In this first of our two-part series on aged care governance, we explain what organisational governance means, why it’s important and what the Aged Care Quality and Safety Commission (ACQSC) will be looking for when they assess compliance with organisational governance requirements.
In Part Two of this series we will take a closer look at clinical governance obligations.
In our article, What's Governance got to do with It?, we defined “governance” as the operational systems and processes that control and monitor an organisation. The key point to note about this definition is that governance is active. In the aged care context, governance is what the leadership team do when they make decisions and use purposeful systems to achieve outcomes for consumers, staff and the organisation as a whole.
“Organisational governance” is the broadest form of governance. It encompasses many sub-sets of governance, including workforce governance, financial governance and clinical governance.
Why does organisational governance matter? Because it empowers aged care providers to proactively take steps to improve consumer care and meet legal obligations.
Aged care providers have always been subject to governance obligations, but now those obligations have been consolidated under Standard 8 of the Aged Care Quality Standards (Standards).
Entitled, “Organisational Governance”, Standard 8 requires providers to demonstrate that they:
On 4 November 2019 the ACQSC conducted a webinar on “Accountabilities of governing bodies in aged care”.
The webinar panellists provided some insight into the kinds of evidence the ACQSC assessors will look for when they assess a provider’s compliance with the requirements under Standard 8.
According to the webinar panellists, when assessing compliance with 8 (3)(a), the assessors are looking for evidence that providers have engaged with consumers, “co-designed” governance programs with consumers and responded to input from consumers.
Assessors want to know: what did you do to get feedback from consumers? What was the feedback and what did you do about it? How do you engage consumers to fix problems? Is there a consumer focus group?
As well as looking at the organisation’s publications (such as newsletters, notices, work instructions, policies and posters), assessors will interview consumers and their representatives and ask them for examples of what the organisation has done to engage them.
Before we get into what the webinar panellists said, it’s important to note that “culture” is a complex and subjective concept, and it may be difficult, or even impossible, to prove that you have a particular culture. This may be why Standard 8 (3)(b) does not require you to demonstrate that you have a safe, inclusive culture, but rather that you promote one.
According to the webinar panellists, when assessing compliance with 8 (3)(b), the assessors want to see “actual examples of how the organisation demonstrates its values”. One such “actual example” might be a statement that is published on the website or is otherwise publicly visible.
Assessors will also ask staff to explain how they and the wider organisation contribute to a safe, inclusive culture.
According to the webinar panellists, when assessing compliance with 8 (3)(c), the assessors want to see how the organisation seeks consumer input with regard to each of the governance areas (information management, financial governance etc) and how the organisation responds to consumer input.
The assessors also want to see how the organisation’s various systems work together. They want to see a combination of systems that work together, and that are flexible and responsive to changes, whether these be changes to consumer needs, staffing, funding or regulation.
The webinar panellists also said that assessors will be looking for evidence that:
With regard to workforce governance, the panellists suggested that assessors would be assessing whether providers had sufficient staff. The panellists were asked how assessors would measure “sufficient staff” in the absence of staffing ratios. The panellists suggested that assessors would look for evidence that providers had gathered data on their own staffing needs and used that data to inform staffing decisions. As an example of how a provider might do this, one panellist suggested that the provider might talk with consumers to determine how many wanted showers in the morning and how many also wanted them in the evening and then use that data to determine appropriate staffing levels at different times of day.
According to the webinar panellists, when assessing compliance with 8 (3)(d), the assessors want to see how the organisation detects and responds to risk. The panellists noted that risks change over time, so assessors are particularly looking for evidence of an “ongoing conversation” with consumers about their concerns.
The panellists suggested that joint planning with consumers was the best way to deal with potential conflicts between a consumer’s safety and being given the freedom to engage in risky behaviour.
We will cover Standard 8 (3)(e): Clinical Governance in Part Two of this series.
The webinar panellists offered some advice on what assessors will be looking for with regard to the role of the board/governing body in an aged care organisation. The panellists said:
Standard 8: Organisational Governance is one of the most important and least understood of the Aged Care Quality Standards. Even after the ACQSC’s webinar, some organisational governance issues – such as staffing ratios and dignity of risk – remain poorly defined.
The good news is that when it comes to assessment of organisational governance requirements, the ACQSC seems to be following one basic underlying principle: consumer engagement. So, if you’re in doubt about how to demonstrate compliance with Standard 8 requirements, it’s worth deferring to this underlying principle and asking yourself: What have we done to get consumer feedback about this issue? How have we responded to this feedback?
Standard 8: Organisational Governance - Mapping Matrix Tool
What's Governance got to do with It?
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Mark is a Legal Research Consultant at CompliSpace. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.
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