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In May 2009 the Minister for Ageing asked the department of health and ageing to carry out a review of the accreditation process (not the agency's performance) This is due by the end of June and hopefully it will be expeditiously released in time for those making submissions to the productivity commission by the end of July to utilise it.
I made a submission in which I highlighted the disenfranchisement and disempowerment of the community, conflicting roles for the agency, a failure to collect useful information, and an almost total lack of transparency.
I urged the splitting the accreditation agency, re-enfranchising and re-empowering the local community, and collecting the sort of information that is useful to the community. This should indicate when problems are developing, and should form the basis for accreditation, ongoing debate and research.
The Aged Care Crisis Centre and a number of other consumers also made submissions.
When I heard that 5 of the 12 members of the agency's board were also providers I made a supplementary submission showing how this conflict of interest compromised the accreditation process and the imposition of sanctions.
Click Here to download my submission.
Click Here to download my supplementary submission.
For information about the progress of the accreditation review go to
There was a performance audit of the accreditation agency by the Australian National Audit Office handed down in 2003. As far as I can determine this is the only review of the agency's performance. The audit was positive about some aspects of the agency's performance but was critical of the collection and use of information. The agency agreed to implement the recommendations of the audit but, although there has been no further audit it is clear from the 2007 review of the process and from current conduct that this was not done. This is undoubtedly because of the close links with the providers and the powerful position they have held on the agency's board. The audit recognised the pressure under which this new venture had operated and made the following comment.
However, the ANAO also concludes that there are some weaknesses in the Agency's management systems, which impact adversely on its management of the accreditation process. These include the Agency's costing systems, information management, and quality assurance mechanisms. The ANAO has made six recommendations addressing observed weaknesses.
The Parliamentary Joint Committee of Public Accounts and Audit in August 2003 asked for an assessment as to whether quality of life had improved as a result of accreditation. This report commissioned from Campbell Research and Consulting in November 2004 was not released until October 2007, 3 years later by which time most would have lost interest. It is available on the departments' web site and I examined it earlier.
The reasons for commissioning the 2009/10 report was the perception that the accreditation process was excessively burdensome. The minister asked the Department of Health and Ageing to review the accreditation process. A broad range of issues were canvassed. Those making submissions were also invited to raise other issues that were considered relevant to the accreditation process. It is still an examination of the process and not an evaluation of the agency and its effectiveness which is what we want.
The review was to be carried out by the department itself. Information was sent out in May 2009 asking for submissions. This indicated that submissions might be made public. To my knowledge, a year later no submissions, nor the agencies findings have been made public. I believe it is due by the end of June. It is critically important that this not be delayed. The productivity commission requires submissions by 31st July. Many from the community will wish to address the problems they see in the way the accreditation process is implemented and their ability to comment constructively will be compromised.
I made a submission on 16 July 2009 and followed this with a brief supplementary submission on 30th July when I found that "nearly half (5 of 12) of the accreditation agencies board is made up of members of the industry" and this included "a director who is also the CEO of a home currently being investigated by the department over the death of a resident."
In the supplementary report I commented on the difficulties experienced by an assessor, particularly from another board member's business, when assessing homes operated by a member of the accreditation board. There was also the possibility of victimization should a board member purchase a nursing home where an assessor worked.
I changed the thrust of my original submission as follows.
I would therefore like to modify my submission by urging that the oversight role of the agency be taken over by DOHA and be closely associated with the Complaints Scheme. The accreditation agency can then become an industry support body whose veracity would be readily assessed and evaluated against the findings of an independent oversight body.
This was much preferable and now that Professor Walton's review has advised that investigation of complaints be separated from the department, this should clearly follow and for the same reasons.
My original submission 17th July 2009
Summary
This submission comes from an outside and very different perspective to that which currently prevails in the sector.
It uses this perspective to critically examine what has happened to the nursing home sector over the last 12 years and to identify what appear to be key and very fundamental problems not only in the whole sector but particularly in the accreditation and complaint handling processes. It is clear that there is insufficient information and that the accreditation and complaints processes are not working for the community.
Four key problems are identified:
1. The disenfranchisement and disempowerment of the community
2. Conflicting roles for the agency.
3. A failure to collect useful information
4. An almost total lack of transparency
It is suggested that the key to redesigning accreditation and complaint handling is to place the community at the centre of both processes and give them responsibility.
To show that this is a real and a practical possibility and not a pie in the sky cop out, I have outlined a possible model in some detail. It is not intended to be final or definitive but to open discussion. There are problems and to be successful the community must embrace it and become involved. For this reason its implementation will require careful and staged introduction and close monitoring.
The discussion paper opens debate by detailing some of the areas in which accreditation has been criticized. The options they canvas will do little more than tinker with the problems. They will not disappear.
The submission examines the discussion paper and shows that, with a model like that proposed, objectives will be better met, processes will be simpler and more effective, and it will be far less burdensome than either the current system or any of the modifications proposed. Many of the issues will simply drop away.
Because the way we use language has played an important part in what has happened in the past, and because it will play an important role in any fundamental changes made, I have included an appendix in which this is explored.
There is a sense of disenfranchisement, distrust, disbelief and suspicion as a consequence of the lack of transparency and the unsuitable and often meaningless nature of the information that is publicly available. The recurrent scandals, and the way in which the press pick these up as newsworthy, is a measure of the distrust. (Page 5)
The limited information made available to the public by the accreditation agency is of little value. It is largely meaningless to the public. The information is inadequate for any meaningful research. This points to the agency's origin as a product of ideology, rather than a considered process of reform. (Page 8)
The actual standards of care in Australia's nursing homes and the validity of
the current resolution of complaints are not critical to my argument here. What is critical is that we do not have the information to make valid decisions in regard to either, and that neither is working for the community.
