Better health and ageing for all Australians

Evaluation of the impact of accreditation on the delivery of quality of care and quality of life to residents in Australian Government subsidised residential aged care homes - Final Report

4. The Aged Care Accreditation System

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4.1 Chapter overview

This chapter focuses on accreditation as a mechanism for quality improvement in the context of incentives provided in a regulatory framework for improving quality in residential aged care. It addresses the project outcome:
'To identify improvement and performance and benchmarking assessment systems to take the provision of world class care for Australian residential aged care into the future.'

It draws upon the Regulatory Review, the Literature Review and the Stakeholder Consultation and CR&C Aged Care Surveys to review accreditation in the context of recognised best practice of regulating quality improvement. This includes:
    • Appropriateness of the regulatory framework in the Australian legislative context and Australian Government's objective of achieving an enhanced quality of life for older Australians;
    • The responsibilities of government and approved providers established within this framework;
    • Capacity of the accreditation system to achieve each of its dual objectives of assuring compliance and stimulating continuous improvement;
    • Evidence of ongoing need for accreditation;
    • Consistency of the approach with other approaches to accreditation internationally and within Australia; and
    • Identification of opportunities to improve the regulatory framework and/or the approach to accreditation.

4.2 The objectives and key features of the Australian regulatory framework for aged care

The Act, together with a range of principles and other regulatory instruments that comprise the aged care regulatory framework, establishes the scheme by which the Australian Government provides financial support for aged care (including for aged care homes) and the conditions under which that financial support is provided.

The objects of the Act include providing for funding that takes account of:
    • The quality of care;
    • The appropriate outcomes for recipients of care; and
    • The accountability of the providers of the care for the funding and for the outcomes of recipients.
The Act incorporates a range of direct and indirect strategies that are aimed at assuring and enhancing the quality of care and quality of life for residents of aged care homes.

In broad overview, the Act and subordinate instruments are designed to protect and foster residents' quality of care and quality of life by:
    • Focusing on the accountability of approved providers rather than on approval of premises as applied under the previous scheme regulated through the National Health Act 1953;
    • Limiting access to residential care subsidies to approved providers, and ensuring that only people assessed as suitable to provide aged care are approved as providers;
    • Specifying in the Act and in the associated Quality of Care Principles 1997 (the Quality of Care Principles), the User Rights Principles and the Accountability Principles many of the legitimate rights and expectations of residents and the responsibilities of providers;
    • Providing for the application of sanctions if approved providers fail to comply with their responsibilities;
    • Providing for a process of certification of physical facilities, with financial incentives available for certified homes; and
    • Providing for a process of accreditation of residential aged care homes, with the availability of residential care subsidies contingent on a home meeting its accreditation requirement.
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4.3 Accreditation in the context of the regulatory framework

The accreditation requirement established by the Act creates a key regulatory link between funding and quality of care and quality of life in aged care homes.

The significant changes introduced by the Act in 1997 have been described as:

'... a move from passive monitoring of standards to an active audited regime of continuous improvement.' 9

The Act authorises the payment of subsidies for residential aged care to an approved provider, on any given day, if the Secretary of the Department (the Secretary) is satisfied that, during that day:

'the approved provider holds an allocation of places for residential care subsidy that is in force under Part 2.2 (not being a provisional allocation);102 and

the approved provider provides residential care to a care recipient in respect of whom an approval is in force under Part 2.3 as a recipient of residential care; and the residential aged care service through which the care is provided meets its accreditation requirement (if any) applying at that time.'11

Section 42.4 of the Act provides that a residential aged care home meets its accreditation requirement at all times during which there is in force an accreditation of the home by an accreditation body.12

Part 5.4 of the Act enables the Secretary to enter into a written agreement with a body corporate under which the Commonwealth makes one or more grants to the body corporate for the purposes of accreditation of residential aged care services in accordance with the (the Accreditation Grant Principles) and any other purposes specified in the Accreditation Grant Principles, including the performance of any of the function of the Secretary under the Act that are specified in the Accreditation Grant Principles. An accreditation grant is a grant payable under Part 5.4, and an accreditation body is a body to which an accreditation grant is payable.13

The Accreditation Grant Principles identify the Agency as the accreditation body. The Agency is a company limited by guarantee whose sole member is the Minister for Ageing. It has a Board of Directors appointed by the Minister. It receives revenue from accreditation fees paid by aged care homes when they apply for accreditation, the accreditation grant and interest and income from educational activities.14

The Act and the associated Principles establish a system, therefore, that makes availability of public subsidy for an aged care home generally dependent on the home achieving and maintaining accreditation by the Agency. Funding provided by the Australian Government is thereby linked to quality as assessed by the Agency.
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4.4 Operation/implementation of the accreditation requirement

The Accreditation Grant Principles set out the accreditation process in detail. All aged care homes must demonstrate how they comply with the Accreditation Standards (as set out in Schedule 2 of the Quality of Care Principles) through the process of assessment conducted by the accreditation body. The purpose of the assessment process is to gather information to assess a home's performance against each of the 44 Expected Outcomes that apply across the four Accreditation Standards.

