Accreditation:  An industry friendly initiative

Reproduced summary: The Accreditation and Complaint Processes - Australian Nursing Homes [Dr M.J. Wynne]

The Australian aged care accreditation agency was set up as an industry friendly body. Industry input has had a potent influence on its design and its operation. They have been consulted at every point and their acceptance of any changes has been crucial.

Without industry agreement the government would not act and without intense public pressure and adverse publicity the industry would not go along with any restrictions on their freedom to operate as they thought fit.

The response of ministers Bishop and Santoro to the 2000 and 2006 scandals was to seek a probably reluctant industry’s backing for the changes forced on them by the public.

Mar 2000 Bishop turns to the industry: 
Despite also releasing details of a new industry forum to help the Government develop strategies to improve the quality of care in nursing homes, Mrs Bishop looks set to remain under intense pressure.
New Crisis For Battered Bishop Australian Financial Review March 31, 2000

Mar 2006 Santoro turns to the industry: 
Senator Santoro said experts from his Aged Care Advisory Committee - largely comprising aged-care providers - were split on the issue of forcing people to report cases of suspected abuse.
Cabinet to consider plan to stamp out elderly abuse
Australian Associated Press General News March 14, 2006

Reportedly, providers have not been supportive of the introduction of spot checks. They argue that all the Accreditation Agency can do is to "check that homes have appropriate policies and procedures in place that minimise the risk of abuse and effectively manage any such incidents and that this could have easily been achieved within the existing regime of auditing, planned and support visits".

Conflicts of interest

The accreditation agency was not set up as a regulatory body but primarily as a body to assist nursing homes to improve standards. There is no problem in a cooperative body assisting nursing homes to improve but it is problematical when that body is also assessing and publishing results into the marketplace. Its positive assessments were used in marketing and this creates a conflict of interest for the agency. It is put under pressure to accredit by its supporters, and is at risk of criticism if it does not.

The ACCT has received feedback that there might, in some instances, be a conflict of interest in the accreditation process. The Aged Care Standards and Accreditation Agency contracts out the assessment of some aged-care facilities and, on the basis of those assessments, the facility is accredited.

Some facilities prepare for these assessments with the help of outside contractors. Clearly if the same contractors are retained by both the facility and ACSAA then there is a conflict of interest, since the contractors are effectively working for two masters.

Needless to say, one can predict the outcome of such a situation. Do some facilities owe their successful accreditation to "paying the umpire"?

The ACCT hopes that, if this is occurring, immediate steps are taken to ensure that the accreditation process is fair and fearless, and above all, that community standards of care are being upheld – and not just during the accreditation period?

Sharing "industry friendly" staff

The pool of trained staff of necessity come from the nursing home industry itself and from government departments as these are the people with experience. A revolving door occurs as staff move between government and regulator and between regulator and regulated.

Staff who have experience and training as accreditation assessors are a valuable asset for the companies seeking to be accredited and to those seeking to circumvent the process. This is already happening here in Australia.

Appeals system helps the owners

As indicated this system was set up to help the providers and protect their rights. The rights of the individual operator rather than their probity or the welfare of the residents were protected by the law.

As indicated elsewhere, there is a divide in perceptions between the aggressive entrepreneurs who seek to exploit a market and those who provide and receive care. The system also selects for the often charismatic but unrealistically self confident so that they are unwilling to acknowledge any failings in their homes and respond aggressively to criticism.

As in the USA these groups challenge the sanctions aggressively through the appeals process. The judiciary is familiar with marketplace perceptions, rather than the complexities of the health and aged care environment. As the owners are plausible in this environment they frequently succeed in overturning sanctions on appeal. This is depressing and demoralising for the regulators and seriously impinges on their willingness to sanction other homes and so protect residents.

A good example of this is Graeme Menere whose companies aggressively and successfully appealed the sanctions imposed on the Kenilworth and Belvedere Park nursing homes through the courts in 2000 and 2001. It was only when the law was changed that he was prevented from managing these homes.

Marnotta was almost successful in appealing the closure of the dangerously substandard Tangerine Lodge in 2003.

Spot checks or sell out?

The public should be aware that, prior to 2007, protective checks/visits were not "unannounced". Facilities always received at least 30 minutes notice before a check – and according to some sources, often much longer.  Assessors now can turn up at a facility "unannounced", but are unable to gain access until the provider has approved their access.

The ACCT would like to know:

• How many "unannounced visits" have occurred since the introduction of this initiative?
• When will the reports based on "unannounced visits" be published on the ACSAA website?
• What difference to the quality of care are these checks making?

It has also been decided that during each spot check inspectors will be limited to checking a pre-determined or small number of specific 'Quality Outcomes'.

How can spot checks, with such limitations, protect our family members? It’s rather like a doctor treating your sore thumb but not bothering with other ailments he/she might notice!

The whole community needs assurance that aged-care inspectors go into facilities with their eyes, ears and minds open to all aspects of the care provided.

The dilemma in closing down homes

The government’s right to take over a nursing home and to bring in its own administrators and staff to protect the residents was compromised by excessive industry friendliness.

