Transition Care Program Guidelines 2011

Attachment A: Transition Care Program Quality Improvement Framework

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The Transition Care Program Quality Improvement Framework has been developed by the Transition Care Working Group (TCWG) as a strategic approach to achieving the goals of the Program and improving the quality of care and service delivery for Transition Care clients nationally.

The Quality Improvement process provides the opportunity to change for the better. The underlying ethos of any quality improvement framework is one that fosters improvement and performance. The results are improved client outcomes, as well as efficiency and ease of compliance with Commonwealth and State/Territory legislation and requirements. The Framework is applicable to Transition Care services of any size and to stakeholders at each level of the Transition Care Program, namely:

1. Governments – Australian and state/territory (Approved Providers);
2. Committees – HPPPC and TCWG;
3. Transition Care Service Providers – regional and/or local managers;
4. Hospitals; and
5. Transition Care recipients.

The roles and responsibilities of the key entities in the Transition Care Program are referred to in section 2.2 Roles and responsibilities within the Transition Care Program.

Framework Dimensions¹⁰

The Framework describes the dimensions of quality and the cross dimensional organisational elements that underpin effective safety and quality improvement.


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Essential Transition Care Quality Components

1 Organisational elements

The Framework is based on four organisational elements¹¹ critical to quality improvement:

1. Governance and leadership
2. Consumer involvement
3. Competence and education
4. Information management

In the context of Transition Care, the four organisational elements critical to quality improvement refer to:
I. Governance and leadership

• Corporate governance exercised by Australian and state/territory governments and their respective structures and processes which ensure fulfilment of strategic, statutory and financial obligations:
  • The Transition Care Program is overseen by the cross-jurisdictional Transition Care Working Group (TCWG) which is chaired by the Department of Health and Ageing and has representation from all state and territory health departments. The TCWG co-opts two clinicians to provide expert advice on Transition Care matters, as required.
  • The TCWG reports to the Australian Health Ministers’ Advisory Council (AHMAC) Health Policy Priorities Principal Committee (HPPPC). The HPPPC advises AHMAC on national issues, in need of reform or the development of new or revised health policy, for the health system generally and specifically in the core business areas of health care of older Australians, mental health, primary care and rural health.
• Clinical governance refers to the accountability of Approved Providers and authorised service providers for monitoring, supporting, evaluating and continuously improving the safety and quality of care and service delivery.

Governance Structure

II. Consumer involvement

• Consumers need to be involved at two levels, either:
  • as people who either directly or indirectly make use of Transition Care services, predominantly older people and their families and carers; or
  • as representatives of the community or population served by the particular service they are attending.

III. Competence and education

• Competence needs to be assured at all levels of the Program and requires the provision of education and training to ensure understanding of the quality framework to foster compliance. Regular review and follow-up action is also required to ensure maintenance of skills and knowledge appropriate to all levels of service provision.

IV. Information management

• There needs to be accurate, relevant and timely collection, analysis and reporting of data, supported by appropriate software and hardware and the capacity to convert the data into information which can be used to support and to enable continuous improvement in practice.

2 Dimensions of quality

Each of these organisational elements intersects with six commonly recognised dimensions¹² of quality:

1. Saftey
2. Effectiveness
3. Appropriateness
4. Stakeholder
5. Access to services
6. Efficiency

These dimensions form the basis for monitoring, managing and reporting on the quality of Transition Care services provided nationally. There is significant overlap and interdependence between them, therefore making it important for all dimensions to be included in a system designed to improve the quality of care and services being provided.

Components of the six dimensions of quality as they pertain specifically to the provision of Transition Care include, but are not limited to, the following activities:

I. Safety

• Management and reduction of risks:
  • Transition Care Service Providers must have up-to-date policies and procedures to manage and reduce risks, including falls, incidents of abuse of older people and other adverse events (see also section 5.1.2 Serious and immediate health and safety risk reporting).
• Police checks:
  • All Transition Care staff and contractors who have or are reasonably likely to have access to care recipients of a Transition Care service are required to undergo a national criminal history record check every three years.
  • This includes volunteers who have unsupervised access to care recipients (see also Accountability Principles 1998 sections 1.17-1.23 and section 63-1 of the Act).
• Building certification and compliance:
  • Transition Care services provided in residential aged care buildings must meet or have a plan in place for meeting certification standards.
  • Transition Care services provided in hospital buildings must meet or have a plan in place for meeting standards for hospital or health service buildings in their jurisdiction.
• Credentialing / professional registration / accreditation of service providers:
  • Allied health, medical and nursing staff who provide Transition Care services must have current national registration or hold or be eligible for membership of the appropriate professional association or be a DVA Approved Provider or a Registered Medicare Provider.
• Environmental safety checks:
  • Transition Care services must meet appropriate environmental standards, including food handling and hotel services in residential based Transition Care services.

II. Effectiveness

• Quality improvement reviews and studies, both quantitative and qualitative, including robust monitoring, reporting and response systems.
• Consumer satisfaction surveys and other feedback mechanisms.
• Monitoring of functional improvement using an endorsed or validated tool*.
  *Note: The use of the Modified Barthel Index for assessments by the Transition Care service at entry to and exit from the Transition Care Program is mandatory for Australian Government subsidy payments.

III. Appropriateness

• Outcome monitoring in accordance with principles of Transition Care, including returning home to live in community and admission to residential care rates, and re-admission to hospital during a Transition Care episode.
• Service settings suitable for meeting Transitional Care outcomes, including provision of a more home-like, less institutional environment in residential services and available space for therapy.

