Nov 02, 2020

“The canaries in the coal mine”, complaints systems set for a massive overhaul, 124 proposed recommendations to Royal Commission

In the final hearing of the Royal Commission into Aged Care Quality and Safety, Senior Counsel Assisting, Peter Gray QC and Peter Rozen QC, presented submissions on behalf of the Counsel Assisting team.

The result being the following two principal reports:

  1. Counsel Assisting’s Final Submissions (PDF) 22 October 2020
  2. Counsel Assisting’s Proposed Recommendations at Final Hearing (PDF) 22 October 2020 

A common theme throughout the final submission report and subsequent recommendations, outlined the inadequacies when monitoring, managing and resolving complaints by providers, as well as the efficacy of the complaints commissioner function itself.

Complaints were described as ‘the canaries in the coal mine’, by Professor Ron Paterson who gave evidence at the hearing last year.

Effectively they are that early warning signs that tells you bigger things are often brewing.

Many would also agree that complaints are a reactive way to run a business. By the time you  have received a complaint you have often made someone so unhappy, they have taken the time to make a complaint. Furthermore, you probably haven’t just made one person unhappy but several and there is a smaller ratio of people who actually complain than people who feel like, but don’t elect to actually go ahead with it. And sometimes, by the time you are hearing about it, it can be far too late and the damage is done, and trust is broken.

A more proactive feedback approach is to establish and leverage “trend data” for actionable insights. This is far more favourable as it ensures actions can be taken before a complaint occurs. It also avoids the ‘survivorship bias’ problem that can surface from actioning change only off complaints misrepresenting the true state of the community and concerns within a facility or experience.

As highlighted in the Royal Commission, effective feedback and complaints systems are lacking across the sector, and it’s frequently deprioritised for various reasons, but one that stands out and has plagued the sector is the culture within some organisations of not actually wanting to hear about issues in the first place. This is because as soon as one hears about an issue, one has to attempt to do something about it.

1. Monitoring and deficiencies in complaints data

On the eve of Christmas, 2018, all approved providers were asked to report on occasions or complaints of substandard care during the period of 1 July 2013 to 30 June 2018.

The final submission report said that identifying and understanding “the precise extent of substandard care in Australia’s aged care system was a difficult task due to deficiencies in the data available to measure the quality of care”.

This raises another critical point about the absence of data on quality of care: “this should not be the case. It should be a straightforward task to assess the quality of care provided in our aged care system”.

Deficiencies in the way complaints data has been monitored and reported has prevented the sector from effectively identifying problematic themes and addressing them. And as evidence before the royal commission has suggested, “providers often do not manage complaints well, and that in some cases complaints are discouraged”.

At present, there is no expressed regulatory requirement that an approved provider’s governing body must receive reports on complaints filed against that provider. This has been identified as a significant shortcoming in governance and management. Consequently, the report concluded “Every provider should implement arrangements to provide its governing body with regular reports on complaints, including an analysis of the patterns of, and underlying reasons for, complaints”.

The very fact that the exact number of instances and location of “substandard care” cannot be easily accessed by those who need to know or those who should be entitled to know at any given time is a critical flaw in the sector.

2. Quality indicators too clinical focused

In 2019, the new Aged Care Quality & Safety Commission shifted the focus of the quality standards away from solely focusing on clinical indicators, and towards what the resident has to say about the care and the service they receive. In retrospect, this was a critical milestone in the progression of the industry signalling a recognition of the basic axiom of our industry, being able to provide care for our residents in a way they perceive it, and in a form that factors in the importance of ultimately leaving them with a good experience and a voice to state it or otherwise.

This was probably the most significant turning point and change in the sectors transformation  from all being about “clinical audits and binary assessments”, to, believe it or not, recognising that asking the resident about their experience of living in their home is a critical factor in their quality of life and quality of care experience.

It made those providers that weren’t already doing so, begin to consider (some for the very first time) that customer experience was not just a ‘nice to have’, or sadly in some cases perceived as a ‘distraction and unnecessary interference’, but is now an essential component to providing quality of care, which extends well beyond customer satisfaction.

The report highlights that despite the leadership of some operators, providers as a whole are still struggling with this transition. From my own observations, the customer experience function in a provider can sometimes be misplaced where it is solely delegated to marketing teams and not part of the executive function, or better yet, a stand alone unit reporting to the CEO and interwoven across business units. These organisational design and reporting decisions are themselves critical. It is often a wrong decision here that leads a provider to mistakenly continue to consider customer experience as the nice to have’, or that their real priority is to solely focus on clinical care right now instead’. It is pleasing to see the report acknowledge some of the gaps here. I have in my own professional experience been told the reason for not pursuing CX/EX as a priority at times is a dismissive, ‘we already know how everyone is feeling as they come and tell us if something is wrong’. As is noted in the Final Submission Report, consumers are not always prepared to speak up.

