. Tracking what is working well is also important, notes Phillips. “What’s the secret sauce that makes great care in Facility A that’s not being replicated in Facility B?” she asks. “Find out what that is and measure it.”

The requirements for enhanced clinical governance are expected to further stretch resources in a sector already operating on low margins. Data from StewartBrown released earlier in the year showed that 51 per cent of the 984 residential aged care homes surveyed were running at a loss. For operators offering a broad range of services this may force a reconsideration of the scope of service delivery and the minimum scale and size that some providers require to deliver services safely. “Some providers just might not be able to do it all anymore,” says Phillips.