Guidelines published by the Department state that:
'... Assessment for accreditation requires a service's management to provide evidence to demonstrate that their system works to deliver effective outcomes.

The key assessment questions are:
a. Is a system in place?
b. Is the system used?
c. Does the system work?

Quality management within each service underpins the system. Quality and continuous quality improvement are management and staff responsibilities in each service. This involves the careful management of every aspect of service at every level within the organisation.'

The Agency has published an Accreditation Guide for Residential Aged Care Services (1998) (the Agency's Guide) to assist aged care homes prepare for and better understand the accreditation process. It is not binding on aged care homes and must be read subject to the terms of the Act and the Aged Care Principles.

The Agency's Guide outlines the accreditation process in eight main stages as follows:
  1. The approved provider and service conducts a self-assessment;
  2. The approved provider submits an application, including the self-assessment report;
  3. A team of at least two registered aged care quality assessors conducts a desk audit examining the application;
  4. The same team conducts a two to three day site audit which includes interviews with residents, their families, staff and management;
  5. The Agency considers the assessment team's findings, any submission from the approved provider and any other relevant information, including input from the Department. It decides whether or not to accredit the service, and if granted, the period of accreditation as well as the form and frequency of support contacts and whether the service must make improvements;
  6. The Agency informs the provider of the decision;
  7. The Agency publishes the team's report and the Agency's decision on the Agency's website (2004a); and
  8. The approved provider manages compliance with the Accreditation Standards and the Act and ongoing continuous improvement to the service throughout the period of accreditation. At the same time, the Agency conducts support contacts to monitor compliance with the Accreditation Standards and the Act and, to assist the service to undertake continuous improvement (1998, p. 7).

The Department has published a Standards and Guidelines for Residential Aged Care Services Manual to assist service providers to comply with their obligations under the Act. This includes information on the quality management and services expected of a residential aged care home.

The Accreditation Grant Principles provide for assessment teams to be created before a desk and/or site audit, and disbanded when they have completed their duties.15

Top of pageThe Agency considers that this ensures the independence of assessment teams for the purposes of conducting and reporting audits.

A two-tiered score of 'compliant' or 'non-compliant' applies for each of the 44 Expected Outcomes. In addition, the Better Practice in Aged Care awards scheme aims to identify and recognise better practice programs, promote adoption of better practice and encourage sharing of better practice amongst aged care homes. Homes are eligible for these awards if they are fully compliant with the Accreditation Standards and have been fully compliant for two years, and may apply for up to three awards.16

If the Agency decides to accredit an aged care home it must decide the period for which the home is to be accredited, whether any improvements must be made to improve its compliance with the Accreditation Standards, and the form and frequency of support contacts for that service.17 The Act does not specify a maximum period of accreditation. The majority of services are awarded accreditation for a three year period, but a lesser period may be awarded if an aged care home is assessed to be not performing well or has a history of non compliance with the Accreditation Standards. The common three year duration is consistent with overseas accreditation systems, including that conducted by the Joint Commission on Accreditation of Healthcare Organisations.

The accreditation body is required to carry out regular supervision of an accredited aged care home by means of support contacts, to ensure compliance with the Accreditation Standards and other responsibilities under the Act.18 The Australian Government made a budget announcement in May 2006 that all funded aged care homes would receive at least one unannounced support visit annually, with a target of an average of 1.75 visits per home per year, and the Agency has commenced implementation of this support visit regime.19

If the accreditation body believes, on reasonable grounds, that an accredited aged care home may not be complying with the Accreditation Standards or its other responsibilities under the Act, it may arrange for a review audit.20 Following a review audit, the accreditation body may decide to revoke the accreditation of the home, to vary the period of accreditation or to make no change.21 The provider is given oral and written information about the findings of an audit and an opportunity to make written submissions to the accreditation body before the decision is made.

If the accreditation body finds non-compliance with one or more Expected Outcomes and decides that non-compliance has placed, or may place the safety, health or well-being of persons receiving care through the home at serious risk, it must report immediately to the Department and make a recommendation on whether sanctions under the Act should be imposed on the provider.22

There is provision for reconsideration by the accreditation body of a decision concerning the period of accreditation or a decision not to accredit a home.2315 There also is provision for review of certain decisions by the Administrative Appeals Tribunal, including the decision of the accreditation body to refuse an application on reconsideration24 and a reconsidered decision itself.

If, following a review audit, the accreditation body maintains its finding of non-compliance, it may vary or revoke the period of accreditation and put in place a timetable for improvement.25 The timetable for improvement gives the provider a defined period within which to take corrective action. The accreditation body schedules a series of support visits to assess progress made by the service in making improvements. The Department is notified and, if upon completion of the defined period, the provider remains non-compliant or there is evidence of 'a serious risk to the health, safety or well-being of a person receiving care', the provider is referred to the Department for action. 26

The Act provides for sanctions to be placed on the operation of aged care homes by the Department under certain conditions.

Part 4 of the Accreditation Grant Principles establishes the framework for enforcement of compliance with the Accreditation Standards.

