Six Attributes of “Leadership”

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This is likely a longer piece than usual, but I think important as we all consider the place of leadership mid-way through the term of appointment of the Royal Commission into Aged Care Quality and Safety.

I have been asked many times over the years I have served as a CEO, to define leadership.  There are of course quotes such as “It is an art, rather than a science”.  Or “You can tell if you are a leader when there is someone following behind you”.  What seems to be true is that you are not born to be a leader, and leadership is not achieved from a one day development training session.  However, we can grow as leaders every day – and indeed we must.  And leadership is about people, whilst management is about tasks and things.

But even those small truisms above do not do justice to this thing called leadership.  Most of us can likely recall our own examples of where we have experienced poor, or ineffective leadership.  We may even now be wincing as we read, recognising our own lack of skills in a leadership role at some time in the past.  We can also likely recall and acknowledge some fine experience of leadership that was such a joy to be party to.

Good leadership is a thing of beauty to experience.  Much like a diamond.  A diamond has so many qualities and when cut well, is a thing of beauty to behold.  It is hardly surprising that “diamonds are a girl’s best friend”.  As the following picture shows, even a so called six sided diamond has much more to offer than the “simple” six sided cuts.

So it is with leadership.

I provide below just six sides, or attributes, of leadership that I believe if practiced (well) every day will not only assist us to be better performing leaders but will drive better performance in our organisations.  I am certain we can all accept that leadership is more complex than these six, but these are a sound foundation.  The attributes are provided in alphabetical order only for convenience:

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Submission to Royal Commission

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The following link points to the substantive comments I made in a recent submission to the Royal Commission on Aged Care Quality and Safety.  As a very recently retired Chief Executive in the aged care sector, with some 37 years of continual involvement in aged care related matters, I feel I can comfortably comment upon my own research into matters around minimum levels of staff. Additionally, and importantly how, I believe, the aged care sector has been left in a quandary as to how best to navigate through these troubled times due to funding constraints placed on (at least) the residential aged care.

You can read the entire Submission here.

Nice chatting

Staff Ratios – Royal Commission Research Paper

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I have read with interest late last week the very freshly released Royal Commission research paper (1) into aged care staffing requirements, and the shortfall in funding needed to raise the staffing mix and levels to appropriately care for the average residential aged care service consumer.  

The following excerpt from the recommendations paints a picture of what residents, families, advocates, and indeed some providers have been saying for some time – the level of service provision (staffing) in residential aged care in Australia is substandard.  

My conclusion is that because that level of provision is so strongly associated with the operating funding mechanism, the funding mechanism for care is equally substandard:

“more than half (57.6%) of Australian residents receive care in aged care homes that have unacceptable levels of staffing (1 and 2 stars).

To bring staffing levels up to 3 stars would require an increase of 37.3% more staff hours in those facilities. This translates into an additional of 20% in total care staff hours across Australia.

We have not limited our analysis to determining the additional resources required to bring facilities up to an acceptable level. We have also provided an indication of the additional resource requirements that are required to deliver staffing levels consistent with good practice and best practice care.

For all residents to receive at least 4 stars (what we consider good practice) requires an overall increase of 37.2% in total care staffing while 5 stars (best practice) care would require an overall increase of 49.4% in total care staffing.” (2)

As you are probably well aware, I am the CEO of Braemar Presbyterian Care (“Braemar”). To put our services into perspective, since I joined Braemar in March 2017 we have been increasing hours per resident per day to a level that is close to the current national average as recorded by the StewartBrown benchmarking service (3) reporting.  And, as far as is reasonable, we have been improving our subsidy income to match the staffing.  But that recurrent income is not enough.  

According to this research paper, prepared for the Royal Commission into Aged Care Quality and Safety, less than 3 star level of staffing is unacceptable, while a 4 star staffing is good practice, and 5 star staffing is best practice.  Yet 57.6% of residents receive less than 3 star (unacceptable) staffing and only 1.4% receive best practice staffing.

How is this translated into the care of our elders? 

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Aged Care Indexation

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I am going to assume that most people reading this article will be aware that there is currently a Royal Commission reviewing matters of Quality and Safety in Aged Care.  Among other things, that Commission is inquiring into matters where poor and substandard care have been provided to residents in residential aged care and to care recipients in home and community-based care.

Where there have been findings of substandard care, all providers in the aged care sector should stand resolutely with care recipients and be highly critical of the events that took place to permit such poor care being delivered.  However, without wanting to escape from the responsibility of being a provider of aged care I do want to highlight again the dilemma that providers find themselves in desiring to provide the best care that they can.

One of the threads arising through the Royal Commission Hearings, and for some time prior to the Commission commencing has been a call for a higher staff ratio in care services being delivered.  

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Funding Cuts: You Decide!

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I gathered these thoughts together the day the Royal Commission into Aged Care Quality and Safety was announced – Sunday 16 September 2018 if my memory serves me well.

This information gathering was in response to the first question of the Prime Minister when making the announcement. The question was around the alleged $1.2 billion cuts to aged care.

Folks, I get it – there have been many cuts from both major sides of our Australian Government over a number of years. And there has been continuing growth in aged care funding based on population related indices etc. But what is galling around these discussions is that the major political parties and the bureaucrats seem unwilling to give simple, transparent responses to questions about these matters.

