Governing Boards and Diversity

Boards of any organisation should be well placed to provide strong and transparent governance. This means the members of the board all need to understand the organisation structure, strategy, finances, client base, market changes and employees for the context in which they are operating.  This includes knowledge of behaviours, culture and ethics. The behaviours of all organisational board members gets reflected in employees to set the culture within the workplace which is experienced by the clients and those advocating for them, their family/whanau and friends.

The skill of judgement is necessary for board members to base decision-making on a set of agreed standards or a clearly defined constitution, organisation vision/mission or philosophy.   To have a progressive Board, there is the need to recruit board members with greater skills than already exist within the board. This ensures progressive diversity of thinking and culture based on more than gender and ethnicity.  A greater diversity is needed to also include creativity, innovation, current commercial practice knowledge, information givers and information seekers to increase depth of conversation and concepts being explored.  The Board member profile could do well to include these attributes, abilities and skills. Collectively they need to advance the organisation purpose, vision/mission or philosophy in a way that meets client current and future needs.

Boards are not the place for the faint-hearted or those at the end of career who simply ‘want to give back’ who may base todays decisions on yesterday outdated models.  Diversity will become a more visible part of boards with the introduction of the new Health and Disability Service Standards later this year.  While they are currently in draft, it seems clear the final version will require more diversity within boards. This will include increased desire for Maori representation and inclusion on Boards.  As American diversity advocate and activist Verna Meyers says, “Diversity is being invited to the party, inclusion is being asked to dance”.

If Maori representation isn’t part of your board make-up, it may be advantageous to look at forming relationships with local Iwi who fit the attributes needed to fit your board member profile. All Board members will need to be available, ethics driven, commercially aware and able to contribute.  The Board Chair will need to show these same attributes and also provide consistent innovative, clearly communicated strategic leadership.  The Board as a whole will also need to be agile in their response to unplanned events.  2020 and the emergence of COVID-19 reminded us of this.  It appears 2021 and into the foreseeable future will also present the need for agile thinking and innovation. I suggest now is the right time to review how your board is made up and how effectively they perform.  How can this be improved in your organisation?  

Bench-marking – Aged Residential Care

his New Zealand designed web based (on-line / in-the-cloud) Bench-marking and quality management system from Healthcare Compliance Solutionhttp://www.hcslqms.co.nz/s Ltd allows you to:

  • Bench-mark in real-time – specific to resident type, event type, date and time of day.
  • Have automated default reports to save you time analysing your data trends and patterns
  • Drill down into your data easily to identify opportunities for continuous improvement
  • Complete your internal audits online and have the corrective actions auto-populate into a corrective action log
  • Log and manage adverse events
  • Bench-marking of adverse events against other aged care providers
  • Support evidencing an active Health & Safety programme is in place
  • Log and manage infections – automatic outbreak registers
  • Bench-marking of infections against other aged care providers
  • Log and manage your complaints with time-frame, investigation and response prompts
  • Dashboard view options for level of care and any chosen 3 monthly time-frame review
  • Dashboard view option of adverse events or infections
  • Logs (event registers) appear with individual events in one colour when open and change to another colour when the event is closed. This allows you to see quickly the status of events. 
  • Use in conjunction with your current policies / procedures or update to the HCSL site specific created policies and procedures. 

Your organisation policies and procedures and related documents (if created by HCSL) are also accessible through the Facility Documents tab on the left of the screen for remote anytime, anywhere access.  The keyword search option on the policies and procedures in addition to precise indexing and coding of documents makes it very quick and easy to locate information for staff to reference.

You can also upload your own documents for confidential safe storage.

This is what Rhonda Sherriff, NZACA Clinical Advisor says about using the HCSL QA system:

“I am very happy to endorse your system as the information is invaluable for CNMs to analyse the data/information and make informed decisions on best practice and innovation to decrease hazards, improve outcomes, and mitigating factors for resident welfare. I’m pleased you are delving into the data to the level you are, as it’s time saving for sites in many respects, and so easy to dice and slice the information to get the trends. CNM’s used to spend hours just writing up the collective information before the analysis, so hugely time saving”

To view a brief video explanation of the system click here. This programme has been operating in NZ Aged Care since mid 2016 so now has many thousands of pieces of data to compare yourself against.  

To find out more contact us here.

Making monitoring your service remotely in LIVE time easy!

Quality Management Systems

The below question and answer were published in the New Zealand Aged Care Association industry ‘In-Touch’ newsletter (19th February 2016).

Question: A member asks “if we purchase a comprehensive quality management system from a provider how assured are we that the system will meet full compliance, come certification and surveillance audit time, as requirements and compliance expectations change frequently?

NZACA Clinical Advisor Answer: “You should be purchasing a complete quality management system that will comply with the Health and Disability Standards specifications, health and safety requirements and meet DHB/ARRC contractual requirements.