If a desk audit, site audit or review audit reveals evidence of serious risk to residents, or the accreditation body identifies a failure to comply with Accreditation Standards which has placed, or may place, the safety, health or wellbeing of residents at serious risk, or the accreditation body identifies evidence of non-compliance with the Act, it must advise the Secretary and, amongst other things, recommend whether or not sanctions should be applied.

The Secretary has a range of sanctions at his or her disposal up to and including revoking or suspending the approved provider's approval under Part 2.1 of the Act. 27

The Agency's role extends beyond assessing services for the purposes of making a decision about accreditation. It includes other responsibilities which are defined in the Accreditation Grant Principles, and are described by the Agency as:
    • Promoting high quality care and assisting industry to improve service quality by identifying best practice, and providing information, education and training;
    • Assessing and strategically managing services working towards accreditation; and
    • Liaising with the Department about services that do not comply with the relevant standards.28
To support its function of promoting high quality care, the Agency conducts educational activities and has processes in place for identifying examples of better practice. 29

The Agency has been accredited to the international quality management standard ISO 9001:2000. 30
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4.5 The Accreditation Standards

The Accreditation Standards are set out in Schedule 2 of the Quality of Care Principles and are defined by section 18.7 of the Quality of Care Principles as:
'... standards for quality of care and quality of life for the provision of residential care on and after the accreditation day.'

Section 18.9(1) of the Quality of Care Principles states:
'The Accreditation Standards are intended to provide a structured approach to the management of quality and represent clear statements of expected performance. They do not provide an instruction or recipe for satisfying expectations but, rather, opportunities to pursue quality in ways that best suit the characteristics of each individual residential care service and the needs of its residents. It is not expected that all residential care services should respond to a standard in the same way.'

There are four Accreditation Standards:
    • Management Systems, Staffing and Organisational Development (Standard 1);
    • Health and Personal Care (Standard 2);
    • Resident Lifestyle (Standard 3); and
    • Physical Environment and Safe Systems (Standard 4).
For each Accreditation Standard, there is:
    • A statement of Principles underlying the standard;
    • A series of Matter Indicators; and
    • An expected outcome for each Matter Indicator.
There are 44 Expected Outcomes across the four Accreditation Standards.

The Accreditation Standards are based on the 31 Outcome Standards which were incorporated in the previous regulatory framework for residential aged care. The Accreditation Standards were developed 'in close partnership with representatives from consumer groups, service provider associations, unions and the Government'31 but it is now some years since they were introduced and there is no clear process for their maintenance and/or review.

The Accreditation Standards are described as outcome standards. They differ significantly in their expression from standards in many other jurisdictions.

As an example, the National Minimum Standards that apply in England and the National Care Standards that apply to care homes for older people in Scotland (the Scottish Standards) have been compared with the Accreditation Standards. The National Minimum Standards and the Scottish Standards are input-based, prescriptive and detailed in comparison to the Accreditation Standards which are outcome-based and structured so as to provide maximum flexibility to providers. For example, the National Minimum Standards specify that:
'15.2 Each service user is offered three full meals each day (at least one of which must be cooked) at intervals of not more than 5 hours.'

The Scottish Standards specify that:
'13.3 You have a choice of cooked breakfast and choices in courses in your midday and evening meals.'

The Accreditation Standards, in contrast, specify that:
'2.10 Nutrition and hydration – residents receive adequate nourishment and hydration.'

'4.8 Catering, cleaning and laundry services – hospitality services are provided in a way that enhances residents' quality of life and the staff's working environment.'

It should be noted, however, that many of the requirements contained in the more detailed, input-based English Standards and Scottish Standards, while not incorporated in the Accreditation Standards, are incorporated within the Act and/or other regulatory and associated instruments. For example, while the Accreditation Standards do not address the dietary requirements in detail, Schedule 1 of the Quality of Care Principles (with which approved providers are required to comply, by the application of section 54.1 of the Act) provides that all residents who need them must be provided with meals and refreshments comprising:
    1. Meals of adequate variety, quality and quantity for each resident, served each day at times generally acceptable to both residents and management, and generally consisting of three meals per day plus morning tea, afternoon tea and supper;
    2. Special dietary requirements, having regard to either medical need or religious or cultural observance; and
    3. Food, including fruit of adequate variety, quality and quantity, and non-alcoholic beverages, including fruit juice.
This example highlights the essential differences between these regulatory schemes:
    • The National Minimum Standards and Scottish Standards are prescriptive standards defined by Government and incorporated into licensing schemes;
    • The Australian standards allow considerable interpretive flexibility and are qualitatively and quantitatively different from the detailed and prescriptive National Minimum Standards and Scottish Standards. However they are complemented by more prescriptive requirements for aged care home infrastructure and services that are incorporated in other parts of the regulatory framework, with which compliance is mandatory or non-compliance is incompatible with financial viability of the home.
The reliability and validity32 of the former Outcome Standards were evaluated by Braithwaite in the early 1990s. While doubts were raised about some standards, in general very strong support was found for the reliability of the standards and limited tests also supported their validity (Braithwaite et al. 1992).

