In Part One of this series we focused on organisational governance. In this article we home in on clinical governance, explaining what it means, why it’s important and what the Aged Care Quality and Safety Commission (ACQSC) will be looking for when they assess compliance with clinical governance requirements.
What is Clinical Governance and Why Does it Matter?
The ACQSC’s Guidance and Resources for Providers to Support the Aged Care Quality Standards (Guidance and Resources) defines clinical governance as:
“The set of relationships and responsibilities between the organisation’s governing body, executive clinicians, consumers and others to achieve good clinical results. It puts the systems in place for delivering safe, quality clinical care and for continuously improving services. Clinical governance usually includes involving consumers, clinicians, clinical review, training, risk management, use of information and workforce management.”
In our article, What’s Governance Got To Do With It? we noted that clinical governance has three core areas of purpose:
- safety of care or the providing of health care without experiencing preventable harm
- appropriateness of care or evidence-based care
- effectiveness of care, which includes evaluation across all parts of the care, underpinned by meaningful partnerships between consumers, and healthcare providers.
Like organisational governance, clinical governance matters because it empowers aged care providers to proactively take steps to improve consumer care and meet legal obligations. At an even more basic level, clinical governance matters because it helps keep consumers safe from harm.
Clinical Governance and the Aged Care Quality Standards
Clinical governance is covered in the Aged Care Quality Standards (Standards) under Standard 8: Organisational Governance.
Standard 8(3)(e) says that all aged care providers who provide clinical care must have “a clinical governance framework” that includes but is not limited to:
- antimicrobial stewardship
- minimising the use of restraint
- open disclosure.
According to the ACQSC’s Guidance and Resources, antimicrobial stewardship involves implementing “new initiatives to reduce inappropriate antibiotic usage and resistance” and “effective organisation wide systems … for preventing, managing and controlling infections and antimicrobial resistance.”
Minimising the Use of Restraint
According to the ACQSC’s Guidance and Resources, “where restraint is clinically necessary to prevent harm, the organisation should have systems to manage how restraints are used.”
Note, in addition to the requirements under the Standards, the use of physical restraint is subject to data reporting requirements under the Commonwealth Department of Health’s National Quality Indicator Program.
According to the ACQSC’s Guidance and Resources, open disclosure requires “organisation wide systems to support communication with consumers about incidents that have caused harm.” For more information, see our article The Aged Care ‘Open Disclosure’ Process Explained in Five Points.
Overall, Standard 8(3)(e) has a “high level” focus. It provides no details on how to administer antibiotics, lock doors or deliver an apology – those issues are dealt with elsewhere in the Standards. Standard 8(3)(e) is not about daily activities themselves, but about the frameworks and systems that govern them.
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(3)(e).
Leadership and Culture
Assessors want to see that consumers and staff are encouraged to raise issues that may be relevant to clinical care, and that complaints are dealt with openly and constructively.
Organisations are not required to have clinical experts (e.g. doctors) on the board but it would be a “value add”.
Assessors want to see evidence of how providers have sought input from consumers about their own clinical care, and evidence of how providers have responded to this input.
Assessors want to see that providers have systems in place to clearly identify those consumers who have representatives, and who these representatives are. Particular care should be taken to ensure that consumers who have difficulty communicating are properly represented.
Assessors want to see systems in place to maintain clear lines of communication with medical professionals.
The webinar panellists noted that restraint was a major concern for ACQSC Assessors. The panellists’ guidance on this issue, however, was not clear.
The panellists were asked who is ultimately responsible for the use of chemical restraint, the prescribing GP or the clinical care staff. One panellist initially suggested that the GP would be responsible but then noted that GP prescriptions are often based on information from staff, so staff may also be responsible.
The panellists were asked if ACQSC Assessors would consider pin-coded doors an inappropriate form of restraint. The panellists did not clearly answer one way or the other, noting that the appropriateness of restraint in a given situation will depend on “many factors”.
Dignity of Risk
The panellists provided several examples of how to manage the conflict between clinical risks and consumer choice.
In one example, a consumer had been assessed as being at risk of asphyxiation and the safest form of food for them was deemed to be pureed food and thickened fluids. The consumer, however, got a lot of joy from eating solid foods. One way to approach this, the panellist said, was to simply follow the speech pathologist’s recommendation and restrict the consumer to non-solid foods. But a better alternative would be to “go to the consumer and say ‘this is a risk and if you aspirate it may be unpleasant and you may get pneumonia, but we could elect to take that risk and you could just continue to eat normal food and see how you go and why don’t you tell us which you’d like to do’.”
In another example, the service wanted to help a consumer reduce their alcohol consumption after the consumer sustained a significant fall. “So the service had adopted an approach which involved a dialogue about the risks in relation to that fall, the reduced mobility as a result of the fall. But a compromise around how they will assist the person who continued to want to consume alcohol, but in a safer way where the quantity that was being consumed could be better understood and managed. So there was better surveillance around that from the service.”
In Part One of this series we noted that organisational governance requirements were complicated and sometimes poorly-defined, but this was not cause for panic because underneath this complexity lay the simple principle of consumer engagement. As long as providers continued to connect with consumers and respond to their feedback, they were in a good position to provide quality care and pass assessments. In the words of the Aged Care Quality and Safety Commissioner: “Jointly planning care and services – provider and consumer working together – is the best way of getting it right every single time.”
That’s organisational governance. Does the same challenging but ultimately hopeful situation apply to clinical governance?
The short answer is: we don’t know.
On the one hand, the webinar panellists seemed confident that the consumer engagement principle could guide providers through any clinical governance challenges. And the examples they gave – the consumer at risk of asphyxiation and the consumer trying to cut down on alcohol – seem to show that problems can be solved by working with consumers.
On the other hand, the Standards and the ACQSC assessment process are still new and largely untested, and the really tough, messy, coal-face problems have not yet come to light. You can see this in the panellists’ two examples, which both barely skim the surface of the issues. Yes, providers should ask at-risk consumers if they want to continue with solid foods or alcohol consumption. But then what? If a healthy compromise is reached, great, but what if it isn’t? What if the consumer refuses to engage or compromise? What if the consumer says one thing but does another? What if the consumer’s suggestions are wildly impractical?
These are not pleasant questions to ask but they alert us to the complex reality that providers will have to face. That complexity should be acknowledged. Clinical governance challenges can be managed, there is cause for optimism, but at this early stage the optimism should be cautious.
For more information see:
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.
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