Quality improvement in residential aged care

[Opening visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Department of Health and Aged Care’, ‘Quality improvement in residential aged care’, ‘2 November 2023’, ‘Ingrid Leonard, ‘Assistant Secretary’, ‘Choice and Transparency Branch’, ‘Department of Health and Aged Care’, ‘Emma Jobson’, ‘Executive Director,’ ‘Aged Care Quality and Safety Commission’, ‘Victoria Angel’, ‘Director’, ‘Quality Indicators Section’, Department of Health and Aged Care’, ‘Katharine Silk’, ‘Acting Director’, ‘Star Ratings Section’, ‘Department of Health and Aged Care’, ‘agedcareengagement.health.gov.au’]

[The visuals during this webinar are of each speaker presenting in turn via video, with reference to the content of a PowerPoint presentation being played on screen]

Ingrid Leonard:

Good afternoon and welcome. Thank you all for attending today’s webinar on Quality Improvement in Residential Aged Care. My name is Ingrid Leonard. I’m the Assistant Secretary of the Choice and Transparency Branch at the Department of Health and Aged Care and I’m hosting this event today with my Departmental colleagues Katharine Silk who is the Acting Director of the Star Ratings Section and Victoria Angel, the Director of Quality Indicators. I’m also pleased to be joined today by Emma Jobson who’s the Executive Director of Regulatory Policy and Intelligence who joins us from the Aged Care Quality and Safety Commission. And also presenting today we have Nikita Divekar and Jessica Patil from Residency by Dillons in Fremantle and Naomi Taylor from Cooinda in Coonabarabran.

I would like to begin by acknowledging the traditional owners of the lands on which we’re virtually meeting today. Kate, Victoria and I are based in Canberra on the lands of the Ngunnawal people and Jessica also joins us from these lands today. Emma joins us from Sydney on the lands of the Gadigal people and Naomi joins us from Coonabarabran on the lands of the Kamilaroi people. Nikita joins us from Perth on the lands of the Whadjuk Noongar people. And I would like to recognise any other people or families with connection to the lands of these regions. I wish to acknowledge and respect their continuing culture and the contribution they make to these lands and the lands of all regions. I would also like to extend my acknowledgment and respect to any Aboriginal and Torres Strait Islander peoples who may be joining us in this event today.

So just a little bit of housekeeping before we kick off. There will be a Q&A session at the end of the webinar. We welcome you to lodge questions through the Slido box on the right hand side of your screen. We’ll certainly try to respond to as many questions as possible during the Q&A session. And your quality improvement questions and answers from today including ones which we may not get to will be available on our website shortly after the webinar. Questions submitted during the registration process have also been considered for the live Q&A session. And just to let attendees know there’s no option to turn on your video or microphone however this session will be recorded and uploaded onto our website along with the slides.

So it is really wonderful to be with you all today to talk about quality improvement and to share valuable information and resources to support your work in this space. Today we’ll hear from Emma Jobson about the Commission’s role in monitoring quality of care including areas for consideration and what good continuous improvement looks like. Katharine will talk about improvement science methods and enablers of success and Victoria will talk about using data to identify areas for improvement. We will also hear from representatives from two providers who will share some examples of quality improvement in practice. We hope by hearing their stories you’ll be inspired to examine what changes you can make to your service’s quality improvement practices.

So firstly what are the benefits of quality improvement for residents? So certainly it supports delivery of safe and effective care and it ensures residents receive care that is compassionate, dignified and respectful and it’s person-centred allowing care to be delivered in a manner that is responsive to residents’ needs and choices. Quality improvement also delivers benefits for providers and staff. For example it ensures that services are well led, collaborative and that they’re open and committed to feedback, learning and improvement. It assists providers to use their resources responsibly and efficiently. It supports the provision of care that’s equitable and does not vary in terms of its quality, and importantly provides benefits to staff so that staff value and enjoy where and how they work.

I’ll now hand over to Emma Jobson from the Aged Care Quality and Safety Commission. Thanks Emma.

Emma Jobson:

[Visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Aged Care Quality and Safety Commission’, ‘How the Commission supports quality improvement’, ‘1800 951 822’, ‘agedcarequality.gov.au’]

Thanks Ingrid.

So on the screen is what we call the regulatory diamond and it recognises how we regulate is aimed at influencing provider behaviour to improve care and services for older people. So this regulatory diamond appears in our recently published corporate plan and previously you might have seen this as the regulatory pyramid which emphasises a more deficit regulation or focus on the problems. And as identified by the Royal Commission aged care like other social care also strives for improvement, quality and the pursuit of excellence and our regulatory diamond now better reflects this.

So down to the left you can also see the compliance stars alongside the diamond. Our compliance rating is geared toward holding providers accountable when consumers are at a higher risk of harm or actual harm and the risk is not being managed well. Where we have a need to take enforceable compliance action the service gets a compliance reading of one or two stars. So when this happens the overall rating is capped at one or two stars drawing the consumer’s attention to the significant issues that need to be resolved. So when providers resolve compliance issues promptly and sustainably this is then recognised by returning compliance star ratings to three initially.

