Put in place a quality system that supports you to deliver safe and quality care and services.

Make sure this system supports safe and quality care and services that centres around older people’s needs.

Put in place a quality system that explains:

• who’s accountable and responsible for specific tasks
• ‘what good looks like’ for your organisation and range of services. This includes identifying key performance indicators (Outcome 2.8)
• how you will monitor performance in line with what the governing body expects
• how you will monitor quality to make sure you achieve outcomes of the Quality Standards
• how you will report the results of monitoring activities in a way that supports you with continuous improvement and practising open disclosure. This includes how you will share this information with older people and your governing body.

Where relevant, use your quality system to make sure:

• you deliver safe and quality care and services to older people. This means care that is person-centred, culturally safe, trauma aware and healing informed (Outcome 1.1). Provide this in line with the organisational governance and quality system frameworks.
• you give older people current, accurate and timely information about their aged care services. Make sure this information is easy to understand and supports the older person to make informed decisions (Outcome 1.3).
• older people give informed consent when you need it. For example, before a treatment, procedure or intervention (Outcome 1.3)
• prices, fees and payments are accurate and transparent for older people (Outcome 1.4)
• you support older people to take part in partnership activities (Outcome 2.1)
• workers have the necessary skills, qualifications and competencies to perform their role (Outcome 2.9)
• your aged care services assessment and planning processes are working (Outcome 3.1 and Outcome 5.4)
• your processes to coordinate aged care services are working (Outcome 3.4)
• older people receive aged care services in a physical environment that is safe and supports their needs (Outcomes 4.1 and 4.1b).

You should also use your quality system to:

• recognise, stop and respond to discrimination, abuse and neglect (Outcome 1.2)
• manage organisational risk (Outcome 2.4)
• record, investigate, respond to and manage incidents and near misses that happen while delivering care and services (Outcome 2.5)
• receive, record, respond to and report on feedback and complaints. Use this to support you with continuous improvement (Outcome 2.6a and 2.6b).
• analyse risks and their causes
• securely manage records (Outcome 2.7)
• put in place workforce planning strategies (Outcome 2.8)
• care for older people living with dementia (Outcome 3.2)
• communicate structured information about older people and their aged care services (Outcome 3.3)
• prevent and control infection (Outcomes 4.2 and 5.2)
• support the appropriate use of personal protective equipment (Outcome 4.2)
• put in place the clinical governance framework to drive the safety and quality of aged care services (Outcome 5.1)
• integrate clinical information into nationally agreed electronic health and aged care digital records (Outcome 5.1)
  • For regional and remote providers, limited access to internet and infrastructure may affect digital maturity. These providers should consider strategies to make sure they’re working towards putting in place a digital clinical information system.
• support the safe and quality use of medicines (Outcome 5.3)
• monitor and continue to improve the food service (Outcome 6.1)
• have services and supports for daily living that improve the quality of life of older people (Outcome 7.1)
• transition older people to and from hospital, other care services and stays in the community (Outcomes 7.2 and 3.4)
• measure against Quality Indicator data.
   

Use your quality system to report quality performance information.

Report quality information to the governing body. Also report this information to older people and their supporters.

Make sure you write and distribute reports in line with the governing body’s expectations and directions. This also includes monitoring the performance of any associated providers.

Make sure reports clearly explain the results from performance monitoring, including where:

• things have gone well
• things have not gone well
• you will make changes to make sure similar situations don’t happen again.

When things go wrong, you need to practise open disclosure (Outcome 2.3). This means you should:

• be open about what’s gone wrong
• acknowledge that something has gone wrong and the affect it has had on the older person receiving care
• apologise for what has gone wrong
• put in place strategies in partnership with older people to mitigate the risk of things going wrong again
• monitor and evaluate strategies to mitigate risk
• share this information with older people, their supporters and others they may want to involve, such as family and carers.

Use this information to develop strategies to stop things going wrong again. You should include processes to investigate what has gone wrong in your organisation’s clinical governance framework (Outcome 5.1).
 

Put in place strategies to help workers use the quality system.

Put in place policies and procedures that support the use of your quality system. Make sure these are:

• current and informed by the latest contemporary, evidence-based practices
• regularly reviewed
• clear and accessible for workers and relevant people.

Provide workers with guidance and training on how to use the quality system. This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand:

• their role in the quality system
• how to use the system to tailor and improve aged care services for older people.

The guidance for Outcomes 2.8 and 2.9 has more information about workforce planning and human resource management.
 

Monitor how well you use your quality system.

Regularly review your quality system to make sure it works well. Look for ways to improve the system.

To check if your quality system works well, you can review:

• older people’s aged care service documents (Outcome 3.1). For example, care and services plans and progress notes. This makes sure aged care services meet the needs and preferences of the older person.
• complaints and feedback (Outcome 2.6a and 2.6b)
• risk and incident information (Outcomes 2.4 and 2.5)
• Quality Indicator data
• worker performance and how well they’re using the quality system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). For example, ask the older person if any issues they’ve raised have been recognised and addressed. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Analyse the service’s quality data to:

• identify organisation-wide issues that need resolving. To help with this, it’s useful to compare actual performance against expected practice. If actual performance falls short of planning targets, you may need to act. This may include asking for additional investment from the governing body.
• identify and resolve any issues that aren’t organisation-wide. For example, if a particular worker or older person needs more targeted support.

If you find any issues or ways you can improve your quality and safety culture, you need to report them. This way, issues are addressed promptly. Report this information to the governing body and the Quality Advisory Committee.