The recent Federal Senate Community Affairs Committee Hansard from 24 October 2018 make for mind numbing obfuscation around this very issue, with Opposition asking relevant questions, and Government, and Officers, all putting in their opinions, without any direct answer to what should be a simple question. This of course happens regularly at such Committees and is not confined to Aged Care. But this Australian is over it!

Why cannot our elected leaders and paid Officers answer simple questions and be held accountable for the policy and funding interventions they create into valued human service provision? We are projecting tens of thousands shortfall of residential aged care places by 2025 (ref 1) and now some 121,000 not provided with an appropriate level of community care packages short for older Australians already assessed by Government as needing community delivered aged care services. (ref 2).

Of that number, almost 57,000 had no package allocated. A discussion around the residential care funding issues can be found below. Parliamentarians prefer to support their side of the debate, but the Department of Health and Federal Parliamentary Library advice really does paint a helpful and insightful picture into this matter of “funding cuts”.

I shall leave it to you to decide. But if you were to ask me, a return to the residential aged care sector of the $1.2 billion in ACFI funding cuts, along with a requirement for providers to sign off on their direct care staff ratios, would provide, on average, an immediate return to a ratio of 3.2 Hours per Resident per Day (“HRPD”), and begin a move to the 4.3 (or from my research, 4.2) HRPD as soon as possible.

Recent changes:

ACFI subsidy expenditure has been growing more quickly than expected. The Australian Government believes the unexpected growth in claims cannot be explained by an increase in the frailty of residents, although many in the industry disagree. In order to rein in expenditure, around $1.7 billion in savings over four years were included in the Mid-Year Economic and Fiscal Outlook 2015–16 (MYEFO) and the 2016–17 Budget, to be achieved through changes to ACFI scoring and subsidy indexation. Despite these savings, residential aged care expenditure was still forecast to grow at around 5.1 per cent per annum.” A summary of the impact of these two difficult measures can be found below – https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Librar y/pubs/rp/BudgetReview201617/AgedCare 

“Rein in expenditure.” Is that not just a euphemism for a cut to funding?

You decide. Nice chatting!

References:

Ref 1- Aged Care Financing Authority, ‘Sixth report on the Funding and Financing of the Aged Care Sector’ (Aged Care Financing Authority, 2018), 36.

Ref 2 – Department of Health, ‘HOME CARE PACKAGES PROGRAM Data Report 4th Quarter 2017 – 18’ (Department of Health, 2018), Table 7, 11.

Image: Courtesy Business News.

What to do with a Royal Commission?

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I am a person with no clinical or “care” background. But after almost forty years in senior management and executive roles across the spectrum of health and aged care – particularly aged care – I have gathered some insights into the nature of care being provided throughout our care services.

And before I suggest anything more, let me say this – my view is that if the major hospitals around Australia – public and private – were put under the same scrutiny and regulatory framework that residential aged care services are for the quality and accreditation of services that are provided in and through them, we would see hospitals falling into sanctions.

I am of the view that we have an aged care system that is too focused on beating the regulatory compliance framework as opposed to funding and providing appropriate levels of care and support to all clients.

On the one hand I am an incredibly strong advocate of high quality services accompanied with some form of accreditation. On the other hand, I believe we have an aged care accreditation system that we can really ill afford.

It underpins inadequate funding levels that cannot provide enough resources for many providers to meet the expressed needs of care for residents. In the same way, our community aged care system is creaking because we cannot provide enough funding for the community aged care packages assessed by the Australian Government as needed by our citizens.

I hear staff all over Australia clamouring, not always for more wages, but for more pairs of hands to do the work. To do more than the system underpins…To go the extra mile… To sit for a few minutes when that is what the client really wants, and really needs… To spend time hearing what the real story is…

To quote a UK study of its Home Help services from the early 1980s – “Too much Charring and not enough Chatting”.

I could ask the question – Which provides more care, the Chatting or the Charring? Neither is necessarily more correct, but often we cannot even get to the question. The bureaucratisation of aged care is with us and the paperwork must be done at our own peril.

I have colleagues that will not (at this time) support minimum staff ratios. Quite rightly they see them as an un-affordable cost under the current funding methodology. How sad that we do not all see them as providing perhaps the single greatest opportunity right now to see a reduction in abuse, and a reduction in short cuts in care. How sad that we do not see minimum staff ratios as an opportunity to support our staff and see a visual improvement in the increased in quality of care. But implementation of minimum staff ratios will be quite costly.

I am still of the view that in Australia we have one the best aged care systems in the world. But for a range of reasons it is creaking.

Let’s all is to consider how much of a cost is there to stop, take stock, and with the next round of changes, really consider the long term impact of where we are heading and fight more intensely to protect the rights of those who are dependent upon us, the general public, for their livelihoods?

And who knows – the Royal Commission might investigate several inter services aspects around care of our elderly folks? One matter that I have discussed for the past decade is how much more proactive care we can provide in our aged care facilities, that might actually have a positive, beneficial impact on our national health and hospital care services.

In the past twenty years we have missed the opportunity to think outside the square with respect to fixing major State based hospitals. As a “cohort” of patients, frail elderly people are significant and frequent users of hospital services. Perhaps if we reviewed the aged care sector and its inherent possibilities we might find better solutions to our hospital problems.

Chatfield’s cartoon below was first published by me in December 2010 in an article containing many of the words in the commentary above. Not much has changed it seems!

To fix hospitals, first fix aged care!

I get it… Do You?