I am looking forward, with timidity, to reading and reviewing the final report from the Royal Commission into Aged Care Quality and Safety.
As you might recall, I retired on 1 November 2019 on grounds of ill following an almost 40 year career in aged care management and leadership, and three Chief Executive Officer positions totaling more than twenty years.
In my view, whilst the funding is the highest it has ever been, the care provided within that funding is at least as poor as that provided in the mid 1980s which prompted the (Senator) Giles review into nursing homes. In my view, based on a competent clinical assessment of their health and multiple morbidities with which most seniors approach care services for support, our current aged care system, whether for residential and/or home based care, is unable to guarantee that each care recipient will receive the care they need, let alone want.
The aged care sector needs MORE:
More funding for care;
More staffing for care;
Mandated minimum staff mix ratios expressed as a required hours and minutes per day based on the appropriate assessment of clinical and support needs of residents and home care clients;
More training for staff;
More regulatory oversight by an assessment/audit authority (with teeth) that can fine and disqualify company directors and/or officers for breaches of regulatory compliance;
More transparency about where the $ billions are spent each year, particularly in profits and shareholder dividends (away from care);
More input from feet on the ground consumer advocacy groups;
More transparency and exposure of inappropriate care that endangers aged care recipients’ health, well-being, and safety;
More initiatives for care and accommodation services for –
People living with dementia; and
Older, frail (mainly) women at risk of homelessness, but reliant on a pension only, due to lack of sufficient retirement funds to support private accommodation.
More high care community aged care packages made urgently available in communities where they are needed, along with a contemporaneous moratorium on the issuing of residential aged care places in those communities so that our dependence on residential aged care is lowered; and
More research into financing models making use of occupational superannuation or similar insurance funding, for example, making use of a wage rise incentive for more superannuation, but the relevant contributions set aside with regulation for later use in instances of aged care and/or disability care services and related purposes.
Mine is a long list, but I think not unreasonable. And I have likely omitted to mention some that I should have included.
My own work on minimum staffing requirements (here) back in 2018 suggests about an additional $6 billion to have a workforce sufficient in number and training to appropriately care for our most frail if elders. Today many residential aged care services do not even have a registered nurse on duty 24 X 7, with perhaps only one or two staff for 100 or more residents. In my view this is a shameful outcome of what has been, in hindsight, some thirty-five years of failure of what promised to be an innovative Aged Care Act in Australia.
There is going to be tough times ahead for all involved and the final report/s are likely going to make for difficult reading. But they must be both read and acted upon.
The question is, will the Australia Government have the appetite and conviction to introduce rights based changes in care for our elderly. Or will older Australians face an uncertain future with respect to their care needs in later life?
UPDATED to include responses to questions I asked of the Australian Government Department of Health’s COVID-19 Vaccine Team
Its been a little while and I haven’t been that well.
I wrote an essay on the weekend of 12, 13, and 14 February 2021 about use of vaccines by Christians (and more generally, people of faith). The essay focuses on how we might best respond to some of the new COVID vaccines that have a development and indeed a testing basis in foetal cell lines, descendant from decades old aborted human foetal cells.
This can be a complex area of morality and bioethics for people of faith. The essay is not a short read, but I do hope you find it both informative and helpful for yourself, and perhaps even your own faith community. If you appreciate the work, please feel free to share and discuss within your community.
Oh, and there is a couple of questions to which I could not (yet) give a more complete response. I have asked the Australian Government’s COVID resource team to provide a considered view. I hope that they come through on this.
Contemporaneously I have been compiling a library of similar indicators that I believe will be useful in our overall aged care sector. There are some differences between my work, the report provided to the Royal Commission, the Australian Government’s mandatory reportable quality indicators, indicators used by the Victorian Government in its State managed residential aged care facilities, and an international source of over 90 indicators that I have used. The main differences are that where most of those other sources focus on quality of care and safety, and quality of life indicators, I have also built in indicators around, quality of assets, equipment, and supplies, and organisational governance.