Industry involvement in the policies had ensured that regulations protected the operators commercial rights rather than the wellbeing of the residents. The owner could for example choose the new administrator for their sanctioned homes when this was a requirement.

There was no effective means of mitigating the severe trauma to residents when homes were forcibly closed because it was unsafe for them to operate. The government had provided no other options.

As a consequence some critics pressed for homes to be closed. Others wanted the state to take over and run the homes until new owners were found.

Agency overruling accreditation staff

A consistent complaint throughout the accreditaton story, particularly after the failures at Riverside, is that nursing homes with serious problems are treated leniently. It takes many months or years before a home which is a recurrent offender is forced to sell or closed down.

Of particular concern were decisions taken by the agency’s management and/or the health department to overrule both the assessments and the advice of the staff doing the assessments when they advised that a home be sanctioned or closed. This was still happening in 2006. Little wonder the assessors lost heart and enthusiasm.

That residents would suffer if the homes were closed was a convenient justification. It was however no excuse for not setting up an industry unfriendly process to intervene and install government appointed administrators to run the homes until new owners were found.

Other pages describing the governments role in Australian aged care show the accreditation system has failed on multiple occasions and has continued to fail after attempts to patch the glaring problems.

Homes where there was extreme tardiness in acting or where the assessors findings were overruled include. Homes operated by Milstern, a company owned by the ministers friend. Other homes included Riverside, Belvedere Park and Kenilworth, Tangerine Lodge and Ripplebrook, Emerald Glades, Templestowe Private Nursing Home, St Catherine's Nursing Home, and Albury and District Private Nursing Home.

Regulators and their political masters

In Australia the accreditation agency was claimed to be an independent organization but some of its officers were appointed from the minister’s close political associates and even her policy adviser, although Bishop eventually decided to make him her chief of staff. It is clear that aged care ministers have imposed their will and their control over the agency. This was particularly evident during Bronwyn Bishop’s tenancy as minister. The favourable treatment afforded the homes owned by a friend, the owner of Milstern, was attributed by some to her influence.

A lack of consistency in assessments

A recurrent complaint confirmed by independent reviews was a lack of consistency in the findings of assessors. Some of this can be explained by the fact that the nursing homes vary because they are given the opportunity to spruce up their activities and bring in extra staffing. Additional factors include funding deficiencies, wooly processes to assess, imprecise guidelines, and poor staff morale.

Aged care is the most easily and accurately assessed of all the health related services. Care is very largely depended on adequate staffing levels and when staff levels and skills decline there is an increased incidence of pressure sores, weight loss, dehydration and contractures. Staff numbers, staff training, and each of these complications of staff deficiencies can be quantified and the information collated centrally to give an accurate pointer to homes where problems are likely. Spot checks and savage penalties would soon put an end to forged figures. Clearly there is much more to good aged care than this but given the frequency of these problems this would form a solid starting point on which assessments can be built and then traced back to deficiencies in process.

A lack of Transparency

The new accreditation and complaints system introduced in 1997 replaced an older one. The results of regulatory inspections in the older system were not published to the public but were available in a library for researchers to peruse.

The new system was to be much more transparent and the results were to be published on the agencies web site. Everything was to be open and transparent. The reality has been anything but.

Fast forward to 2008:  Only the results of the most recent inspection are available on the web site. There is often a long delay between inspections and the appearance of the report on the web site. Nursing homes, particularly the larger ones move in staff to fix the problems and an early follow up inspection of the home soon replaces the bad one so that bad reports are often out there very briefly. Some bad reports such as the DCA report on their home at Caulfield are missed by the press.

This may act as an incentive to the companies to address the problems but it denies future residents and their families the overall knowledge of a homes track record so that they can make informed decisions.

As far as I am aware the agency does not publish figures showing the long term results of the accreditation of the homes, critical information for detecting recurrent offenders. Nor does it publish analyses of the figures, or provide evidence of the consistency and the effectiveness of its practices. It is left to others to speculate and infer.

The inference from this lack of information is that either the agency’s self assessment is so bad that it will not disclose it or worst still it is so ideologically driven that when it was set up no arrangement was made to collect and collate the information.

In fairness to the agency it does offer to supply assessments from its archive and it did send me the few I asked for. Eventually.  To obtain the many thousands of assessments made over the last several years and personally analyse them is more than I am prepare to do. It would tie me up for a year!

The press reports make a number of other criticisms.

At a critical stage over the period when the Riverside scandal broke the web site was down for a long period of time. An advocacy group rose to the occasion and posted the reports it possessed on its web site including some of the older reports.

This caused angst in the industry and the powers that be were clearly threatened. They mounted an attack on what they called a "rogue" site. They criticised the posting of older reports when new assessments showing compliance and problems corrected - but not yet posted on the agency’s web site. At the same time "legal reasons" were used for refusing to make information available.

Why the nursing homes track records should be hidden from the public whose members had been put at serious risk just because they claim to have patched it up is unclear.

If we are to have a market then we need to know what they were capable of when no one was watching - not what they did when their future operations were at stake.