Australia's Approach to Aged Care

Introduction

As the population ages, there are increasing numbers of elderly making up the proportion of the Australian population. This population is aging in healthier way but also living well beyond retirement, which creates more demand for institutionalised care. Whilst there is an increasing push to facilitate care at home rather than institutionalised care, it means that those entering into care are frailer and more ill; at the same time, they or their families have greater expectations on the quality of care provided.

The World Health Organisation has listed the elements of healthy ageing, which are meant inform policies on assisting people to age healthily. The World Trade Organisation emphasises on the importance of maintaining mobility, building and maintaining relationships, making decisions for their own health and well-being, and remaining as independent as possible in the satisfaction of their basic needs.

To reflect these values, the Australian government passed new legislation with a set of 8 standards to assist organisations to enable residents to age healthily. This legislation came into effect in October 2018. The legislation reflects the views and opinions of the stakeholders as well, because the Australian Government released the new standards after a 2-year consultation with the stakeholders, including consumers, the aged care sector, experts and the wider community. Enacting the legislation after a prolonged period of consultations with a variety of stakeholders reflects a more holistic approach to policy and law making in this area.

Regulation implies an underlying mistrust between the government and providers. One of the important aspects of regulation is the accreditation policy. Accreditation is the formal recognition of a service meeting an authorised standard or service criteria. Central to the intention of the standards is for continuous quality improvement. The Australian accreditation philosophy is outcome orientated and it focusses on serious systemic issues rather than one off incidents. The aim of the standards is to create a framework which allows the system to assess whether similar incidents would occur again. Monitoring process is used to ensure that appropriate systems and processes are in place and being used to ensure that whatever systems are chosen, are producing the outcomes for residents. Thus, there are no rigid concepts on the tools and their application, but rather if the system is yielding constant improvement in outcomes. This allows the aged care sector to be better at responding to the needs of elderly people.

Current accreditation process

The government maintains close control of the aged care sector by determining the funding in the sector, to prevent over supply and to ensure geographic equity in the distribution of facilities. Part of this control is exerted through the Aged Care Act 1997, which gives the Health Minister the power to set prices and beds in the aged care sector. Based on the number of population over the age of 70, the Department of Health determines how many beds to fund each year. Providers bid for approved places from the for-profit and not-for-profit sectors. It has thus far been dominated by not for profit providers with a trend of increasing for profit organisations in the sector. What does this mean?

In Australia, aged care facility boards are governed by the common law. If the corporation is for profit, the Corporations Act 2001 is applicable. In case of the corporation being a not for profit organisation, then the applicable law is the Governance Standards of the Australian Charities and Not for profits Commission Act 2012. These legislations are also part of the regulatory mechanisms applicable to the aged care sector. Through appropriate provisions in the legislations, the government ensures that the sector is managed through some set regulations.

The framework for aged care quality monitoring encompasses a complaints scheme and an accreditation framework. The Australian Aged Care Quality Agency enforces the monitoring of accreditation through announced and unannounced visits and audits. Accreditation starts with facilities applying to be re-accredited, for which they are required to complete a self-assessment document. This directs the assessors with areas to enquire on during site visits, which generally last over 2 days. This period allows the assessors to have ample time to ask all the questions necessary to assess the facilities and also inspect documents and on site provisions. Inspections consist of a team of two or three assessors, meeting the CEO of the facility, then walking through the facilities ending with an exit conference. The assessors inform the nursing home of their impression of the facility’s compliance to standards discussing possible ways of improving the facilities.

One of the important aspects of the assessment process is the publication of the assessment report, which makes it a public document. If the facility does not fulfil criteria for accreditation, the process is far more intense and monitoring ensuring plans are implemented within the required time frame. In such cases, unannounced inspections become more frequent and there is more emphasis on providing further guidance and support. Then a review audit is conducted in which all standards are covered by the assessors. The Department of Health gives a warning about impending sanctions which would be imposed on the facility for the violation of standards. If a sanction is put on a facility, then before this is lifted, the facility needs to show “sustainability of the system” so that non-compliance with the standard does not to reoccur.

The standards address four main aspects of aged care facility operations, which are: 1) management systems, staffing and organisational development; 2) health and personal care; 3) resident lifestyle; and 4) physical environment and safety. The eight standards that proceed from this are:

1) consumer dignity and choice – residents are given appropriate choices and all aspects of the person’s identity are respected in their care;

2) ongoing assessment and planning with consumers – the residents’ needs are current and appropriate care delivered in response; as far as possible allow the resident to participate;

3) personal care and clinical care – up to date appropriate level of care is administered;

4) services and supports for daily living – all aspects of the resident is catered for, meals, spiritual needs and emotional needs;

5) organisation’s service environment – residents to be safe and a sense of belonging;

6) feedback and complaints – residents and families and friends have avenues for feedback and the facilities respond accordingly;

7) human resources – residents are cared for by appropriately skilled staff; and

8) organisational governance – the facilities have an established hierarchy of people responsible for the care of the residents and staff.

Accreditation of the aged care facilities aims to focus on the compliance with the system by the facilities from service delivery to clinical governance. It should be integrated into the process of continual improvement of a service. For the standards to be useful, a service needs ongoing monitoring of quality indicators to identify areas of strengths and weaknesses. Facilities can easily involve such mechanisms and measures by which they conduct a continuous analysis of their services and standards. Such mechanisms ought to be inbuilt and linked to the quality assessment strategies adopted by the facilities for internal assessment purposes.

Thus, whilst the process of accreditation is external, the organisation should not wait for the external assessors to tell them what the problem is, but rather pro actively make changes itself. Assessors can assist facilities in providing ideas on how other facilities have achieved standards.

As an old age psychiatrist working with many residents in residential facilities, the essay will discuss my opinions on how the standards could be adjusted to target improvement of care. I will first outline concerns regarding the limitations of accreditation as a concept, and limitations in enforcement. The substantive part of the essay will discuss each standard in turn and my suggestions for alterations for better target service improvement.

