Clinical governance supports aged care organisations to deliver high-quality care and services to achieve good health and wellbeing outcomes through positive care experiences. [1] Although there is no ‘one-size fits all’ approach to clinical governance, [1] the Aged Care Quality and Safety Commission (ACQSC) suggests six core, interrelated elements to clinical governance which together promote optimal health and wellbeing outcomes for people receiving aged care services. [2] Governing bodies should consider each of these and set up systems to manage, operationalise, and monitor success against them. One of these elements is consumer partnerships. The other core elements are covered in our clinical governance themes.
Why are consumer partnerships important to clinical governance?
Care recipients should be central to care decisions and outcomes. [3] In clinical governance, the individual needs and preferences of people receiving aged care (and their loved ones, where appropriate) guide how care is delivered. [2] To provide safe and high-quality care (which is subject to perception), care recipients should be encouraged and supported to express their needs, wishes and values, and make decisions about how they receive care. [2] When care recipients and/or their families are partners in planning and decision-making, it allows the workforce to understand their individual needs and goals for care, and to provide better care, which leads to better outcomes. [2] Care recipients can provide a valuable perspective on how a service operates, and both positive and negative feedback can be used to improve the care provided. [2]
Everyone receiving aged care has the right to:
- Receive safe and high-quality care
- Be treated with dignity and respect
- Have their identity, culture, and diversity valued and supported
- Have control over, and make independent choices about their care, as well as their personal and social life, even when choices involve an element of personal risk
- Be listened to and understood
- Have a person of their choice support them or speak on their behalf
- Complain without reprisal, and to have their complaints dealt with fairly and promptly. [4]
Consumer partnerships and the regulation of Australian aged care
The importance of care recipient partnerships in the context of clinical care and care more broadly is reflected across the current (2019) Aged Care Quality Standards, particularly within Standards 1, 2, 4, 6, and 8. [5]
Standard 1 (Consumer dignity and choice)
- The organisation supports consumers to exercise choice and independence (1(2)(b); 1(3)(c)).
- Each care recipient is supported to take risks to enable them to live the best life they can (1(3)(d)).
- Information provided to care recipients is current, accurate and timely, communicated clearly, presented in an easy-to-understand way, and enables them to exercise choice (1(3)(d)).
Standard 2 (Ongoing assessment and planning with consumers)
- The organisation undertakes initial and ongoing assessment and planning for care and services in partnership with the care recipient. Assessment and planning are focused on optimising health and wellbeing in accordance with the care recipient’s needs, goals, and preferences (2(2)).
In addition, the organisation demonstrates that:
- Assessment and planning, including consideration of risks to the care recipient’s health and wellbeing, informs the delivery of safe and effective care and services (2(3)(a))
- Assessment and planning identify and address the care recipient’s current needs, goals, and preferences, including advance care planning and end-of-life planning if the care recipient wishes (2(3)(b))
- Assessment and planning are (a) based on ongoing partnership with the care recipient and others that the care recipient wishes to involve in assessment, planning and review of the care recipient’s care and services, and (b) include other organisations, and individuals and providers of other care and services, that are involved in the care of the care recipient. (2(3)(c))
- The outcomes of assessment and planning are effectively communicated to the care recipient and documented in a care and services plan that is readily available to the care recipient, and where care and services are provided (2(3)(d))
- Care and services are reviewed regularly for effectiveness, and when circumstances change or when incidents impact on the needs, goals, or preferences of the care recipient (2(3)(e)).
Standard 4 (Services and supports for daily living)
- The organisation demonstrates that each consumer gets safe and effective services and supports for daily living that meet the consumer’s needs, goals and preferences and optimise their independence, health, wellbeing, and quality of life (4(3)(a)).
- The organisation demonstrates that Information about the consumer’s condition, needs and preferences is communicated within the organisation, and with others where responsibility for care is shared (4(3)(d)).
Standard 6 (Feedback and complaints)
- The organisation regularly seeks input and feedback from consumers, carers, the workforce and others and uses the input and feedback to inform continuous improvements for individual consumers and the whole organisation (6(2)).
- The organisation demonstrates that consumers, their family, friends, carers and others are encouraged and supported to provide feedback and make complaints (6(3)(a)).
- The organisation demonstrates that appropriate action is taken in response to complaints and an open disclosure process is used when things go wrong (6(3)(d)).
Standard 8 (Organisational governance)
The Charter of Aged Care Rights lays out the rights of individuals receiving aged care, including how they should have control over, and make decisions about their care. [6]
Current aged care reforms are intended to strengthen and reinforce the importance of working in partnership with care recipients and their families. In the Revised Aged Care Quality Standards (2023), requirements for partnering with care recipients in their care are conveyed across:
- Standard 1 (The person)
- Standard 2 (The organisation)
- Standard 3 (The care and services)
- Standard 5 (Clinical care).
