Major Aged Care Reforms in 2024: What to expect

How to Meet Your Aged Care Governance Obligations Part 1: Organisational Governance


In this first of our two-part series on aged care governance, we explain what organisational governance means, why it’s important and what the Aged Care Quality and Safety Commission (ACQSC) will be looking for when they assess compliance with organisational governance requirements.

In Part Two of this series we will take a closer look at clinical governance obligations.


What is Organisational Governance and Why Does it Matter?

In our article, What's Governance got to do with It?, we defined “governance” as the operational systems and processes that control and monitor an organisation. The key point to note about this definition is that governance is active. In the aged care context, governance is what the leadership team do when they make decisions and use purposeful systems to achieve outcomes for consumers, staff and the organisation as a whole.

“Organisational governance” is the broadest form of governance. It encompasses many sub-sets of governance, including workforce governance, financial governance and clinical governance.

Why does organisational governance matter? Because it empowers aged care providers to proactively take steps to improve consumer care and meet legal obligations.


Organisational Governance and the Aged Care Quality Standards

Aged care providers have always been subject to governance obligations, but now those obligations have been consolidated under Standard 8 of the Aged Care Quality Standards (Standards).

Entitled, “Organisational Governance”, Standard 8 requires providers to demonstrate that they:

  • engage with consumers
  • promote a safe, inclusive culture
  • have effective organisation-wide governance systems relating to:
    1. information management
    2. continuous improvement
  • financial governance
  1. workforce governance
  2. regulatory compliance
  3. feedback and complaints
  • have effective risk management systems
  • have a clinical governance framework.


Organisational Governance: What are the Assessors Looking For?

On 4 November 2019 the ACQSC conducted a webinar on “Accountabilities of governing bodies in aged care”.

The webinar panellists provided some insight into the kinds of evidence the ACQSC assessors will look for when they assess a provider’s compliance with the requirements under Standard 8.


Standard 8 (3)(a): Consumer Engagement and Co-Design

According to the webinar panellists, when assessing compliance with 8 (3)(a), the assessors are looking for evidence that providers have engaged with consumers, “co-designed” governance programs with consumers and responded to input from consumers.

Assessors want to know: what did you do to get feedback from consumers? What was the feedback and what did you do about it? How do you engage consumers to fix problems? Is there a consumer focus group?

As well as looking at the organisation’s publications (such as newsletters, notices, work instructions, policies and posters), assessors will interview consumers and their representatives and ask them for examples of what the organisation has done to engage them.


Standard 8 (3) (b): Promotion of a Safe, Inclusive Culture

Before we get into what the webinar panellists said, it’s important to note that “culture” is a complex and subjective concept, and it may be difficult, or even impossible, to prove that you have a particular culture. This may be why Standard 8 (3)(b) does not require you to demonstrate that you have a safe, inclusive culture, but rather that you promote one.  

According to the webinar panellists, when assessing compliance with 8 (3)(b), the assessors want to see “actual examples of how the organisation demonstrates its values”. One such “actual example” might be a statement that is published on the website or is otherwise publicly visible.

Assessors will also ask staff to explain how they and the wider organisation contribute to a safe, inclusive culture.


Standard 8 (3) (c): Effective Organisation-wide Systems

According to the webinar panellists, when assessing compliance with 8 (3)(c), the assessors want to see how the organisation seeks consumer input with regard to each of the governance areas (information management, financial governance etc) and how the organisation responds to consumer input.

The assessors also want to see how the organisation’s various systems work together. They want to see a combination of systems that work together, and that are flexible and responsive to changes, whether these be changes to consumer needs, staffing, funding or regulation.

The webinar panellists also said that assessors will be looking for evidence that:

  • information management systems capture consumers’ individual needs and preferences and protect their privacy
  • continuous improvement systems identify needs and risks and are used to plan and improve care
  • financial governance systems are flexible and responsive to consumers’ needs. The panellists noted that assessors don’t need to see complete financial records, but they do want to “understand the interaction between consumer needs and how finances are distributed in the organisation” and will seek examples of how problems were detected and funds allocated in response.

With regard to workforce governance, the panellists suggested that assessors would be assessing whether providers had sufficient staff. The panellists were asked how assessors would measure “sufficient staff” in the absence of staffing ratios. The panellists suggested that assessors would look for evidence that providers had gathered data on their own staffing needs and used that data to inform staffing decisions. As an example of how a provider might do this, one panellist suggested that the provider might talk with consumers to determine how many wanted showers in the morning and how many also wanted them in the evening and then use that data to determine appropriate staffing levels at different times of day.


Standard 8 (3) (d): Effective Risk Management Systems

According to the webinar panellists, when assessing compliance with 8 (3)(d), the assessors want to see how the organisation detects and responds to risk. The panellists noted that risks change over time, so assessors are particularly looking for evidence of an “ongoing conversation” with consumers about their concerns.

The panellists suggested that joint planning with consumers was the best way to deal with potential conflicts between a consumer’s safety and being given the freedom to engage in risky behaviour.

We will cover Standard 8 (3)(e): Clinical Governance in Part Two of this series.


The Role of the Board/Governing Body

The webinar panellists offered some advice on what assessors will be looking for with regard to the role of the board/governing body in an aged care organisation. The panellists said:

  • board members do not need to be available to the assessors during assessments, but if they want to engage, the assessors are very happy to hear from them
  • organisations are not required to have clinical experts (e.g. doctors) on the board but it would be a “value add”
  • boards are not required to stay informed about daily operational details, but they need to have information about the bigger picture. For example, the board should regularly receive a report on “adverse events” that states how many adverse events have happened and what is being done to prevent them. The report need not include detail on individual adverse events except maybe as “illustrative examples”
  • boards should always be asking themselves if they are getting enough data, and if the answer is no, they should take steps to fix this
  • while the panellists said that the board’s responsibilities are to consider “high level” data, they also said that they expect board members to get down to ground level and personally engage with consumers. The example they gave was with regard to food, where it’s “not enough to know the menu” – board members should “try some of the food themselves”.]


Standard 8: Organisational Governance is one of the most important and least understood of the Aged Care Quality Standards. Even after the ACQSC’s webinar, some organisational governance issues – such as staffing ratios and dignity of risk – remain poorly defined.

The good news is that when it comes to assessment of organisational governance requirements, the ACQSC seems to be following one basic underlying principle: consumer engagement. So, if you’re in doubt about how to demonstrate compliance with Standard 8 requirements, it’s worth deferring to this underlying principle and asking yourself: What have we done to get consumer feedback about this issue? How have we responded to this feedback?


For more information see:

Standard 8: Organisational Governance - Mapping Matrix Tool

What's Governance got to do with It?

What Keeps Aged Care Providers Up At Night? – Results From Our Recent Survey



Mark BryanMark B-1

Mark is a Legal Research Consultant at CompliSpace. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.

Critical Success SolutionsCritical Succss Solutions logo-1

Critical Success Solutions is a wholly owned Australian company that was established in July 2002. Critical Success Solutions was developed in response to an identified need for businesses to be able to access fresh and innovative approaches to business quality and system solutions – with a focus on health and aged care. Contact us to see how we can assist you in finding solutions.

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ACE Editorial Team

ACE is published by Ideagen. CompliSpace is Ideagen’s SaaS-enabled solution that helps organisations in highly-regulated industries to meet their governance, risk, compliance and policy management obligations.

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