Limitations with accreditation – the process

Whilst it is important to pick the activity most reflective of quality of care, it is also important to evaluate how the standards of quality of care are assessed. The Australian standards prioritise issues by risks. As risks are multifactorial, the framework from which the agenda arises has an important impact on how the risks are framed and how they are to be monitored. The framework needs to incorporate variations to encompass the different perspectives – care givers, consumers, managers, and families, to name the important ones. What risks are selected for attention at a given time, are subject to many drivers including political, societal and operational forces. The new accreditation format proposes only unannounced visits. Unannounced visits have been criticised on the ground that if on the day of inspection, one thing went wrong, then the of entire organisation is put at risk. In other words, it is argued that unannounced visits put too much burden on the organisation and leaves the organisation exposed to negative assessment even for one-off incidents of non-compliance. It is noteworthy that the US stopped unannounced random sampling of residents for nursing home inspections because lawyers questioned the likelihood of their findings to be a pattern of substandard care and challenged this practice. In Australia however, this practice is allowed in the assessment framework itself. Coming back to the standards, these standards aim at fostering improvement in the quality of care within the system, rather than monitoring individual care activity. In other words, the focus of the standards is on macro conditions within the aged care system and not on individual care providers. This would suggest a system of assessment that is holistic. However, that is not the case in its entirely as there is often a sense of lack of holistic systems evaluation with assessors spending majority of time poring over documentation rather than actually understanding how the system works. In other words, the assessment is more a technical process rather than a qualitative assessment of how the facilities are provided to the aged. It may be said that less emphasis had been placed on observation of care and/or staff hand over than is ideal. Quality improvement measures quantify the processes of care and identify areas that require attention. But the associated increase workload is often seen as a factor that negates its usefulness. Assessors are not spared from resource limitations either. They are not allocated more resources to check additional standards but are pressured to provide good reports to avoid bad press to the industry and retribution from the nursing home. This is counter-productive considering the entire process of accreditation and assessment is based on the objective of improving the services being provided and maintaining effective standards of quality of care. If the process becomes too technical and based on the idea of doing assessments for the sake of doing them without reference to the underlying goal of such assessments, this being improvement in quality of care, then the process needs to be re-examined. At this point, it may be noted that adequate resourcing for visits with a mix of expertise and consumer involvement is needed. This will be elaborated on in the discussion on standard 5 and 7.

Limitations of the assessors

Assessors need to be open and helpful with a relaxed attitude on site visits to encourage family and resident participation. Assessors have the additional role to help staff appreciate what they do and why. Therefore, when feedback from a study on continence found that staff felt there was varying standards in the assessor’s assessments it is a cause for concern. Such varying standards beat the purpose for which the entire framework is created, which is to guide the compliance with certain set standards of quality of care across facilities. With varying degrees of standards being adopted, the purpose of the framework is not achieved. Consistency is needed in the assessors who gather risk information with the regulators as to how the risks are to be categorised. For instance, misadministration of medication can be seen as not meeting standard 3 or 7 with potential elements of standard 8 not being met. How an assessor classifies the risk can be highly subjective and this is a problem for the development of universally applicable standards of quality of care. It is interesting that in Braithwaite’s book in 2007, he already noted that there were instances where non compliance was observed, sometimes from multiple sources during a visit, from all the assessors. But at the exit conference, no findings were reported verbally or written. Instead the positive areas were emphasised. In other instances, assessors expressed concerns that if they reported non-compliance, their supervisors would change it or blame the assessor. Assessors had no feedback on why their recommendations were not followed. In my view, these findings make the findings from Oakden report unsurprising. In a study by Makkai and Braithwaite, assessors found concerns that assessors were in the profession with the view to position themselves for a job in the aged care sector later, much like how tax officers position themselves for a job in accounting firms for the future. This is a worrying suggestion because it poses concerns of conflict of interest within the profession and compromises the work that is done by assessors. In practice, one may note that often nurses are shamed when failing accreditation. Some quit, others use substances; worse still, some nurses displace their shame to the residents. Stigmatisation is conveyed by body language, tone of voice, and eye contact without excessive emotions. This has negative implications for the aged within the care system who often depend on the nurses for their day to day comfort. If the nurses are negative in their approach, this affects the quality of their interaction with the aged and has a negative impact on the latter.

Assessors need to ensure that their inspections are fair and not personal; targeting the issue not the person or organisation. Makkai and Braithwaite found a difference of 39% in improved compliance with homes that were assessed by understanding and tolerant assessors compared to stigmatising assessors. The impact of assessment is not only during the visit. Effective assessing affects the staff meetings, quality assurance meetings and organisational deliberation afterwards. This is not to say that the assessors need to be dishonest in their reports about the organisation just so that they do not come out too harsh. Assessors can give honest reports about the organisation without maligning the organisation or its members. Assessors may also be biased. They may have encountered residents with complaints thus deliberately chose to speak to that resident on visit. Information may be unevenly obtained between clients. Assessors avoid or deliberately speak to residents of poor care because of laziness, fear of retribution, and assessors having professional ties with homes. Assessors need to be ethically strong. There is little information on the training that assessors undergo. Considering the attitudinal, ethical and analytical skills required in accreditation process, in my opinion, authorities need to be more transparent in assessor training and qualification to reassure the public on the standard of accreditation is reliable. There is limited information on the training of assessors and their own standards of conduct. Increased transparency on the type of scrutiny assessors come under would increase the public’s confidence in the accreditation process.

Limitations with accreditation as a regulatory mechanism

Governments all over the world have adopted accreditation processes to drive organisational and clinical improvement in quality of patient care. Accreditation may promote change but whether it leads to process improvement remains a topic of debate. Care facilities are under continual scrutiny for ongoing improvement of care and safety. Greenfield et al looked at 389 institutes that participated in accreditation from 2007-2011, with facilities divided according to the assessors’ assessments to high performers and average performers. In high performing facilities, accreditation was seen as a way to provide independent, industry endorsed external assessment but incorporated into its organisational processes. It was found that organisations that are high performing on accreditation do so because of an internal driven to best practice. Participating in accreditation was not the cause. Similarly, In Denmark, between 2002 to 2008, research found that accredited hospitals that provided better quality care at baseline also achieved greater improvement of processes of care; accredited and non accredited hospitals both improved when subject to analysing of quality of care data. But there was no difference between those that were non-accredited and those that were. This suggests that accreditation is not particularly responsible for improvement of quality of care; rather, internal drivers of achievement of quality are also relevant to achieving quality standards. Nonetheless, whilst not all studies supported accreditation programmes to improve the processes of care provided by health care services, accreditation provides an opportunity for the organisation to be reviewed internally and externally. But it would seem that a positive organisational culture, which leads to a positive mindset towards accreditation, is what makes the process helpful. Regulations cannot address this. I will return to this point in standard 8. Standards that are too specific, make for easy game playing. For instance, if activities were required to fulfil a criterion, then the entire unit of gravely ill residents would be wheeled into the activities room. This is not useful when considering how the needs of clients may vary and therefore, flexibility needs to be maintained in approach to client needs.

