With the predicted increase in community services delivering more high-level care, the onus will be on providers to have the appropriate clinical governance systems in place, writes Lorraine Poulos.
First, let’s look at some examples:
Case one: Bob is an insulin dependent diabetic and staff are contracted to provide personal care. The care/support plan outlines the tasks however provides no information about what a hypoglycaemic attack means, and what to do if Bob displays any symptoms of this. Bob has a skin tear on his shin. The care worker provides personal care and puts a band-aid over the skin tear.
Case two: Mary is on Warfarin and needs to have her blood levels checked each week and her dose adjusted accordingly. The community service says “we don’t deal with her medications, we leave this to the community nurses”. The care worker visits and notices Mary has not taken her medication for three days but does not report it. Mary has a fall and ends up seriously ill in hospital and blame is apportioned to the community service.
These two examples demonstrate a need for clinical governance. Why? Let’s look at what it means and then how a provider might put systems in place to ensure safe care.
Below is the definition and the policy framework recommended by the Victorian Government and some ideas from me in italics about what I believe is needed in community care.
The Australian Council on Healthcare Standards defines clinical governance as: “…the system by which the governing body, managers, clinicians and staff share responsibility and accountability for the quality of care, continuously improving, minimising risks, and fostering an environment of excellence in care for consumers.”
The Victorian Government has recently released a policy framework for clinical governance that provides the structure for this plan. This framework has the consumer experience as a central part of the approach, reflecting the significance of the consumer in the identification of, and solution to, many safety and quality issues.
The framework principles provide a basis for supporting excellence and good governance of clinical care. These are:
- The focus is on the consumer experience throughout the continuum of care. Documentation in care plans, work instructions about how the consumer manages the situation and how the service is able to assist in clinical care e.g. diabetes, mobility, medications, diet, cognition, psychosocial care.
- Priorities and strategic direction are communicated clearly to support quality and safety systems. There are clear clinical policies in place for safe care e.g. medication management, wound care, bowel and bladder care. Reports to board and management include clinical information such as falls, medication incidents, hospitalisations, behaviours and clinical incidents.
- Planning and resource allocation supports achievement of goals. There is a clinical position or resource to assist with clinical issues. There is a clinical governance committee with terms of reference.
- Strong clinical leadership and ownership. Managers discuss clinical issues regularly and staff are supported to gain knowledge and seek expertise where necessary. There is clear evidence of effective case management in all documentation.
- Organisational culture supports patient safety and quality improvement initiatives and is supported through committee structures, systems and processes. Data is collected on the necessary indicators and monitored regularly for trends and opportunities for improvement and education. Referrals are made regularly and there is a referral register noting the outcomes of clinical referrals. Instructions about what to do in clinical emergencies are clear and within the scope of practice of each staff member.
- Compliance with legislative and departmental policy requirements. Information available is disseminated regularly to staff, policies are updated and referenced. e.g. medication management in community service, relevant government circulars are read and actioned and all staff are aware of program guidelines.
- Rigorous measurement of performance and progress, including reporting and review. All incidents and accidents are reviewed and actioned, education is planned and includes information on clinical care and staff responsibilities.
- Continuous improvement of quality and safety. Continuous quality improvement plans and registers include information about clinical issues and areas for improvement.
- Clearly defined roles and responsibilities are understood by all participants in the system. Competence is checked regularly via a systematic process including evidence of competence e.g. in medication management, use of hoist, dementia care, wound care. There are regular reminders to staff about the importance of observing and reporting changes in consumer health status. There is a regular feedback system in place with brokered or subcontracted services.
I hope this helps and please forward any ideas or comments for discussion.
Lorraine Poulos is a trainer and consultant with experience working with government and aged care providers. She contributes to a regular column in Community Care Review Magazine. See the November issue for her advice on communicating the value of case management. Feedback can be sent to firstname.lastname@example.org
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