The organisation | Aged Care Quality and Safety Commission

Key tasks

Governing body

Information for governing bodies

As a governing body member, you play an important role in making sure your organisation delivers quality care and services and has systems in place to support organisation-wide governance. Your role is to:

supervise provider activities
lead a culture of safety, inclusion and quality
help identify and address issues.

Governing body members bring together different pieces of information to form a bigger and clearer picture of the organisation’s activities and performance. It is important the governing body puts in place processes to check the organisation’s systems and strategies for delivering tailored aged care services meet each older person’s needs and preferences. This includes through partnership with older people and by monitoring the organisation’s performance. For example, by reviewing reports on:

how the provider is delivering aged care services
how the provider is managing complaints, feedback and incidents (Outcomes 2.5, 2.6a and 2.6b)
the quality of aged care services workers are delivering. For example, through quality assurance or system reviews (Outcome 2.8).

This guidance can help you as the governing body identify continuous improvement opportunities and make recommendations for the provider to improve its culture of safety and quality care. You can do this by providing feedback and support to your organisation. As a governing body, you need to be confident the information you use to inform your decisions is accurate, current and reliable. You need to make sure there are processes that support the governing body’s authority and make sure decisions reach everyone in the organisation.

Key tasks:

Partner with older people to set the organisation’s priorities and strategic directions.

The governing body must monitor how well the organisation is partnering with older people. This helps make sure the care they deliver is quality, safe, responsive, and based on the needs and preferences of each person (Standard 1). This includes assessing how well the provider collaborates with older people to plan their care and make decisions. It also includes how involved older people are in continuous improvement processes. This supports the governance, design, evaluation and improvement of quality care and services.

Partnership with older people can include:

forums
meetings
feedback sessions
surveys.

The governing body should make sure the organisation is:

treating older people with dignity, respect, and privacy when they receive aged care services (Outcome 1.2)
supporting older people to make informed decisions about their individual care (Outcome 1.3)

The Commission expects the governing body to make sure older people receiving care have the opportunity to take part in a consumer advisory body. The consumer advisory body is responsible for:

giving advice on how care is delivered
giving advice on improving how services are delivered
giving advice on the needs and preferences of older people and their consideration in the organisation’s decision-making.

The consumer advisory body lets older people provide feedback about the quality and safety of care they receive. When you set up the consumer advisory body (Outcome 1.3), you must:

consider all the feedback from the consumer advisory body when you make decisions
tell the consumer advisory body in writing how the governing body considered their feedback.

This can include the governing body asking the provider to put in place a quality care advisory body.

The governing body should use information from partnering with older people to shape how the organisation delivers quality care and services (Outcomes 2.1 and 2.7).

Lead a culture of safety, inclusion and quality that focuses on continuous improvement and involves older people and workers in strategic and business planning

As a governing body member, you can encourage a culture of quality, safety and inclusion by involving older people and workers in creating a strategic plan of the key priorities for the organisation. The plan should focus on continuous improvement and include clear strategies for achieving these goals, such as:

identifying and meeting legislative requirements
supporting the rights, safety, health and quality of life of older people
managing organisation and operational risks (Outcome 2.4)
managing workforce needs and the needs of the organisation
basing the organisation’s decisions on the aged care services standards (Outcomes 4.1a, 4.1b and 2.8). Making sure that aged care services are accessible to, and suitable for, people with specific and diverse needs, such as Aboriginal and/or Torres Strait Islander persons and people living with dementia
making sure the organisation has, and uses, incident management and information management systems (Outcomes 2.5 and 2.7).

Your strategic and business planning needs to consider the context of the organisation and your legal requirements. This includes understanding your wider organisational and operational risks and needs.

The governing body needs to outline behaviours that create a positive culture of quality and safety and monitor the organisation’s performance. This makes sure older people receive quality care and services that meet their needs and encourages quality care and services and continuous improvement. Set expectations for all governing and leadership members about their role in creating a positive culture of safety, inclusion and continuous improvement. These expectations should be clear through the organisation’s roles. You can communicate the expectations through:

training
conversations
descriptions that explain each role’s responsibilities in leading a positive quality and safety culture.

Make sure the organisation puts in place a quality system that has older people’s needs at the centre.

