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Quality of care within aged residential care services has been a priority for Canterbury DHB and across the country. Audit plays a valuable role in monitoring contractual performance but is limited in its current focus in that it does not always add direct value to resident care, and timeliness of feedback to providers limits responsiveness. This paper outlines a number of proposed changes to our audit programme which will ensure audits are more focussed on resident care, timely and include provision of assistance as required to address issues. It also proposes that summary reports are made public; this will ensure future and current residents and family members have access to information to assist them make informed decisions when selecting an aged residential care provider.
As reported in the Chief Medical Officers report to the Board in August 2008 the quality of residential care provision is problematic to assess and ensure.
The Older Persons Health (OPH) sector has been identified by the Canterbury DHB as a priority for transformational change. Aged residential care is an integral component of the OPH sector and the Canterbury DHB is reliant on it to provide quality clinical and support services to the relatively small proportion of our Canterbury population that are frail or have advanced dementia, and require 24 hour residential care.
Public interest in the Aged Care Sector remains high and we anticipate it will remain so.
Over the last eight months Canterbury DHB has reassessed its approach to audit, complaints management and monitoring of quality. In addition to this the Ministry of Health (MoH) has been reassessing its approach to monitoring and is poised to introduce a number of national initiatives designed to improve the quality of residential care. These are focussed on improvements in monitoring and increasing public confidence through publication of certification audits. Other key MoH initiatives include third party accreditation of Designated Audit Agencies (DAAs); reducing duplication of audits and unannounced spot checks.
Audits
We recognise that the current audit approach is too focussed on contractual requirements that don’t always add direct value to resident care. However, our experience tells us that if effective management systems are not in place the whole service becomes fragile; contractual audits do have a place in our system. The contractual audit usually takes place over two to three days and is conducted by a team of two people experienced in the aged care sector and qualified to undertake audits. The focus is on seeking examples of compliance or non-compliance with contractual and sector standard requirements. They provide a useful, independent snapshot of how a facility is operating and the infrastructure (policy, procedure, systems etc) to support quality service delivery.
The limitations of contractual audits to date have been around the lack of detailed resident related information as useful indicators of quality of care such as weight management, clinical assessment and care planning, wound care, feedback from residents and families etc. We also have concerns about the timeliness of follow-up and monitoring, following identification of issues and completion of the audit report.
We are currently refining the Canterbury DHB audit tool to ensure it requires more resident related information, i.e. review at least 20% of care plans of resident population for comprehensiveness and evidence that they are being implemented and updated. This contrasts with current approach of random sampling several care plans for evidence of completion.
We are very supportive of the Ministry of Health’s intention to publish certification audit reports.
It is our strong recommendation to the board that full contractual audits are not published. We rely on full and frank disclosure of the findings of auditors against all of the categories in the audit template and we will be requesting client related information in the revised audit template. It is our concern that publication of entire audit reports will limit the ability and desire of the auditors to report as comprehensively as we would like.
It is also our recommendation that audit summary reports (currently part of the standard audit proforma) are published from July 2009, once the audit template has been refined. These will give a balanced appraisal of areas that the facility was found to be achieving well against contractual and standards requirements and areas requiring improvement. Monthly progress reports should be published by the lead auditor for the following three months identifying achievements against required actions.
Issues Based Audits (IBAs)
Issues Based Audits are undertaken following identification of immediate and serious concerns with the care being provided within a facility and/or unsatisfactory response by the provider to address serious concerns about care in a facility. Although these audits are usually more targeted than contractual audits and there is a limited period of notification to the provider, they are still largely focussed on meeting contractual and standards requirements and often move at a pace that makes it difficult to provide the feedback needed to act in a timely fashion.
Therefore in recent times, on identification of serious and immediate concerns, we have substituted a clinically led, Comprehensive Service Assessment of the functioning of an aged care facility. We have done this by engaging an experienced registered nurse and qualified auditor to work alongside clinical, care and management personnel, to thoroughly explore not only systems, but how they are being operationalised on a day to day basis, with a focus on resident care and safety. This has been initiated both formally (as statutory manager) and informally. The difference between these comprehensive assessments and contractual audits has been the focus on clinical requirements and a flexible approach to ensure the assessment includes coverage of all shifts around the clock and all aspects of care with particular emphasis on weights, nutrition, pain management, wounds, staff management and genuine resident and family engagement as part of continuous quality improvement.
Comprehensive Service Assessments are considerably more cost effective and timely than our current Issues Based Audit process.
Feedback from providers that are currently or have in the past been engaged in this process report extremely positively on the learnings gained and supportive approach of the auditor and Canterbury DHB. The focus moves from assessment, looking for evidence of compliance/non-compliance and requesting that providers independently rectify any issues; to providing hands on support with assessment, identification of issues and best practice, then following through with guidance and advice on how to address the issues, often in real time.
Complaints Management
Receipt of complaints from residents, families, and other stakeholders in the Older Persons Health sector is increasing within Canterbury DHB and across the country. In Canterbury the nature of complaints are not increasing in severity, however they are growing in volume, particularly at times of heightened publicity of issues in the sector.
Planning and Funding encourage people with concerns to approach aged care facilities directly and are provided with information about the services of Health and Disability Services. A register is kept to monitor the frequency and nature of concerns. Feedback is regularly and routinely provided to aged care providers on complaints received.
As a result of the importance and scale of the issue, the South Island Shared Service Agency (SISSAL) has been asked to scope an alternative complaints management system on behalf of the South Island DHBs. This scoping is currently underway and Canterbury DHB is an active participant in the project.
Planning and Funding is also participating in the Ministry of Health’s national discussion with DHBs and the Health and Disability Commissioner about ensuring that we continue to improve how we work together on complaints that require attention from multiple agencies.
Monitoring of Quality
The pilot to introduce interRAI assessment of older people in a residential care environment is well underway. Eighteen residential facilities were selected to participate in the pilot through an Expressions of Interest process.
Twenty-five registered nurses from these facilities are currently being trained to use the RAI 2.0 interRAI residential care tool for assessments of new residents and reassessments of existing residents of the facilities in which the nurses work. This pilot will be formally evaluated. The evaluation will assist in understanding the value that interRAI can add for assessment and care planning in Aged Residential Care Facilities, its role in monitoring quality, and to consider future directions for Canterbury DHB’s use of the InterRAI. We will share information with the Ministry of Health about our learnings regarding the value of this tool for the residents and staff of Aged Residential Care facilities, which will contribute to the national planning context.
