An Australian Institute of Company Directors (AICD) webinar held this week had some plain talking advice for aged care directors.

The ‘Clinical Governance essentials for aged care boards’ was hosted by Rosina Hislop, a former partner at Ernst & Young who is an experienced Board Director and currently the Deputy Chair at SA provider ECH); and Greg Adey, an operational executive, including Chair of the Minda Board Clinical & Services Governance Committee, Chair of Clayton Church Homes, and member of the Yorke Northern Local Health Network Aged Care Board.

Boards need to revisit Royal Commission submissions

Greg told the audience, which was made up of 50% board directors, around half with less than five years’ experience, and a mix of other executives, that the main question coming out of the Royal Commission has been the issue of care and clinical oversight: “What did the boards know about this, and if they didn’t know, why not?”

“The Royal Commission was for many boards their first exposure to clinical governance responsibilities,” he said.

12 months on, Greg says boards should be formally revisiting their self-declarations made to the Royal Commission.

More medical experts on boards?

One viewer questioned why board members are expected to have financial knowledge and not rely on having one director with a ‘financial’ background, but are now being expected to have a ‘clinical’ person as a member – highlighted this week by Professor Kathy Eagar’s call this week for more medical experts on aged care boards.

Rosina says there is “no right answer” to this question, noting that clinical governance has traditionally been delegated off as part of the operational side of the business.

“Our view is there is not ‘a one size fits all’,” she said.

Directors need level of clinical literacy

However, she stated that every board should be weighing up their composition and whether they have the necessary depth of experience.

“This isn’t about relying on that one person on the board,” she said.

“Every single person should have a base level and knowledge of clinical literacy.”

Greg added this could mean further professional development is needed to ensure that literacy.

Boards making unannounced visits?

Another viewer asked whether boards should be making unannounced visits to aged care homes during the pandemic.

Rosina advised against unannounced visits, saying they could undermine the role of the CEO and management.

“Ultimately it is management’s role,” she said.

However, she did still encourage directors to make visits with the support of the CEO to gauge the culture on the ground.

Invest in IT and software and look at agency staff

Rosina also recommended directors look out for a number of ‘lag’ indicators that could indicate an issue including:

• A lack of meaningful scheduled reports.
• Responses such as ‘we can’t get staff’ or ‘we don’t have the systems to do that’ – Rosina says boards should keep asking for information regardless and invest in software and IT to capture the data needed if necessary.
• A high use of agency staff (a struggle to attract staff could be a sign of issues in workforce culture, she said).

High clinical turnover a red flag

Other ‘red flags’ that could show that care on the ground could no longer be of a high standard according to Rosina are:

• Statements without evidence: when you never receive ‘bad news’ and are always told that ‘everything is great’.
• Data but no narrative: when the information is available, but there is nothing to piece it together.
• A high turnover of clinical leaders: “the board needs to understand what is creating and leading to that,” she said.

Sanctions and not mets result from poor governance

However, Greg pointed out that the biggest indicator is any sanctions or not mets imposed by the Aged Care Quality and Safety Commission (ACQSC).

“My experience is that the root cause comes down to ineffective governance systems [and] inadequate board line of sight,” he stated. “It’s about not knowing what is going on.”

He puts this on a lack of ownership by directors, the board relying on short-term fixes that aren’t sustained and “I’m still seeing this one a year later, underestimating the risk-based rigour of the Quality Commission.”

Ask the right questions of management

Rosina said the best way for boards to respond to any not met standards is not to erode the CEO’s authority, but focus on asking the right questions and seeking information then making sure solutions are actioned.

“It’s about setting clear indicators and holding management accountable,” she said.

Greg also advised boards always conduct a root cause analysis of any incidents to make sure they understand the reasons for the issue and look at what the issue was not picked up by the board previously.

“Boards do need to spend some time and reflect on how they can change their practice,” he said.

“Trust but verify” information from CEO

Rosina said the key message is that clinical governance is core business for boards – and directors need to have a line of sight to what is happening on the ground.

Rosina added that boards should also make sure they have a committee that focuses on clinical governance or quality and safety and “trust but verify” the information that they are receiving from the CEO and management.

“We are accountable and we role model the leadership and culture that we want to see in the organisation,” Rosina said, concluding with a quote from the Banking Royal Commission: ‘don’t just tell us but show us’.