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 effective workforce. The other core elements are covered in detail in our clinical governance themes.
Why is an effective workforce important to clinical governance?
Everyone has a role to play in delivering safe and high-quality care. While the governing body is ultimately responsible for clinical quality and safety in aged care, the workforce (including visiting health practitioners) is responsible for working within the clinical governance framework. [3] It is crucial that health practitioners (including those who are employed by the organisation and those who are contracted) and other staff are appropriately qualified and adequately skilled to deliver safe, respectful, and high-quality care. [2, 4]
Aged care services are expected to have sufficiently qualified and skilled staff to meet the needs of the people in their care. [4] In addition, individual members of the workforce are expected to perform their duties effectively, communicate well, and build relationships with care recipients. [4] Organisations need to regularly assess, monitor, and review the performance of the workforce to ensure appropriate care is being delivered to individuals. [4] However, approaches to ensuring workforce effectiveness are likely to differ across care organisations.
Effective workforce and the regulation of Australian aged care
The importance of an effective workforce in delivering safe, high-quality clinical care is captured in the current (2019) Aged Care Quality Standards, particularly within Standard 7 (Human resources). This requires aged care organisations to have ‘a workforce that is sufficient, and is skilled and qualified to provide safe, respectful, and quality care and services’ (7(2)). [4 p148] The Standards also stipulate that the workforce should be:
- Planned to enable, and the number and mix of members of the workforce deployed enables, the delivery and management of safe and quality care and services (7(3)(a))
- Competent, with appropriate qualifications and the knowledge to effectively perform their roles (7(3)(c))
- Recruited, trained, equipped, and supported to deliver the outcomes required by these Standards (7(3)(d)). [4]
Furthermore, the organisation’s leadership is charged with the regular assessment, monitoring and review of the performance of each member of the workforce (7(3)(e)). [4]
Current aged care reforms are intended to strengthen and reinforce the importance of an effective workforce. In the Revised Aged Care Quality Standards (2023), considerations for an effective workforce are predominantly covered in Standard 2 (The organisation). The Revised Standards align well with the current requirements regarding the importance of an effective workforce with some slight refinements. These include an increased emphasis on engaging workers as employees wherever possible and reducing the use of contracted staff. [5]
The Australian Government has also amended the Aged Care Act 1997 to include new responsibilities for providers when employing or reviewing the suitability of key personnel (section 63-1A). Key personnel include people with authority, influence, or responsibilities for decision-making or service planning across the organisation. These changes stress the importance of provider due diligence by requiring them to:
- Consider all key personnel against certain suitability criteria every 12 months
- Be satisfied that these personnel are still suitable to provide care
- Keep records of suitability matters that were considered and provide an explanation as to why they were satisfied with personnel suitability. [6]
Under section 63-1D(11) of this Act, providers and their governing bodies are also required to ensure that all staff:
- Have the appropriate qualifications, skills or experience to provide the care or other services delivered by the approved provider
- Are given opportunities to develop their capability to provide this care or deliver these services on behalf of the organisation. [6]
The new Code of Conduct for Aged Care requires aged care services to demonstrate that their workforce is competent, and that staff have the appropriate qualifications and knowledge to perform their roles effectively. [7] The Code also sets out the behaviours expected of providers, aged care workers, and governing persons to ensure care aligns with community expectations and consumer rights. [7]
In recognition that quality of care is impacted by the number, knowledge and skills of residential aged care staff, the Australian Government is mandating a minimum number of care minutes per resident. The government is also requiring residential care facilities to always have at least one registered nurse on site. These initiatives are aimed at improving resident care quality and safety by increasing access to personal care workers and experienced clinical care staff. [8]
Components of an effective workforce
An effective workforce is needed to support safe and high-quality care. [9] There are multiple components to establishing and maintaining an effective workforce, including clearly defined roles and responsibilities, appropriately qualified and skilled staff, and clear guidance for visiting health professionals.
To provide safe, high-quality care, aged care providers need to ensure that all members of the workforce (including employed staff and visiting practitioners) understand their specific roles and responsibilities, and work within the organisation’s clinical governance framework, even if they do not personally provide clinical care. [10] Furthermore, providers are required to regularly assess whether staff are working within their scope of practice. [2] The roles and responsibilities of different people working for an aged care provider should be included in the clinical governance framework. [10]
Some components of clinical care may be delegated to personal care workers. Organisations should have processes in place to ensure that when this occurs, these workers are trained and supervised by health practitioners, or have demonstrated that they can perform these duties under their direction. [2]
What might this look like in practice?
The following are signs that an organisation has provided clear guidance around roles and responsibilities in the context of clinical governance.
- The clinical governance framework defines roles and responsibilities for all personnel across all levels of the organisation and describes where and how each role is accountable for delivering safe, high-quality care [10]
- All staff work at the level appropriate to their skills, qualifications, and knowledge [4]
- Staff are trained and educated in their duty of care obligations and how these relate to the Quality Standards and other regulatory requirements [11]
- The organisation’s goals and expectations for care quality and safety are clearly communicated to staff at induction and orientation and continue to be reinforced
- The organisation has appropriate structures in place to ensure staff work within their scope of practice and according to the Code of Conduct for Aged Care
- The organisation regularly reviews the roles, responsibilities, and accountabilities of its workforce. [4]
The organisation needs to have a skilled and qualified workforce to be able to deliver safe, respectful, and high-quality care and services. [4] This is dependent on there being effective recruitment and selection processes in place, including appropriate pre-employment investigations to verify qualifications, experience, and work performance. Checks should include police and referee reports. [4]
Aged care providers are also responsible for using their Australian Government funding to ensure they have the staff numbers and appropriate mix of skills needed to provide good care and services. [4] This requires a strategic approach to workforce planning and recruitment. [12] Aged care governing bodies also need to ensure staff, especially those with less experience, have ongoing access to training and professional development opportunities and are provided with the support, supervision, and feedback on their performance that they need to fulfil their roles. [4]
To be effective and safe, clinical care practices should be based on the most robust, trustworthy research evidence available, or ‘best evidence.’ [13] Evidence should also guide the delivery of personal care to older people. Staff, therefore, need ongoing access to evidence-based information in the form of guidelines and standards to ensure their knowledge and skills remain relevant and aligned with what is currently considered best practice. [10]
What might an appropriately qualified and skilled workforce look like?