Courtesy Michal Mrozek – https://unsplash.com
This is not to suggest that my library of currently 194 indicators is complete. On the contrary, the ROSA report prepared for the Royal Commission “A total of 305 quality and safety indicators for residential aged care were identified”. At some point a limit is reached as to what quantity is manageable to be measured, recorded; and if made mandatory, reported.
things never really do stay the same – we can and will adapt to the new normal
Toward the end of my previous essay I indicated that I would focus on KPIs in this Blog Piece. I will get to that next time – I feel it important to make some commentary on the impact that COVID-19 is having on the services of our aged care colleagues in Victoria. This week saw a specific focus by the Royal Commission into Aged Care Quality and Safety on the management of, and planning for, COVID-19 outbreaks in New South Wales and Victoria. The following dot points are some of a tweet thread I made on Saturday morning summarising my take on the week’s evidence:
Surely what we are seeing is just the unintended consequence of an uncontrollable pandemic virus? No! Early “antidotes” to this situation could have been planned as proactive mitigation action;
In February 2020 we could already see the impact of COVID around the world. When Dorothy Henderson Lodge and Newmarch House hit in March and April in NSW, who indeed was occupying the empty hospital beds? Why not admit COVID+ residents;
But it is more than that. For almost two decades there has been calls for regulated 24X7 RN coverage and mandated staff mix and supply. The benefit to care quality/safety has been demonstrated;
Others have relentlessly advocated for greater transparency in reporting of complaints and poor quality outcomes, knowing that incremental improvement can lead to better care outcomes;
Others have lobbied for increased funding for provision of services based on wage inequality for care staff vs the health care sector. Aged care lags behind Health as a poor cousin – again negatively impacting care;
We are left with residents dying and families in despair. Tragic outcomes from known, foreseeable, and preventable failure of over 20 years of aged care policy and funding.
Committing to the formation of strategy, developing that strategy and communicating it are significant responsibilities of any board.
How best can the developed strategy be measured, reviewed, and managed?
I will leave the measurement of strategy performance for the third in this series of short essays. This short essay focuses on the board’s management of its strategy through the Chief Executive (howsoever titled).
There is nothing that quite replaces the annual board get-away for deep, focused strategic thinking about its role, its responsibilities, and the organisation in which its fiscal duties and fiduciary responsibilities are invested. These can be richly rewarding times, and if well facilitated, can bring long term, positive momentum to the board and senior management, with a renewed focus on organisationally important things to be achieved. But if your board’s last strategic thinking and planning session was, say, in November 2019, you know now that the world has almost completely changed within one calendar quarter.
Your board no doubt meets several times each year. But do you meet to drive an Agenda to get the business done or are you meeting to drive a transformational and winning organisational culture? There is a world of difference between these two outcomes. Without detracting from the value of still getting away for an annual, thorough review of strategy, there are useful alternatives that make more frequently inclusive focus on strategy at regular “any time” board meetings, and more formally on a periodic basis throughout any given year. Whether conscious or unconscious, you and your board drive the culture of the organisation in how you use the opportunities of your governance meetings.
Essentially there can be three types of meetings in which strategy can be given a dedicated place on your board agenda for its appropriate diligent review:
The Greek word σκέφτομαι (skéftomai – thinking) has the sense of contemplation, that is, more than just thinking as in this familiar image below. More like thinking with care or weighing up the impact of thoughts. From this word we get the word skéfto.
Over the years I have been on boards where strategy, its measurement and monitoring have been left to the CEO to lead; and where strategy was not a matter that was on the board agenda in regular (monthly) meetings.
I encourage us all to seriously think about how we can amend agendas to include strategy as a priority item on each board meeting.
Boards can learn how to ask questions of the executive team and management around matters rolled into their Strategic Plan. For example, if you have ten overarching objectives in your current strategic planning document, and your board meets ten or eleven times each year, you could consider a well thought out sixty minutes of discussion around each of these high level objectives at each Board meeting, and the entire Plan would be discussed throughout the year. To provide time for input from the CEO and executive team, even if the Board were to conduct that review of each item in the Plan over a two month period, the entire plan could be thoroughly discussed and re-invigorated every two years. This does not detract of course from the value of a formal annual Strategic Planning review.
However, too often we lay responsibility (blame) at the feet of the CEO and executive team if strategy is not achieved or seems to waver along the path the organisation sets. This is most unfair if the board itself is not taking care of the primary responsibilities of monitoring and oversight of the organisation’s strategy and strategic plan for which it is responsible.