So our non-compliance decisions are also published on My Aged Care as a compliance issue. They include sanctions, notices to agree and notices to remedy resulting in one or two compliance stars. They can also include a direction to revise a plan for continuous improvement which results in three stars. So when a direction is issued any existing four or five star compliance ratings drop to three stars. In some circumstances where we consider the risk to be low to medium we will engage and work with providers to develop improvement plans that offer timely and sustainable solutions. So this gives the Commission increased assurance that the provider has addressed the non-compliance and is managing the risk to the older people in their service appropriately. In these circumstances we are unlikely to need to issue a direction. As such higher compliance stars can be retained by providers as a result of their responsiveness when things do go wrong and they demonstrate that the risks are well managed and investments are made in preventing them from reoccurring.

So of course we would also expect where providers make quality improvements to result in better outcomes for older people in their care which may also be reflected in improved resident experience survey results or quality indicators which impact providers’ other sub-categories in the overall star rating.

So this slide also shows the fifth compliance star near the middle of the diamond. This recognises that there is more providers can do to improve and strive for better practice beyond compliance. Besides driving quality measures and resident experience sub-category star ratings the Commission also uses quality indicator data and resident experience survey data for our risk profiling which informs risk assessment and our targeted monitoring activities.

So whilst we continue to hold providers accountable for their performance tradition has shown at the bottom of the regulatory diamond we also want to drive performance beyond minimum standards and to achieve best practice and this is highlighted at the top of the diamond. We support providers to do this with our education and outreach activities. And some examples include To Dip or Not To Dip, antimicrobial stewardship initiative, our pharmacy outreach program, our food, nutrition and dining experience campaign, infection prevention and control campaign, the appointment of our senior practitioner in restrictive practices and restrictive practices unit, publication of our Serious Incident Response Scheme insight reports and our ALIS, our Aged Care Learning Information System modules which are regularly created and updated. We also run webinar series to translate some of these learnings which most recently included a webinar on continuous improvement through complaints handling.

So in response to the Royal Commission recommendation consultation on the new regulatory framework considers further investments to incentivise and recognise where providers achieve excellence or exceed requirements.

So on our left here is our sector performance report. We’re exploring how we can better use data to present trends and benchmarks to show sector performance. This is to help providers better understand their performance in relation to their sector and their peers. We will seek feedback from the sector to improve the quality and usefulness of these reports and in the meantime we’re encouraging providers to compare your performance to your past performance and to continue to strive for improvement. On the right is one of our Serious Incident Response Scheme insight reports, this one being on resident to resident unreasonable use of force notifications. A report on unexplained absence notifications will be out shortly as well. So these insight reports aim to help providers in two key ways. They aim to improve how providers respond to serious incidents with a focus on the older person’s experience. They also aim to identify and apply learnings to put in place preventative measures at operational and governance level.

So in the same way we expect providers to examine their own practices and make improvements the Commission also invests in getting feedback on our activities and evaluating the impact of our regulatory campaigns. We are currently evaluating the impact of our infection prevention and control campaign to determine what worked well and areas for improvement.

Shown here is also the evaluation of our pilot program to reduce the inappropriate use and prescribing of antibiotics for urinary tract infections called To Dip or Not To Dip which aimed to reduce the use the unnecessary urinary dipstick testing. Our evaluation showed a marked improvement in the appropriate antibiotic use across the residential service pilot sites. We also seek feedback from providers on our site visits as well as feedback from complainants and providers about our complaint resolution processes. We use this feedback to assist our workforce training and development, improve our processes as well as communication and education content. So in the same way we expect providers to have a positive complaints culture we welcome complaints and feedback about us. You can access information on providing feedback or making a complaint about us through our website.

So more information on our quality improvement initiatives and resource materials for providers are available on our website which is on the slide here. But for now thank you everyone for being with us today and I’ll now pass over to Kate.

[Visual of slide with text saying ‘Australian Government with Crest (logo)’, ‘Aged Care Quality and Safety Commission’, ‘Contact us’, ‘info@agedcarequality.gov.au’, ‘www.agedcarequality.gov.au’, ‘1800 951 822’, ‘Food, nutrition and dining hotline’, ‘1800 844 044’]

Katharine Silk:

[Visual of slide with text saying ‘Improvement science: Plan, Do, Check, Act approach’, ‘Presented by: Katharine Silk’]

Good afternoon and thank you Emma. Yes. My name’s Katharine Silk and I’ll be taking you through the Plan, Do, Study, Act approach. So quality improvement is a system of regularly reviewing and refining processes to improve them with the aim to enhance the quality of care your residents receive and their care outcomes and experience along with the experience of your staff. For this process and change to occur there are some enablers that will set you up for success. Support from senior organisational leaders is often vital to this success as well as ensuring governance arrangements and processes are able to identify issues requiring investigation and improvement, that can enable your improvement teams through endorsement and resourcing.

Where improvement is central to an organisation’s strategy staff will be empowered to question current practice, report issues and test change. To keep momentum and enthusiasm we know that culture is critical. This can include things like embedding champions for change where staff members across your organisation share ownership and create the right conditions for staff and resident engagement and support, and building capability and skills through training, practice and exposure to create an environment and people ready to drive change.