The provider of the system would normally initially tailor the full quality management package to reflect accurately the site specifications, H.R. component, and best practice guidelines, after consultation with the owner and management on site. These documents need to be site specific. The provider will normally contract to the site, which sets out obligations between the provider and the site management.

The contract will include the full review and updates of policies and procedures on a bi-annual basis, unless specified more frequently, to keep documents accurate and reflective of best practice. There may be an educational element provided within the contract as well, to benefit staff knowledge and skills. There is normally a good document control system in place and cross referencing of information where required.

Quality management systems are reliant on the skills and knowledge of the site personnel working with them, the way the system is managed and the outcomes/reviews, content and information extricated from the use of the system to improve quality care provision/outputs. The documentation system is reflective of the people using them, and the depth to which documentation and information is created, analysed and utilised for improvements.

Auditors on site rely on the provision of robust up-to-date policies and site adherence to them. Partial attainments can sometimes result from staff deviating from, or not following, their sites actual policies or processes as outlined in their quality management system.”

Where can you get such a system? 

Here at Healthcare Compliance Solutions Ltd we provide the services described above and noted as being optimal for achieving excellence in care and audit outcomes.   To see a brief video about the Aged Care software update and now in use by over 3,800 users in NZ, click here. 

Request a no obligation consultation here.  

Staffing levels – is skill-mix the formula for success?

This month we look at the discussion around whether mandated staffing levels in aged care, as a ratio of care hours to residents, would improve care services?

Rather than numbers of personnel alone, to provide safe and appropriate nursing services, staffing skill-mix (taking into consideration the workforce diversity) is essential to ensuring appropriate effective staffing. These factors are not taken into account or provided for within the industry funding levels which puts additional pressure on those working in aged care services.

While performing statutory (temporary) management roles over past years, adequate numbers of staffing alone hasn’t guaranteed safe and appropriate care. Nursing outcomes for residents have been reliant on a mix of highly skilled staff working in conjunction with newer or less experienced staff to guide and mentor.  There could be 10 staff on duty but if none of them have had previous experience working in aged care services, these staff are set-up to fail in performance of their duties, and the resident care outcomes are likely at risk.

SNZ HB 8163:2005 – ‘Indicators for safe aged-care and dementia-care for consumers‘ is a national document which includes formulas for staffing levels based on acuity of residents. This document set industry guidelines and although not mandated, defines staffing from a best practice perspective. Numbers alone as already mentioned are not sufficient.

Outdated for the acuity of residents needs in 2019 and onward, the 2005 guidelines didn’t take into account a range of factors. For example the size and physical layout of the facility, location of resources, the leadership structure and how work teams are configured, economy of scale and appropriate cover.  The minimum staffing requirements in the ARRC   is well below that sufficient to meet resident needs.  Having been implemented in 2005 (SNZ HB 8163:2005) when resident needs were less complex than they are now, it’s well past time to review how staffing skill-mix is determined and more importantly how the industry will be funded for increased staffing to meet the increased needs of residents.

HCSL developed a 5 step acuity assessment tool in response to providers requests after being frustrated by using the two tier InterRai assessment which give outcomes of resthome or hospital level of care. InterRai doesn’t reflect the range of acuity represented in SNZ HB 8163:2005 from a care level perspective.  As reported by numerous registered nurses working in aged care, the complex clinical presentation of residents being admitted into care is not accurately reflected in InterRai which is why they still need to supplement InterRai at times with more detailed clinical assessments.

Achieving desired outcomes for residents and the timeliness of appropriate care support based on individual assessed needs should be the aim for the allocation funding to ensure adequate staffing levels.

ANZAC day commemoration

On the 25th April each year we remember those who went before us to fight for the protection of others.  While emphasis is often on those who died in service to their country, it’s also a time to remember those who returned from war changed and altered forever by the experiences they’ve had.  Not just for the soldiers going and returning to war but their family.

The mother who describes holding her son as he heads off to the front line. Embracing him, breathing in his smell which a mother knows so well.  Holding her head against his chest hearing the beat of his heart wondering if she’ll ever be able to hold him and hear his heart beat again.  Feeling the harshness of the fabric of his uniform and wondering what other harshness he’ll encounter.

The soldier as a member of a family, not only left grieving mothers behind but were sometimes already parents themselves going off to war leaving wives and children behind.  All family members impacted in their own way from their own perspective of events.  How does a wife or child accept the decision of the men in their life going to war, to do ones duty leaving children wondering why they were being deserted in favour of the uncertainty of battle? Those children then growing older day by day until the time they themselves are in their 80’s and find themselves still welling up in tears at the memory of the day their father left to go to battle. Not understanding but seeing the change in the father who returns, different, distant and ill from the effects of sand breathed into his lungs while stationed in Egypt.  The soldier returning, having nightmares of horrors seen which cannot be unseen or forgotten. Limbs and body intact but emotional scars and ongoing adverse health issues.  Not all wounds are visible.   

