Partner with older people to set the organisation’s priorities and strategic directions.
The governing body* must monitor how well the organisation is partnering with older people. This helps make sure the care they deliver is quality, safe, responsive, and based on the needs and preferences of each person. This includes assessing how well the provider* collaborates with older people to plan their care and make decisions. It also includes how involved older people are in continuous improvement* processes. This supports the governance*, design, evaluation and improvement of quality care* and services.
Partnership* with older people can include:
- forums
- meetings
- feedback* sessions
- surveys.
The governing body* should make sure the organisation is:
- treating older people with dignity, respect, and privacy when they receive care and services (Outcome 1.2)
- supporting older people to make informed decisions about their individual care (Outcome 1.3)
The Commission expects the governing body* to make sure older people receiving care have the opportunity to take part in a consumer advisory body. The consumer advisory body is responsible for:
- giving advice on how care is delivered
- giving advice on improving how services are delivered
- giving advice on the needs and preferences of older people and their consideration in the organisation’s decision making.
The consumer advisory body lets older people provide feedback* about the quality and safety of care they receive. When you set up the consumer advisory body (Outcome 1.3), you must:
- consider all the feedback* from the consumer advisory body when you make decisions
- tell the consumer advisory body in writing how the governing body* considered their feedback*.
This can include the governing body* asking the provider* to put in place a quality care* advisory board (QCAB). You can find more information about QCABs (refer to the Resource Centre).
The governing body* should use information from partnering with older people to shape how the organisation delivers quality care and services (Outcomes 2.1 and 2.7).
Lead a culture of safety, inclusion and quality that focuses on continuous improvement* and involves older people and workers* in strategic and business planning
As a governing body* member, you can encourage a culture of quality, safety and inclusion by involving older people and workers* in creating a strategic plan of the key priorities for the organisation. The plan should focus on continuous improvement* and include clear strategies for achieving these goals, such as:
- identifying and meeting legislative requirements
- supporting the rights, safety, health and quality of life* of older people
- managing organisation and operational risks (Outcome 2.4)
- managing workforce* needs and the needs of the organisation
- basing the organisation’s decisions on the care and services standards (Outcomes 4.1a, 4.1b and 2.8). Making sure that care and services are accessible to, and suitable for, people with specific and diverse needs, such as Aboriginal and Torres Strait Islander people and people living with dementia*
- making sure the organisation has, and uses, incident management* and information management systems* (Outcomes 2.5 and 2.7).
Your strategic and business planning needs to consider the context of the organisation and your legal requirements. This includes understanding your wider organisational and operational risks and needs.
The governing body* needs to outline behaviours that create a positive culture of quality and safety and monitor the organisation’s performance. This makes sure older people receive quality care* and services that meet their needs and encourages quality care* and services and continuous improvement*. Set expectations for all governing and leadership members about their role in creating a positive culture of safety, inclusion and continuous improvement*. These expectations should be clear through the organisation’s roles. You can communicate the expectations through:
- training
- conversations
- descriptions that explain each role’s responsibilities in leading a positive culture of quality and safety*.
Make sure the organisation puts in place a quality system* that has older people’s needs at the centre.
The organisation’s quality system* needs to:
- include a set of documented procedures* that outline step-by-step processes* for achieving the outcomes of the strengthened Standards
- define clear roles and responsibilities*
- be suitable and relevant to the organisation’s operations.
The governing body* must make sure this quality system* is developed and maintained. You need to support a culture of open disclosure* and continuous improvement*. Organisations can get this information through quality reports and audits. The organisation needs to:
- monitor their governance* frameworks to make sure they’re providing safe, and quality care* and services
- set performance monitoring processes*, including clear expectations (such as key performance indicators)
- have reporting processes* to help the governing body* make informed decisions and meet its responsibilities.
Review and endorse key components of the quality system*. For example, procedures* for delivering care and services and monitoring how the organisation is performing in delivering quality care* and services. This can include analysing the organisation’s reports about the quality and safety of their care and services. You need to particularly focus on reviewing:
- feedback* from older people, family, carers, and workers*
- risks, complaints* and incidents* (and their underlying causes)
- quality indicator data
- contemporary, evidence-based practice*.