Plan, Do, Check, Act is an approach to continuous improvement where changes are tested in small cycles that involve planning, doing, checking and acting before returning to planning and so on. Before you get started on your quality improvement cycle you’ll want to ask a few questions. Firstly what are you trying to achieve? This is where you can set your goal. You want it to be timed and measurable. A SMART goal would be good here. How will you know that a change has resulted in an improvement? What does success look like? Identify what measures you’ll use to determine a change that leads to improvement. And finally what changes can you make that will result in improvement? This will come from having a good understanding of your issue or problem and working with staff and residents to understand the potential solutions to test.

We’ll now run through the PDCA cycle and steps. So plan. You’ll first need to identify the issue. Identify areas for improvement that matter most to your residents, their families and your staff. Steve Jobs has said if you define the problem correctly you almost have the solution. There are lots of techniques to better understand the problem, for example the fishbone diagram where you unpick all the potential reasons, the five whys where you ask a series of why questions consecutively to better understand the issue, a SWOT, so understanding the strengths, weaknesses, opportunities and threats, journey mapping of the process, service or a particular resident’s experience, or investigations following an incident. All of these techniques can provide critical information to better understand the issue and potential changes to test. I encourage you to investigate some of these further to see what might work best for your issue. For complex issues you may actually involve a few of them.

Each quality improvement cycle starts with thoughts, ideas and theories and helps them to evolve into knowledge that can inform change ultimately resulting in improvement. Once you understand your problem it’s time to plan potential changes.

Do. Quality improvement activities can take many forms including interventions, changes to the physical environment, changes in practices, processes or policies, clinical audits, practice reviews or satisfaction surveys. It will really depend on the issue at hand.

Check. Once you’ve tested your change you’ll need to measure to understand if it’s been effective. You’ll also need to look for any unintended consequences.

Act. If the outcomes have been successful it’s important to consider why. Each improvement cycle will help you identify more potential solutions to test and will eventually help you refine your solution. It’s at this point you can look to implement the solutions and ensure that they are sustained.

To provide a really brief example let’s say you notice there’s been an increase in the number of residents that have fallen in your home. This would be your issue. To understand the problem you might look at the incident reports for all ten people who’ve fallen in the past month. This will help you understand if there are any similarities or common factors. Falls are often multifactorial but you might identify that the residents that have fallen have also had some unplanned weight loss resulting in frailty. This incident audit might be your first quality improvement cycle.

To plan some potential solutions you might consider undertaking some short interviews with the ten residents who’ve fallen in the past month or the staff who were present at the time of their fall to ask specifically what they think the reasons were for their fall, is there anything that they can suggest that may have helped prevent the fall and any suggestions they might have to improve their dietary intake and nutrition. This might form your second quality improvement cycle.

You understand some of these residents have seen the dietician due to their recent unplanned weight loss so your next quality improvement cycle might be a notes audit or a discussion with the clinician. It might identify some targeted interventions for testing in this cohort of residents. Your next cycle might be testing potential strategies for enhancing food and mealtime practices or for ensuring residents with unplanned weight loss are assessed for falls risk or have additional falls prevention strategies implemented. And you would choose measures that were relevant and sensitive to the expected change. For all of these cycles you will plan, do, check and act and then start again. It’s also important to document your steps. The Commission provides a template for planning your continuous improvement to help keep track of your tested changes and improvements.

Now you have a good understanding of applying the PDCA approach and how you might plan, test, observe the results and act on what has been learned I have some practical tips that can help you achieve your goals. The most important is keep it small and expect to do a number of cycles before you’ve identified, refined and scaled your solution. Make sure you choose measures that will identify the change you’re testing. Choose an issue that is meaningful. Codesign with residents, families and staff. Engage and involve your staff, colleagues, executive and board along the way and keep them informed of progress even if it is slow. They will be your biggest advocates. Thank you. I’ll now hand over to Victoria to discuss Departmental resources and data.

Victoria Angel:

[Visual of slide with text saying ‘Using data for improvement’, ‘Presented by:’, ‘Victoria Angel’]

Thank you Katharine. Hi everyone. So the Department has developed resources to support quality improvement in aged care which are available on our website. The Star Ratings Improvement Manual available in the star ratings section of our website uses the Plan, Do, Check, Act approach that Katharine has just run you through with specific guidance across each of the sub-categories. The QI Program Manual Part B available in the quality indicators section of our website contains a range of tools and resources to support continuous quality improvement for each quality indicator. The QI Manual Part B also includes the Plan, Do, Check, Act improvement tool targeted specifically to each quality indicator.

You can compare your service’s performance against past results and against national figures. This might also include looking at the results of services with similar characteristics for example not for profit, rural and remote or dementia specific services which may present unique challenges. The QI Program includes the reporting of both quantitative and some qualitative data. Quantitative data being the numerical inputs and qualitative data in the form of comments. Services should be capturing, analysing and learning from all QI data throughout your improvement work. For example qualitative data from the QI reporting as well as additional data that may not be collated or formally reported under the QI Program may provide valuable insights to your service. This data could be clinical or administrative in nature and may be resident level, service level or circumstantial. It may be noting down the number and type of staff you had working on the day a fall occurred or whether there were specific factors relevant to the resident on the day of an incident. Was the resident’s care plan reviewed carefully before an intervention or device was put in place? These details if documented can give additional meaning to the quantitative data you are collecting and reporting.