The organisation’s quality system needs to:

include a set of documented procedures that outline step-by-step processes for achieving the outcomes of the strengthened Standards
define clear roles and responsibilities
be suitable and relevant to the organisation’s operations.

The governing body must make sure this quality system is developed and maintained. You need to support a culture of open disclosure and continuous improvement. Organisations can get this information through quality reports and audits. The organisation needs to:

monitor their governance frameworks to make sure they’re providing safe, and quality care and services
set performance monitoring processes, including clear expectations (such as key performance indicators)
have reporting processes to help the governing body make informed decisions and meet its responsibilities.

Review and endorse key components of the quality system. For example, procedures for delivering aged care services and monitoring how the organisation is performing in delivering quality care and services. This can include analysing the organisation’s reports about the quality and safety of their aged care services. You need to particularly focus on reviewing:

feedback from older people, their supporters, family, carers, and workers
risks, complaints and incidents (and their underlying causes)
quality indicator data
contemporary, evidence-based practice.

The governing body should use this information to understand the quality and safety culture (Outcome 2.2a and 2.2b.). They should also monitor investments in priority areas. This makes sure the provider is spending money to provide quality care and services for older people. If the governing body finds problems or ways to improve, you must address them. You also need to support the organisation to address them in a timely way.

For example:

You should use older people’s feedback to understand if workers deliver aged care services that meet their needs, goals and preferences. If you find workers aren’t consistently providing person-centred, culturally safe, trauma aware and healing informed care, you need to support the provider to figure out why and address it. For example, delivering worker training to improve care delivery.
You should use worker feedback to see if the provider is supporting workers and resourcing correctly to deliver aged care services. If you find that aged care services don’t have appropriate resources, you need to support the provider to address its workforce gaps.
Use contemporary, evidence-based practice to check if the provider’s quality system supports delivering the best care. If there are more contemporary practices, the governing body should help the provider to start using them. You need to do this in a way that fits the context and ability of the organisation. They should use change management principles where relevant.

Be accountable for the delivery of quality care and services

As a governing body member, you are accountable for the delivery of quality care and services and must maintain oversight over all aspects of the organisation’s operations. This includes being accountable when things go wrong and making sure the provider practises open disclosure

You will need to regularly monitor and review the organisation’s performance, including:

feedback from older people, their supporters, family, carers and workers
analysis of risks, complaints and incidents
quality indicator data
contemporary, evidence-based practice

This will help you identify and support providers with continuous improvement.

The governing body needs to monitor and evaluate how the organisation uses their risk management system.

The organisation’s risk management system needs:
to be organisation-wide and be regularly reviewed and improved
to include a risk register the governing body uses to manage strategic risks. The provider can also use it to manage day-to-day risks to operations.

You will need to oversee the management of risks and review risks escalated to the governing body. This may include risks to the organisation or its people. For example, risks to safety, older people, finances and reputation.

The governing body needs to address any issues or areas for continuous improvement they identify. You also need to help the organisation make any necessary changes.

One such example could include risks associated with equipment. For example:

The governing body needs to make sure the organisation uses effective equipment management strategies. These strategies should focus on the safety and wellbeing of older people.
You need to review reports on how effective these strategies are. These reports include the maintenance, cleaning, and suitability of equipment the provider uses to deliver in-home services . You should check incident reports and feedback on equipment safety and functionality (Outcomes 2.5 and 2.6a and 2.6b). This needs to include feedback from older people, supporters, and workers.
You need to be confident the provider’s equipment management practices support safe and quality care and services.
If you find any issues or areas that could be improved, you must address them.

Evaluate how well the providers incident management system works.

The governing body is responsible for:

making sure the provider responds to incidents appropriately. You also need to make sure the incident management system helps people to report incidents correctly and timely. Learning from incidents can drive continuous improvement of the services being delivered.
making sure the provider is complying with incident management regulatory requirements. Non-compliance can result in serious consequences for the older person and also for the provider and governing body members.

Monitor the organisation’s performance to put in place their feedback and complaints management system.

As a governing body member, you can expect providers to report on the outcomes of feedback and complaints. By regularly reviewing this data, you can understand how effective the feedback and complaints management system is, identify organisation-wide issues and support a culture of continuous improvement.

Monitor how the organisation’s information management system is performing.