The Revised Aged Care Quality Standards align well with the current standards in the importance of consumer partnerships. However, there is an increased focus on how meaningful and active partnering with older people can enable organisations to provide person-centred care that is culturally safe, and trauma informed. More specifically, where clinical governance is concerned, the Revised Quality Standards require the governing body to implement a system for older people to be partners in their own clinical care (Action 5.1.2). [7]
The Code of Conduct for Aged Care forms a further part of the government’s strategy to reform aged care. The Code gives specific guidance to those providing care (and governing persons) on how they should conduct themselves in building appropriate relationships with care recipients and their families. The Code also makes clear the rights of care recipients to self-determination and the autonomy and freedom to make their own choice. [3]
Recent legislative changes to the Quality of Care Principles 2014 also support the importance of partnerships with aged care recipients. [8] These changes provide greater clarity and strengthen requirements around the importance of establishing informed consent for restrictive practices in residential aged care settings. There is also a greater focus on alternate means for establishing consent for individuals who may not have the ability to provide consent for restrictive practice use for themselves (e.g., a family member or representative). [9]
Components of effective consumer partnership
Effective care recipient partnerships are needed to support safe and high-quality care. There are multiple components to establishing effective care recipient partnerships within an organisation, including person-centred care, respecting individuals’ choices, a culture of engagement with care recipients, and partnership in collecting feedback and designing solutions.
At the core of clinical governance, and simultaneously the Aged Care Quality Standards, is person-centred care. [10, 11] Person-centred care is care that is ‘respectful of, and responsive to, the preferences, needs and values of the older person’. [7 p55] What may be valuable and important to one individual, is not always important to another. [5] Care and services should be provided in a way that supports the function, independence, dignity of risk, and personal goals of the older person receiving care. [5, 7] To deliver person-centred care, organisations need to understand and value the identity, culture, diversity, beliefs, and life experiences of everyone in their care. [7]
What might person-centred care look like?
Staff and care recipients within organisations achieving a high level of person-centred care are likely to agree with the following statements.
- The workforce can describe how the needs, goals and preferences of people receiving care guide the delivery of their clinical care. [5, 12]
- The needs, goals, and preferences of individual care recipients are known, recorded in their care plan and regularly updated. [5]
- Services are developed in partnership with recipients and tailored to the needs, preferences and values of individuals. [7]
- There is continual improvement regarding awareness of and approaches to inclusion and diversity. [5] This extends to providing interpreters for people with limited English proficiency. [13]
- Staff provide care that is trauma aware, healing informed, and culturally safe. [7]
Everyone receiving aged care has the right to make choices about their care, and their personal and social life, including choices with personal risk attached. [4] The organisation needs to provide options that support individual choice and encourage the workforce to listen to and respect the care recipients’ views. [5] The information the workforce is provided should assist them to provide care and supports that are respectful of care recipients’ choices. [5]
Dignity of risk is ‘the right [of care recipients] to make decisions that affect their lives and to have those decisions respected, even if there is some risk to themselves’. [7 p50] The organisation should ensure that the care recipient understands the risks behind their decisions and how these risks may be managed. [5] Here, it is important for the organisation and the care recipient to work together to look for solutions that minimise risk whilst allowing the individual to make autonomous decisions about how they live, and how they receive care.
How can an organisation demonstrate respect for individuals’ choices?
There are several ways to determine whether an organisation has effective processes in place to ensure respect for individuals’ choices. For example:
- There are processes in place to ensure compliance with the relevant informed consent procedures [14]
- Members of the workforce have a clear understanding of information sharing and different types of consent [5]
- The organisation has accurate, up-to-date records that reflect how consent has been provided.. [5]
- There are processes that support effective care delivery for care recipients who cannot make their own decisions, and/or do not have family or other representatives [14]
- The organisation recognises the rights of those receiving care and respects their dignity and autonomy [5]
- Dignity of risk is understood, respected, and exercised with each person receiving care [5]
- Advance care plans are in place for each care recipient based on preferences and needs [15]
To deliver person-centred care, the organisation needs to understand the individual. Furthermore, care recipient wishes and feedback should be sought and considered when implementing a clinical governance framework. [10] To achieve this, the organisation needs a culture of engagement, which involves placing the focus on the care recipient, and putting mechanisms in place to allow continuing engagement with them and their loved ones. Resolving issues in partnership with care recipients may lead to better outcomes and help to build the relationship between the care recipient and the organisation. [5]
What might a culture of engagement with care recipients look like?
Within an organisation with an effective culture of engagement:
- All policies and procedures encourage and support active partnerships with care recipients, their families and representatives [5]
- Care recipients receive adequate information about their care and are supported to be partners in care planning and decision-making [14]
- The organisation acknowledges and apologises when mistakes are made [7]
- Members of the workforce can describe how they might encourage and support care recipients to provide feedback or make complaints [5]
- The organisation can demonstrate how the identity of those who want to complain anonymously is protected [5]
- Care recipients are made aware of and have access to resources (e.g., advocates and language services) to allow them to raise complaints [5]
- Individual care plans are regularly reviewed in consultation with the older person and their families or other social supports where appropriate [11]
- There is an effective care management system in place to provide staff with relevant information, without the care recipient having to keep repeating their preferences to multiple people. [5]
To create an environment that optimises outcomes for care recipients, organisations need to provide a culture where individuals feel supported to provide feedback and make complaints. [5] Organisations should have an organisation-wide approach to involve care recipients in the development, delivery, and evaluation of the care they receive. [5] This is essential for delivering care that is person-centred. It is important to keep in mind that some older people may need additional support or encouragement to voice their opinions and potential concerns about the care and services they receive. The organisation is also expected to review and respond to the information given by care recipients and/or their families and should work to foster a safe, supportive environment where older people, their families, and care staff feel comfortable raising issues or reporting incidents (including near misses). The organisation should also demonstrate how they use the feedback provided to improve the care they deliver. [7]
What might effective partnerships in feedback and solutions look like?