One key point in your improvement cycle when data is critical is at the planning stage when you are trying to identify what matters most and what your service’s biggest opportunity for improvement is. A baseline is the value of an indicator before implementing change actions. This could be looking at the number of pressure injuries sustained at your service last quarter and deciding you would like to reduce this number. You could look at all the various data you hold on your residents such as their risk of pressure injuries, any previous pressure injuries they have had and the unique factors around how these were previously acquired and managed as well as any current prevention practices in place at your service. This process will assist you to identify what might need to change and what you might be able to implement or change when reviewing your approach in the check and act stages.

Using both quantitative and qualitative data throughout your Plan, Do, Check, Act cycles will help you to understand, test and evaluate whether changes implemented are resulting in improvements over time and how changes implemented fare compared with your original or previous approach. Your service can also use the Government Provider Management System or GPMS to not only self-manage, view and maintain your records but also to set up QI targets to monitor your performance against your own quality improvement targets for each indicator, display data trends and patterns over time to provide high level insights, display an in-depth view of data from a service focusing on individual outcomes rather than progress over time, display data for a service in a line and bar chart format, tabular and targets. The graphs provide a visual representation of data to support easier analysis and interpretation enabling you to identify patterns, SWOT anomalies and understand the overall trajectory of your data.

You can also use other tools not in GPMS to track improvements. Evidence shows that time series analysis using small amounts of data collected and displayed frequently for example in the form of a graph is the gold standard for using data for improvement. There is no right or wrong way as long as evaluation and re-evaluation is occurring. I will now hand back to Ingrid.

Ingrid Leonard:

[Visual of slide with text saying ‘Case Study: Residency by Dillons Fremantle’, ‘Presented by:’, ‘Nikita Divekar, Quality & Lifestyle Manager & Jessica Patil, Executive Director of Quality, Innovation and Marketing’]

Thanks very much Victoria. I’d now like to introduce Nikita Divekar and Jessica Patil from Residency by Dillons in Fremantle who will talk about how they use the Plan, Do, Check, Act approach to improve their quality of care for residents.

Jessica Patil:

Thank you Ingrid. In 2019 changes were made to the aged care standards placing increased emphasis on person-centred services. From a lifestyle perspective our goal was to assist individuals in identifying and cultivating their own strengths and abilities enabling them to lead independent and fulfilling lives. A resident might have some challenges in their health and abilities but they still have goals they want to achieve. And despite coming into aged care there is a desire to continue being part of a community.

The questions we had were could a resident carry out an activity for their peers? Would there be more engagement from peer to peer in an activity? Would this create a sense of purpose and community connection?

One of our organisation’s philosophies is what am I waking up for today? It’s not solely about waking up, getting dressed and having a meal. We wanted to support our residents to be excited about each day. Who are they going to meet? Are they going out or having family and friends visit? What activity are they going to participate in or what activity are they going to take the lead in?

We approached the task by identifying an individual’s skills or past interests and encouraging them to pursue or maintain these talents in a leadership role through peer to peer activity. During this stage we used observation, resident engagement and feedback to assist us with planning.

Nikita Divekar:

I would like to share how we brought this into effect. Our initial step involved transforming our monthly calendar to incorporate more personalised activities tailored to individual preferences generating anticipation amongst residents. Our objective was to meet each person’s unique care needs and preferences rather than focusing solely on their cognitive abilities or medical conditions. We found that activities connected to individual values, life experiences, roles, routines and personal hobbies were more meaningful and enjoyable for our consumers. This approach facilitated the customisation of our monthly lifestyle calendar.

The personalised activities were prominently featured on a calendar and consumers received weekly reminders and support for planning and execution. We emphasised that they shouldn’t feel pressured and had alternative options available if they chose not to participate on the day of the activity. Our primary concern was to ensure they enjoyed the process, looking forward to it without feeling burdened or anxious.

I would like to share a few examples. We had a resident who had a strong passion for arts and crafts before transitioning into our aged care facility. However over the years she experienced a gradual loss of eyesight, eventually reaching a point where she was legally blind upon her admission to our facility. During our activities we recognised that despite this visual impairment her artistic and crafting talents remained intact and very impressive. So we proposed the idea of her leading classes for our fellow residents. Every month she introduced new creative concepts to engage all the residents which soon became one of our most anticipated events. She said ‘I’m pleased that the residents find my classes enjoyable. This keeps me engaged in the planning process and I’m excited about organising next month’s event’.

Another example. We had a resident who had a remarkable background as an opera singer having achieved notable recognition in the entertainment industry including a nomination for the Australian Arts Award for entertainment and being acknowledged as the Queen of Entertainment at the Casino. Singing professionally and teaching brought her a profound sense of fulfilment. An especially noteworthy chapter of her life was when she performed for the Commonwealth Games officials in Perth. Recognising her rich history it was evident that singing was not only her passion but also an integral part of her identity. Our team then collaborated with her to plan all the necessary logistics for hosting a concert within our facility. We successfully organised her inaugural concert at the nursing home and it was an event thoroughly enjoyed by everyone. This event swiftly became a regular feature on our monthly lifestyle calendar offering joy and entertainment to all residents. She said ‘It gives me a great deal of satisfaction organising these concerts for the residents. It’s a wonderful feeling when residents approach me personally to express their gratitude for my efforts. It fills me with a sense of pride’.