Information management systems and processes are vital for delivering safe, high-quality, person-centred care. They make sure older people and those involved in their care have access to consistent, reliable and up-to-date information that is managed appropriately in line with applicable privacy laws and informed consent. This can lead to better outcomes for older people and helps your organisation with continuous improvement.

An effective information management system helps the governing body to oversee the organisation by tracking progress against strategic objectives. Information management can be one of the key tools that inform and support your organisation to make changes and innovate. For example:

Accurate information that is communicated to and accessible by the relevant people can lead to better care. It can also increase the confidence and trust older people and the community have in the organisation.

As a governing body member, you need to understand the different parts of an effective information management system.

The provider needs to have systems to:

report and monitor information security incidents. These reports must be regularly reviewed by the governing body
record the governing body has reviewed the information management system to make sure it complies and meets stakeholder needs
record the roles of the governing body in overseeing information management and cyber incidents and responses
make sure key issues and concerns around information security are discussed during governing body meetings and communicated from management
make sure the governing body receives current data and analysis from the information management system. This means that you can review how effectively the system meets older people’s needs and compliance requirements and addresses risks in the organisation. This can include making sure that information is accessible, inclusive and easy to understand for older people.

You should make sure you regularly audit the information management systems and record keeping systems as well as the incident reporting process. This will help you to identify, analyse and respond to any policy breaches, issues or gaps in processes and identify system improvements. This allows for the timely identification and analysis of gaps and issues and appropriate corrective action.

Audits of information management systems and record keeping systems can include:

reviewing how the organisation complies with the information management policy and regulatory requirements
regularly reviewing records to identify any data quality issues, unauthorised changes or file damage
regularly reviewing new technologies that you could use to improve record keeping
monitoring and reviewing cyber security threats, with timely worker communication and training.

Governing body members can encourage workers to comply with information management policies and procedures by:

making sure governing body members and all workers receive sufficient training on the policies and procedures for information management and compliance. Regular training that sets out key responsibilities, as well as how to identify information management incidents and data breaches, can help people to comply
including compliance in the culture of the organisation. The organisation needs to provide enough support to workers to meet their information management obligations. This can include:
- providing appropriate systems and tools
- telling workers that information management and good record keeping is a priority
- leading by example
- encouraging an open and continuous improvement culture
- making sure you investigate any non-compliance with the information management policy.

Monitor how the organisation maintains a safe and healthy workforce and workforce strategy.

As a governing body member, you can expect to review reports on the organisation’s workforce strategy and how well it’s working. This includes information about the provider’s:

workforce structure and requirements
specific working needs
plans for the future
strategies for promoting a psychologically safe workforce.

Monitor the organisation’s strategies or processes to roster workers and how effective the training system is.

Providers have obligations to make sure workers are skilled, competent and supported to deliver quality and safe aged care services that meet older people’s needs. As a governing body, you should have oversight over the organisation’s hiring practices, including pre-employment checks (Outcome 2.8) and their rostering and training system and strategies (Outcome 2.9) and be confident there are appropriate systems and processes for providers to meet their obligations.

Oversee how the organisation puts in place strategies for emergency and disaster management plans.

Governing body members need to understand the key parts of a strong emergency management plan. The organisation’s systems need to:

identify and assess potential risks and hazards that may impact the safety and wellbeing of older people. These risk assessments need to be regularly reviewed by the governing body
record that the governing body has reviewed and approved the emergency and disaster management plan, making sure it complies and meets safety standards
define and document the governing body’s role in overseeing emergency planning and preparation, response strategies and post-incident evaluation
make sure the organisation communicates critical issues and risks around emergency management during governing body meetings
make sure the governing body receives current data and analysis from emergency drills and incident responses. This allows you to evaluate how effective the emergency management plan is in protecting older people and mitigating risks.

You should audit emergency management practices, including training and incident reporting, to identify gaps, issues, and opportunities for continuous improvement. Audits of emergency and disaster management plans can include:

reviewing how the organisation complies with emergency preparation policies and regulatory requirements
evaluations of drills and exercises to identify areas where you can improve and to make sure emergency responses are effective
updating risks and best practices to improve emergency preparations and your ability to respond
monitoring worker training in emergency procedures, with updates on new protocols or equipment as needed.

