ACMA were engaged by a newly appointed CEO of a medium sized residential care provider in NSW. The Organisation’s clinical manager position was vacant, and the CEO had identified issues with their clinical practices including medication management, wound management, clinical documentation, and clinical monitoring systems. Furthermore, the CEO advised that risk was not clearly identified, managed, and reported, the Organisations Plan for Continuous Improvement and Self-Assessment were out of date.

ACMA were engaged to provide visibility into the extent and nature of quality and safety issues; make recommendations for continuous improvement; identify and assess risks, and make recommendations around the ongoing risk management; and provide a structured approach to information management and reporting.

ACMA’s approach included:

• Undertaking an onsite Gap Analysis against the Aged Care Quality Standards (inclusive of staff and consumer engagement surveys)
• Facilitating a risk assessment workshop with managers
• Facilitating an education session with Registered Nurses and senior clinical staff to introduce data collection and reporting practices, captured via ACMA’s Clinical Monitoring and Reporting tool.
• Facilitating Clinical Documentation toolbox education with Registered Nurses, Enrolled Nurses and Care Staff.
• Establishing a relationship between service staff and ACMA’s Quality Partner who provided support to develop staff understanding of continuous improvement processes and how to effectively capture and maintain CI data.

At the conclusion of two site visits, ACMA Advisors presented the Board, CEO and Managers with a comprehensive Gap Analysis scorecard, providing visibility into the level of achievement against each requirement of the Aged Care Quality Standards. An Audit Report provided detailed commentary, with recommendations for improvement which were incorporated into the Plan for Continuous Improvement. ACMA shared the Organisations risk profile and consulted with board members to reach agreement around the ongoing monitoring and reporting of risk at a board level.

With remote ACMA support for the following three months, the Organisation were able to achieve

• Monthly Clinical Governance Committee meetings, operating with clear terms of reference.   The meeting minutes demonstrated:
  • evidenced based decision making and clearly assigned responsibility for actions.
  • outcomes achieved within target timeframes, with evidence of consumer evaluation.
  • 60% reduction in medication errors
  • 43% reduction in wounds
  • 25% reduction in chest and skin infection rates
• A reflective practice approach to clinical documentation, with Registered Nurses mentoring Enrolled Nurses and Care Staff leading to improve the quality of progress notes, incident reports and documentation.
• Quarterly risk reviews and a consistent approach to board risk reporting
• Increased awareness and commitment to continuous improvement throughout the organisation, with a 43% increase in CI activities captured, actioned, and evaluated within target timeframes.