I visited the Gallipoli exhibit at the Museum of New Zealand ‘Te Papa’ (our place) in Wellington with my mother and sister.  I was mesmerized and deeply affected by the raw emotion depicted in the models created for the exhibit by Weta Workshop. The image of this nurse, Staff Nurse Lottie Le Gallais who was on board the hospital ship Maheno which set out from Wellington. She’d hoped to catch up with her brother but the model shows the anguish of the moment she receives her returned letters to him saying “killed, return to sender”.  I can’t imagine the strength needed to sustain such pain amidst the anguish of war but still carry on to serve those needing care.

I live in Christchurch and after the recent terrorist attack resulting in the death of 50 people, we’re seeing and feeling the result of war-like destruction of life. You see it in the faces of those closely affected. The internal pain of senseless loss.

A time to ponder on the Anzac values of courage, compassion, commitment and comradeship and see if they are reflected in our own organisations as relevant to care services. This Thursday, 25th April, Anzac day is a time to reflect and be grateful – lest we forget.

 

 

 

Great audit result

Hi Gillian,

Great  news, we did very well with the audit.

The Lead Auditor tells us she cannot see we have any corrective actions to complete!

Also she acknowledged a CI  from one of the Quality Improvements I completed. She was very impressed with the Quality and risk management systems via your Policies and procedures and says we are using your systems to the max.

Well, where would we be without your Policy and Procedures, they are great to work with – thank you.

kind regards

Rose Kennedy (Dixon House – Greymouth)

Leadership of your team

 

Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge.  How many leaders play the blame and shame game when things don’t go as planned?  Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath.  My version is noted below as an example.

You may want to create your own for your organisation, or adopt this.

The Leader’s Oath

I focus on the betterment of this organisation above my own career needs

I  focus on accountability above the need to be popular

I focus on caring for those in my charge over being in charge

I focus on clarity above certainty

I share clear expectations

I hold myself accountable for all employees poor performance including my own

I welcome respectful challenges

I will table the tough issues

I treat all interactions as though my career depends on a successful outcome

I am committed to personal and professional development

I am focused on excellence.

 

While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice.  The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable.  Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard.  This in turn means the service provided will be below the expected standard.  If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.

Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

 

Critical thinking – the foundation of good nursing practice

There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.

It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff.  To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential.  The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.

Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care.  The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario.  Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.

There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.

Click here to read more on critical thinking.

 

 

Audit Tips for Clinical Documentation

Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents include:

 

  • Age Related Residential Care (ARRC) contract
  • NZS 8134:2008 Health and Disability Services Standards
  • Clinical best practice (EBP) guidelines – eg; Lippincott
  • The Code of Health & Disability Consumers Services Rights 1996

 

Clinical documentation errors of any type noted during audits will result in partial attainments at best.  This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.

 

Below are some of the common compliance gaps which relate to clinical documentation:

   
General compliance

gaps

Missed signatures off notations.

Not dated.

Not signed by the author with a full signature.

No designation written with signature.

Not legible.

Inconsistent structure of resident files.

Unclear or unsecured archiving of documents.

Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.

Initial assessments

including InterRai

Not completed within time-frames defined in ARRC.

Baseline recordings at time of admission not recorded.

Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.

Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.

Failure to re-assess for each period of admission eg; respite care.

Clinical risk

Assessment not describing risk.

Risk not reflected in care plan interventions.

Lack of risk reviews.

Level of risk noted in interRai assessments not included in care planning

Progress notes

Not recorded in on a shift by shift basis.

Lack evidence of regular registered nurse input.

Writing beyond the bottom line of the page.

Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).

Lack evidence of interventions being implemented.

Lack evidence of RN response to clinical symptoms reported by care staff.

Lack of evidence of rationale for PRN medication administration or the resulting effect.

Short Term

Care Plans

Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).

24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).

Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.

Not recorded as resolved or transferred to Long Term Care Plan.

Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.

Long Term

Care Plan (LTCP)

Not reflective of all presenting potential and actual medical / clinical problems.

Not documented within 3 weeks of the date of admission (ARRC requirement).

Not changed at the time of health status / functional change.

Interventions not reflective of each medical diagnosis.

Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.

Frequency of clinical assessment for each actual clinical presentation eg; pain.

Do not clearly indicate the level of function, assistance required for each component of care / support.

Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services             for the elderly etc.

Care Plan

Evaluations

Review of care plans not reflecting changes in residents health status as they occur.

Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.

Not completed within ARRC defined time-frames (at least six monthly).

Multi-Disciplinary

Input

Lack evidence of MDT input into care plan reviews and/or evaluations.

Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.

Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.

Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical           consultation notes however not evidenced as having been done.

Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.

Policy and

procedures

Not consistent with service delivery as noted in clinical documentation.

 

Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.

If you have any comments to make about this article, please contact us here.