In an attempt to specify standards, the US broke down regulations into over 500 standards. Assessors at best would be familiar with standards within their field, e.g. nursing. Inter assessor reliability was extremely low for the US under these circumstances. Australia’s broader standards however yielded much higher inter rater reliability. The team generally discuss their impression and agree on the findings. Then the team discuss their findings with the home and give rationale for them. Australia has a small number of broad standards such that if ever a decision was appealed, documentation on how the team came to its conclusion could be reviewed and each of the standards can be accounted for. Notably, in the 1990s with 31 standards, reports were often over 50 pages long. From 1990 onwards, reports were given under 7 objectives, which were more reader friendly. Rationale can be elaborated on each rating. It gives room for assessors to look at the broader picture of the facility. In this regard, the Australian accreditation system seems to have an appropriate balance. The accreditation agency claims that if a facility complies with the continuous improvement outcome it will comply with all other standards. Ritualism and game playing however can still sneak in. Facilities were observed to say “let something slip’ so it can improve later. Homes have been observed to survey for a yes/no answer from staff on whether it provided a good diet. There was no verifying or supporting evidence required. The focus was on obtaining the ‘answer you want to hear’ to produce the outcome the home desires. There is also an obvious lack of qualitative assessment of the standards when such close ended questions are put forth to the respondents. The impact of certification has unintentional consequences for consumers. Later, this essay will discuss studies that found smaller facilities provide better person centred care for residents. It is therefore also concerning that international literature suggests that for profit residential aged care services have a lower nurse to resident ratio than not for profit services and that for profit services are more at risk of not meeting standards of care. Private facilities can start to choose not to admit elderly with difficult mobility, cognitive or behavioural problems because they make it difficult to meet some accreditation requirements without major financial investment. The loss of one resident has greater financial impact on a small facility than larger corporations. This means regulation can drive smaller facilities out of the sector. In this way, regulations may inadvertently lower the general standard of care in the sector.

Issues with accreditation - Resources

It is interesting to note that studies have found that care staff felt that the need to document has taken up time that would have been allocated for care. Auditing places the focus on regulation and a medical therapeutic agenda rather than focusing on quality of living and dying. Documents records clinical indicators, behaviour risks, medical diagnoses but little on the person’s biography. In food selection, the time spent between staff and consumer to choose the menu is often more important that what is ordered. Documenting incontinence had not led to better continence care. This again reflects on a lack of a qualitative approach to care giving, with a greater focus being driven on whether technicalities of assessment have been observed or not. What is important to a consumer in long-term care is the quality of life offered to them. What is important to providers is that health and safety regulatory obligations and financial limitations are addressed.This fundamental difference in priorities makes regulations necessary and accreditation easily rendered into a ritualistic process. The following sections look at each of the eight aged care standards in turn. As an old age psychiatrist, I will be using specific aspects of residential care living to illustrate my opinions on how the standards can be assessed to give better assurance of addressing quality of care.

Standard one – Consumer dignity and choice

The Institute of Medicine defined quality as safety, effectiveness, patient centred, timely care, efficiency and equity. It recognises that patient centred care is directly linked to quality care. The Review of National Age Care Quality Regulatory Process recognised the residents’ dignity and need for respect as a stand-alone standard. Standard one is set to ensure that the consumer is treated as a person of dignity. Indeed, most consumers in long term care “want an opportunity to live as normal and unconstrained a life as possible”. If providers have the goal of treating each of the consumers with dignity and having freedom of choice, then all the rest would fall into place. But as with most health care activities, what this means in practice is complex and difficult to break down. It is not possible to specify how to care for any consumer at any time so that they feel they are respected as a whole person. Australian Commission for Safety and Quality in Health Care has a set of defined legislated standards of care. For care to be patient centred, it needs to strive towards “being with” rather than “doing for”. It requires safeguarding of the patient’s dignity and autonomy by shared decision-making. The standard emphasises on this more by specifying that a consumer should be allowed the dignity of risk by being given choices about their care and services. Given that many older persons in long term care have dementia of varying degrees, inclusion also needs to consider surrogate decision makers. Facilities should be encouraged to consider risk contracting on written agreements to document that the risks had been considered and the outcome decision made regarding the care as a result. Whilst it may not have any legal ramifications, it is a way for assessors to ascertain that such choices have been offered to the clients. As with any documentation, this should be reviewed regularly or whenever care needs change. This will be expanded on in Standard 3 using continence management as an example. As an alternative focus of care from the medical impairment model, residential facilities should be mandated to adopt a restorative model of care - to provide means for the resident to compensate for their impairment to resume the capacity for past activities. For example, in 2016, Low et al designed the Lifeful reablement program. Workshop with consumers, aged care providers, clinicians were held to discuss and commence the program. The intervention involves training of all staff in communication in dementia, engagement, the concept of reablement, case studies and the use of music and play in quality of life. Attention was paid to ensure all staff at different shifts attended. Resident quality of life was measured. Overall, staff noted positive improvements in the residents being more settled, more involved and families more accepted as part of the team. Care is relational and takes time to build. Whilst person centred care may take more time and require staff to have a lower task orientated workload, it is reported that the care is associated with perception of a better use of time where interactions are more positive. Auditing tends to target problems at workers and processes rather than assessing the quality of relationships. The focus on auditing may make workers more alienated. The process then focuses on documentation rather than care. Even with the Lifeful program, the list of tasks required to perform reportedly made it difficult for staff to find the time to spend with their allocated residents and their families as instructed. Smaller facilities found this more of a barrier to provide quality of care.

Relationship care takes time, consistency, communication, flexibility and respect. Regulations cannot foster these qualities as they separate the conditions of care from facility processes. Given what residents consider important is time and the care givers also concur that insufficient time limits the quality of care provided, perhaps the government should consider regulating the amount of time each resident is entitled to for their care, in order to form a measurable goal for providers to fulfil.

Standard two – ongoing assessment and planning with consumers

This standard emphasises on the importance of involving the resident in his or her own planning of care. Even though it is well established that social relationships are an important part of health and well being, aged care assessments seldom include this aspect of the residents’ lives. A study looked at the implementation of a questionnaire to elicit social background of the elderly in an aged care facility. For the same study, staff was interviewed 9 months later and overall they found it convenient and useful in eliciting information for care plan development without significantly increasing their workload. The information obtained was useful to engage with residents and allocate appropriate care. But for changes in practice to be sustained, there needs to be provider commitment – to provide the resources necessary. The need for leadership for sustaining changes in practice will be discussed in the Human Resources section. The difficulty lies in how to translate information collected into useful change in care. The assessor may consider requesting documentation on how social information gathered altered the resident’s care as evidence of consideration of the resident as a person. Family and friends provide significant support for consumers in residential care but support for their involvement in their care is ambiguous. The increasing emphasis is on relational enrichment in later life, and it is understood that increasing family and consumer participation in their care is important. A seven year multinational project tried to identify practices that facilitate the dignity and respect of workers, consumers and unpaid carers. Purposeful communication from admission was deemed important for this purpose. At admission, families share their expertise, biographical information on the resident whilst the facility explains their care practices. It identified that throughout the life of the consumer in the care home, there needs to be consistent and ongoing interactions with staff who knows the consumer for families to feel confident about voicing concerns and making recommendations. It mattered less whether it was formal surveys or informal approaching for such information to be gathered. This is a point emphasised when addressing standard 6. Finally, at the end of life, information needs to be shared whilst provision is made for support for family members and the consumer. Care homes that prioritise communication training were found to be able to realise person centred care practice. It added ‘time’ as a crucial factor. Time is needed to take into account information gathered from families and consumers, and tailoring the information for different consumers and families, and reviewing this information for further clarification and discussion. Furthermore, consistent staffing also fosters the trust between carers and consumers and families to communicate more effectively.