Top of pageThe study concluded that:
''The validation results are very encouraging indeed and reliability is much stronger than that found in any of the American studies of the reliability of nursing home ratings by government inspectors.

For 29 of the 31 standards, over 95 per cent of directors of nursing thought they were clear. For all the standards, at least 95 per cent of both directors of nursing and standards monitors thought that the standards were desirable. For 24 of the standards, over 90 per cent of both directors of nursing and standards monitors thought they were practical.' (Braithwaite et al 1992)

A similar study has not been conducted in relation to the Accreditation Standards, although many of the Expected Outcomes of the Accreditation Standards are similar to the previous 31 Outcome Standards (with the exception of those under Accreditation Standard 1, Management Systems, Staffing and Organisational Development, which was introduced in 1997) and have a similarly high degree of face validity. The current system, which is considered to be less prescriptive than the previous approach, was introduced for a number of reasons including enabling providers to develop flexible approaches to achieving desired outcomes.

The most significant criticism made about the Accreditation Standards is that they lack specificity and are too open to interpretation. Some stakeholders would prefer more specific, input- or process-based standards that provide more certainty with respect to compliance. The conclusion drawn from the analysis of the available evidence, however, is that while there are opportunities to improve the Accreditation Standards and that they should be subject to periodic review, their design and expression is consistent with modern approaches to quality improvement generally and accreditation specifically. In addition, many of the input-based criteria that are expressed in standards internationally are expressed in other forms within the Act in a way that establishes a direct compliance requirement. The inclusion within the accreditation framework of outcome-based standards which require a continuous improvement orientation, and the inclusion within the Act of input-based criteria which establishes a direct compliance obligation, is consistent with the overall objectives of the regulatory framework.

4.6 The appropriateness of the regulatory framework in achieving the Australian Government's objectives

Many international regulatory systems are based on a strict system of licensing, with the availability of a license contingent on compliance with input-based standards. In many international systems, compliance requirements are state- or provincially-based rather than national. Also in many systems, the quality of care for residents of aged care homes has been the subject of ongoing concern and regulatory activity.

The Australian aged care regulatory framework, in contrast, is a national system that combines compliance and continuous improvement objectives for quality in aged care homes in a unique way.

Most significantly, the Australian aged care regulatory framework is based on a continuous improvement philosophy which aims to stimulate, through appropriate standards and incentives, the capacity and motivation within the sector to both comply with acceptable standards of care and strive to continuously improve performance over time. Because the Australian constitutional framework limits the extent to which the Australian Government can legislate directly to control providers of residential aged care homes, regulatory effectiveness has depended on establishing a strong link between the availability of public subsidy and compliance with the Act and associated regulatory instruments.

There is no doubt that the link between funding and compliance (with the regulatory framework generally and the accreditation requirement specifically) has captured the attention of the sector effectively. The current regulatory framework establishes, in practice, a compulsory compliance obligation, because non-compliance is incompatible with financial viability in almost all circumstances. The key question for regulators, however, is whether the incentives are structured in such a way that compliance is optimised, focused on outcomes for residents and supports aged care homes in raising minimum standards.

The results of the CR&C Aged Care Surveys of quality managers and care staff of aged care homes who have worked in the sector for longer than 10 years and who have observed the impact of the current regulatory framework (see Section 6) is extremely reassuring for regulators, policy-makers and all those who have an interest in the quality of residential aged care. There is strong support for the propositions that:
    • Accreditation has improved the quality of care of residents; and
    • Overall quality of service and clinical care is good.
Some issues arise around the regulatory structure and its sustainable ability to influence both compliance and continuous improvement. During consultation in the early stages of this project, some stakeholders raised concerns about a potential 'blurring' of roles between the regulator and the Agency with respect to compliance. These tensions also have been identified by the Administrative Appeals Tribunal.33
'Accreditation as it is generally understood is directed to assisting the public, the users and the government that they will have a service of an appropriate quality. The standard setting authority, the accrediting authority, the payment authority and the inspecting or compliance authority are separate bodies operating independently so that each can carry out its function appropriately and the system as a whole can ensure that the public receives services of an appropriate quality. … we have formed the view that the necessary separation of the four functions is absent.'

The tensions created when an approved provider who is judged to have not complied with their responsibilities is denied access to a portion of their funding, and the potential 'spiralling' effect on quality of care, also has been the subject of comment by the Administrative Appeals Tribunal34:

'There are instances in which there may be a tension between an approved provider's accountability and the Act's object of protecting the health and well-being of the recipients of the aged care services and that tension is as a result of the approved provider's financial position. That tension may arise in instances in which a sanction is imposed and the outcome of the imposition of that sanction is effectively to reduce the total amount of subsidy payable to an approved provider. A reduction could occur, for example, if a sanction restricted an approved provider's approval as a provider of aged care services to care recipients to whom it was providing care at the time the sanction was imposed but not to those to whom it subsequently provided care. If it should come to pass that the number of recipients in relation to whom it was an approved provider fell below the level at which an approved provider's business is viable and if the approved provider cannot recover from other sources the amount that would otherwise be paid to by way of subsidy under the Act, then there must be a very real possibility that the health and well-being of the recipients of aged care services may be compromised …'

Overall concerns regarding the complexity of the legislation have been expressed:
'Justice Weinberg described the system as a "somewhat convoluted legislative scheme". We can only agree.'35

The project team has concluded from the available evidence that the regulatory framework has been effective in improving quality by achieving compliance with minimum standards across the system of residential aged care. At the same time the complexity of the regulatory framework is acknowledged, as is the scope for improvement within the current legislative structure.

