The Aged Care Quality Association was invited to participate on an inquiry into the Aged Care Amendment (Staffing Disclosure) Bill 2018 at Parliament House in Canberra on 26 October 2018.

Prior to manking it’s submission, input and feedback was sought from nurses, nurse managers and directors of member Aged Care providers, and their feedback was integrated into our submission.

Chairman Gail Harding was in attendance, and the following post contains the transcript of the submission made to the enquiry by ACQA.

The ACQA Committee would like to acknowledge and thank members who completed the survey and contributed to the submission. 

---

INQUIRY INTO THE AGED CARE AMENDMENT (STAFFING RATIO DISCLOSURE) BILL 2018

Submission 26/10/2018, Prepared by Gail Harding, Chairman

Who is the Aged Care Quality Association?

Aged Care Quality Association (ACQA) is an incorporated not for profit organisation. Members are from across the range of aged care service providers including for profit, not for profit, faith based, charitable, community, rural, remote, government and non-government organisations.

ACQA has partnered with aged care research specialists and IT experts to develop innovative, evidence-based solutions for our members that have revolutionised the way they monitor their achievements against aged care accreditation standards.

ACQA is driven by member Aged Care providers and their staff. Members work together on all aspects of quality management, continuous improvement, evidence-based practice, accreditation and consumer-directed care.

General Comments on the Bill

ACQA has surveyed its members to gain an insight into their opinions on the Inquiry into the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018.

On behalf of the ACQA members we welcome the opportunity to present their responses along with the opinions of the Executive Team.

1. Obligation to notify Secretary of staff to care recipient ratios:

Measurements of ratios may not be reliable indicators of quality of care – For example, the measures do not consider acuity of a care recipient or respite numbers.

The data must enable the reporting of incidents where facilities are rostering staff over and above their normal allocation of staff to cater for times when care recipients require ad-hoc 1:1 care.

Many services call in additional staff for care recipients for a range of circumstance including but not limited to:

• Care recipients who display sporadic challenging behaviors
• Palliative Care residents particularly when they are actively dying
• New admission of care recipients
• ‘Special occasion’ activities and events

There is concern that these occasions will not be adequately captured and are a major factor in the provision of quality care.

ACQA recognises that the Aged Care Act define a staff member of an approved provider means an individual who is employed, hired, retained or contracted by the approved provider (whether directly or through an employment or recruiting agency) to provide care or other services. Clearly this is not well understood by many organisations and needs to be clarified for reporters of this information. We received the following responses from members.

The term “staff members” implies that the person is a direct employee of the organisation. The data should take into account those service providers who are not directly employed but are contracted to the organisations for specific services. Larger organisations can employ allied health professional directly. Smaller and particularly rural and remote organisations contract professionals on a sessional or hourly basis and these do not directly appear in their full time equivalent calculations.

Measures do not address different resource engagement mechanisms – The counting of staff does not clearly differentiate between contractors, agency staff, shared staff and staff employed directly or the use of volunteers (who provide very valuable services). Members recommended that there is provision to include this cohort in the data.

There is some concern that the data will reflect those that are not directly involved in care recipient care. Many organisations have several levels of highly skilled Nursing and other staff who are employed at an organisational level and are not actually carrying out work at the site. There is a possibility that these staff will be included in the full time equivalent when in fact they are responsible for multiple sites and are not physically at the site reporting their employment.

Conversely smaller organisations that have multi skilled staff carrying out many roles in the organisation will not be identified for the various functions they are performing. Measures do not account for shared services in larger providers. The counting of staff does not clearly define how facilities should account for employees that are shared across multiple facilities, which may result in ambiguity or double counting.

In some larger organisation some administrative staff are employed to also manage a range of Community Home Support Services. There will be difficulty distinguishing the hours spent in various programs as well as residential care. This will cause discrepancies in the data and interfere with the transparency of information.

There may be discrepancies arising from the wording around the counting of care recipients. Will the data include those care recipients who are on either social or hospital leave? There needs to be clear definition of those that will be included in the data. Inaccuracies in the ratios may occur when care recipients are on leave, staff numbers cannot be adjusted for minor changes in care recipient numbers giving a false representation of the ratio.

Counting staff for four days cannot give an indication of the total numbers of staff especially if one of those days falls on a Public Holiday or weekend. ACQA notes that January 1st is listed as one such day. Many facilities have residents on social leave for the Christmas or New Year period and therefore will reduce staff to reflect this change. This may for some facilities result in a change of staff which is equal to or greater than 10%.

There is concern that this day will result in an unrealistic representation of staffing ratios. As stated in the documentation, this Bill is to aid future consumers’ greater transparency and choice in deciding on a facility to reside; the inclusion of staffing ratios on 1st January will not give a true indication of services especially allied health professionals. In many facilities allied health professionals do not work on public holidays particularly if this is a service that can be provided on an alternative day, without detriment to the care recipient’s well-being. There is also some concern that organisation may deliberately load staff on these days specifically to aid their ratio.

