What is Governance?

NurseWho Clinical Governance May 23, 2022

What is Governance?

Governance is a term used regularly in the echelons of high-ranking businesses. The business has largely grasped the concept of Governance to improve outcomes for all stakeholders. However, the same cannot be said for Aged Care.

Governance and Clinical Care. Are they related? I just had somebody come to tell me that Governance is totally separate from care, and that management of an aged care home is not involved in care governance. I did not wish to argue but felt the need to point out that Governance is All About Care.

The new Aged Care Standards (2019 – introduced 3 years ago now) are focused on Governance. Governance is oversight of the resources required to provide appropriate care. Resources incorporate all the standard things like staffing, equipment, cleanliness, clinical stores, and so on. However, with an increased focus on consumer rights, and safety, there is a requirement for increased clinical assessment. Assessment when communicated clearly and documented well on the care plan meets the care and governance standards. When this is done poorly both areas are similarly affected.

Registered Nurses

Are Registered nurses essential for good care? The answer is simple, yet complex. If you see a medical specialist and are booked in for surgery, you expect the people preparing you and operating on you to have the knowledge and skills to perform safely and effectively. It is exactly the same in aged care.

When someone enters an aged care home, they do not automatically give up their right to good care. Does a registered nurse have the appropriate knowledge and skills to undertake comprehensive clinical assessments and to document these? The answer is Yes! If you answered no, it could be best to review the skill levels of your staff. We talked about just this matter, in our previous post (https://clinical-governance.com.au/upskilling-staff-savvier-than-enlisting-new/) – the dilemma of finding or training to ensure you have competent staff.

So what!

So where is the connection between a bowel management chart and Governance, you ask! Allow me to explain. If a consumer suffers with constipation, and this goes on for many days unnoticed, with no records documented, the consumer is at risk of bowel obstruction. When admitted to hospital for surgical management of said bowel obstruction, and simultaneously become sick with septicaemia; the Governance rises to the fore. Governance is about the systems of documentation to ensure everyone has such details recorded accurately. Governance is about having appropriately skilled staff, through education, competency or a combination of both, to ensure the staff managing care have the relevant skills. Governance links directly to consumer safety and choice. All consumers wish to remain safe, and none would make a choice to have surgery unless necessary. The very nature of this small issue, as it started has turned into one affecting care and governance standards.

Good care is good governance. Good governance results in good care. The two are permanently interlinked; they are not separate.

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Upskilling staff savvier than enlisting new

Upskilling staff is definitively smarter than enlisting new ones.

Current market labor forces would have you believe there is a shortage of nurses. Alas, if we look in the right places, and attract the right staff; there are mountains of people looking to work with you. To support this, I bring to your attention the hundreds of virtually retired registered nurses, who were brought back to life again by AHPRA during the Covid Crisis.

The situation is so ridiculously serious that Aged Care Journals have in recent months published articles from University Professors. However, there are some interesting points raised by this research. Firstly, that onboarding is a complex and costly process. Then there is the push for full-time workers. Staff need options, not weeks of onboarding paperwork, and inflexibility with working shifts. Pulling the hard line on shifts relies heavily on attracting that market workforce where there is a shortage – new staff that knows no better. If you want experienced staff, then you may have to change some of the onboarding processes and offer more flexibility.

Staffing Ratios

Staffing ratios have always been a thing. Since the beginning of time nurses have been battling to maintain some sort of staffing ratio. In aged care, prior to the introduction of the Aged Care Standards in 1997, there was a funding tool that by its own virtue required a certain number of staff to meet clients’ care needs. This has all been superseded by Quality Outcome goals.

What we know is when a registered nurse commences work in Aged Care, there is an expectation that the registered nurse is able to perform a huge number of tasks competently: clinical assessment, medical communications, appointment bookings, crisis family management, human resource management, rostering, and legally appropriate documentation on all of these events. Oh, and don’t forget that all this must be done whilst filling in the incident form, completing the computerized care plans, and meeting the Quality Standards. Then we hear complaints about the new registered nurse not performing well. In what other industry do you expect someone to complete their degree and function at the level of a Major General, on day One.

In the coming weeks, we are going to look at how to best work with these registered nurses, for the benefit of all stakeholders. Stay tuned, and drop us a line to say hello.

