Better health and ageing for all Australians

Review of the Aged Care Complaints Investigation Scheme - October 2009

Risk assessment and escalation of complaints

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Appropriateness of risk assessment framework and escalation of complaints

The Aged Care Complaints Investigation Scheme Procedures Manual (the ‘Procedures Manual’) currently provides limited guidance for CIS officers regarding risk assessment and management of cases. The Office is currently putting in place more formalised guidance for CIS staff and their managers regarding risk assessment and management. In relation to prioritising of cases as they are received within the CIS, the Procedures Manual provides the following advice:

Once information is received, the Investigation Officer will have to determine the urgency of each issue in the case. The following three options are available:
  • Critical – the case must be referred to the Intake Manager within 2 hours, and is immediately considered. Depending on the circumstance, a site visit may be organised;
  • Major - the case must be referred to the Intake Manager within 24 hours, and is put on the high priority list for early complaints management and/or investigation; and
  • Minor - the case must be referred to the Intake Manager within 48 hours, and management of the complaint will occur as soon as possible.
Examples of critical issues are:
  • Assault;
  • Harassment;
  • An immediate threat to the security of tenure of the care recipient;
  • Immediate threat of loss of accommodation bond (these cases should be reported to the Prudential Regulation and Approved Provider Branch in Central Office immediately);
  • The care recipient is demonstrating severe distress;
  • Issues relating to a criminal investigation; and
  • Issues that could immediately threaten the health, safety or wellbeing of a care recipient.
Examples of major issues include:
  • Slow response to call bells;
  • Adequate hydration; adequate nutrition;
  • Pain management;
  • Management of constipation;
  • Behaviour management;
  • Number of care staff available; and
  • Medication management.

Examples of minor issues include:
  • Possible overcharging on pharmacy bill;
  • Limited choice of menus;
  • Wheelchairs do not have foot plates.

Information from the submissions

All submissions about the risk assessment framework came from providers. The following is a summary of the issues raised in relation to risk assessment:
  • Generally not aware of the risk assessment framework used for escalation of complaints;
  • Current risk assessment framework is onerously risk averse resulting in high volume of unannounced visits;
  • Support the use of a risk framework to escalate complaints;
  • Too many provider reports investigated after meeting mandatory reporting obligations;
  • The threshold test for matters to be investigated is a very broad test and does not operate within a risk assessment framework;
  • Very limited circumstances where the Secretary may decide not to investigate (where the information given is vexatious or frivolous or not given in good faith);
  • Currently unclear as to how the Secretary measures risk;
  • Loss of focus of the original complaint when other issues are identified during a complaint investigation that has escalated the matter. Where other issues are identified during a complaints investigation and these pose no immediate or severe risk to care recipients, further investigation should only occur once the initial complaint has been finalised; and
  • All complaints should be subjected to a filtering process whereby only complaints judged to be serious or which present a risk to residents, are assessed for immediate investigation, while the remainder are referred for mediation.
The following provider25 gave an example of inadequate complaint management with the threat of escalation.
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Because of the mandatory 24 hour reporting a service manager reported that there was a possible incident of abuse (not yet investigated). Within a minute of the service starting to outline the possible issue, a young, obviously untrained CIS person (reading from a script) asked the service manager if this assault (not alleged, not investigated) had been reported to the police and had the resident’s doctor been called. She then said that this was a terrible incident and would have to go to the Minister - keep in mind the service still didn’t even know if any incident/s had actually occurred. The service manager tried to inform this person that the possible incident/s had occurred at least 2 to 3 weeks previous, and that a resident’s daughter was not raising a complaint but letting us know in a family conference that she thought that we might have had a process problem, not an assault.

Discussion

CIS staff have adopted a very low threshold of risk in their assessment of complaints for investigation, notwithstanding the risk assessment protocols outlined above. This is no doubt related to the CIS policy that ‘in scope’ complaints require investigation. There is also the perception that if they make a mistake in the assessment, harm may befall the resident (and possibly reflect badly on the CIS). Fear of mistake becomes a significant factor in complaint management when a risk assessment framework is not used, or inconsistently applied.

A strategic approach to risk assessment includes providing a decision-making tool that permits everyone to understand the basis for a decision. Providing complainants with an opportunity to request review of a decision is an additional safeguard for complainants in relation to how their complaint has been managed.

