Improving Quality in a Complex System

In preparation for the implementation of the strengthened aged care quality standards, it’s essential to understand how standards can be used to provide focus to quality and education roles when developing quality improvement plans and staff training initiatives. Quality and Learning and Development (L&D) roles in aged care are at the interface between interpreting the standards and helping the aged care workforce make a meaningful difference in the lives of those using the service.

This article outlines how aged care educators, quality and safety staff, and care staff working with older and vulnerable adults can use insights gained from understanding high-impact, highly prevalent events that can occur in clinical care.

The article also introduces some valuable concepts around dealing with complexity at a systems level in the critical quest to improve clinical care and enhance the safety and well-being of older adults.

What is a High-impact, High-prevalent event?

A high-impact, high-prevalent event in aged care refers to a situation or incident that occurs often and has significant consequences for residents, staff, or the facility itself. If and when it happens, the severity of the clinical care risk to the older person makes a high impact, and a high prevalence of clinical care risks is imperative to prevent. In the case of an older adult with frailty and multiple chronic co-morbidities, this impact includes:

• Preventable harm, pain and suffering
• Distress to the older person, family and carers
• Reduction in quality of life
• Introduction of new medicines, previously not required, increasing the risk of polypharmacy and medicines-related incidents
• Preventable hospitalisation
• Unnecessary transition of care
• Avoidable presentation to an emergency department
• Cost

Standard 5, in particular, outcome 5.5 Clinical safety of the strengthened aged care quality standards lists the following as high impact and high prevalence clinical care risks:

• Choking and swallowing
• Continence and incontinence-associated dermatitis
• Falls and injuries from falls
• Undernutrition
• Malnutrition
• Dehydration
• Distress and deterioration of mental status
• Deterioration of oral health
• Pain
• Pressure injuries and wounds
• Medication-related errors or adverse events
• Aggressive or violent behaviour
• Delirium
• Outbreaks of infectious diseases

A Complex Adaptive System

Thinking about aged care as a complex adaptive system can assist us in understanding why serious events can, unfortunately, occur frequently or continue to occur despite the harm incurred. A complex adaptive system is an approach that rejects and challenges the idea that there are clear causes and effects. Instead, the aged care system of care and clinical practices influence outcomes in a dynamic process. For example, a continuous learning and innovation culture enables high-quality care by bringing improvement practices as part of day-to-day activity to strengthen the system against incidents and adverse events. A key role for aged care staff involved in education and quality assurance is to ensure staff have the right qualifications, skills and experience to provide care and that clinical governance and guidance are embedded in what they do, where they work and how care is provided.

Learning from Acute Care

Every organisation that provides aged care services will employ a quality framework. A quality framework encompasses quality assurance processes, staff roles and responsibilities, and accompanying policies and procedures. Healthcare, particularly acute care, has established mechanisms for system monitoring through long-standing education and coordination of engagement with the elements that make up the National Safety and Quality Health Service Standards (NSQHS Standards). The approach works well because the standards are well articulated, consistently applied and embedded in service delivery. Entire health services can ‘get behind’ the standards, but critical roles provide guidance and support to see the standards meaningfully applied. Policies and procedures are the reference tools for providing quality care. The organisation’s critical statements establish expected standards for behaviour and performance, along with instructions and information about operational steps and actions staff are expected to take.

Organisational Risk Prioritises Quality and Training

Outcome 5.5, clinical safety, states that providers must implement a system to identify, monitor, and manage high-impact and high-prevalent clinical care risks. Creating a risk assessment matrix helps an organisation identify their potential for high-impact situations and events and evaluate the degree of adverse outcomes they potentially cause. Interventions and changes introduced to mitigate risk are part of the quality plan monitored for effectiveness. Critically, this is transformed into action areas to inform education, training and upskilling. This systematic approach intends to understand the contributing factors and causes that create risk (or are already issues), mitigate them using a consistent approach and then measure the impact of the associated interventions. L&D teams are essential in translating this information to help aged care staff comprehensively embrace the changes, interventions, and educational initiatives assigned to the risk. In my experience, engagement and compliance with the initiatives are much higher when staff understand the ‘why’ behind what we have implemented, be it a quality initiative or the assignment of mandatory training or education.