The governing body should oversee emergency and disaster management. You need to make sure the organisation has suitable controls, resources, and reporting mechanisms. This includes strategies for emergency and disaster preparation and response.

You can find more resources about the role of the governing body and governance in the Quality Standards Resource Centre.

The Commission developed the Governing for Reform in Aged Care Program to support the key recommendations of the Royal Commission into Aged Care Quality and Safety. The Program supports governing body members, leaders and emerging leaders to strengthen corporate and clinical governance capabilities and enact critical reform.

Workers

What does this Standard mean for workers?

Standard 2 focuses on the systems and governance needed to deliver safe and quality care and services and achieve continuous improvement. This includes requirements relating to:

the organisation’s culture – how it promotes safety, quality and inclusion and how it partners with older people and workers to continuously improve aged care services
the management of risks, feedback and complaints, incidents, information, emergencies and disasters
workforce planning and human resource management.

While many of the requirements in Standard 2 are more relevant to the governing body and management of the provider, there are several ways you, as a worker, can contribute to the organisation’s governance and continuous improvement systems.

Give feedback, make complaints, raise any concerns and suggest opportunities for improvement. Workers are an important part of the organisation's governance and continuous improvement systems. You and your co-workers play an important role in shaping the workplace culture and the quality of services and care delivered to older people. You can contribute to your organisation’s improvement by:
- finding new and different ways of doing things that may lead to better outcomes for older people and raising these opportunities for improvement to the organisation
- escalating issues and concerns to the right person in your organisation so they can take action
- recognising errors or mistakes and addressing them quickly
- identifying areas where you may need more training or support and raising these with your manager or supervisor
- identifying areas where workforce planning and rostering is affecting quality care and delivery
- being aware of the organisation’s emergency and disaster management planning and participating in emergency drills
- supporting your co-workers to also identify issues, concerns or opportunities for improvement.
Your provider has a responsibility to encourage and support you and your co-workers to make complaints and give feedback about their delivery of aged care services. You should feel confident to provide any feedback, both positive and negative, and make complaints without fear of reprisal. You should also provide feedback to your organisation or governing body where you feel they are not proactively engaging with you on quality aged care delivery.
Support and empower older people to provide feedback and make complaints. Feedback and complaints are a key source of information to help the organisation continuously improve. It’s important older people feel safe, supported and encouraged to provide both positive and negative feedback and make complaints about the aged care services they receive. This includes feedback or complaints related to the organisation, or to a worker, which they may choose to raise directly with you.

Older people may not feel comfortable, or have the ability, to give feedback or raise a complaint directly with their provider. As such, it’s important you support older people to make complaints and give feedback by:
- letting them know how to make a complaint directly to their aged care provider
- involving their supporters, family, carers, loved ones and others involved in their care to help older people ‘speak up’
- connecting them with advocates, language services or other ways of raising and resolving complaints and feedback
- helping them make a complaint to the Aged Care Quality and Safety Commission.
When an older person makes a complaint or gives feedback, you should acknowledge and respond to their complaint or feedback. Let them know:
- the process for managing and resolving feedback and complaints in a timely way
- how you will escalate their complaint or feedback how long they can expect to wait for a response
- how their feedback and complaints will be used to improve the quality and safety of aged care services or reinforce best practice in care delivery.
Identify, report and respond to risks and incidents. Risk and incident management is key to providing safe and quality care. Refer to the dignity of risk concept in Standard 1 for more support on how to best support an older person taking risks.

Workers will often be the first to identify things that may put the older person at risk of harm. You may also notice risks to your safety (or that of your co-workers), or risks that may affect the ability of the organisation to effectively operate (for example, resourcing risks). Where you find risks, you should:
- assess the risk and escalate to the appropriate person in your organisation. This may involve using a risk assessment (if this is within your scope of practice) and sharing information with your co-workers. If this is about an older person, get their informed consent before you disclose their information to other parties.
- communicate this risk to the older person, recognising they can live the way they choose, including living with risk
- change the way aged care services are delivered to manage identified risks and document any changes in the older person’s care and services plan.
You are also the most likely person to identify or witness an incident related to an older person’s care. It is important you understand your role and the responsibilities in your organisation’s incident management system and respond to the incident accordingly.
Comply with your organisation’s information management system. Your organisation will have a system to manage information relevant to the delivery of aged care services to older people. It’s important you:
- get informed consent from older people before collecting, using and storing their information, or disclosing their information (including assessments) to other parties
- comply with privacy and security protocols to protect the information of older people
- maintain the accuracy, currency and completeness of information
- make sure you have access to the information you need to deliver care safely and in line with the older person’s preferences.
Take part in training and performance development activities. Your organisation will have systems to make sure you are appropriately trained, educated and supported to do your role. You should take part in mandatory training and regular performance reviews to continuously improve your skills and knowledge to deliver safe and quality care. When you find a need for more training, help, or would like to further develop your skills, you should talk to your manager. They should give you the support you need to deliver quality care.

