Quality indicator expansion hits a roadblock, rollout delayed

The Department of Health and Aged Care has released its final report on the new staffing quality indicators with four deemed not ready for immediate implementation. 

The implementation date for several new staffing quality indicators in the National Aged Care Mandatory Quality Indicator Program (QI Program) has been pushed back. Five of the nine indicators will be introduced from April 1, with the rest requiring additional work.

Key points

• A six-week pilot conducted with 69 aged care services demonstrated the ‘importance, acceptability, feasibility and usability of four quality indicators
• The final assessment ticked off the staffing QIs linked to enrolled nurses (ENs) and care minute totals for allied health and lifestyle officer staff
• Four other QIs linked to allied health and lifestyle officer services will require further research and evaluation to ensure they reflect service delivery and care recipient needs.
• A QI for allied health calculating the percentage of recommended services was reported as suitable for near-term implementation but it will rollout with the other approved QIs

The report follows a nine-month period of collaboration between the Department, HealthConsult, the South Australian Health and Medical Research Institute (SAHMRI) and the University of Queensland (UQ) that uncovered valuable insights for the incoming QIs. 

Internationally, there are very few staffing QIs that focus on ENs, allied health and lifestyle officers in residential aged care settings. The development of the nine new QIs drew inspiration from a variety of countries and settings.

Mixed views on new indicators

Detailed consultation with industry stakeholders garnered broad support for expanding the QI Program. Most viewed it as ‘a positive step towards improving the recognition, value, and employment of ENs, allied health professions and lifestyle officers within the sector’. 

However, there were mixed views regarding creating new and separate indicators for each staffing group. Many thought they would become ‘blunt’ instruments for measuring quality of care which can be hard to do in certain circumstances. 

There was general support for collecting the data as it can help generate evidence from which outcome indicators can be identified and developed. This includes one of the proposed QIs designed to calculate the percentage of recommended allied health services received.

Two EN QIs approved for implementation

Two EN QIs were piloted, with both ultimately deemed suitable for implementation:

• QI 1: EN care minutes per resident per day
• QI 2: Proportion of EN care minutes to total care minutes (RNs, ENs and PCWs)

Feedback highlighted the importance of ENs in providing quality care alongside the value of having visible care minutes data for all care staff to understand a service’s staffing and skill mix.

Others said the EN QIs are useful snapshots that leverage data already being collected, ensuring no additional administrative burden. Meanwhile, many said QI 2 has the potential to provide valuable insights to see the full scope of EN care delivery. 

The median number of EN minutes was 13 minutes per resident per day, lower than the international standards of 25-56 minutes identified in the evidence review. This equalled 7% of the total care minutes time. Government-operated services recorded above-average results. 

Ultimately, both QIs addressed information gaps while utilising existing data with the Department stating there’s potential to inform practice change. 

Additional research for allied health QIs

Three allied health QIs were initially proposed for the pilot, with a fourth being included and tested during post-pilot analysis: 

• QI 3: Allied health care minutes per resident per day
• QI 4: Percentage of care recipients who received at least one instance of care from an allied health professional
• QI 5: Percentage of care recipients assessed as requiring allied health services who received at least one service instance
• QI 6 (New): Percentage of recommended allied health services received

The definition of allied health professionals includes physiotherapists, occupational therapists, speech pathologists, podiatrists, dietitians, allied health assistants and an extensive list of ‘other allied health’ such as art therapists, counsellors and osteopaths.

Concerns were raised about using a single measure of allied health minutes, as well as the need to distinguish between direct and indirect care minutes. Fears over an increased administrative burden were common. 

QI 3 benefited the most from existing data being collected and reported; many pilot participants said QI 4 and 5 were difficult to manage. 

“Only one third of the pilot participants reported having a reliable, automated process to report QI 4 and QI 5. Some participants reported that relevant data for QI 5 is captured in clinical notes, so reporting requires manual auditing of care recipient records,” the report explained.

“This led to inconsistencies in pilot data due to varying practices in collection and categorisation of allied health services. Some sites benefited from data collection software, while others struggled without standardised documentation.”

Data collection found that the median allied health care minutes per resident per day was four minutes, far lower than international standards of 22-24 minutes. Nine out of ten residents received at least one instance of allied health care during the pilot.

QI 6, while it requires additional work, found that speech pathology, dietetics and occupational therapy recommendations were the least met. Physiotherapy made up 73% of allied health services delivered.

Feasibility was the biggest issue for all but QI 3 (allied health care minutes). The pilot found that data was not readily available and could be unreliable. 

The Department made several recommendations to improve the allied health QIs, including improving data collection templates, developing minimum standards for allied health assessments and offering more on-site support for providers. 

Lifestyle officer QIs require further evaluation

Finally, three lifestyle officer QIs were piloted: 

• QI 7: Lifestyle officer care minutes per resident per day
• QI 8: Percentage of care recipients who attended at least one lifestyle officer service
• QI 9: Percentage of care recipients with lifestyle recommendation in their care plan who attended at least one service delivered by a lifestyle officer

While lifestyle services are recognised as beneficial for the well-being of care recipients, there are significant concerns regarding data collection, standardisation and reporting on lifestyle activities. Pilot participants worried about the extra administrative burden.

Participants also highlighted challenges with assessing needs as there is no consistent framework for the discipline. Meanwhile, monitoring attendance to evaluate the effectiveness of lifestyle programs is another hurdle due to stretched resources. Some cited the use of volunteers and allied health assistants to deliver lifestyle activities, further complicating data collection.

Pilot participants averaged seven lifestyle officer minutes per resident per day with 12.5% reporting zero minutes. The median proportion of care recipients that attended at least one lifestyle officer service across the 69-pilot residential aged care services was 89%. Similarly, 89% of residents were recommended to attend at least one service. 

The data shows valuable insights into what services are being delivered, including excursions, cooking classes, exercise sessions and games. However, more work is required to implement QI 8 and 9. Both need standardised definitions, stronger parameters and better data collection and analysis.

Further research and evaluation are required to determine their suitability for broader implementation. QI 7 (lifestyle officer care minutes) can be implemented alongside the other approved quality indicators. 

The Department has not advised whether all nine indicators will be introduced together by July or in separate stages. Click here to read the report in full.