We tested the initiative by reviewing staff and resource feasibility and resident engagement particularly looking at the quality of life measures. The success or failure of each activity was determined by daily activity charts, feedback from consumers both immediately after the activity and on an ongoing basis. Emotional support was provided to residents when an activity was no longer available and alternate activities were coordinated where possible. This program has now been successfully established at our other Residency by Dillons locations with recognition given to residents who coordinated activities.

So My Engaging Talent was a positive success not only for the residents who led the activity but also for the residents who participated. We saw an overall emotional improvement in wellbeing and social interaction. A stronger community was formed, one that cared about each other. Friendships were made with a deeper connection. Residents felt proud of their contribution, making a difference for their peers. My Engaging Talent is a program that supports residents to recognise the importance of self-worth and to continue being a part of the community by fostering social inclusion, health and wellbeing. Consumer satisfaction around the activities and lifestyle program increased through this peer to peer activity model. Thank you.

Ingrid Leonard:

Thank you Nikita. Thank you Jessica. They were excellent examples of quality improvement in practice. So a question for you both. In your planning stage who did you enlist, the people, the teams, health professionals, to support the project?

Nikita Divekar:

For person-centred care to thrive it was vital to maintain ongoing communication amongst families, caregivers, staff and other professionals like the GP, physio and other allied health. This project necessitated not only the involvement of the lifestyle team but also our personal care assistants, nurses, hospitality team and all of the departments to oversee its implementation and also assess its effectiveness.

Ingrid Leonard:

Thank you. Thank you. That’s really helpful.

I’d now like to introduce Naomi Taylor from Cooinda in Coonabarabran who will talk about how they applied the Plan, Do, Check, Act approach to improve their quality of care for residents.

Naomi Taylor:

[Visual of slide with text saying ‘Case Study: Cooinda Coonabarabran’, ‘Presented by:’, ‘Naomi Taylor, Operations Manager’]

Great. Thank you so much Ingrid. So my name’s Naomi Taylor and I’m the Operations Manager here at Cooinda Coonabarabran in rural New South Wales. So we’re a not for profit 78 bed residential facility with a memory support unit, retirement living options as well as home care and CHSP. So we’ve been in operation for over 40 years and over that time some of our buildings have naturally aged prompting us to look at opportunities to renew and refresh our facility. So in particular our kitchen space was becoming quite small for our increasing occupancy rates and the growing food, nutrition and dining requirements as well.

So today I’d like to talk about our quality improvements in our food services here at Cooinda over the recent months. So taking a step back we identified that our food and dining experience needed improvements to increase our resident and staff satisfaction. So this was done through observations from the management team, CEO morning tea meetings with consumers where we’d gain specific feedback and staff meetings as well.

So we came to the decision that the quality outcome that we wanted to achieve was to design, build and operate a new kitchen for our facility that allows for a high quality and safe food and dining experience for our consumers. So we knew in turn that this would also enhance the morale but also proof the operations for future growth as well. So our initial barrier was financial, so where we needed to seek financial assistance to be able to commence our project. So we were lucky enough and successful in securing a grant through the Building Better Regions Fund, the projects stream, which allowed us to commence works and support this project.

So part of the post-build improvement plan was to ensure that we now leveraged our beautiful new kitchen now to deliver on our strategy of a high quality and safe food dining experience for our consumers which I’d like to share a little bit more about.

So after the build we implemented many improvements, some smaller, some larger improvements. So I’ve listed nine to share with you today. So the first one. We opened our brand new kitchen with state of the art equipment which improved the efficiency of the meal preparation. Secondly we had our menu reviewed by an approved dietician and input from our consumers. So even though this is a very standard practice this demonstrates our commitment to providing meals that cater to consumers’ dietary needs and preferences in alignment with the standards. We have a dedicated support services supervisor who’s also a qualified chef. She assists in the training and management of our onsite cooks and kitchen team. So this ensures that our staff are adequately skilled and trained to handle food safely and effectively, reducing the risk of complaints, promoting resident choice, dignity and safety.

So another small improvement. Our cooks now present in chef whites, so a chef uniform. So this is not only one to ensure a safe food barrier when preparing food but it also promotes professionalism and enhances the dining experience for our residents. We also introduced a monthly dining experience called Foodie Friday. So this is where it’s a bistro style service at the evening meal where residents are invited to attend and order off the menu including drinks as if they were dining out. We provide live music and a waitress comes to their table and takes their order or requests. And our residents have really enjoyed this new experience with one of our residents letting our chef know that this was the best night of his life and it was something that he’d remember forever. He also got to have a beer on the night so I think that might have contributed to that.

Number six. So we had previously been receiving some complaints about our food which now this has dramatically decreased and the only feedback now that we receive on the whole is really just based on preferences. So our compliments have increased not only from our residents but also from our staff which is really great to see. Second last. We were lucky enough to receive a scholarship to attend the Institute of Hospitality in Healthcare national conference just recently held a couple of weeks ago in Adelaide which again has now opened up another world of opportunities and ideas leading through transformation.