Meaningful Integration of Quality Data

Quality of care is currently measured using clinical indicators. For example, falls with significant injuries or consecutive unplanned weight loss are quality indicators included in the National Aged Care Quality Indicator Program. Data collection and assessment of 11 quality indicators relating to older adults in aged care are mandatory and used to generate insights about safety trends, risks and issues. However, when used in isolation, indicators can fail to embed the importance of the care experience into the selected actions or interventions designed to reduce risk and prevent harm. Like feedback, audits and measures become meaningful only when tied back to a proactive approach to improvement in which care demonstrably improves. For example, the outcome is better, the issue is resolved, or the risk is removed or mitigated.

Rejecting the Normalisation of Poor Practices

Worryingly, a highly prevalent, high-impact event may be ‘normalised’ due to its frequency. Suppose staff see an event such as a fall, incontinence-associated dermatitis or a medication incident occurring constantly. The clinical care risk is seen as inevitable, and deviance from practice is validated. Remaining in an environment where better practice options are reduced compounds this belief that clinical care risks are ‘normal’.

An example of this deviation of practice is evident in the case of restrictive practices. Over the last decade, numerous reviews and recommendations about aged care quality repeatedly echoed concerns about restrictive practices. These continue to be a potential and actual high-impact, high-prevalent event. L&D teams and quality coordinators must be loud advocates to call out that despite a prevalent practice, it does not make it acceptable. The critical importance of education and the use of transparent audit and reporting systems can ensure that restrictive practices are used only when strictly adhering to the guiding principles promoted in the Charter of Aged Care Rights.

Sustaining Quality Improvements and Education Initiatives

Traditionally, many quality improvement initiatives have been reactive and event-based. They address key ‘moments’ where care systems do not meet the expected standards. The consequence is that quality improvement projects may only elicit short-lived improvements. Resource constraints, such as time and budget, exacerbate the sustainability of quality initiatives. As attention to the ‘call to action’ drops, so does the ‘change’ and the positive and protective effect. Then, it’s back to before, with the risk still present while the next challenge or issue causes new distractions and demands a response.

For example, a sharp increase in the number of falls experienced by residents might drive training efforts focussing on addressing environmental factors. Falls prevention weeks make for a helpful quality improvement campaign to improve awareness of physical safety. Still, they can’t always systematically address the other social, organisational or clinical factors that precipitate clinical risks such as malnutrition and dehydration. Education campaigns that help create a focus on a priority issue are still helpful when backed by visible and sustainable improvement, mainly when the campaign is a public one and when a whole community works together to highlight a shared problem and works together on potential solutions. Quality and L&D teams should dance in sync to collaborate, encourage and support implemented initiatives and maximise their effectiveness over the short and long term.

Using Feedback Wisely

Patterns of high-prevalence events raised in feedback are often a quality signal before an escalation or high-impact event occurs. This is particularly true of complaints. Feedback and complaints about the quality of aged care are a rich source of information about what is working and what needs to be improved. Aged care settings where speaking up and speaking out is encouraged and valued benefit from greater transparency and trust because issues are not ignored or minimised. Education resources designed and complemented with information and feedback from older adults about what is a priority or meaningful to them regarding the quality of care help shape a cohesive approach to enhancing clinical care while developing resilience to systemic problems.

The perspectives of the older person sit at the centre of incident investigation. This mechanism supports a more robust review and accurate findings, leading to better improvements (Safer Care Victoria, 2023). So, it’s worth sharing themes when appropriate in ways that do not compromise a fair and just complaint response. Increasing feedback rates in response to risks isn’t alarming—increasing feedback can measure engagement and interest in a system that uses complaints, compliments, and feedback to improve care and develop critical educational resources.