To summarise the relevant issues identified from the evidence:
    • While a 'pure' accreditation system would not depend on Government to develop the standards against which performance is to be assessed, the Accreditation Standards were developed in close consultation with consumer and industry stakeholders and have been assessed as reliable and valid. Provided future development is progressed in a similar manner, it is not unreasonable for Government to assume the dual roles of standard-setting and compliance.
    • The broad regulatory framework, the key regulatory objectives and the compliance obligations of providers are well understood within the residential aged care sector, and both the Agency and the provider sector have developed a sound understanding of their relative roles and responsibilities and those of the Department.
    • Consumers and carers appear to have a lower level of understanding of the relative regulatory roles, and continuing provision of quality information will be appropriate.
    • The Agency is developing its educative and support role progressively and effectively.
    • The requirement for the Agency to inform the Department of serious deficiencies in care it identifies as it carries out its responsibilities is a very appropriate feature of the regulatory framework, given the Department's responsibilities to ensure Government money is expended efficiently and effectively and resident safety is protected.
    • The increased focus on unannounced visits is appropriate and will address some of the concerns expressed to the project team about homes that increase resource availability solely for the purpose of creating a misleading impression regarding resources when an Agency visit is anticipated.
    • There remains some tension around the role of the Agency in investigating concerns about provider performance, which may be incompatible with its educative and support role. On practical grounds, however, the Agency's access to skilled assessors and its growing experience in assessing quality of care and resident safety places it in the strongest position to undertake this role. Its continuation, however, will require ongoing care and strict attention to the boundaries of its responsibilities.
Later in this report, (Section 8) recommendations are made about ways in which the regulatory framework could be strengthened. Our strong overall conclusion, however, is that the current framework is sound and, while complex, is well understood by providers and is impacting positively on outcomes for residents through improvement in the quality of care of residents in aged care homes.
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4.7 Assuring compliance and stimulating quality improvement

The tensions inherent in a regulatory scheme that has the dual objectives of stimulating continuous quality improvement and assuring compliance with minimum standards are obvious and have been referred to throughout this report.

Skok (2000) noted that the notion of standards implies clear-cut criteria and fixed definitions of quality, whereas the notion of continuous quality improvement implies a continual process of self-examination and a never-ending search for improvement without a fixed destination. She suggested that the tension between these concepts – continuous quality improvement requires continual revision, standards require certainty – is being reconciled by the development of more flexible and less prescriptive standards.

The tension is also being addressed by the development of standards specifically requiring organisations to demonstrate continuous improvement systems. An organisation that is able to demonstrate compliance with input, process, output or outcome-based standards at a point in time, particularly during a periodic accreditation survey, nevertheless will only be equipped to respond quickly and appropriately to emerging risks and opportunities that will impact on quality of care if it also has well-established continuous improvement systems in place.

Contemporary regulatory approaches that are based on a continuous improvement philosophy operate on the philosophy that ultimately, successful ongoing identification and management of risks and opportunities will only be achieved if an effective, dynamic continuous improvement system is in place.

To demonstrate compliance with a continuous improvement standard generally requires an organisation to demonstrate that it reflects on its performance systematically and continuously, takes actions to improve its performance based on the outcomes of that reflection, and reviews and confirms the validity of the outcomes of those actions. When a continuous improvement standard is also expressed as an outcome standard, the organisation has a high degree of flexibility and choice about how it constructs its processes in order to achieve an effective continuous improvement system.

Each of the Accreditation Standards has a priority focus on continuous improvement. The first Expected Outcome of each of the four Accreditation Standards requires the organisation to actively pursue continuous improvement.36 Although the continuous improvement outcome in each Accreditation Standard is expressed independently from the remaining 40 Expected Outcomes, it seems clear that the continuous improvement requirement is not an entirely independent requirement and is expected to overlay all other Expected Outcomes. It is understood that the Accreditation Body accredits organisations on this basis. The Accreditation Standards could be updated to better reflect the overarching nature of the continuous improvement requirement, across all aspects of an aged care home's performance, particularly in relation to resident outcomes.

The objective of continuous improvement is to promote the establishment of dynamic approaches to quality that will be sustainable over time and that will operate effectively between accreditation visits or other inspection processes. For Accreditation Standards to enable such a process they must be able to reflect developments in improved practice.

The following points are noted:
    • The results of CR&C Aged Care Surveys conducted for this project, and the outcomes of accreditation surveys, support the conclusion that continuous improvement cultures and practices are developing and strengthening in accredited aged care homes, although continuous improvement is the area where providers experience the greatest difficulty in complying with the Accreditation Standards;
    • A majority of experienced managers and care staff identify the accreditation process as having stimulated continuous improvement practices; and
    • The Agency's educational and support activities almost certainly have impacted on continuous improvement practices in the sector.
The conclusion of the project is that the current system of accreditation is capable of achieving both stimulating continuous quality improvement and assuring compliance with minimum standards, and increasing evidence is emerging that the system is successfully doing so.