Your rights as a worker

As a worker in aged care, you have the right to a safe, supportive and empowering work environment where you can deliver high-quality care. Providers have a responsibility to make sure workers are valued, respected and able to succeed in their roles. This includes:

prioritising your safety, health and wellbeing
giving you clear reports on the performance of the organisation's quality systems, to build trust and accountability
making sure you have access to the information, tools, support and resources you need to do your job. These should be culturally sensitive and accessible, including if English is your second language and include clear and accessible policies and procedures
creating a culture where you feel supported to make suggestions, give feedback and make complaints, without fear of reprisal or discrimination. This includes supporting you to access advocates and external services for raising and resolving complaints and feedback if and when required
investing in your ongoing training, supervision and performance reviews to improve your skills and support professional growth.

By supporting these rights, providers create a positive and inclusive workplace that benefits both workers and the older people they care for.

Key concepts

Quality, safety and inclusion culture

Your organisation should support you to contribute to an organisational culture of quality, safety and inclusion by:

having systems and processes in place to address and communicate risks in the provision of aged care. This includes communicating information relevant to your safety and using alerts to notify you to address risks
engaging, listening and consulting with you and using your expertise in aged care service delivery to identify opportunities for continuous improvement
making sure you feel safe and supported to provide feedback and raise concerns
creating a blame-free environment where you can report errors or near misses without fear of reprisal
collaborating across all areas and levels of the organisation to find solutions and improve the quality of care
directing resources to manage safety and quality concerns
making sure you can access, understand and apply organisational policies and procedures.

Open disclosure

Open disclosure is the open discussion an aged care provider has with the older person when something goes wrong. This includes an error that has harmed, or had the potential to cause harm, to an older person. Open disclosure typically involves:

identifying when things go wrong – for example, when an older person makes a complaint or a mistake has been made in delivering care to them
addressing immediate needs and providing support – making sure the older person is safe and providing practical and emotional support that meets the older person’s preferences
acknowledging and apologising or expressing regret – this is important, even when no one is at fault
finding out and explaining what happened – getting all the information to find out what went wrong and explaining this to the older person
learning from the experience and making improvements – this gives your organisation the opportunity to learn and make improvements to current systems, practices or cultures, including to prevent mistakes from happening again.

Honest and timely disclosure to older people is not only ethically, morally, and professionally expected, but it's also important for creating a culture of continuous improvement in partnership with older people. Transparency improves trust between older people, workers, and the organisation as a whole.

Incident management

Effective incident management supports you to provide safe, quality care and services for older people.

An incident is any act, omission, event or circumstance that occurs in connection with the provision of care or services that has or could reasonably be expected to cause harm. The harm could be to an older person, or another person (such as a co-worker or visitor).

Your organisation should have an incident management system (IMS) and policies and procedures relating to incident management. Your organisation is responsible for training you to use its IMS and providing you with the tools and policies so you know how to and can report and respond to incidents. The Aged Care Code of Conduct outlines the importance of promptly raising and addressing concerns that could affect the quality and safety of care, support and services.

While your role in relation to incident management will vary depending on your organisation’s IMS, it’s important you know how to:

identify when an incident has (or may have) taken place
respond to an incident, including by immediately supporting those affected
escalate and report the incident to the appropriate person in your organisation.

Depending on the incident and its cause, your organisation may identify opportunities to improve the way aged care services are delivered to reduce the risk of harm to older people. As such, it’s important your organisation lets you know about any updates to organisational policies and procedures, or changes to an older person’s care plan.