Staff needs to be a cohesive team. Staff shortages, and use of agency staff means that they are unfamiliar with the needs of the consumers and their families. The organisation needs to invest in team building, in house training and permanent positions to overcome these barriers. Assessors can consider using continuity of staff / consumer relationship as an indicator of resident quality of life. Spot survey of staff and residents about the names of staff in their wing over the course of a two-day visit can be an easily administered test on continuity of care and strength of the care relationship. Location and space can also impact on families’ willingness to contribute to consumer care. Car parks, distance from public transport stations, visiting times with family space or ensuring their rooms are suitable for family gatherings can promote the atmosphere of socialisation and inclusion. This aspect of care will be expended in standard 5, addressing more specifically the service environment.

Standard three – personal care and clinical care

In facilitating personal and clinical care, there is often a lack of personalisation of care needs. Policies, protocols may standardise procedures, but resident cannot be standardised. I will focus on two aspects of clinical care with existing resources for better care, which are under utilised so far.

Medication management

Pharmacists are often neglected but important experts in the team of professionals in aged care facilities. It was thought that 20-30% unplanned hospitalisation were medication related for people aged over 65. De prescribing is a process that should occur regularly in residential aged care facilities through regular reviews of medications. This generally requires the expertise of a pharmacist and GP to work together to weigh up harm and benefits of medications. A plan is made after review for medication rationalisation for monitoring. Elderly people living in the community can be referred by their GP for home medicines review. The same resource is available to GPs in residential facilities. Pharmacists can help with reconsolidating medications between agencies, which is important as residents often travel between tertiary health facilities and residential care. Antipsychotics are commonly used for treatment of dementia related behaviours. It is associated with higher rates of strokes and can cause mortality. Benzodiazepines are similarly commonly used but associated with falls and memory impairment. These medications may be helpful but should be reviewed frequently and ceased as soon as practicable. In 2014-2016, a programme targeting reduction of inappropriate antipsychotic and benzodiazepine use involving 150 residential care facilities was conducted. Pharmacists were deployed to facilities for staff education and medication audit. Antipsychotics use declined by 13% and benzodiazepines by 21%. The dosage of antipsychotics and benzodiazepines used also declined significantly with no observation of substitution of antidepressants or other psychotropics. This study echoed the results of the UK Focussed Intervention Training and Support program, which used extensive education on non-pharmacological approach to manage behaviours associated with dementia. In my opinion however, authorities should also be aware of the concern that these reviews often place without adequate input from other health professionals – nurses, physiotherapists or family. Standard 3 can be made more specific by mandating facilities involvement of evidence based, government funded medication management programs where assessors can check for compliance by review of pharmacy records. However, the emphasis should be on the process of review rather than on blind elimination of medications.

Continence management

In a study on continence management in nursing homes, Ostaszkiewicz found that staff reported that the requirements for funding made them engage in more difficult and onerous practices such as waking residents up to help them use the toilet to minimise incontinence even though it may be safer to let them use the pads. Because of fear of being deemed negligent in continence management, they practised highly protective risk adverse care. Over protective paternalistic care can cause excess disability and functional decline in aged care. It is concerning that the funding model may in fact obfuscate continence assessment. The more residents in a facility have incontinence, the more funding it attracts so there is little incentive to treat the cause. This is a worrying trend as it points at the lack of application of proactive quality of care and impacts the elderly clients adversely. The Australian Productivity Commission had warned that zero tolerance approach to risk could actually cause deterioration in quality of care. This can negatively impact on the carer’s interactions with the residents. Whilst the standards are aimed to increase transparency and accountability, they can lead to staff being over protective and fostering dependency rather than independence. Falls management is another similar area that deserves attention on this point. In my opinion, standards for specific aspects of care needs to have escape clauses for facilities. The idea of risk agreement with families or with competent residents can personalise their care to the level of risk they are willing to take in order to live their lives the way they wished, as far as practicable. It may be that residents would be allowed to walk rather than restrained, in spite of the risks of falls. It may be that residents would be put in pads overnight to allow them a full night’s rest. Such risk documents will be beneficial in any case even if it runs a risk of being a paper exercise as it fosters conversation and participation.

Standard four – services and support for daily living

Without knowing the resident as an individual through building relationships, it is difficult for care to be emotionally and physically matched with residents’ needs. Assessors cannot have a full understanding of the facilities’ efforts at matching resident needs if they only check the choice on a menu, or the variety and number of continence pads provided to each resident. This section will comment on particular aspects of daily living in residents’ lives and how they can be subject to accreditation.

Caregiver service

Residents of care facilities may have cognitive or physical impairment, but they still retain the freedom to make choices even if they cannot execute some of these choices on their own. A review of studies on quality of life of residential facilities found three elements to be crucial. Formal caregivers need to be familiar with the resident to know the needs of the residents. Frequent contact between formal caregiver and resident is needed to better understand the resident’s behaviour. Residents should be cared for in as natural a context as possible. Flexibility is needed for formal caregivers to respond to residents’ behavioural expressions. Carers need to have attitudinal openness to doing things differently and including residents’ choices in context of decision making. Formal caregivers need to welcome informal caregivers, such as, families, which in turn improve informal care. In this way, small facilities are in a better position to foster relationship between formal caregivers and their residents as they spend more time with one another and there is less caregiver to get to know. Similarly informal caregivers will also get to know formal caregivers more easily in small home like facilities.

Meal service

One study reported that 50% residents in residential care were malnourished. This is particularly important as residents depend almost entirely on the facilities for their nutritional needs. Dining is an important social experience as well as being the means for physical nourishment. As aged care sector becomes more consumer focused, residents’ preferences and choice becomes more important. Choice and variety is an aspect of daily living that can be enriched overtly, especially considering the findings of the following studies. A study of 292 residents in 3 aged care homes, found that residents preferred to have set time for meals rather than flexible times. They preferred to choose their meal the day before the meal as opposed to choosing on the day or having no choice. Being able to serve themselves, like at home, was deemed to yield more participation at meal times, maintaining appropriate body weight and improving sense of quality of life. Patient food choices determined satisfaction of service. But it was not unlimited choice and flexibility that mattered. Rather, residents wanted carers to take the time to know their preferences and help optimise their autonomy within limited choices. Rather than observing how many choices there are on a menu, assessors can make observations and enquiry about whether staff takes time to plan the menu with residents over the course of accreditation.