The governing body* should use this information to understand the quality and safety culture* (Outcome 2.2.). They should also monitor investments in priority areas. This makes sure the provider* is spending money to provide quality care* and services for older people. If the governing body* finds problems or ways to improve, you must address them. You also need to support the organisation to address them in a timely* way.
For example:
- You should use older people’s feedback* to understand if workers* deliver care and services that meet their needs, goals and preferences*. If you find workers* aren’t consistently providing person-centred*, culturally safe*, trauma aware and healing informed care*, you need to support the provider* to figure out why and address it. For example, delivering worker* training to improve care delivery.
- You should use worker* feedback* to see if the provider* is supporting workers and resourcing correctly to deliver care and services. If you find that care and services don’t have appropriate resources, you need to support the provider* to address its workforce* gaps.
- Use contemporary, evidence-based practice* to check if the provider’s* quality system* supports delivering the best care. If there are more contemporary practices, the governing body* should help the provider* to start using them. You need to do this in a way that fits the context and ability of the organisation. They should use change management principles where relevant.
Be accountable for the delivery of quality care and services
As a governing body* member, you are accountable for the delivery of quality care* and services and must maintain oversight over all aspects of the organisation’s operations. This includes being accountable when things go wrong and making sure the provider* practises open disclosure*.
You will need to regularly* monitor and review the organisation’s performance, including:
- feedback from family, carers and workers*
- analysis of risks, complaints* and incidents*
- quality indicator data
- contemporary, evidence-based practice*
This will help you identify and support providers* with continuous improvement*.
The governing body* needs to monitor and evaluate how the organisation uses their risk management system*.
The organisation’s risk management system needs:
- to be organisation-wide and be regularly* reviewed and improved
- to include a risk register the governing body* uses to manage strategic risks. The provider* can also use it to manage day-to-day risks to operations.
You will need to oversee the management of risks and review risks escalated to the governing body*. This may include risks to the organisation or its people. For example, risks to safety, older people, finances and reputation.
The governing body needs to address any issues or areas for continuous improvement* they identify. You also need to help the organisation make any necessary changes.
One such example could include risks associated with equipment. For example:
- The governing body* needs to make sure the organisation uses effective equipment management strategies. These strategies should focus on the safety and wellbeing* of older people.
- You need to review reports on how effective these strategies are. These reports include the maintenance, cleaning, and suitability of equipment the provider uses to deliver in-home services. You should check incident* reports and feedback* on equipment safety and functionality (Outcomes 2.5 and 2.6). This needs to include feedback* from older people, families, and workers*.
- You need to be confident the provider’s* equipment management practices support safe and quality care* and services.
- If you find any issues or areas that could be improved, you must address them.
Evaluate how well the providers* incident management system* works.
The governing body* is responsible for:
- making sure the provider* responds to incidents* appropriately. You also need to make sure the incident management system* helps people to report on incidents* correctly and timely*. Learning from incidents can drive continuous improvement* of the services being delivered.
- making sure the provider* is complying with incident management regulatory requirements. Non-compliance can result in serious consequences for the older person and also for the provider* and governing body* members.
Monitor the organisation’s performance to put in place their feedback* and complaints* management system*.
As a governing body* member, you can expect providers* to report on the outcomes of feedback* and complaints*. By regularly reviewing this data, you can understand how effective the feedback* and complaints* management system* is, identify organisation-wide issues and support a culture of continuous improvement*.
Monitor how the organisation’s information management system* is performing.
Information management systems* and processes* are vital for delivering safe, high-quality, person-centred care*. They make sure older people and those involved in their care have access to consistent, reliable and up-to-date information that is managed appropriately in line with their informed consent*. This can lead to better outcomes for older people and helps your organisation with continuous improvement*.
An effective information management system helps the governing body* to oversee the organisation by tracking progress against strategic objectives. Information management* can be one of the key tools that inform and support your organisation to make changes and innovate. For example:
- Accurate information that is communicated to and accessible by the relevant people can lead to better care. It can also increase the confidence and trust older people and the community have in the organisation.
As a governing body* member, you need to understand the different parts of an effective information management system*.