But like with anything that involves significant cultural change and adoption, there will be leaders and there will be laggards. Fortunately there are enough leaders in our sector now committed to this new way of thinking which involves genuinely wanting to know what the customer’s experience is rather than just because they had to be seen to be doing it for accreditation and compliance purposes alone. It is finally the transformational change this sector has needed.

In the report, “Recommendation 30: Quality indicators” highlighted many challenges with the Australian National Mandatory Quality Indicator Program. It was “questioned by witnesses before the Royal Commission because of its limited scope”, and that the”suite of current indicators are too clinically focused and that they do not adequately measure the experience of care from a person centred, or quality of life, perspective”.

“It has also been said that the current indicators do not capture many characteristics that impact wellbeing or which recipients of aged care believe are important.As a result, the program does not address the information asymmetry which exists between providers and people accessing aged care. There has also been a lack of digital development regarding the collection and collation of this data which places an administrative burden on approved providers”.

This Recommendation 30 echoes COTA’s 2018 report on ‘Measuring quality and consumer choice in aged care,’ a government funded initiative which was highlighting that consumers had a strong preference for information about consumer experience and quality of life when comparing and selecting aged care providers. Despite COTA’s report being produced 12 months earlier, the Australian National Mandatory Quality Indicator Program proceeded, only to later be highlighted as inadequate and not surprisingly not an effective tool for consumers, providers or government a year after investment was made and the inadequacies of its purpose was called into question.

3. New governance standard recommended

The boardrooms of providers have also increasingly learnt the cost of not paying attention to complaints and feedback. Many historically have been caught off-guard by management’s advice all too late (as have management!) about a serious governance failure or tragic gap in the care provided that was missed. The impact being lower occupancy in a lesser of two evils scenario, or more severely being faced with sanctions.  By increasing greater accountability, liability and obligations on Board Directors and elevating feedback and complaints data to the boardroom level as a critical reporting item on the agenda, performance data that extends beyond clinical audits but focuses more on consumer and employee sentiment will gain greater visibility, and provide predictive and preventative insights for board’s to be aware of, well before things like sanctions are required.

Complaints and feedback are the ‘canary in the coalmine’.

As reported in the research commissioned by the Royal Commission from the National Ageing Research Institute, based on a survey of aged care residents, “complaints are a critical source of information about not only the performance of and risks presented by particular providers…. but they can also shed light on systemic issues with the performance of the system overall. An ineffective complaints scheme can diminish the supply of that critical information. 

This represents a lost opportunity to improve the system by addressing issues at their inception before they have become major problems”.

Without adequate reporting on feedback and complaints up to head office or even board level if needed, allowing the consumer to bypass the aged care facility level (often because this is where the issue is not being adequately resolved by middle management), then we will sadly continue to see serious examples of substandard care occur. Almost always there are triggers ahead of time if you speak with people and workers in the home. Unfortunately providers are not using these insights to effectively manage risk.

The proposed new governance standard, Recommendation 53, highlighted the need for a better system for receiving, reporting and analysing complaints.

53.1. Any governance standard for aged care providers developed by the Australian Commission on Safety and Quality in Health and Aged Care should require every approved provider to: 

 

  • have a system for receiving and dealing with complaints,
  • including regular reports to the governing body about complaints and containing, among other things,
  • an analysis of the patterns of and underlying reasons for complaints

Secondly, the governance standard should require each approved provider to: 

  1. allocate resources and implement mechanisms to support regular feedback from and engagement with people receiving aged care, their representatives, 

and staff to obtain their views on the quality and safety of the services being delivered and ways of improving the delivery of those services; and 

  1. have a system for receiving and dealing with complaints, including regular reports to the governing body about complaints and containing, among other things, an analysis of the patterns of and underlying reasons for complaints.

In my own organisation, this proposed Recommendation 53 speaks to the heart of what we do.  We believe in tools and a culture of an always-on feedback approach, alongside an effective internal complaints system, allowing providers something that drives their business to continuously improve and greater visibility over complaints data – themes, trends and at high-risk homes ahead of time.

4. Greater weight to be placed on consumer experience

Recommendation 113: Greater weight to be attached to consumer experience, is pleasingly seeking to offer older people a louder more prominent voice.

The proposed recommendation stated “from 1 July 2021 onwards, the quality regulator, whether it be the Aged Care Quality and Safety Commissioner or the Australian Aged Care Commission, should: ensure that consumer experience reports for a service are informed by consumer experience interviews with at least 20% of care recipients or services users (or their families)”.