Exercise and leisure services

Globally, 60-70% older adults do not engage in 150 minutes a week of moderate to vigorous physical exercise according to the US Surgeon General Report in 2014. Walking has significant positive impact on strength and flexibility to avert disability. Leisure activity is an important aspect of health and well being. Studies have found that community-dwelling elderly have 92% of their time devoted to leisure activities compared to 48.7% in residential facilities. Residents often come to terms with being in care that they are not expected to fulfil any responsibility. This however speeds up the process of decline. Leisure activities also encourage interactions with others thus improving connectedness and improving physical fitness and delaying cognitive decline. Older adults maintain an image of themselves through leisure pursuits. The current situation is that even when activities were scheduled, if residents did not like the typical Bingo, crafts or word finds offered, there was little alternative. The present level of leisure occupation does not match the variation in abilities and needs of the residents. Occupational therapists are trained in interventions that can mitigate the limitations consumers have in order to maintain or develop their leisure activities. But other members of the care team can also use their expertise to tailor activities according to each resident’s past. This should involve their families and friends in compiling a set of activities meaningful to that person. Physiotherapy is widely accepted as beneficial to the general older population with lessening occurrence of falls. There is increasing evidence that it improves mood, cognition and functional ability. It also improves the impression staff and family have on care. Physiotherapists are also important in aiding pain management. Chronic pain is common but complex which can benefit from physiotherapists’ assessment and treatment through massage, positioning, TENS, acupuncture and other non-pharmacological interventions. However exercise and physiotherapy are not prioritised in residential aged care facilities. Despite the importance of these aspects of healthy ageing, no funding is allocated to provide support for these facilities. There is also little support for physiotherapists who work in the sector – there is little peer support, there is less access to professional development and little mentoring.

Accreditation should consider including mandatory regular assessments by physiotherapist and occupational therapist or activity assistant, to optimise the resident’s capabilities physically and cognitively. Whilst not all residents would want to participate, in my view, documentation requirements can at least start such a conversation for the choice to be offered.

Interagency transfer of care

Apart from services within the facility, aged care organisations also need to frequently liaise with tertiary care facilities. Older people often have multiple health problems requiring more frequent use of acute health care than younger people. Unplanned acute care for the elderly often does not fulfil their needs, resulting in repeat presentations. A case series of 17 patients were analysed to look for common cause. It found that for 21% of the discharges, GPs were not informed of the discharges for over 7 days and only 19% patients were given their copy of discharge summary. Majority of patients presented due to functional decline, which needed the cause to be investigated. Because these patients were generally presented with long term conditions that required long term management, communication between crisis care and long term care was crucial. It was found that if a patient’s GP did not receive discharge summary within 7 days, 79% were re-presented within 7 days. Few had written information of any form provided on discharge, or a follow up appointment information. Patients were disempowered, and their safety compromised when there was failure to communicate any changes made to their management without adequate communication to the GP and to the patient or families themselves. Whilst facilities themselves can do little to force hospitals to provide information, additional professionals like pharmacists, physiotherapists can boost efforts at contacting tertiary agencies for information. Allied professionals can contact their counterparts in the hospital rather than relying on junior doctors to provide medical discharge summaries. A systematic review of economic value of bettering the process of care in residential aged care has found that increasing direct care time actually has been associated with increasing cost savings. This was due to decreased hospitalisation and improved functional capacity of the residents. The studies with the best of these outcomes were studies that focused on the care team – occupational therapist, physiotherapy and nurses. Interestingly they were often care homes that were small and home like. The evidence showed that a multidisciplinary team is required for good outcomes for residents and the staff that looks after them; therefore, accreditation should consider more specific mandatory involvement of allied professionals to participate in the care of the aged. Assessors can be more specifically required to monitor this through ensuring facilities showing employment of allied professionals in the organisation, evidence of assessment and review of function by these team members. A specifier of the standard can mandate an area of resident’s own statement in their care plan, or their family’s comment in their relative’s care plan as a more concrete way for assessors to assess if the services and supports are recognising the resident’s needs.

Standard five – organisation’s service environment

Environmental workplace performance can be seen through three aspects of comfort – physical, functional and psychological. Physically the environment needs to be hygienic, safe, and accessible. Psychologically the workspace should create a sense of belonging, and respect privacy of the clients. The environment needs to assist or ease the tasks that need to be performed. The elderly in nursing homes are more commonly depressed than those living in the community. This fact should be factored in while planning the environment in which the clients live and carry out their daily activities. Environment has been linked to residential satisfaction and psychological well-being. In China, a study of 1429 elderly who were interviewed regarding depression, found that 46.1% respondents were suffering from clinically significant depressive symptoms. The study found that environmental aspects with geographic position, air quality, transportation and resident satisfaction were strongly associated with depressive symptoms. Better appraisals of the environment were associated with less depressive symptoms. Physical environment that allows residents to perform activities they used to engage in, like gardening, helps them retain a sense of self. This facilitates compliance to standard 1 as well. Physical environment that fosters independence and positive interactions between residents and staff, is deemed person centred. There are increasing number of studies that found more inclusivity of elderly into existing community spaces as a positive attribute of good physical environment. Marsh et al have found that meaningful connections enhance community acceptance of people with dementia. The programme found that just being among nature, plants, gardens and birds facilitated participants to interact with each other on equal terms. Roles of professionals and volunteers versus participants lessened. Community participants tended to accept the way dementia residents gardened, even if it appeared unconventional. Community participants were able to treat consumers with dementia as fellow gardeners with varied skills and interests rather than varying capacity. This activity facilitates positive risk taking which assumes ability over disability. This is consistent with person centred care of assumption of capacity. Given that not all residential care facilities can have outdoor spaces for residents, utilising community gardening spaces can provide physical and emotional connection for dementia residents to be a citizen of their community.

Residential care facility environment not only affects residents but also affect staff, which in turn affects the care of the residents. A qualitative study of a residential facility was conducted in outer Melbourne for eliciting information on the impact residential aged care workplace can have on staff. It was found that in order for staff to feel valued, be productive and feel safe, the environment needs to be home like, have access to outdoor spaces, with indoor environment that is of good quality, and access to open comfortable work areas. Lighting, space and plants had an impact on staff behaviours, productivity and social interactions. It found that staff was happy when the residents were felt to be happy thus there was a convergence of needs for a workplace that had the above qualities. The diminution of an elder’s living environment makes residential environment all the more important given its implication for psychological well being. The elderly should be empowered to advocate for better living environment themselves, given its importance. Residents and staff should be engaged and encouraged to participate in reviews to adjust and adapt regularly as part of the facility’s mandate to fulfil standard 1 and 2. Acknowledging that one’s preference for one’s environment is highly subjective, accreditation needs to be a mechanism that ensures each facility had made efforts at making the facility the resident’s home, and this requires a more qualitative approach to assessment rather than a technicality driven and document centric approach. The skill to discern a balance between safety and comfort is important for the assessor. He is in a unique position to speak to the resident, the staff, and members of family to gain background knowledge of resources available to care facilities, and to gather a comprehensive view on how best to manage the balance. In my view, the accreditation team should ensure either an occupational therapist or architects be part of the team in examining this aspect of a facility. They can also comment on whether the facility is visitor friends as mentioned in standard 2.