4.8 International regulatory structures for aged care homes

The structure of the regulatory framework in Australia contrasts with the approaches to aged care regulation adopted in many other countries. Below, we describe systems for the regulation of residential aged care in a range of international jurisdictions.
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4.8.1 Canada

Long-term facility-based care is governed by provincial and territorial legislation in Canada. Across the country, jurisdictions offer a different range of services and cost coverage and there is little consistency in the level or type of care offered and how it is measured.

The province of Ontario provides an example of the Canadian approach. The Ontario approach is based on licensing and inspection. Compliance with standards is overseen by the Ministry of Health and Long-Term Care, which undertakes regular reviews and inspections against service agreements, the relevant legislation and regulations and the standards outlined in the program manual for long-term care homes.

The standards establish minimum expectations relating to care and services for residents. Each long-term care home operator must comply with these standards and policies. There are a total of 37 standards and 426 supporting criteria.37

When a home fails to address identified problems or other issues of non-compliance, the government can impose sanctions on that home. In order to bring a home up to standard or back into compliance with the regulations and policies, the government can:
    • Suspend admissions;
    • Suspend or revoke the home's license or approval for a license;
    • Refuse to renew a license (nursing homes must renew their licenses each year); and/or
    • Take over the operation of a home.38
Homes against which enforcement measures are taken undergo increased monitoring to ensure that the needs of existing residents are being met.39

Providers also can seek accreditation voluntarily through the Canadian Council on Health Services Accreditation, which is an independent, non-government organisation. Accreditation, however, is not an element of the regulatory framework.

The Ministry of Health and Long-Term Care also publishes inspection findings and details of 'verified concerns'.40
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4.8.2 Denmark

This brief description of the regulatory framework for aged care homes in Denmark has been sourced from a report by the Ministry of the Interior and Health, and the Ministry of Social Affairs and Gender Equality: Questionnaire on health and long term care of the elderly.41

In Denmark, local authorities are responsible for providing services to older people in compliance with national legislation. Funding is via local taxes and block grants from Government.

The provision of care services is based on the older person's specific needs and requirements rather than the housing in which they reside. There is a focus on home-based care. No traditional nursing homes have been built in Denmark since 1987. Subsidised housing for older people is constructed instead, including housing with nursing facilities and care staff. Traditional nursing homes are available to older people (and people with disabilities) who need such facilities.

There are no mandatory accreditation programs or national standards for quality for residential services for older people. National legislation creates a policy framework and defines rights in relation to care of the elderly. Local authorities who provide these services are required by legislation to prepare quality standards including a description of the services available to citizens who need personal or practical help and assistance, physical rehabilitation or general physical exercise provided at the local level. Descriptions of the nature, scope and performance of help and assistance must be concise and must include quality objectives which the local authority can subsequently use to evaluate performance and results.

The quality standards must be adopted by the local authority, which at least once a year must follow up on the quality and management of the services provided.

A voluntary, private certification scheme called Certification of Quality Management and Development of Eldercare has been set up to monitor and develop the quality of services provided to older people. The certification scheme covers all services offered in the field of aged care. To obtain certification, providers of aged care must meet certain standards in three key areas: management; objectives and services; and process and resource management. Having obtained certification, service providers are entitled to describe their services as 'quality-certified eldercare services' and to use a certification logo.
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4.8.3 England

In England, a licensing and inspection approach applies. There is no accreditation requirement.

The Department of Health has published National Minimum Standards for Care Homes for Older People (the National Minimum Standards) which form the basis on which the Commission for Social Care Inspection determines whether care homes meet the needs of people who live in them.

The introduction to the National Minimum Standards explains the regulatory context:
'The Care Standards Act created the National Care Standards Commission (NCSC), [note: the functions of the NCSC have been assumed since then by the Commission for Social Care Inspection] an independent non-governmental public body, which regulates social health care services previously regulated by local councils and health authorities …

The CSA sets our a broad range of regulation making powers covering, amongst other matters, the management, staff, premises and conduct of social and independent healthcare establishments and agencies.

Under the Care Standards Act the Secretary of State for Health has powers to publish statements of National Minimum Standards. In assessing whether a care home conforms to the Care Homes Regulations 2001, which are mandatory, the [National Care Standards Commission] must take the standards into account. However, the Commission may also take into account any other factors it considers reasonable or relevant to do so.

Compliance with national minimum standards is not itself enforceable, but compliance with regulations is enforceable subject to national standards being taken into account.

The Commission may conclude that a care home has been in breach of the regulations, even though the home largely meets the standards. The Commission also has discretion to conclude that the regulations have been complied with by means other than those set out in the national minimum standards.'42

In other words, compliance with the national minimum standards is not itself enforceable, but compliance with the regulations is enforceable subject to national standards being taken into account.
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4.8.4 New Zealand

Most residential care is provided in the private sector in partnership with the Government, which provides the funding for those who qualify for the subsidy.43

The New Zealand system is closer in design to the Australian system than the licensing systems described above. New Zealand has moved from a licensing system to a certification system, with compliance with standards audited by approved independent auditors.