The Burden of Addressing High-Prevalent Events

We know more nuanced change is hard to sustain, even at the individual level, if the system as a whole doesn’t shift and when there isn’t apparent reward and recognition for the ‘great saves’ and ‘near misses. When bench-marking thresholds are involved to ensure compliance against an agreed or pre-determined outcome for an individual or a group of older adults, there are often ‘explainable’ exceptions, something unexpected happens, or other reasons why the threshold isn’t reached. Often, the volume of competing priorities regarding quality means a loss of clarity. When that happens, confusing, contradictory goals emerge, derailing improvement efforts. Motivation is lost when risks and issues are repeatedly the focus, and staff, as well as older adults and their families, become cynical about improvement practices in the setting of ongoing preventable error or harm.

Focus on Iterative Change

There are many reasons why our care systems aren’t perfect. The Aged Care Quality and Safety Commission has comprehensively detailed the sobering and complicated reasons, including those caused by organisational structures, the tension between differing values, capabilities, financial imperatives, and the increasingly complex health conditions an older person may be living with. It can, therefore, be challenging to decide where to put energy and effort into helping transform care systems, be it education, training, or quality improvement initiatives. How can we tackle the complexity around high-risk, high-prevalent risks? Is it possible to positively influence the systems we operate in and help others ‘make sense’ of what needs to occur to improve the quality and safety of care? Continuous quality ensures that standards of care are met or exceeded through ongoing iterative efforts. We need to keep “repeatedly asking members of the care team to determine, “How are we doing?” and “Can we do it better?” and ensure that incidents or near-misses are vital drivers for continuous improvement initiatives.

Amplifying the Voice of the Older Adult

The strengthened aged care quality standards holistically outline how meeting older adults' social, personal and clinical needs will be demonstrated and measured in the future as part of an approach that fosters ongoing quality improvement and ensures we amplify the voice of the older person receiving care. Incorporating the consumer’s voice is integral to high-quality care at all steps: design, delivery, and evaluation. L&D and quality teams should proficiently use various communication strategies to effectively convey information to staff, residents, and families during high-stress situations when events unfold dynamically. Utilising clear and concise language to convey critical information and establishing communication channels for timely updates and feedback are opportunities to respond successfully to high-impact and high-prevalence incidents.

An Exciting Opportunity

By utilising the strengthened standards as a blueprint for continuous improvement, L&D and quality teams will design learning programs that will grow the skills and capability of the aged care workforce. It’s an exciting time for these key support roles, which have a clear opportunity to facilitate best practices and support their teams in providing person-centred care. L&D teams need to be well-versed in preventing, mitigating, and responding to high-risk, high-prevalent events to ensure the safety and well-being of older adults. Teams should have comprehensive knowledge of relevant policies, procedures, and regulations governing aged care facilities, as well as training in risk assessment and communication management, as well as skills to deal with uncertainty and ambiguity while drawing on the standards to continue to guide care excellence. The opportunity here for staff involved in quality coordination or learning and development in aged care is exceptionally positive because your role is integral to the success of the changes we all hope to see realised.

References

The Health Foundation. (2010). Evidence scan: complex adaptive systems [Online document]. Retrieved from The Health Foundation.

Australian Institute of Health and Welfare. (2023). Measuring quality in aged care: What is known now and what data are coming. In Australia's welfare 2023 data insights. Retrieved from AIHW.

Aged Care Quality and Safety Commission. (2022). Aged Care Quality and Safety Commission: Sector performance report July–September 2022 [Online document]. Retrieved May 2024, from ACQSC.

Aged Care Quality and Safety Commission. (2023). Serious Incident Response Scheme (SIRS) insights Series: Report 2 - 2023. Retrieved from ACQSC.

Aged Care Quality and Safety Commission. Topic guide - Quality in aged care. Retrieved from ACQSC.

Aged Care Quality and Safety Commission. (2022). Effective incident management systems: Best practice guidance (December 2022). Retrieved from ACQSC.

O'Donnell, B. & Gupta, V. (2023). Continuous Quality Improvement. 2023 Apr 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Retrieved from NIH.

Safer Care Victoria (2023). Amplifying the voices of consumers impacted by adverse events. 13 April 2023. Retrieved from SCC.

Department of Health and Aged Care, Australian Government (May 2024) Quality obligations for providers - Charter of Aged Care Rights. Retrieved from Department of Health and Aged Care.

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