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What must be done if accreditation, oversight and complaints are to work is to fully engage the community in the process and to produce valid information that will mean something to them. (Page 9)
As the discussion paper points out the agency is charged with supporting and
assisting nursing homes to put in place processes that will result in good
care. At the same time they are charged with policing the standards of care
and are ultimately responsible for the information that results in penalties
being applied.
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Either the agency should be split or there should be
two
arms. The oversight role should be more closely aligned with the complaints system.
(Page 9)
There is no information about the acuity of residents' needs, and little if any assessable data about the incidence of complications, adverse events, medication errors and other failures in care or the quality of life of residents.
Either the nursing homes do not audit their services by collecting this information, the information is so unreliable that it is not worth using or the agency does not want to collect it. This must change if it is to become credible.
The community need to know what sort of care the local nursing home is providing, care which their family members will receive and which they will one day be subjected to. They are less interested in process. Without assessable information documenting care it is impossible to compare services, do any useful research, or engage in assessable "continuous improvement".
No one can provide perfect care. That almost all homes achieve a rating of 44 out of 44 is an illustration of its current lack of utility, and its lack of value for family and community as well as for both continuous improvement and scientific assessment. Veteran US health care legislator Pete Stark has criticized accreditation in the USA as little more than a marketing tool. Is this different? (Page 10)
Not only is the information of little relevance to the community, but so little is released that no conclusions can be drawn.
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This is a travesty, and makes a mockery of claims to transparency and accountability. (Page 10)
I indicated how this might be done but in light of Professor Walton's report I would now modify it.
My Supplementary Submission 30 July 2009
When I heard that 5 of the 12 directors of the accreditation agency were from provider groups and that the home of one of them was being investigated I made a supplementary submission in which I highlighted the conflict of interest. In light of Professor Walton's report I will be urging the productivity commission to place both accreditation and complaints under a totally independent community body.
It is totally unacceptable for the fox to be guarding the hen house. An oversight body should not be governed and controlled by those who are the subject of the oversight process.
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The homes associated with all of the 5 industry directors are subject to the full range of accreditation and support visits. However far these directors distance themselves from the process, the assessors will inevitably be reluctant to find fault with their own executive. Even if there is no bias there is a perception of bias that should not be there.
We can envisage a situation where assessors working in a director's company would fear for their own jobs when assessing the nursing homes owned by the mate of a director - or when the reverse situation existed. There is also the threat that the assessors company be taken over by the directors. (Page 1)
This confirms my assessment that the agency was set up as, and intended to be primarily a support group (and so a marketing resource) for the industry. Its mode of operation and patterns of behaviour are directed to this and not to its increasingly important role in oversight.
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It has also been pointed out to me that the agency is exempt from FOI so is not publicly accountable. This created difficulties for the present government, in 2005 when it was in opposition. (see Hansard s8086.pdf - 17 Feb 2005 page 135). Having 5 directors from the industry makes the agency directly accountable to the industry.
I would therefore like to modify my submission by urging that the oversight role of the agency be taken over by DOHA and be closely associated with the Complaints Scheme. The accreditation agency can then become an industry support body whose veracity would be readily assessed and evaluated against the findings of an independent oversight body. (Page 2)
Aged Care Crisis Centre Submission
My experience with the US accreditation system has made me very skeptical about the use of this process as a means of control in the face of strong market forces. I wrote about this when I started the aged care pages in 2006. The Aged Care Crisis Centre has been acutely aware of the number of homes who get into trouble soon after receiving a glowing 44 out of 44 accreditation review. They have written about this on their web site.
The Aged Care Crisis Centre made a submission to the review of the accreditation agency in 2009. They stressed that the process measured the ability to pass the accreditation process and not the quality of care, They drew attention to the many conflicts of interest impacting on the accreditation process. They were concerned about excessive documentation. and the burden imposed on staff. They drew attention to the potential benefits of technology in addressing these problems.
Their submission criticised the time given for accreditation visits and their infrequent occurrence. Nursing homes were even told when unannounced "spot checks" were to be done. Other issues were the lack of consistency in the process, the lack of transparency and accountability, the lack of consumer input into the process. They stressed that the care of the aged was a responsibility for all of us and we were being excluded.
Click Here to view the Aged Care Crisis Centre's submission.
Accreditation chief congratulates industry on "really good report"
On 21st May 2010 there was an interesting publication on Australian Ageing Agenda web site. Did the review say anything about collecting data?
EXTRACTS ONLY
Mark Brandon (CEO of the Aged Care Standards and Accreditation Agency) told the Aged Care Association Australia NSW (ACAA-NSW) State Conference that the industry had improved on its solid performance in the previous accreditation round.
In December 2009, 94 per cent of the nation's aged care facilities were compliant with all 44 of the agency's expected outcomes, up from 92 per cent in December 2006.
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The biggest stumbling block for homes was expected outcome 1.8 which deals with information systems.
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Mr Brandon said information management was fundamental in running any type of business.
"You need to be measuring the things that need to be measured and monitoring the data in a way that's meaningful," he said.
"A lot of groups know how to collect the information but where they fall apart is in making sense of it all. You find there is a problem when staff and management don't have the skills to analyse the information."
If there was some independent person from the local community it would be very helpful for the providers who don't know what data showing pressure sores and weight loss means.
For information about the progress of the accreditation review go to
Click Here to go back to the main report page
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