The provider* needs to have systems* to:
- report and monitor information security incidents*, these reports must be regularly* reviewed by the governing body*
- record the governing body* has reviewed the information management system* to make sure it complies and meets stakeholder needs
- record the roles of the governing body* in overseeing information management and cyber incidents* and responses
- make sure key issues and concerns around information security are discussed during governing body* meetings and communicated from management
- make sure the governing body* receives current data and analysis from the information management system*. This means that you can review how effectively the system meets older people’s needs and compliance requirements and addresses risks in the organisation. This can include making sure that information is accessible, inclusive and easy to understand for older people.
You should make sure you regularly audit the information management* and record keeping* systems* as well as the incident* reporting process. This will help you to identify, analyse and respond to any policy breaches, issues or gaps in processes and identify system improvements. This allows for the timely* identification and analysis of gaps and issues and appropriate corrective action.
Audits of information management* and record keeping systems* can include:
reviewing how the organisation complies with the information management policy and regulatory requirements
- regularly reviewing records to identify any data quality issues, unauthorised changes or file damage
- regularly reviewing new technologies that you could use to improve record keeping
- monitoring and reviewing cyber security threats, with timely* staff communication and training.
Governing body* members can encourage staff to comply with information management policies and procedures by:
- making sure governing body* members and all staff receive sufficient training on the policies and procedures for information management and compliance. Regular training that sets out key responsibilities, as well as how to identify information management incidents* and data breaches, can help people to comply
- including compliance in the culture of the organisation. The organisation needs to provide enough support to staff to meet their information management obligations can include:
- providing appropriate systems* and tools
- telling staff that information management and good record keeping is a priority
- leading by example
- encouraging an open and continuous improvement* culture
- making sure you investigate any non-compliance with the information management policy.
Monitor how the organisation maintains a safe and healthy workforce* and workforce* strategy.
As a governing body* member, you can expect to review reports on the organisation’s workforce* strategy and how well it’s working. This includes information about the provider’s*:
- workforce*
- specific working needs
- plans for the future
- strategies for promoting a psychologically safe* workforce*.
Monitor the organisation’s strategies or processes to roster workers* and how effective the training system* is.
Providers* have obligations to make sure workers are skilled, competent and supported to deliver quality and safe care and services that meet older people’s needs. As a governing body*, you should have oversight over the organisation’s hiring practices, including pre-employment checks (Outcome 2.8) and their rostering and training system* and strategies (Outcome 2.9) and be confident there are appropriate systems and processes for providers to meet their obligations.
Oversee how the organisation puts in place strategies for emergency and disaster management plans.
Governing body* members need to understand the key parts of a strong emergency management plan. The organisation’s systems* need to:
- identify and assess potential risks and hazards that may impact the safety and wellbeing* of older people. These risk assessments need to be regularly reviewed by the governing body*
- record that the governing body has reviewed and approved the emergency and disaster management plan, making sure it complies and meets safety standards
- define and document the governing body’s* role in overseeing emergency planning and preparation, response strategies and post-incident* evaluation
- make sure the organisation communicates critical issues and risks around emergency management during governing body* meetings
- make sure the governing body* receives current data and analysis from emergency drills and incident* responses. This allows you to evaluate how effective the emergency management plan is in protecting older people and mitigating risks.
You should audit emergency management practices, including training and incident* reporting, to identify gaps, issues, and opportunities for continuous improvement*. Audits of emergency and disaster management plans can include:
- reviewing how the organisation complies with emergency preparation policies and regulatory requirements
- evaluations of drills and exercises to identify areas where you can improve and to make sure emergency responses are effective
- updating risks and best practices to improve emergency preparations and your ability to respond
- monitoring staff training in emergency procedures, with updates on new protocols or equipment as needed.
The governing body* should oversee emergency and disaster management. You need to make sure the organisation has suitable controls, resources, and reporting mechanisms. This includes strategies for emergency and disaster preparation and response.
You can find more resources about the role of the governing body* and governance* in the Commission Resource Centre.
The Commission developed the Governing for Reform in Aged Care Program to support the key recommendations of the Royal Commission into Aged Care Quality and Safety. The Program supports governing body members, leaders and emerging leaders to strengthen corporate and clinical governance capabilities and enact critical reform.
