With older people entering residential aged care at older ages and with increased fragility, clinical governance – as distinct from governance of resident ‘care’ – is a critical element in ensuring the health of residents. But what is it, or what should it be, in daily practice in residential aged care facilities (RACFs)?
The Australian Commission on Safety and Quality in Health Care defines clinical governance as the ‘set of relationships and responsibilities established by a health service organisation between its governing body, executive, clinicians, patients and consumers, to deliver safe and quality health care’.
In the aged care system, provision of clinical care in RACFs is monitored by the Australian Aged Care Safety and Quality Commission (the Commission). From July 1, clinical governance is now reviewed under the new Aged Care Quality Standards, which focus on aged care consumer outcomes. Clinical care falls under Standard 3, where a consumer can expect to ‘get personal care, clinical care or both personal care and clinical care that is safe and right for me’.
In daily practice of any RACF this should mean that a resident has access to a GP and other medical professionals they need. Ideally, this should be their usual GP with whom they have had an ongoing relationship before entering the RACF. Internationally, there is body of evidence that continuity of care is directly linked with improved health outcomes for consumers.
Secondly, a sufficient number of registered nurses should be available and on staff in RACFs. Registered nurses who know their residents well can quickly register and act on any change or deterioration in their condition. So when, for example, an older person develops a pressure sore where previously there was none, the nurse can effectively treat that sore or contact the resident’s GP should the need arise.
Finally, providing optimal clinical care should mean that there are no unwarranted transfers to hospitals for issues such as UTIs, fever and sore throats, that could and should effectively be managed in the RACFs. Hospital transfers should be the final outcome if all other attempts of clinical care provision have failed.
For all this to happen, a RACF needs to set the parameters for provision of care and the minimum standards for that care. It then needs to ensure that staff are trained and available in sufficient numbers, and to be accountable for any failures to achieve the consumer outcomes under the Quality Standards.
The Commission recognised the need to support residential aged care providers in the development and implementation of relevant clinical governance processes. Some of this work has arisen in the context of the concerning evidence emerging from the Royal Commission into Aged Care Quality and Safety, where cases of lack of proper clinical care have been documented, as well as a failure of accountability by the governing bodies of RACFs.
To support the providers who will be reviewed and accredited under the new Quality Standards from July 1, the Commission has developed a set of clinical governance materials for governing bodies of RACFs to utilise.
In this endeavour, the Commission has recognised the crucial role that medical practitioners play in provision of clinical care.
However, the twin factors of GPs providing care as entities which are independent from a RACF both from a final and clinical responsibility standpoint – they represent a different ‘silo’ of care – as well as the patently inadequate funding of GPs visiting RACFs, are clearly barriers to GPs being incorporated into the watertight clinical governance structures proposed by RACFs. Disconnects such as this can lead to gaps in clinical care, in particular ‘who’ is clinically responsible for ‘what’ at any given time, which can in turn lead to resident harm.
The governing bodies of RACFs will be expected to work together with their visiting medical specialists, including GPs, to develop clear policies regarding procedures and practices for appropriate clinical care of residents. The AMA has worked with the Commission to develop materials to support this. They range from basic information on what clinical governance is to ready-to-use templates.
The AMA has urged the Commission to include in their materials guidance on communication between doctors and RACF staff. Information to visiting practitioners about the clinical governance framework and the policies and procedures of the organisation will have to be provided. Additionally, protocols will have to be established hand-in-hand with visiting practitioners regarding aspects such as lines of clinical responsibility, acceptable modes of communication and agreed forms of documentation of clinical notes and treatment decisions.
At the moment, this is very much theory. It remains to be seen how clinical governance in aged care will be implemented in practice, particularly by those RACFs where there have been failures in the past. It also remains to be seen whether the existence of frameworks and procedures will actually improve the environment for medical practitioners in their work in aged care.
Currently, doctor attendance at RACFs hangs in the balance. According to the 2017 AMA Aged Care Survey, one in three doctors intended to either visit current patients but not new patients, decrease the number of visits, or stop visiting RACFs entirely over the next two years. Inadequate funding and a lack of support from RACFs to provide a service were revealed as major influencers to decrease visits.
Hopefully, some standardisation of clinical care and improvement of processes will help address some of these obstacles and reduce the failures in care of our vulnerable elderly which the Royal Commission has laid bare for all to see. Restoring adequate funding for medical aged care services remains an unanswered need that the AMA will continue to advocate for.
Professor Miller is Chair of the AMA Medical Practice Committee