Lastly a positive improvement has been an increased job application rate for kitchen staff increasing by 35%. So we all know in the challenging time of resourcing this is a really great thing to see as well.

So through our improvements we were able to collect and document information and evidence to check how improvements were being made. So we did this through resident feedback via our CEO morning teas where residents would come along, give us feedback. We have QR codes, feedback QR codes where family members are able to scan and give specific feedback, and we also have scheduled staff pulse surveys to be able to collect data and specific questions about our newly implemented food service operations and how that’s impacting our residents, family and staff.

So through analysis of this data we discovered three unintended consequences. So one we saw increased levels of communication and encouragement between care and kitchen staff. So that workplace culture which we all like to see, increased workplace culture. Secondly we saw an increased community engagement on our social media platforms which was really encouraging to the staff as well. The third one and as I mentioned before we saw an increase in job applications for kitchen roles and this was mainly done through the visual imagery of our beautiful new kitchen, state of the art equipment. It’s the best kitchen in the town now which we’re really proud of.

So this planned project and subsequent activities have resulted in overall large improvement to our facility, for our staff, but more importantly for our residents and their family. It’s really changed our identity which is really cool.

Now projects or improvements as we know don’t just happen on their own. So some of the contributing factors for our improvement came down to five things. So number one. It was really the passion and buy in from key staff and management to really drive the project and improvements. And as previously mentioned breaking down each project into a documented quality improvement process and action points numbered and allocated to those that are responsible to really track the quality improvement is really important. The third one is celebrating the wins together as a team. I know we always looked at what’s the next thing to do but it’s really great to do that.

The fourth one is gathering and encouraging feedback directly from consumers, residents, family members and staff wherever possible and being objective and open to that feedback and using it. The fifth one was conducting quality checks and action any speech pathology, dietetic recommendations or requirements quickly and making sure that everybody’s communicated.

So one of the questions through the case study was did we have any improvements that didn’t work. So we didn’t but we did have some challenges along the way. And the main challenge was the skill shortage in chefs and cooks which is a national thing. But the way that we combatted that was to lean on the equipment technology including our food safety program which is an application that helps guide, direct kitchen staff on workflow, cooking times, temp checks, cleaning duties and any other safety checks required of them. The IHHC conference was a really great way to learn more about how to leverage the technology abilities and features on the cooking equipment that we have as well so that was a really great thing.

So I guess overall our project improvements were really successful but without that challenge that I just spoke about. So there were some key learnings that I’d like to share with you. So it’s already been mentioned but at the beginning just be clear with what you’re wanting to achieve and why. Number two, make sure that you bring your team along with the journey and they understand why they’re doing it. Number three, keep consumers and families informed. Number four, be realistic about your resourcing capacity. We tend to try to do it all so just be realistic about what you can and can’t do. Five, design and over manage food and dining processes, so the really sweet spot between under managing and micromanaging. So it’s in between making sure that things are spot on. And as I mentioned in the dynamic industry make sure that you pull the handbrake on and celebrate the wins within the team.

Seven. This is the second last one. Maintain good associations with consultants and industry bodies. So really listen and learn from their expertise and advice. And the last one, and we all know this, however you must maintain accurate financial oversight particularly with large expensive projects like this one.

So I do appreciate you all listening to me today in my brief presentation. I hope it’s been insightful and helpful in some sort of way. So we celebrated our project and improvements along the way with staff and we’ll be celebrating again with our residents and community members at our grand opening later this month. And thank you all again for listening.

Ingrid Leonard:

Thanks so much Naomi. That was a really excellent example of quality improvement in practice. I particularly really liked how you summarised your key learnings and absolutely particularly loved celebrating with your team. Thank you for sharing that. I guess one question from me. Can you tell us what your next steps look like to really sustain and build on I guess these really great outcomes that you’ve shared with us this afternoon?

Naomi Taylor:

There’s lots of opportunities but I think I previously mentioned that we attended the IHHC national conference in Adelaide which focused on embracing transformation in the aged care food and dining space. So we’ll be now focusing on the new proposed food standards which will help us guide further improvements and quality outcomes. The other thing that we’d like to see is expanding our food services further into HCP or CHSP and retirement living. So there’s lots of things that we can do but thinking about those key takeaways, key learnings as well.

Ingrid Leonard:

Thank you. Thanks Naomi.

So we will now move to the Q&A session. We’ll be posting further information about quality improvement including a written version of the case studies that you’ve heard about today. Thank you very much to those who have submitted pre-session questions and for those coming in live during today’s webinar. So I might just I guess kind of move to one of the first questions and this is for Jessica and Nikita just really reflecting on the story that you shared. And one of our participants has asked:

Q:        How do you engage residents with moderate dementia?

Nikita Divekar:

Obviously residents in aged care would have not the same level of dementia. Not all residents would have the same level of dementia so it’s important for us to look into aspects like their behaviours or any other challenges that they would have while participating in the activity. It was important for us – to give you an example, the example that I shared about the resident who takes concerts at our nursing home, it’s really important for us to also maintain the ambience for the resident who is singing for the other residents. It is important for us to understand that the ambience is maintained with residents who are having challenging behaviours, having that one on one support during that concert, but also ensuring that our other alternative options are available for them if they would not like to participate in the activity.