In organisations where staff are well qualified and possess the necessary skills to provide good care:
- Processes are in place to confirm new and existing staff have the appropriate qualifications and experience to provide appropriate care, including clinical care [1, 14, 15]
- Workers have access to supportive supervision and receive constructive feedback to improve their performance [5]
- Staff are confident in performing their clinical and care roles
- Aged care recipients are confident that the staff caring for them know what they are doing. Staff also listen to them and provide care that takes into account each person’s needs, preferences and wishes
- Staff performance is regularly monitored and reviewed [5]
- Staff training and skills development are priorities for the organisation [14] and are fully budgeted for
- Care managers keep up to date with current best practices in providing safe and effective care to older people. This knowledge is made available to the workforce through staff training sessions and by implementing protocols and procedures for the workforce to follow
- The organisation routinely reviews the training needs of its staff and works to improve training quality and effectiveness. [5]
Clinical governance enables clear understanding of accountability for the clinical outcomes and care experiences of people receiving aged care. However, there is no straightforward guidance for clinical governance in a shared care model. [16] While visiting (or contracted) health professionals are required to comply with relevant organisational policies and procedures when working in an aged care setting, they are also governed by their professional group’s clinical governance framework (e.g., allied health). [17] However, there should be agreements and processes in place to ensure that visiting practitioners are appropriately qualified and demonstrate that they provide care that is in line with the organisation’s expectations and clinical governance framework. [2]
What might clear guidance and systems for visiting health practitioners look like?
In an organisation with clear guidance and systems for visiting health practitioners regarding clinical responsibilities:
- There are processes in place to ensure that contracted and visiting health professionals have appropriate qualifications and experience to provide appropriate clinical care. [1, 14, 15]
- The organisation works with visiting health practitioners to develop clear policies regarding procedures and practices for appropriate clinical care of residents. [18, 19]
- 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. Fact sheet 1: Introduction to clinical governance. Canberra, ACT: ACQSC; 2019 [cited 2023 Apr 14]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_1_Introduction_to_clinical_governance.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
- 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
- Aged Care Quality and Safety Commission. Consider the suitability of your key personnel [Internet]. Australia: ACQSC; 2022 [cited 2023 Apr 28]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/acr_pg_007_consider_suitability_of_key_personnel_v3.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
- Anderson J. A fair and sensible approach to regulating 24/ RN and care minutes responsibilities [Internet]. Canberra, ACT: Aged Care Quality and Safety Commission; 2023 [cited 2023 Apr 29]. Available from: https://www.agedcarequality.gov.au/news/latest-news/fair-and-sensible-approach-regulating-247-rn-and-care-minutes
- Aged Care Workforce Strategy Taskforce. A matter of care: Australia's aged care workforce strategy [Internet]. Australia: Department of Health; 2018 [cited 2023 Apr 29]. Available from: https://www.health.gov.au/sites/default/files/a-matter-of-care-australia-s-aged-care-workforce-strategy.pdf
- Aged Care Quality and Safety Commission. Fact sheet 4: Roles and responsibilities for clinical governance. Canberra, ACT: ACQSC; 2019 [cited 2023 Apr 14]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_4_Roles_and_responsibilities_for_clinical_governance.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.
- Riverview Lutheran Rest Home Inc. Clinical governance framework. Loxton, SA: Riverview Lutheran Rest Home; 2020 [cited 2023 20 April]. Available from: http://www.riverviewresthome.com.au/application/files/2215/8071/1875/Clinical_Governance_Framework.pdf
- Hoffmann T, Bennett S, Del Mar C. Evidence-based practice across the health professions. 3rd ed. Chatswood, NSW: Elsevier Australia; 2017.
- 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.
- Martyn J-A, Zanella S, Wilkinson A. Perspectives from practice: Complexities of personal care workers. Aust Health Rev. 2019;43(2):238-239.
- Thomson S. Shared or brokered care: A paradigm shift for clinical governance frameworks. Australia: Deeble Institute for Health Policy Research; 2022 [Available from: https://apo.org.au/sites/default/files/resource-files/2022-06/apo-nid318083.pdf
- Australian Commission on Safety and Quality in Health Care. Clinical governance for allied health practitioners. Sydney, NSW: ACSQHC; 2020 [cited 2023 Apr 28]. Available from: https://www.safetyandquality.gov.au/sites/default/files/2020-02/clinical_governance_for_allied_health_practitioners_feb_2020.pdf
- Goodman C, Davies SL, Gordon AL, Meyer J, Dening T, Gladman JRF, et al. Relationships, expertise, incentives, and governance: Supporting care home residents' access to health care. An interview study from England. J Am Med Dir Assoc. 2015;16(5):427-432.
- Miller AC. Clinical governance in residential aged care facilities. Australian Medicine. 2019;31(14):16-17.
Connect to PubMed evidence
This PubMed topic search is limited to home care and residential aged care settings. You can choose to view all citations or citations to articles available free of charge.