15% of survey respondents believe that the categories are not sufficiently defined – Staffing categories do not look at roles, e.g. quality management, administration and management. This may incentivise providers to hire clinical people into management and administration roles to bolster their reported numbers, for which these clinical people may not be the appropriate person for the role.  Respondents reported that it is necessary to distinguish between staff responsible for delivery of care from those allocated to management, quality and /or administrative functions and 14% of respondent maintained that they would have difficulty separating these roles.

‘Other staff members’ may include service employees that prepare meals for the wider community such as Meals on Wheels service. There may be additional staff hired for this purpose especially in smaller rural and remote communities where a separate Meals on Wheels service is not provided. How will the Secretary separate this component form the staffing ratio? There are also organisations that invite members from the wider community or those receiving Commonwealth Home Support Programmes into the facility where additional employees are engaged. There is the opportunity to add these staff to the ratio giving an unrealistic result. Will there be measures taken to preclude this information? Will staff on leave be counted into the calculation and how will these be distinguished from those available for work?

Will this require managers to identify staffing ratios for each day of the year and report when there is a change in 10% on any of those days? If so this will be a very onerous task which will require constant monitoring to ensure that deviations are identified in a timely manner to report to the Secretary. This will be particularly onerous on small rural and remote facilities that do not have economy of scale with staffing to be able to produce this information on either a daily or weekly basis.

Routinely reporting staffing levels if they fall on a weekend or public holiday will require numerous unnecessary reports to the Secretary. There will be a deviation in staffing numbers as soon as a ‘normal working day’ is worked, not necessarily in larger homes but certainly in smaller rural and remote organisations. This again will be an onerous task.

2. Failure to comply

This proposed Bill outlines that there will be penalties enforced for providers who do not furnish this information to the Secretary. However, it does not describe a process for ensuring the accuracy of the information that is submitted.

There needs to be a transparency of the way this data will be monitored for accuracy and possibly a tiered system of penalty for inaccurate submission of information. This will allow for some discretion particularly when genuine errors may be made in initial stages of reporting. It should be noted that some facilities may need assistance in converting hours to full-time equivalents.

3. Making Public Information

The members have concerns that publishing staff ratios may empower ineffective behaviours/decisions – The measurements are likely to empower decisions and behaviours that are counter-productive to the intent of the amendments and the intent of the new Standards, i.e. decisions made to make the numbers work, rather than to deliver outcomes for care recipients.

4. Observation – the new Standards

ACQA believes the Bill is inconsistent with new Standards – The amendments seem to focus on staff ratio measures from a clinical mindset. This is inconsistent with the new Standards, which focus on a consumer directed care or hospitality mindset.

Measures are detached from the legislative intent – The classification of staff is based on a clinical classification and may or may not be linked to consumer outcomes from a quality perspective. Quality management is the key in improving service delivery and maintaining accreditation.

ACQA maintains that an emphasis on openness, clear communication, innovation and effective workplace culture triumphs over rules-based compliance. It recognises that there are many new initiatives introduced through Legislation, particularly in relation to the New Standards or through the Australian Aged Care Quality Agency and the Consumer Experience Reports. It maintains that whilst in their infancy, these are more likely to bring about change than an onerous reporting mechanism.

5. Summary

• ACQA has concerns regarding the inability to compare like with like facilities. No two facilities can benchmark against each other as no two facilities are the same. Acuity and diversity are extremely important factors and play a major role in staffing ratios which is not taken into consideration. Maybe an average ACFI rate per day could be an indicator of care required.
• ACQA would like clearly definition on how facilities should account for staff that is shared across multiple facilities, which result in ambiguity or double counting.
• ACQA believes that there may be some education required for some facilities on the exact requirements of this Bill and the way to fulfill their obligations.
• We recommend there be further clarification on the counting of care recipients.
• Recommendations that acuity of care recipients be taken into consideration in the Bill.
• Recommends that there be recognition of those organisations that have the ability and practice calling in additional staff on a needs basis or in the event of a major incident in the facility.
• Recommend that there be provision for reporting those directly involved in care recipient care rather than those providing administrative, quality or other management functions.
• We would like to see different parameters for the time frame for reporting. Our members do not believe that 4 single days in a year gives a true resemblance of the facilities staffing practices and the impact that this has on care.
• We assert that staffing ratios do not give a sufficient picture of the facilities practices and that Accreditation Agency reports give a clearer indication of service provision.
• We recommend that the already introduced Legislation in relation to the Aged Care Standards be given an opportunity to effect change rather than an additional task for facilities in reporting staffing ratios.
• ACQA recommends that an expanded definition around roles rather than qualifications be considered.
• Recommends that this information be provided through the already established Medicare payment system and report monthly rather than 4 days per annum.
• Asserts that the Bill does not create greater public transparency in the provision of residential care.
• Asserts that staffing ratios do not directly equate to quality care and is a very small indicator in a much bigger picture of quality measures.

ACQA is available for further clarification if required.