Standard six – feedback and complaints

Traditionally aged care had a medical model in its management. Consumers are seen as impaired needing to be managed. But as consumers and their families become more aware of their rights to care, there had been increasing calls for consumer participation in their own care. Technical care, interpersonal relationships and the care environment all influence the perception of quality of care. In the drive towards patient centredness, the culture of professional-knows-best needs to change. This requires increased sharing of power between organisations and consumers. For this, accreditation programmes can help to drive system level changes.

Complaints management

There are three main objectives to complaints. Complainants want to know what happened and what were the rights and responsibilities of the provider. Secondly, they want to seek validation of their grievances from the provider. Thirdly, to see that improvement has been undertaken to avoid further repetition of incident. Aged care complaints more often involve relatives and friends as compared to other disputes. If the provider is focused only on the provision of care to the consumer only, then complaints can arise from relatives if there had been no communication between the parties. Those in residential care are vulnerable. Their ability to advocate for themselves is often lost. When things go wrong, there is no one to translate the legal jargon and process for their complaints or grievances. Advocates are often not trained in communication with the residents with impairment but know that the information was too complex not to be translated. The effects of this gap in care needs is often most felt by the residents themselves and for this it is important to address this issue. In the past, Aged Care Lobby Group had commented that families gave up complaining because they were trivialised as well as documented retribution. The Victorian Institute of Forensic Mental Health have found that half of the complaints involved agency hostility in 5% of cases and in 20% of the cases the organisation denied any responsibility. Complaints are a resource and feedback mechanism to be taken into account in the planning of future service delivery. An appropriate complaint process can safeguard the organisation against persistent complainants, for instance by allocating a specific staff member to manage the interactions. Every organisation needs to have a process for managing complaints so that complaints do not escalate further and disrupt the running of the organisation. This can also help minimise the amount of resources required to manage the impact on staff morale. The Standards Australia Committee has set recommendations on complaints handling (AS 4269-1995) identifying 13 essential factors of an effective complaints handling process. They are commitment, fairness, resources, visibility, success, assistance, responsiveness, charges, remedies, data collection, systematic and recurring problems, accountability and review. The persons handling complaints should also understand the interpersonal aspects of complaints. Conflict often arises because of different styles of personalities rather than deliberate confrontation or fight. When people are fearful or feel threatened, resistance arises and leads to conflicts.

Training for complaint management is available through the ombudsman of various states. The concerned prganisation can be mandated to send staff to undergo training in complaint management on a regular basis as a more proactive way to drive facilities to prepare for complaints management and receive feedback. This can be a part of an effective internal assessment process.

Resident and family participation and feedback

Facilities can easily include family or residents in their committees whilst limiting the person’s knowledge about certain areas of operations; or limiting their ability to participate in meetings or communicate with the board. In a study involving focused groups and interviews across 17 aged care services of Australia, it found that collaboration occurs on a day to day level but higher level decision making was largely consultative rather than collaborative so that their opinions were sought to enforce organisational agenda rather than facilitate care for the consumers. Care planning, resident meetings, complaints procedures were existing channels of community but were ad hoc and reactive, remaining at the level of information sharing rather than true empowerment. Residents’ influence was largely restricted to their own care. Strategic and executive level decisions communication tended to be one way thus lack accountability so that when a resident spoke about an issue, it was only communicated to one staff member or a specific service department, even though the issue may have wider implications. Ultimately, staff had limited ability to convey issues to management due to lack of streamlined processes established for that very purpose. The difficulty lies in how to use standards effectively to avoid game playing and providing of tokenistic changes rather than actual improvement in care. Stakeholders have concerns that consumer views should not askew assessors’ overall accreditation assessment. Concerns also arise that consumer surveyors or consumer input lacked clinical expertise. Whilst patient measured outcomes focus on effectiveness of care, it is true that safety and experience needs other measures to complete the full dimensions of quality. The challenge lies in finding measures that detects unacceptable performances but also avoids unfair criticisms of a provider. Feedback should also be encouraged within the organisation. A report from the Department of Health and Human Services in the US looked at 195 hospitals and found that 86% of adverse events go unreported in hospitals. An Irish hospital survey found that nurses who perceive a more positive work environment were more likely to report adverse events. Nurses’ proximity to patients makes it inherently key to maintaining patient safety. The nature of their work being monitored further enhances the role of nurses. Historically however, nurses have suffered when they tried to alert management on issues of inadequate care. The nurses’ perception of a safety culture in the workplace is a significant predictor of incident reporting. Creating a supportive environment that demonstrates to staff the organisation’s commitment to patient safety is crucial in establishing such culture.

Authorities can mandate aged care facility governance structure to include the residents and family as well as front line nursing staff participation in their governance structure. Actual inclusion of nursing staff in policymaking, and increased contact between management and nurses, improves the perceived practice environment of nurses. In order to ensure a well-rounded accreditation process that takes into account the expected level of care through various stakeholders’ viewpoint, the assessing team can consider using an assessor with a professional background to accompany a consumer assessor during site visits.

Standard seven – human resources

As workers in the front line are accorded low status and their employment is often precarious, compounded by an overwhelmingly female work force, it is a part of the aged care workforce that is prone to be exploited.

Staff resident ratio

In a systematic review of qualitative studies that surveyed the experiences of clinical nurse managers who were registered nurses from 1997-2011, it was found that nurses in aged care seek being valued by the community and are generally passionate about the work. In 2016, Talbot and Brewer conducted semi structured interviews of care assistants in long term care homes. Care staff typically reported exhaustion and emotional detachment typical of burn out. It is established that the higher levels of stress the care provider has is associated with the poorer quality of care. Whilst mandating staff resident ratio to ensure quality of care seems intuitive, Whitehead et al in their longitudinal survey of residential care and continuing care hospitals, have found no significant association between hours of work for registered nurse or enrolled nurse, or support worker staff time and the five quality indicators: falls, weight loss, urinary tract infections, polypharmacy and the use of indwelling catheters. It is noteworthy that increasing staffing when the environment is perceived to be unsupportive has not been found to have substantial impact on improving patient outcomes. Albeit the lack of research evidence, staff would like a staff-client ratio to enable safe practices as well as reducing unnecessary documentation. If these measures increase nursing satisfaction, then care and patient outcomes may indirectly improve. Thus, implementing mandatory staff nurse ratio still appears to be a worthwhile criterion to assess, in my view.