In the past, the Quality Agency, with assistance from Latrobe University aimed to interview about 10% of residents in each home, with sample sizes of about 10 people.

The adequacy of this sample size was explored.

Results indicated sample sizes of 10 in each home are the lowest number possible for estimating proportions and for detecting large differences in a meaningful overall total consumer experience between samples.

Increasing the sample size to 12 would provide a more reliable result.

Sample sizes of 12 per home allow detection of large differences when response categories are combined, but further increases to 15 would be more preferable again.

Clearly, this recommendation is highlighting that the samples are too small and maximising those surveyed and engaged with, will give the best and most accurate result.

By increasing the sample size to 20% it will provide a more accurate insight for the purposes of regulation, but from a business perspective if you’re only surveying 20% every 12 months to 2 years then it really doesn’t even come close to being an effective measure of consumer experience, and won’t provide an effective data set for continuous improvement that can be actioned and measured at a management level for service. It remains a base level compliance measure only.

Proposed Recommendation 113 emphasises the benefits of the Consumer Experience Reports and suggests taking “consumer experience reports into account in accreditation, assessment and compliance monitoring processes” and to “publish consumer experience reports for each aged care service”

What this exactly means remains unclear given the  announcement last year from the Aged Care Quality and Safety Commissioner that stated Consumer Experience Report (CER) interviews would no longer be undertaken as part of the site audits.

That is from the announcement itself: “From 9 December 2019, Consumer Experience Interviews (CEIs) will no longer be undertaken as part of site audits at residential services”.

5. Why do people choose not to complain?

The final submission report highlighted a number of reasons why people receiving aged care, their families and staff may choose not to make complaints to approved providers. It’s all too easy to see how these reasons are allowed or tolerated within homes but they are not acceptable excuses if a provider wants to make a change and with it, get the benefits of more data driven decisions to provide better service.

“The reasons for this include:

 

  • that providers do not take complaints seriously
  • nothing changes following a complaint,and because
  • people receiving aged care and their families fear negative repercussions if they do complain”.

Recent research commissioned by the Royal Commission from the National Ageing Research Institute, based on a survey of aged care residents, suggests that only a minority of concerns are made as formal or official complaints to approved providers, and complaints to the regulator are even rarer. There is a reducing conversion ratio of minor concerns escalating to complaints to the provider escalating in the most severe cases to the regulator or department (or police).

However, the rarity of complaints to the regulator cannot be taken as a good sign: the research also indicated that about two-thirds of ‘official’ complaints to providers were not resolved to the satisfaction of the complainant.

Looking at this, a director on the board of a provider that sees a complaint of the most severe form would be encouraged to see this as a signal of wider lesser complaints that may not have surfaced (or never will). It is not necessarily an indicator in this instance of a cultural or systemic failing in the quality of care and therefore quality of life of the residents, but it is a critical warning sign that something may not be quite right and needs attending to and perhaps a review.

It therefore appears that the current complaints processes are not working as they should when these issues are allowed to survive within the current system.

This is of great concern, because complaints are a critical source of information about not only the performance of and risks presented by particular providers. They can also shed light on systemic issues with the performance of the system overall.

Enabling approved providers to engage in a meaningful way with older people and their families about the services they receive and the way they are delivered are often underdeveloped or non-existent.

Those who raise concerns are too often seen as troublemakers to be managed rather than what they really are;a valuable source of information to drive improvement in service delivery.

Aged care workers are also not always empowered to raise concerns or provide feedback. When in fact these valuable stakeholders are often the front line of defence and the last line of defence at the same time for any issues that do arise.

Indeed, there is no explicit requirement for approved providers to ensure workers have an opportunity to express their views about the quality of care which systematically is disregarding a critical resource for quality improvement.

6. So what can be done?

Herein lies the residual challenge: we need to rally together as a sector to transform the culture within ALL organisations to a sense of ‘service’ from ‘compliance’. We need to encourage a culture of actually wanting to hear feedback and to see it for the valuable insights feedback provides, and not just to the service quality, but increasingly to the viability of the underlying provider’s business itself as these changes and recommendations begin to become requirements of basic compliance as well. If they are not already, they will eventually.

An ineffective complaints scheme can fundamentally diminish the valuable supply of that critical information necessary to operate successfully and serve residents quality experiences. A lack of change here represents a massive lost opportunity to improve the customer experience of residents and their families by addressing issues at their inception, and before they have become major organisational problems that not only cost more to address, take longer and more resources, but can also cost lives and jobs, and reduce happiness of those at the heart of our industry, our residents.

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