So like I mentioned we don’t want to focus on residents’ medical conditions when we are planning these activities. It is more about what the residents’ hobbies are, what the residents like to do in their past and just supporting them and ensuring their independence is still maintained.

Ingrid Leonard:

Thank you Nikita. Thank you. That’s really helpful.

A question for the Department and I’ll ask Victoria Angel to respond to this one. We’ve been asked:

Q:        Where can we find national benchmark data to compare my organisation’s data to improve our quality of care? A few of our clinical indicator data is below national average meanwhile some is up. Where can I find some national average data?

Victoria Angel:

Thanks Ingrid and thank you for the question. So the AIHW undertakes quarterly reporting on the quality indicator data and those reports are published on the Gen aged care website. So I might get one of the Q&A moderators to actually answer on the screen with the link to where those reports can be found.

Ingrid Leonard:

Thanks Victoria. That’s really helpful.

Katharine Silk:

I’d also probably just add Ingrid that for quality measures data, so as part of the star ratings, you’ll be able to see how your service performs compared to the national average both on the My Aged Care website and also available in the provider portal. So you can have a look at how you’re performing compared each quarter to those national averages.

And that’s a risk adjusted value as well.

Ingrid Leonard:

Thanks Kate. A question to our providers this afternoon.

Q:        How do you engage your residents or families in quality improvement?

Nikita Divekar:

I would like to answer this. So we’ve recently started this year with our consumer advisory committee meetings where we encourage families to be a part of our committee. And that’s our platform wherein we discuss improvements for quality, we encourage them to put in their suggestions, bring in ideas or if there are any concerns. We have our – obviously we discuss this at our resident meetings as well but we are focusing now on our consumer advisory committee wherein it would be a platform not only for the residents or staff but also family members to bring in their ideas and suggestions to the board.

Ingrid Leonard:

Thanks Nikita. Naomi is there anything you’d like to add to that response?

Naomi Taylor:

No. I think Nikita hit the nail on the head there. No. I think that was a perfect response.

Ingrid Leonard:

Thanks so much. Thank you. I might pose this question to Emma Jobson from the Commission. One of our attendees have asked:

Q:        If the Commission has found a problem but hasn’t issued a direction or decision will people know?

Emma Jobson:

Yeah. Thanks Ingrid. There’s a few different ways information is shared about provider performance. So the Commission undertakes performance assessments of services against the quality standards both as audits and as part of less routine monitoring. The performance report that’s published on our website, they detail all the findings against the requirements under the standards, compliant and non-compliant. Those same findings are represented on the Department’s My Aged Care website on the service pages. So quite specific information is available there. And where we take compliance actions they’re also listed under compliance issue on the service pages on My Aged Care.

Ingrid Leonard:

Thanks Emma. Thank you. Another one for the Commission. The question is:

Q:        What clinical education topics does the Commission recommend as mandatory training?

Emma Jobson:

I don’t think the Commission has a role in determining mandatory training but we certainly produce training material to support providers to understand and apply the quality standards and other areas of their obligations and regulatory arrangements. And we have an ever growing and comprehensive set of training material on our ALIS learning platform that we encourage providers to visit and have a look at the material.

Ingrid Leonard:

Thanks Emma. Thanks. There’s some really valuable information for providers to find there. Naomi a question for you. One of the attendees have asked whether you’d provide more information regarding funding just kind of coming from what you described earlier?

Naomi Taylor:

Yeah. Sure. So I guess really in the initial stages of any type of project you really need to understand what your strategy is, so the overarching project that you’re wanting to achieve and if it meets strategic goals rather than looking for a grant then seeing what you can do with it. I know that sometimes we do do that to try to look at ways to improve. But really there’s two websites that I referred to. So the first one is the Department of Health and Aged Care. So it’s under funding. So you’ll be able to have a look at some of the grants that are available on there. So it’s places, capital grants for residential aged care and some other things on there. The second website is the GrantConnect and just typing in a keyword ‘aged care’ or anything in particular that you’re looking for and it will detail the grants that are available and when the application close dates are due as well.

Ingrid Leonard:

Thanks Naomi.

Got a question here that I’ll pose to the providers first but then probably give both Katharine and Victoria an opportunity to also contribute.

Q:        What if we make changes that seem like they would be effective but we don’t actually see any improvement?

I guess I’d welcome the views of our providers here where you may have in fact had that experience in identifying I guess a change that you expected to see – the outcome of course would be quality improvement but it hasn’t necessarily translated.

Naomi Taylor:

Yeah. I can just answer this briefly. I think really the key is the documentation of the quality improvement. So you’re identifying that there is something to improve. And maybe all the action steps, maybe it wasn’t the best way to approach it or the outcome didn’t turn out but the documentation is really important because you learn through the process. So it could be something really small but it really could affect resident care, safety and other bits and pieces or how all of your quality improvements that you’ve identified really stack up and tick off some of those requirements as well. So I think the documentation but learning through the continuous improvement process I think is also the key. None of us are experts but we make sure that we really try to work through the process and to make the improvement at the end.

Ingrid Leonard:

Thanks Naomi. Nikita anything you’d like to add to that?