Signs that an organisation values the feedback from care recipients about how they are performing and what they might do to improve care experiences and outcomes may include:
- The organisation encourages feedback from care recipients, their families, or representatives concerning the quality of their care [7]
- Care recipients feel safe and comfortable in providing feedback to the organisation [5]
- Care recipients feel confident that their feedback is used to improve the quality of their care and services [5]
- There is a variety of prominent mechanisms in place to receive and manage feedback and complaints that concern care quality and safety [5, 14]
- Feedback is openly acted upon [16]
- There is communication to care recipients on the existence, purpose, and processes of the organisation’s incident management system. People are also encouraged to report incidents and near misses [13]
- Care recipients and their families are actively engaged in resolving incidents and developing strategies to prevent them from reocurring [13]
- Data are analysed, reported, and used for continuous quality improvement [7]
- Tan M. Aged care regulation through the looking glass of clinical governance: A framework for aged care providers. Australian Health Law Bulletin. 2022;30(5/6):116-126.
- Aged Care Quality and Safety Commission. Fact sheet 3: Core elements of clinical governance [Internet]. Canberra, ACT: ACQSC; 2019 [cited 2023 Apr 14]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_3_Core_elements_of_clinical_governance.pdf
- Aged Care Quality and Safety Commission. Code of Conduct for Aged Care: Guidance for aged care workers and governing bodies. Canberra, ACT: ACQSC; 2022. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/code-of-conduct-for-aged-care-worker-guidance.pdf
- Aged Care Quality and Safety Commission. Charter of Aged Care Rights. Australia: Australian Government; 2019 [cited 2023 Apr 27]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/charter-of-aged-care-rights-a5-booklet.pdf
- Aged Care Quality and Safety Commission. Guidance and resources for providers to support the Aged Care Quality Standards [Internet]. Canberra, ACT: ACQSC; 2022 [cited 2023 Apr 20]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/quality-standards-guidance-resource-sep22.pdf
- Aged Care Quality and Safety Commission. Charter of Aged Care Rights (information for providers). Australia: ACQSC; 2022 [cited 2023 Apr 27]. Available from: https://www.agedcarequality.gov.au/providers/provider-information
- Department of Health and Aged Care (Australia). Revised Aged Care Quality Standards: Draft for Pilot [Internet]. Canberra, ACT: Department of Health and Aged Care; 2023 [cited 2023 Jun 6]. Available from: https://www.health.gov.au/sites/default/files/2023-05/strengthened-aged-care-quality-standards-pilot-program.pdf
- Quality of Care Principles 2014. Sect. 96.1 (2014).
- Aged Care Quality and Safety Commission. Aged care reforms - an overview. Canberra, ACT: ACQSC; 2022 [cited 2023 Apr 20]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/aged_care_reforms-an_overview_fact_sheet.pdf
- Tan M. Clinical governance in changing times: Balancing risk, regulation and duty of care in aged care. Australian Health Law Bulletin. 2020;28(9):150-155.
- Tan M. Clinical governance and the serious incident response scheme in home and community aged care. Australian Health Law Bulletin. 2023;31(1):10-15.
- Aged Care Quality and Safety Commission. Fact sheet 2: Clinical governance and the Aged Care Quality Standards [Internet]. Canberra, ACT: ACQSC; 2019 [cited 2023 14 April]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_2_Clinical_governance_and_the_Aged_Care_Quality_Standards.pdf
- Aged Care Quality and Safety Commission. Effective incident management systems: Best practice guidance [Internet]. Canberra, ACT: ACQSC; 2022 [cited 2023 Apr 25]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/effective-ims-guidance-august-2021.pdf
- Aged Care Quality and Safety Commission. Organisational self-assessment tool 2: Clinical governance arrangements. Canberra, ACT: ACQSC; 2019. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Organisational_self-assessment_tool_2-Clinical_governance_arrangements_0.docx
- Martin A, Boyle N, Cooke J, Kennelly SP, Martin R, Mulroy M, et al. Responding to needs of residents in long term care in Ireland. Ir Med J. 2020;113(9):1-7.
- Australian Institute of Company Directors. Clinical governance for boards in the aged care sector [Internet]. Australia: AICD; 2021 [cited 2023 Apr 20]. Available from: https://www.aicd.com.au/corporate-governance-sectors/clinical/best-practice/clinical-governance-for-boards-in-the-aged-care-sector.html
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