The Health and Disability Services (Safety) Act 2001 aims to improve provider accountability using approved independent auditing to ensure compliance with the health and disability standards. The standards establish requirements for safe practice and continuous quality improvement systems. Providers are audited against the standards and receive certification when they meet the level of service required.

Service providers are able to choose from a list of designated audit agencies. These agencies, which are approved by the Ministry of Health, audit services against the appropriate standards. Providers are required to demonstrate to the auditors that the services they provide are:
    • Safe;
    • Focused on patient services and the outcomes;
    • Continually improving in quality;
    • Compliant with the standards; and
    • Consonant with the Director-General's conditions.
Quality Health New Zealand (QHNZ) is an accreditation agency. QHNZ accreditation and certification audits can occur at the same time, but certification depends entirely on compliance with all the standards approved under the Act.

The auditors report their findings to the Ministry of Health. If providers meet the required standards, the Director-General of Health issues a certificate for relevant services to the provider. All providers under the legislation must comply with the standards and the Ministry of Health offers what assistance it can to ensure they do. The Director-General of Health has statutory authority to close a service if there are serious concerns for patient safety. Certification usually lasts three years, although in some instances it may only run for one or two years. Safety and continuous improvement in service provision may result in a longer than three year certification period.44
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4.8.5 United States of America

This brief description of the regulatory framework for aged care homes in the United States of America (USA) has been sourced from a report by the United States Government Accountability Office: Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High Quality Care and Resident Safety.45

Oversight of aged care homes in the USA is a shared federal–state responsibility and is based on an inspection model. The Centers for Medicare and Medicaid Services (CMS) defines standards which aged care homes must meet to participate in the Medicare and Medicaid programs. CMS contracts with states, for annual surveys and complaints investigations, to assess whether services meet these standards.

Each aged care home receiving Medicare or Medicaid payment must undergo a standard survey not less than once every 15 months, and the statewide average interval for these surveys must not exceed 12 months. During a standard survey, separate teams conduct a comprehensive assessment of federal quality of care and fire safety requirements, while during a complaints investigation the focus generally is on a specific allegation regarding quality of care. The standard survey process involves review of resident assessment data documented by the home according to standard criteria, as well as interviews of staff, residents and family members and observation of the care provided. Inspection teams generally comprise health care professionals such as registered nurses, social workers and dieticians. Fire safety inspections also are conducted, reviewing compliance with federal standards.

Deficiencies identified by inspectors are classified in one of 12 categories according to their scope and severity. CMS imposes sanctions on homes with Medicare or dual Medicare/Medicaid certification on the basis of state referrals, while the states are responsible for enforcing standards in homes with Medicaid-only certification. CMS sanctions may include, for example, requiring training of staff, imposing fines, denying the home subsidy for new admissions and terminating the home from participation in the Medicare/Medicaid programs.

While data suggest that the incidence of serious quality problems in nursing homes has declined in recent years, the review by the United States Government Accountability Office, referred to above, concluded that this trend masks two important and continuing issues: inconsistency in how states conduct surveys and understatement of serious quality problems.

4.9 Regulation of quality in other sectors in Australia

As part of the analytical work undertaken for this project, a review of regulatory approaches in a number of other sectors (centre-based long-day child care, food safety, occupational health and safety, safety and quality in acute care hospitals) was undertaken. These regulatory systems have a primary focus on safety and quality with an emphasis on safe practices that will minimise risk to the community. The objective of this analysis was to compare the approach of aged care regulation and accreditation with the regulation used in other systems in Australia. In the following pages the unique aspects of accreditation as a single national system are outlined together with the similarity of issues for regulatory systems in Australia. The key findings of the analysis are summarised in Table 2 and 3.

None of the regulatory approaches in other sectors exactly mirrors the approach taken to the regulation of aged care homes. For example, many regulatory systems are based on inspection by the regulator, and in many the responsibility for oversight and monitoring rests, either wholly or in part, with state governments. Incorporation of an accreditation requirement is unusual – while regulation of centre-based long-day child care in Australia incorporates an accreditation requirement; it is complemented by a licensing/inspectorial approach at a jurisdictional level, and while it is linked to funding there is greater tolerance of non-accredited status than exists in the residential aged care system. There are national standards but their adoption is at a state/territory level into licensing systems, rather than via the accreditation system.