Nikita Divekar:

Not really. Like Naomi said it’s a learning process so we would have our successes, we would have our failures. I’m not able to – I do have a lot of success stories but cannot give you an example right now for something that we’ve planned and that has not gone through. But in saying that that could happen. So it’s about trialling that process and looking at the risks involved as well and discussing that with the consumers, families, to ensure that we are right in the implementation but the results can be a learning process for us.

Ingrid Leonard:

Thank you Nikita. I’ll just hand to Katharine or Victoria. Anything else that you’d like to add there?

Katharine Silk:

Yeah. Thanks Ingrid. I’d probably add to this it’s really important to consider what you’re using to measure. So you might find that you’re looking at an outcome measurement, something that’s a lot further down the track, a long term thing, and you’ve applied whatever improvement it is to that problem. And you might find that approaching it through a process measure or some marker that’s kind of going to look at something in the interim step, might give you an idea. You might also look to find feedback in different ways. So you might have been trying to for example improve your quality improvement or your res scores. However you might want to then look at other ways of finding out if that seems to have been an improvement to the people that you’re working with. So it might be checking with your staff, seeing how they think the improvement’s gone, seeing if their experience is better. Similarly you could go to your residents and do a similar thing.

I think it’s also really important to then be looking at the issue that you’re trying to – the problem or the issue you’re trying to work on and really drill down into that about what the other markers might be for success or for seeing a measurable change. So I really think that’s a good place to start is it might actually take a bit longer time so you might want to just implement for a bit further and see if another cycle, another practice run, another trial of another three weeks might be something that then allows you to see that measurable change.

Ingrid Leonard:

Thanks very much.

Naomi Taylor:

Sorry Ingrid. If I could just add I think just in the comments it was about any tips or tricks to share about what could be considered as continuous improvement, so eg painting a wall or something sturdy might not be a continuous improvement. I think then referring back to the aged care standards, so that could tick off standard five, so organisation’s environment. So we are obligated to provide a safe but comfortable service environment that promotes independence and that sort of thing. So it’s definitely worth documenting that continuous improvement or improvement.

Katharine Silk:

I’d probably just add as well Naomi that goes back to coming up with your problem, working out what your issue is. Just doing every fix might not be quality improvement but if someone’s come to you and said ‘I’m sick of the bright yellow wall that’s there with nothing on it. It makes me sad’ then that’s something that you can go about and do a continuous improvement cycle, a PDCA cycle about. It’s about really framing your improvement cycle and what you’re looking to improve. Not every fix is going to fit into that but it might. It might if that’s the feedback that you’ve got. So I suppose it really depends.

Ingrid Leonard:

Thanks Kate. I think we’ve certainly talked about this but welcome I guess any additional examples. So the question is:

Q:        How do you engage residents?

And we’ve spoken about the outcome of the resident experience surveys for example as a really rich data source. We’ve also spoken about committees, resident committees and other things. But I guess I’d just invite any of the panel members to add I guess other opportunities to engage residents.

Nikita do you have a regular cadence of engaging with your residents and is that a formal or an informal approach?

Nikita Divekar:

You mean in the activities or as a committee?

Ingrid Leonard:

Really in terms of obtaining their ideas, feedback and input regarding I guess continuous improvement activities.

Nikita Divekar:

Yep. So like I spoke before about our consumer advisory committee we do have our committee members now on board which are not just residents but also family members. And it is really important for outside community to have that engagement with the residents as well. So a lot of our family members or visitors they do play an active part in volunteering in planning activities for our residents. Just to give you an example one of our resident’s husband, he comes and visits her every day at the home but his background was he used to have a travel agency for many, many years, and now when we have our activity like armchair travel every month on the calendar this family member, this husband of this resident comes and talks about different countries. And we do like a slideshow, PowerPoint presentation, and he really engages all the residents. So it’s about involving close family members, close visitors and making them a part of our continuous improvement. And these are the ideas that have come through our committee, through the meetings that we organise each quarter now.

Ingrid Leonard:

Fantastic. Thank you. I am very conscious that we’ve just reached time but I will just ask one final question and it is to the providers again. So thank you so much I guess for sharing your experiences and your approach to this issue in your services.

Q:        How do you share outcomes with your families and residents?

Naomi Taylor:

So I’ll answer. So we have our bimonthly resident meetings where we do have a structured meeting to make sure that we do cover everything. So we bring the minutes from the previous meetings to make sure that any suggestions, complaints or anything that we follow up and are resolved with them, which we’ve got some really great feedback. We’re about to hold our first consumer advisory body. So that will be a structured meeting as well with terms of reference. So we’re excited to share a little bit more with I guess a wider audience on what we’re doing with any continuous improvement or quality improvements.

Ingrid Leonard:

Fantastic. Thank you so much. Look I very much appreciate you attending today’s webinar. We hope you have found it helpful regarding quality improvement activities in your service. The recording of today’s webinar will be available on the Department’s website shortly. And when the webinar closes you will actually receive a short survey in your browser. It takes about one minute to answer the three questions and we’d very much value your feedback in terms of how to improve future webinars. A big thank you to my fellow panellists and of course everyone who tuned in today. Thanks very much.

[Closing visual of slide with text saying ‘agedcareengagement.health.gov.au’, ‘Phone: 1800 200 422’, ‘(My Aged Care’s free call phone line)’]

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