In his well-known text on governance, Tricker describes the basic board functions working through management as:
Just the other day on 15 June 2020 we honoured World Elder Abuse Awareness Day, a day that highlights elder abuse in all of the forms it manifests itself.
Australia has had its own recent and continuing struggles with prevention of spread of COVID-19, and I feel proud to be both an Australian and supporter of most of our aged care providers in how they have managed well in these complex times. As we know, our experience has not been shared with numerous other western nations.
Just one week ago, the Kaiser Family Foundation (“KFF”) released the following summary of data around prevalence and mortality rates due to COVID-19 in USA long term care facilities – for ease of discussion, let’s call them all nursing homes. Remembering that the population of the United States of America is about 13 times that of Australia:
As at 11 June 2020, 44 States reported 9,192 current cases of COVID-19 infection in nursing homes;
Collectively, 43 States have reported a total of 230,776 COVID-19 cases in nursing homes;
From 40 States, there has been a combined total of 45,833 COVID-19 related deaths reported in nursing homes;
From 43 States, nursing home facility COVID-19 cases represent an average 15% of the States’ total cases reported;
From 41 States, COVID-19 related deaths represent 45% of total States’ deaths.
At the start of May 2020, I proposed a way in which the (residential) aged care sector might reconsider its apparent very widespread lockdown of facilities and prevention of family members visiting with loved ones in care. Various alternates of “window visits” etc had been quite successfully trialled by some providers, but they fail, for example, where a residential care facility is in a multi storey complex, with all residential living contained at above ground floor level.
There is no doubt that aged care providers have been caught in a bind with the onset of the COVID-19 pandemic. Can they have visitors at all, or on a very strict basis? What is the best guidance? Hospitals have become focused on well controlled prevention strategies – so much so that emergency department traffic has significantly slowed during this pandemic, and only now beginning to return to normal frenetic activity.
Both in hospitals, and in longer term care settings the notion of visits – human touch – in these pandemic times has been a much debated phenomenon. As a species, humanity craves touch contact with those dear to us – particularly when we are ill and so frail that we are facing death, no matter how imminent. This certainly affects the older person in care, as well as family and friends who wish to provide the touch of comfort as much as the words of caring love, concern, and, in a final sense, farewell to this life.
I am not sure how you have been managing your time during these past seven weeks. Because I am now “semi-retired”, I have taken the opportunity to read and refresh my earlier learnings over the past almost forty years on leadership, management, and strategy, while focusing on completing some studies in executive and leadership coaching.
What has struck me is that in this time of turbulent change, particularly in human services delivery right now where the impact of COVID-19 is taking its toll, is that many theories about leadership, management, strategy, and human resources management, actually have not changed, and likely do not need to. Sometimes the “old” fundamentals are as reliable as granite …
In his now famous, and dated article, Henry Mintzberg defined as a plan, ploy, pattern, position or perspective (Mintzberg, 1987, The Strategy Concept I: Five Ps For Strategy). Mintzberg described:
Stop the world – I want to get off is the title of a musical created in the 1960s.
Some 55 years later as we
become globally enmeshed in a pandemic the like of which none of us has
experienced before, one could be forgiven for wanting to shout those words from
the roof tops.
I don’t need to remind you
of the enormity of the task ahead of every organisation in every industry
sector – particularly those in a sector I am so fond of and have given over
half of my career to. I won’t belabour the size of the task ahead of
you. But I do want to ask the rhetorical questions in this group – are we
doing enough in our aged care sector to make an impact?
For providers – if you could get hold of adequate supplies of personal
protective clothing and equipment, are you considering gloving, gowning, and
masking all your front-line care staff? Are you having a skilled
Registered Nurse meet and greet every visitor and taking a temperature prior to
allowing a visitor, contractor, family member, Aged Care Quality and Safety
Commission staff member enter the facility?
Australian government – Department of
Health and Aged Care Quality and Safety Commission – have you increased the
ACFI rate per resident per day, or introduced a coronavirus supplement to cover
the cost of additional medical supplies, staffing supplies, and loss of revenue
when facilities empty due to untimely death of residents? Have you
considered the financial risk and impact of failure of the RAD scheme?