In last week’s article we set out five reasons why you should invest in data management, including this: you will be assessed on your data management system.

As part of the budget announcements, the Government promised to give the Aged Care Quality and Safety Commission (ACQSC) about $25 million to undertake an additional 1,500 safety audits in residential care facilities in 2021-22. So, not only is it more likely that your data management system will be assessed more frequently – it’s more likely that all your systems will be assessed more frequently.

Good data management can help you improve quality and pass assessments across all areas of your operations. But how do you ensure good data management? Today we set out three things you can do to improve your data management system and increase your chances of passing an ACQSC assessment. But first:

What is a data management system?

By “data management system” we mean the policies, procedures and mechanisms you use to collect, store and use data. A good data management system will include training for staff, privacy protections, and mechanisms for consolidating data, avoiding inconsistencies and generating useful reports. A data management system is often part of a broader enterprise risk management system.

Here are three things you can do to improve your data management system.

Audit for Consistency

Are there some incidents that you reported in your clinical management system (or the consumer’s progress notes), under the QIs but not under the SIRS? The ACQSC will cross-reference different sources of data that it gets from you and if it finds inconsistencies it may hit you with a ‘not-met’.

To mitigate this risk, consider taking a proactive approach to ensuring consistency by doing your own audit across your different reporting areas. If you find inconsistencies, be curious and ask why. Are you entering the same information in too many different places? Could you create a primary location where the information is recorded and then distribute it to the necessary areas from there?

Beware of casual, imprecise language

Auditing for consistency means not only checking for consistent numbers but also consistent language. The SIRS and QIs use precise definitions that sometimes do not match the way we speak in casual conversation. For instance, the definition of “fall” under the QIs is “an event that results in a person coming to rest inadvertently on the ground or floor or other lower level.”

Consider this scenario: a resident stumbles while walking but manages to steady themselves without injury. The resident is happy and well, so staff decide there’s no need to report this under the SIRS or QIs. However, in a progress note they record this incident as a “fall” with no additional context. On review during an assessment contact, the ACQSC reads this as it appears documented: a “fall” that you failed to report under the SIRS and QIs. This leads to a (potential/possible) not-met.

The key to avoiding this kind of situation is to ensure your staff understand key terms and make their reports in precise, consistent language.

Collect Your Data Regularly and Continuously

Data goes out of date quickly. The ACQSC will want to know not only what you’ve collected but when you collected it, how you acted upon it and what systems you have in place to collect it again, and again in the future.

The first step to prepare for this is the easy one: note down the date that you collect data and then make sure you include this date when you mention this data in your reports to the ACQSC.

The second step is easy to do but not always easy to remember to do. When compiling your materials to submit to the ACQSC assessors, you need to note the date that data was collected and make a judgment call about whether it is fresh enough to use. It can be a hassle to recheck records or reissue a survey, and you’ll be tempted to settle for submitting old data – but the ACQSC won’t be.

Finally, ensure you have a statement, in writing, that tells the ACQSC what data you collect, how you collect it, how often you collect it and who is responsible.

Use Data for Your Own Purposes

Why are you collecting and reporting on data? If your only answer is “because the regulator says we have to” then you’re making life harder for yourself.

A strategy that focuses on ticking the minimum boxes required to pass an assessment is flawed from the outset because it assumes you know what those boxes are. You don’t. You can’t. It’s impossible to predict what a particular ACQSC auditor will want to see on a given day. And there’s no guarantee that the next auditor will want to see the same things. So if your strategy is to only tick the minimum boxes required to pass an assessment, you’ll have to tick every possible box that every possible auditor might want to see on any possible day. As a result, your strategy to do the minimum will end up costing maximum effort.

What is the alternative? Collect and use your data to achieve what you want to achieve. This involves, first and foremost, clearly articulating what it is you want to achieve. Be specific. Broad goals, such as “to improve quality of care” are of limited help in this context (of course you want to improve quality of care). Better goals are more targeted, specific things such as:

• Find out when, where and why falls are most likely to happen in the facility.
• Find out how much time staff spend on admin each day.
• Find out if the Board/governing body actually read the reports they receive.
• Give the Board accurate data showing needs of the resident cohort in each home to allow for effective governance.

The bottom line is that regulation and assessment are becoming more and more focused on data. You are going to have to collect and use data anyway. Why not use it to your advantage?