IPC in residential care

NurseWho Clinical Governance October 4, 2021October 4, 2021

Clinical Governance & Covid

How is your Infection Prevention and Control (IPC)

Over recent months we have seen many residential aged care facilities suffer at the hands of Covid-19. Concurrently we have also seen increased vaccination rates for residents and compulsory vaccinations for staff. In addition IPC leads are a regulatory requirement, and their role will evolve post pandemic.

Current Covid Case Numbers

As of 2 October 2021, the Commonwealth Department of Health shows 728 people have died from Covid-19 in residential care, across Australia. The largest numbers in New South Wales and Victoria. Every week the current Covid cases in residential care are listed. At the time of writing, there are 39 Active Covid-19 Active Outbreaks in Residential Care across Australia.

The updated advice to residential aged care facilities in New South Wales, can change daily. If your home has an IPC Lead it could be advisable for them to check this information daily. If your home does not yet have an IPC Lead, consider having someone else allocated to this important information update task.

Covid Lockdown

There are number of things that will happen when a Covid positive case, in either residents or staff, is identified. The positive Covid identification engages supports from Commonwealth and State Health Departments.

However, each home also has to implement an Outbreak Management plan. The best guide available is from the Aged Care Quality and Safety Commission. The Aged Care Royal Commission makes mention of the input from external experts on developing appropriate outbreak management plans.

The Outbreak Management Plan is in addition to the home’s Infection Control Policy, Donning and Doffing competencies and Hand Hygiene competencies. Each document forms part of the suite of information to meet Infection Control and Covid Pandemic requirements.

Another source of vital information is the Clinical Excellence Commission. They have valuable information and resources for infection control, and residential care specific resources.

PPE and other services

PPE becomes the primary thing in lockdown. PPE inventory, PPE usage, PPE donning and doffing, PPE donning and doffing stations, PPE orders, and PPE waste removal.

Mask fitting becomes a crucial component of keeping safe. Incorrectly fitted masks increase the risk of spreading Covid. There is information available on how to correctly fit a face mask. Correctly applied, the face mask reduces the risk of spreading Covid-19.

Depending on the number of residents and staff, size and shape of the building; an appropriate zone allocation for cohorting staff plan needs to be put in place. This will ensure that staff work in one area of the home only, whereby reducing the risk of spread.

PCR and RAT testing

The number of Polymerase Chain Reaction (PCR) and Rapid Antigen Testing (RAT) have increased to phenomenal levels during 2021. But which one works best. The research shows RAT are fast and largely accurate. However, the PCR test holds the Gold Standard for accuracy.

Some providers have moved to regular usage of RAT testing. Consider, this in itself can also be time consuming to perform on site. In addition, any false positive will need to be followed up by PCR testing to confirm or deny Covid-19.

Covid Vaccination

Around 97% of aged care staff has now received at least their first dose. This is expected to reach 100% soon, with the availability of vaccination venues becoming more readily available.

Clinical Governance

In July 2019 the new Aged Care Standards were introduced. As part of the process Governance was introduced into residential aged care. Governance is now a critical part of the process for residential aged care providers to meet the Standards. So what exactly is Governance.

The Australian Standards, outside of residential care demonstrate that Governance provides principles to guide governing bodies to meet their responsibilities. This is the most positive and innovative change to the Aged Care Standards since 1997. Correct implementation of Governance will enhance care outcomes for consumers, whilst promoting the business simultaneously.

Where to next

Implementation of appropriate Governance alongside adequate IPC processes, will reduce your risk of exposure to Covid-19. How do I know? Because I have expertise in Covid testing, on Covid hospital wards, and in Covid lockdown residential care facilities. With a background in ED Nursing, and Aged Care Auditing, I have immense knowledge and expertise around how to reduce your risk, and get out of lockdown quickly and safely.

As we come towards a reduction in Covid numbers in New South Wales, nobody has a crystal ball for what the future holds. Get in touch so that we can help you reduce your risk.

Why a Registered Nurse

NurseWho Clinical Governance December 28, 2019August 26, 2020

registered nurse

Why a Registered Nurse

Since time immemorial registered nurses have been at the forefront of care.

Whether in the hospital setting or aged care. Registered nurses provide care for the patients as well as assisting physicians in providing treatment to patients in various hospital and community settings.