A summary of different approaches to regulation of safety and quality in various sectors in Australia and internationally is presented in Table 2.
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4.10 Key findings of the Regulatory Analysis

The comparative Regulatory Analysis conducted as a component of this project raised a number of issues relevant to this project. With respect to the ability of the aged care regulatory scheme to achieve its outcomes, the project team concluded that:
    • There is a clear and accessible national policy framework for quality in aged care homes, and the place of accreditation within the quality framework is clear.
    • This single national regulatory scheme is preferable to a scheme that is administered partially or fully by state and territory governments. The current national nature of the scheme lends to efficiency and consistency for clients and staff, and minimises administrative burden. During the consultation for this project, stakeholders expressed a clear preference for a national rather than a state/territory-based system.
    • The inclusion of the Accreditation Standards in the Quality of Care Principles facilitates access to the Accreditation Standards by a broad range of stakeholders. It also provides certainty about their content. On the other hand, their content is relatively inflexible and they have not been reviewed since the aged care reform package was legislated in 1997.
    • The Accreditation Standards generally reflect stakeholder views about important parameters of safety and quality in residential aged care.
    • The Accreditation Standards generally are well-structured with respect to their content, expression and outcome-focus, but contain some repetition and gaps, and there are opportunities to refine and simplify them.
    • The regulatory framework linking funding to compliance with Accreditation Standards, via the accreditation requirement, is conceptually sound, although there is some blurring of the roles of Government and the Agency.
    • The regulatory framework is structured so as to foster an appropriate balance between compliance and continuous improvement.
    • The accreditation process is fostering some innovation, encouraging the best providers to take the field up through the ceilings of high quality performance (as opposed to setting floors through standards), but this will improve further as the sector continues to adapt to a stricter regulatory environment.
    • Sanctions are structured appropriately to facilitate compliance and improvement, and to punish non-compliance.
The question of whether quantitative performance measures should be incorporated into or complement the accreditation process is addressed later in this report, in section 7.3.

Table 2: Regulatory system for safety and quality (Part A)

Regulatory Feature

Residential Aged Care


Food Safety

Residential Aged Care (England)

Acute Hospital Safety and Quality

Centre Based Long Day Child Care

Safety and quality a community priorityYes Yes Yes Yes Increasingly so, but low levels of awareness of riskYes
Identifiable national policy/strategyYes – Australian Government policy frameworkYes – 2002–2012 National OH&S Strategy endorsed by all Ministers. NOHSC has key strategic roleYes – Intergovernmental Food Regulation AgreementNot identified Increasingly so – national plan promulgated by ACSQHC, endorsed by all ministersYes – Choice and Flexibility in Child Care (Australian Government)
Comprehensive legislative framework for safety and qualityYes – Aged Care Act 1997Yes – dedicated legislation in each state/territory Yes – dedicated legislation in each state/territoryYes – Care Standards Act 2000No – variety of licensing requirements, no dedicated safety and quality legislationYes – funding requirements expressed in taxation legislation in each state/territory has explicit focus on safety and quality
Uniform national system for safety and qualityYes No (state/territory jurisdiction)No (state/territory jurisdiction)Yes No – varies by jurisdictionPartially National accreditation system, state/territory compliance/licensing system
Uniform national standards for safety and qualityYes Partially – standards developed by NOHSC, but dependent on adoption into state/territory legislationYes uniform national standards adopted into legislation by referenceYes No – varies by jurisdiction, public/private etc.Partially standards agreed by Ministers, but dependent on adoption into legislation. Quality areas and principles applied consistently through national accreditation system
Standards incorporated into regulatory instrumentYes – Quality of Care PrinciplesYes, but incorporation into state/territory legislation varies between jurisdictionsYes – adopted into state/territory legislation by referenceNo No No
Standards plainly outcome- or performance-basedYes Yes Yes No Yes Yes
Compliance with standards linked to licence to operate No Provisional Improvement Notices can require operations to cease until compliance is achieved.Yes Yes, although compliance is not mandated but must be taken into accountNo Yes, at state/territory level
Compliance with standards linked to fundingYes No No No Yes, in private sector through practical effect of HPPAsYes, although greater tolerance of non-accredited status than applies in Aged Care
Standard setter Australian GovernmentNOHSC FSANZ UK Government ACHS and other accreditation providersNCAC
Voluntary accreditationNo Yes Yes No Yes No
'Practical compulsion' accreditationYes Increasing via commercial incentivesIncreasing via commercial incentivesNo Private sector only Increasing
Mandatory accreditationNo No No No No No
Performance measurement element of accreditation/ inspectionNo Yes Yes No Yes (CEP) No
Explicit continuous improvement focusYes Yes Yes Not prominent Yes Yes
Educative focus of regulatory authoritiesYes – Aged Care Standards and Accreditation AgencyYes – NOHSC and state and territory agencyNot prominent Not prominent Yes – ACHS Yes – NCSC
Inspectors/surveyors/accreditorsAppointed trained professionals, many with experience in aged careOH&S inspectors employed by state/territory agencyEnvironmental Health Officers employed by local governmentProfessional inspectorsVoluntary trained peersValidators are trained peers who are released from their service to undertake assessments. Moderators are appointed trained professionals with experience in child care
Explicit processes when public safety at riskYes – refer to DoHA Yes – enforcement action at state/ territory levelYes – enforcement action at local government and State/Territory
LevelYes – enforcement action by regulatorNo Yes – refer to FaCS
Government sanctions if unsatisfactory accreditation/licensing performanceYes N/A N/A Yes No Yes
Criminal or civil penalties for failure to comply with standardsNo Yes Yes No No No
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