IV. Stakeholder Satisfaction

• Complaints monitoring and management – internal and external:
  • See section 6.1.5 Complaints of these Guidelines.
• Stakeholder consultation and feedback, including satisfaction surveys, focus groups and interviews with internal and external stakeholders at all levels.¹³

V. Access to services

• Review of utilisation of services encompassing target groups and special needs populations to optimise access.
• Compliance with admission / entry criteria governing access to services.

VI. Efficiency

• Systematic review and updating of policies and procedures to ensure consistency at national, state and local levels.
• Transparent data analysis and reporting on performance, including occupancy rates, lengths of stay and re-admission rates.
• Regular benchmarking and comparing of organisational performance.

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3 Operating Environment

There are a number of key external and internal safety and quality drivers impacting on the environment in which the Transition Care Program Quality Improvement Framework operates.

• Compliance with legislative and regulatory requirements – Commonwealth and state/territory
• External accreditation standards and review processes
• An internal self assessment and reporting system
• Local quality improvement plans which address operational priorities and implications for safety and quality and are reviewed and updated annually or in line with requirements of the Approved Provider and the accreditation agency

1. Compliance with legislative and regulatory requirements – Commonwealth and state/territory:

• All Approved Providers are required to ensure that Transition Care provided in their jurisdiction complies with all relevant requirements of the Aged Care Act 1997 (the Act) and the Aged Care Principles, the Transition Care Program Guidelines and the Transition Care Payment Agreements.
• All Approved Providers are required to enter into Payment Agreements with the Australian Government to receive the flexible care subsidy for their Transition Care places. This includes responsibility for providing Annual Reports to the Department to substantiate ongoing compliance under the Act.
• When states and territories enter into agreements/subcontracting arrangements with other agencies/organisations to provide Transition Care, all contracted service providers – and, in turn, any service providers sub-contracted for parts of service delivery - are accountable to the Approved Provider and must be able to demonstrate compliance with all relevant legislative and regulatory requirements and have these responsibilities articulated in all payment agreements/contractual relationships.
• All Approved Providers must comply with the Transition Care Program Quality Standards for the provision of Transition Care (see Appendix 1 of this Framework).

2. External accreditation standards and review processes that:

• provide mechanisms for assessment of and reporting on the quality and safety of the Transition Care service;
• focus on aspects of service which distinguish Transition Care and the mainstream services in which service providers may operate;
• define key requirements for the provision of Transition Care;
• identify Transition Care Program Quality Standards covering the unique aspects of a Transition Care service;
• are conducted by external quality assessment agencies;
• involve a site visit by an independent assessor contracted by the external quality assessment agency endorsed by the organisation within which the Transition Care service operates. Participants in the site visit are to be negotiated by the local service provider and the Approved Provider; and
• require a copy of the external assessment agency’s report on the Transition Care service to be provided to the Approved Provider, including level of achievement of both generic and Transition Care Program Quality Standards.

3. Transition Care Service Providers must ensure an internal reporting and self assessment system is put in place. This system should include:

• for all new Transition Care Service Providers, self assessment against the assessment tool provided in Attachment A – Appendix 2, within 6 to 9 months after commencement of service provision (to be reported through the state/territory Approved Provider if it does not occur through an external accreditation process); and
• ongoing self assessment and review reports made available to the Approved Provider and external quality assessment agencies.

4. Local quality improvement plans which address operational priorities and implications for safety and quality and are reviewed and updated annually or in line with requirements of the Approved Provider and the external quality assessment agency. The local plans must:

• reflect an organisational or service level culture which fosters safety and quality improvement;
• enable individual Transition Care services to draw on appropriate organisational structures, processes and resources (including technical support and information) to monitor, manage and improve service delivery; and
• utilise a simple quality improvement methodology, comprising:
  • a feedback loop which ensures that data and information are collected, analysed and acted on, with the results of action review for effectiveness and all parties concerned kept informed of progress;
  • improvements that could be adopted by individual organisations or services;
  • improvement tools and techniques that could be utilised and chosen locally and which are consistent with the environment in which the Transition Care service operates; and
  • the involvement of people who are directly impacted by change as a result of improvement activities. These people could be staff, consumers, the community, and other stakeholders.

4 Review of Framework

This Framework should be reviewed every three years or in line with major policy shifts in the Program to ensure it remains current and consistent with new developments in health and aged care, and to facilitate changes identified through growing experience with the Program.

The review should be undertaken by a group which includes representatives from the Department of Health and Ageing and state/territory Approved Providers to ensure the perspectives of all jurisdictions are taken into account.

Formal evaluation of the national Transition Care Program

• To be repeated following national rollout of all 4,000 Transition Care places post June 2012.
• Should build on initial national evaluation conducted prior to rollout of the first 2,000 places and reflect experience gained through maturing of the Program.
• Quantitative and qualitative data captured on quality aspects of the Transition Care Program will be made available for the National Evaluation of the Program.
• Should include a review of the Transition Care Program Quality Improvement Framework.
• Should include a review of data definitions and coding accuracy used to monitor performance.
• Should be based on research and evidence based performance indicators and benchmarks – national and international.

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10. Victorian Government Department of Human Services, 2005. A Safety and Quality Improvement Framework for Victorian Health Services, Victorian Government Department of Human Services, Melbourne.
11. Ibid.
12. Ibid.
13. NSW Health, 1999. A Framework for Managing the Quality of Health Services in New South Wales, NSW Department of Health, Sydney.

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