The tasks often associated with nursing includes monitoring, recording and reporting symptoms or changes in patient’s conditions.

The primary issue of the day is why do we need a registered nurse in aged care, when someone with a certificate III or IV can administer medications and perform wound dressings?

The answer is the same as it has always been.

A bowel chart defining seven days with no bowel motion, is just that – a chart.

Any person will know there is a problem; however a registered nurse will understand how serious the problem is, will take immediate action to have it rectified, will undertake a detailed assessment and analyse the data to prevent this from happening again; will contact relevant people to notify of any potential changes; and will clearly document all events.

What happens if there is no registered nurse in this situation..

is not for discussion in this article. The resultant perpetuating medical problems are potentially insurmountable.

Why again?

Registered nurses provide not only physical care in terms of administering medication and other treatments, but they also undertake the provision of emotional support during care transition; counsel and educate families in the transition process; collaborate with other medical professionals about changes in care needs; and registered nurses clearly document the issue, the actions taken and the resultant outcome.

But!

If your staff are not performing at this level, you have a problem.

Call me right now, so that you can get the professional care you require from your registered nurses.

Aged Care Funding

NurseWho Clinical Governance November 26, 2019August 26, 2020Aged Care Funding, clinical governance systems

HISTORY

The 1970’s and 1980’s saw a growth in the number of nursing homes built and operated by what we know as the Charitable sector, or Not for Profit (NFP). Resulting in an explosion in the proposals for building new nursing homes and hostels. In the late 1970’s a deficit financing system was established, where Government would meet the deficits incurred in running of homes in the NFP sector. This resulted in more homes taking up the scheme, increasing by 54% by 1983.

As a result a new funding model was introduced in 1987. This was the Standard Aggregated Module (SAM), the Care Aggregated Module (CAM), Other Cost Reimbursed Expenditure Module (OCRE) and the Resident Classification Instrument (RCI).

At the same time was the introduction of the geriatric assessment teams which were the forerunners for the Aged Care Assessment Teams (ACAT) that are currently in place. Outcome standards were introduced in 1987 and respite care subsidies introduced in 1988.

In 1992 the Personal Care Assessment Instrument (PCAI) which was modelled on the RCI was introduced into hostels. Funding moved from the RCI to the Resident Classification Scale (RCS), which operated across both hostels and nursing homes. In 1990 a national plan for dementia care was funded.

In 1997 the Aged Care Act was introduced.

CAM (Care Aggregated Module)

These funds were provided to pay for the nursing and personal care of residents. CAM funding is provided at different levels for different residents based on the level of care each resident requires. Residents are classified according to their care needs using the Resident Classification Instrument (RCI). This places residents into one of five categories, with Category One residents requiring the most care, and Category Five residents requiring the least. More funding is provided for those residents with higher care needs. This removes the disincentive to admit residents with greater (and thus costlier) needs.

The audit process used by the Department of Health and Family Services to verify the expenditure of CAM is called validation.
Validation identifies any CAM funding not spent on care, and this was recovered by the Department. Hence at that time we see providers penalised for not utilising the RCI funding on direct care costs.

SAM (Standard Aggregated Module)

SAM funding is for non-nursing care costs, such as food, administration, and building maintenance. SAM funding was a uniform grant, with all nursing homes receiving SAM at the same rate. Unlike CAM, any unspent SAM funds are kept by the operator as profit or surplus. This provides an incentive for operators to reduce SAM costs, so that they can increase their surplus.

OCRE (Other Cost Reimbursed Expenditure)

These funds are provided to reimburse staff related costs such as superannuation, workers’ compensation and payroll tax. Nursing homes in each State receive OCRE at a rate based on the average costs of these staff-related expenses in their State. OCRE funds are also validated by the Commonwealth Department of Health and Family Services.

RESIDENT CONTRIBUTION

In addition, residents also contribute to their care costs. The standard contribution was 87.5% of the full single pension plus rent assistance. A small number of nursing homes have been allowed to charge above this rate in return for a higher level of services. These homes were called “exempt” homes, and they had to gain approval through a formal application process.

Aged Care Standards form part of the Corporate Governance Frameworks in place.

https://clinical-governance.com.au/corporate-governance/