Understanding the problem

No one would dispute that complaints need to be assessed to decide the most appropriate course of action and to ensure serious incidents receive immediate attention. This is particularly the case in aged care where the care recipients are frail and elderly and dependent on the providers for their personal health and wellbeing. The first level of assessment in the CIS is at intake where staff assess whether the complaint comes within their jurisdiction. The designated CIS complaints manager performs risk assessments at this level.

The first step is to understand the problem. Submissions from care recipients, relatives and advocates report that instructions/information from complainants may not reflect their real concerns. The CIS advises that this information is recorded in the IMS. Skill, time and patience are required to gain an understanding of complainants’ underlying issues. Research by Professor Linda Mulcahy26 in the United Kingdom found that up to 40 per cent of people who had made complaints to the National Health Service were not clear about what they wanted, or minimised the seriousness of their complaint because they did not feel confident to question the standard of clinical care. Residents and carers who are equally vulnerable may need assistance with articulating their complaint and exploration of the issues they are worried about.
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Assessing risk

All complaints should be assessed immediately after they have been received to identify the level of risk and the appropriate course of action that needs to be taken. The purpose of risk assessment at this stage is to identify high risk or ‘serious risk to the health, safety and wellbeing of a care recipient(s)’. Officers should be alert to complaints that raise significant safety, legal or regulatory issues and need to be notified to senior management immediately.

A risk assessment framework is a useful tool to assist with consistent and reliable risk assessment. A fixed rank rating can be obtained by combining the consequences (or impact) of an incident with the probability (or likelihood) of the same type of incident recurring. The rank rating correlates with actions that need to be taken, providing the complaints manager with a clear course of action that is linked to the risk assessment system. For example, the highest rank rating of ‘4’ prompts notification to senior management and detailed investigation of the causes of an incident. A rating of ‘2’ or ‘1’ is managed in the routine way, which means the complaint is still reviewed to find out what happened and possible improvement strategies.

Many health agencies27 have developed risk assessment matrixes to assist them to determine risk. One such severity assessment matrix is set out on the next page. Details of its use in the NSW Department of Health are provided at Appendix 5. The matrix template should be reviewed and developed to reflect the issues raised by aged care complainants.

Risk Matrix

Consequences

Serious

Major

Moderate

Minor

Minimum

Likelihood

Frequent

44322

Likely

44322

Possible

43322

Unlikely

43211

Rare

22211

Risk Rating

Performance of individuals

Risk assessment also requires assessment of individual workers to enable the identification of behaviour that may give rise to a breach of a standard or necessitate referral to another agency.

External referral

There needs to be a clear policy in the Procedures Manual setting out when the complaint officer is legally obliged to notify agencies such as police and coroners, and circumstances where the officer will consult with professional registration boards and health care complaints commissioners about the behaviour of an individual.

The senior manager should consult with the relevant professional registration board or health care complaints commissioner where there is a significant risk to the health and safety of care recipients, or raises a significant concern as to the appropriate care or treatment of a care recipient. All providers and staff need to have a basic awareness of this policy and the identity of the person responsible for making notifications.

Reliability of the Risk Assessment Framework

To ensure that the risk assessment framework is reliable and valid, senior managers should review how it has been used and the appropriateness of the decisions made. This should occur on a monthly basis to ensure the framework remains reliable and valid. These reports should be made available to the Minister and the Secretary (or delegate) of the Department.

25 - Submission 75 – Catholic Health Australia
26 - Turning wrongs into rights, keynote address by Professor Linda Mulcahy, Birbeck College, University of London, 2003, available at www.hccc.nsw.gov.au.
27 - Guidance Document to the Queensland Health Complaints Management Policy, Making feedback work for you!, Queensland Health, 2002; Severity Assessment Code, NSW Severity Assessment Code (SAC) November 2005 http://www.health.nsw.gov.au/pubs/2005/pdf/sac_matrix.pdf ; Department of Health Western Australia, Complaints Management Policy, 2003. Australian Standard, Risk Management AS/NZ 4360:1999;Open Disclosure Standard, Australian Council for Safety and Quality in Health Care, 2003; Open Disclosure: Health Care Professional’s Handbook and Open Disclosure: Manager’s Handbook; Australian Council for Safety and Quality in Health Care, 2004, available at www.qualityandsafety.org


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