Mandatory employment conditions for training in care workers

Care workers and student nurses were the whistleblowers in 1996 to the practices at Garlands Hospital, and the internal inquiry deemed them ignorant of how real world practice operates and blamed the type of patients in the facility. For care workers to have sufficient moral agency to call out problems, workers need to have a clear sense of professional identity. Education in ethics that prepares workers to affirm their value and identity as care givers would have helped them to continue to advocate for residents. Leadership training can increase nurses’ confidence in autonomous management as well as widen their repertoire of skills in clinical judgment. Low pay conditions necessitate the organisations to recognise the cost of education for nurses to take up leadership training. Instead of setting non-specific standards to optimise training and education, legislation should require facilities to provide nursing contracts that set aside funding and study leave for continued training, ethics workshop and leave to network for nurses. Nurses’ union should advocate for aged care facilities to make pay conditions comparable to other nurses in the healthcare sectors. Residential care facilities are a unique product in that it should satisfy comprehensively the needs of the resident – psychologically, physically, socially and spiritually. Time and again, it has been shown that staff perception of care, availability of training, and staffing training have implications for safety as well as staff satisfaction. The more satisfied the team is, the better the quality of care. For assessors, I recommend mandatory anonymous staff survey as a way of gauging the overall strengths and deficits of a facility’s management of its human resources. Assessors should be required to observe handover or care planning meetings to see the inclusion of allied professions in the care team to be a guide that the facility appreciated the expertise they bring to care.

Standard eight – organisational governance

At companies with a culture of compliance, employees are expected to ‘do the right thing—not the fast thing, the most profitable thing or the thing that makes them look good’.

Top managers need to act as role models to be honest, transparent and fair.

For example, in 2004 a Sydney nursing home was experiencing recurrent falls in the residents. Staff would just pick up the residents off the floor without documenting as they were afraid that recording falls would result in them being deemed at fault. A quality assurance committee was able to identify the root cause of the falls and non-slip footwear was implemented via advertisements to residents and families on safe footwear and encouraged to give safe footwear as gifts for special days. There was no carer being found responsible. Residents and families were not blamed for falling. In 2017, Sjogrens et al surveyed 1460 residents and 1213 staff from 151 residential care facilities to report their ratings on the organisation and environment including measures of person centeredness. The facilities found to be highly person centred have a structure of leadership with the vision, staff to spend time with residents but also work collaboratively with other staff and with the residents. Staff had continued education in dementia and a high proportion received regular supervision. Opportunities to progress and develop through education and training were needed to improve retention and recruitment. Geriatrics nurse practitioner was one such potential pathway. It is worth noting that facilities implementing the Lifeful programme referred to in Standard 1, reported that the program stalled in facilities where there was no person to continually remind staff, assign focus carers, role model and schedule timetable for carers to spend time with residents. Positive leadership practices have found increased resident satisfaction and reduced adverse events.

A double blind cluster randomised controlled trial was conducted in 12 residential and 12 community aged care sites in Australia from 2011 to 2013. Staff of over 6 months employment duration were surveyed through the implementation of a clinical leadership in aged care programme for middle managers to facilitate person centred care. The programme uses 360 feedback, case scenarios, action learning and individual interactions with the program facilitators to put individual practice improvement projects into place. By the end of the program, care staff perceived greater support from management and their manager’s leadership to be more transformational (to inspire, motivate and innovate beyond expectations) and transactional (promote performance to achieve expectations with rewards and corrective actions), and less passive avoidant (waiting for problems to arise). Given the ease of paper compliance in this standard, assessors should be wary of organisations that state no cause for concern. If an organisation have never had any fluctuations in their quality indicators nor any staff voicing dismay at working conditions or no reporting of incidents, these are tell tale signs that the governance structure is not functioning properly because it is virtually impossible for an organisation to work with such consistent smoothness. At the very least, there will be some concerns raised as that would be a sign of a healthy governance structure. Therefore, even if an organisation reports consistently good outcomes, assessors have an obligation to drill down to the details on the ‘how’ ‘why’ and ‘who’ of reaching compliance. Even with the best policies and intentions, performance changes according to the mix of staff, residents and social climate of the time. Effective governance structures are willing to take up the ultimate responsibility of the outcomes. Policies and structures on paper cannot tell if staff feels disinterested or indeed feel disincentivised to report and policies on paper cannot reflect an air of defensiveness in the governance structure. Assessors need to interview staff across the organisation to ascertain if staff had the sense of responsibility for their duties, and a sense of empowerment by being part of the organisation.

Summary

Good standards and regulations are responsive. This is based on the hypothesis that it is best to persuade change first before resorting to sanctions. But persuasion works better when there is a sanction as a back up. Paying for rewards is more expensive than asking for compliance. Authorities should appeal to the aged care sector that as it becomes an increasingly competitive market, the ability for provider to identify consumer concerns is an important way of remaining responsive and to survive in the market. It also demands consumers to increase their participation. The requirement of interactions with residents and families in new standards should be seen as facilitating the organisation to increase participation. In this essay, I have outlined the limitations of accreditation as a mechanism for quality assurance and the limitations the assessing process is subject to. I emphasised the importance of assessor training and transparency to be improved to ensure consistency in their work with an ethical and attitude of facilitation rather than criticism and shame. Adequate resources need to be allocated to facilitate appropriately detailed site visits, which should encompass documentation review, staff and resident interviews as well as environmental assessment. Regulations highlight deficits. It is through conversation that these deficits are communicated and rectified. Ideal standards are strengths based to foster hope and assess for opportunities rather than risks. The base is education and persuasion to develop strengths. Inspection and reward are incentives for progress. In my view, adherence to standard 1 would lead to adherence to all the other standards listed. Facilities needs to be encouraged to see the resident as a person with choices and rights. Time spent with resident has been consistently rated as an indicator of resident satisfaction of care. It facilitates interactions and helps the carers to see the resident as a person. In my view, assessors could consider using the amount of time allocated for cares as an indicator of quality of care. To ensure ongoing assessment and planning, facilities often use various tools of assessments but checking their documentation cannot assess continuity of care or presence of care relationship. Spot survey of staff, residents and their families for the names of those in their care and their team can give the assessor a rounded impression on the involvement of the residents and their families. Regulations can lead to practices that are risk avoidant, stifling the resident’s right to take risks and live according to his or her values. Mandatory review of risk documentation on aspects of care such as falls; continence and restraints can be a way assessors encourage facilities to ensure residents have the dignity of choice. Assessors should look for evidence of multidisciplinary approach to assess physical and occupational function but more importantly, they need to be looking for evidence that the residents or their families have participated through collaborative note writing for instance with family or residents themselves, to confirm how the information is translated into daily care through documentation. Organisations also need to remember that a facility is the resident’s home. Thus, apart from being safe the facility needs to convey a sense of belonging for the residents. Assessors should look for ways that allow the residents to participate in the wider community or the ways in which the community remains in contact with the residents. But what makes a place home is the people, care staff that knows their residents again has been shown to be a crucial factor in residents’ rating of their environment. Assessors need to look for signs of such continuation of relationship in their site visits through interviews of staff, residents and their families. Assessors should be alert to facilities that do not have complaints or reports not to be struggling in any aspects of their functioning. Complaints are made when residents, staff and families feel safe to do so. Assessors should look for evidence of complaint management training in the organisation as a proxy indicator that the organisation does not discourage feedback. Indeed, adequate training is part of standards 3 and 7 as a way of ensuring that staff is able to provide up to date care with professionalism. In my opinion, mandating staff resident ratio can alleviate staff anxiety about workload and improve staff morale and in turn improve patient care as it is well established that there is a positive link between staff satisfaction and patient satisfaction of care. To this end, improving staff employment conditions, both in the physical work environment and in the work entitlements, would lead to improvement in outcome. Whilst the assessor can only review documentation and conduct site visits, a review of incident reports, with an inquisitive open mind following through the evolution of incident investigations, 360 degree interviews asking the necessary questions to gain a granular understanding of the level of daily care provided, are vital steps to painting an accurate picture of the organisation’s quality of care. There has been a move towards standard of care that drives continuous improvement to circumvent the difficulty of “yoyo compliance” whereby a facility only “pick their socks up” for accreditation and lapses as soon as accreditation is achieved. This is not appropriate. The risk based accreditation process whereby established facilities are left for 3 years before they are reviewed again can unintentionally encourage this. However, this needs to be balanced with the costs of accreditation. Thus, changing the standards that mandates facilities to pursue ongoing performance improvement is useful. But the possibility of game playing can have a serious detrimental effect on fulfilling this purpose. Facilities’ intentional or unintentional falsification of activities can easily fool the inexperienced accreditor. The government needs to ensure adequate training of the accreditors to make the accreditation process trustworthy enough for the public and health professionals to utilise the information.

Regulations are needed but a strength based model of positive reinforcement as the means to lift the standard of care above the minimum will be more appropriate. It is a constant balance between prescriptive standards that are clear but not so prescriptive that it falls into ritualism. Nursing home managers need to be persuaded or forced into ongoing pursuit of continuous improvement. Care staff and residents need to be empowered to speak up. They need access to training and support. The process of accreditation can be realised through well-trained assessors astute to signs of paper compliance and game playing facilities. But they need to have a sophisticated understanding of the industry to identify the underlying root cause of problems. They need to be prepared to make fair but tough assessments. Finally, they need to be well resourced in time and training to do their work well.

Bibliography

Ao, Kate Carnell, ‘REVIEW OF NATIONAL AGED CARE QUALITY REGULATORY PROCESSES’ 188

Baldwin, Richard, Lynn Chenoweth and Marie dela Rama, ‘Residential Aged Care Policy in Australia - Are We Learning from Evidence?: Residential Aged Care Policy in Australia’ (2015) 74(2) Australian Journal of Public Administration 128

Baldwin, Robert and Julia Black, ‘Driving Priorities in Risk-Based Regulation: What’s the Problem?’ (2016) 43(4) Journal of Law and Society 565

Banerjee, Albert and Pat Armstrong, ‘Centring Care: Explaining Regulatory Tensions in Residential Care for Older Persons’ (2015) 95(1) Studies in Political Economy 7

Barken, Rachel and Ruth Lowndes, ‘Supporting Family Involvement in Long-Term Residential Care: Promising Practices for Relational Care’ (2018) 28(1) Qualitative Health Research 60

Boumans, Jorge et al, ‘How Can Autonomy Be Maintained AndINformal Care Improved for People with Dementia LIving in Residential Care Facilities: A Systematic Literature’ (2018) XX(XX) The Gerontologist 1

Bravo, G et al, ‘Does Regulating Private Long-Term Care Facilities Lead to Better Care? A Study from Quebec, Canada’ (2014) 26(3) International Journal for Quality in Health Care 330

Brett, Lindsey et al, ‘Sufficient Exercise for Australians Living with Dementia in Residential Aged Care Facilities Is Lacking: An Exploration of Policy Incoherence’ (2018) 42(5) Australian and New Zealand Journal of Public Health 427

Chadwick, Liam M et al, ‘Senior Staff Perspectives of a Quality Indicator Program in Public Sector Residential Aged Care Services: A Qualitative Cross-Sectional Study in Victoria, Australia’ (2016) 40(1) Australian Health Review 54

Edvardsson, David, Elizabeth Watt and Frances Pearce, ‘Patient Experiences of Caring and Person-Centredness Are Associated with Perceived Nursing Care Quality’ (2017) 73(1) Journal of Advanced Nursing 217

Greenfield, D et al, ‘Health Service Accreditation Reinforces a Mindset of High-Performance Human Resource Management: Lessons from an Australian Study’ (2014) 26(4) International Journal for Quality in Health Care 372

Hoti, Kreshnik, Dawn Forman and Jeffery Hughes, ‘Evaluating an Interprofessional Disease State and Medication Management Review Model’ (2014) 28(2) Journal of Interprofessional Care 168

Liu, Susu et al, ‘Neighborhood Environment, Residential Satisfaction, and Depressive Symptoms Among Older Adults in Residential Care Homes’ (2018) 87(3) The International Journal of Aging and Human Development 268

Marsh, Pauline, Helen Courtney-Pratt and Marina Campbell, ‘The Landscape of Dementia Inclusivity’ (2018) 52 Health & Place 174

Moll, Sandra E et al, ‘“Do-Live-Well”: A Canadian Framework for Promoting Occupation, Health, and Well-Being: « Vivez-Bien-Votre Vie » : Un Cadre de Référence Canadien Pour Promouvoir l’occupation, La Santé et Le Bien-Être’ (2015) 82(1) Canadian Journal of Occupational Therapy 9

Nicklin, Wendy et al, ‘Leveraging the Full Value and Impact of Accreditation’ (2017) 29(2) International Journal for Quality in Health Care 310

Petriwskyj, Andrea, Alexandra Gibson and Glenys Webby, ‘What Does Client “Engagement” Mean in Aged Care? An Analysis of Practice’ (2018) 38(07) Ageing and Society 1350

Tuckett, Anthony G et al, ‘The Built Environment and Older Adults: A Literature Review and an Applied Approach to Engaging Older Adults in Built Environment Improvements for Health’ (2018) 13(1) International Journal of Older People Nursing e12171

Whitehead, Noeline et al, ‘Quality and Staffing: Is There a Relationship in Residential Aged Care?’ (2015) 6(1) Kai Tiaki Nursing Research 28