Day 1 of the online Governance in Aged Care: Beyond the Royal Commission conference has provided delegates with a range of highlights, notably a presentation by ACU’s Adjunct Professor Alan Lilly on lessons learned so far about the pandemic and its impact on residential aged care facilities.
The digital conference, designed in partnership with COTA and ACSA, has brought together experts, advocates and leaders from across Australia to unpack the royal commission’s final report and to delve more deeply into the biggest issues relating to effective governance.
Lilly, along with University of Sydney infectious diseases expert Professor Lyn Gilbert AO, has co-led independent reviews of the COVID-19 outbreaks in NSW at Dorothy Henderson Lodge and Newmarch House, along with the St Basils and Epping Gardens facilities in Victoria. The pair are also a currently conducting a national review, with all of the reviews commissioned by the Commonwealth Department of Health.
“In the national review we want to build on the existing literature and importantly to identify what the critical factors are that allow residential aged care facilities to successfully respond to an outbreak,” Lilly said during his presentation.
“What we’re really trying to do is understand what are the preconditions for success in terms of managing an outbreak.
“We also want to recommend to government how the preparedness and responsiveness to potential future outbreaks can actually be improved and monitored and evaluated.”
Much has been done, delving into what has happened in Australia’s aged care facilities and how we can avoid outbreaks and system shortcomings in the future.
As a background, there have been almost 30,000 COVID cases to date in Australia, with more than 130.5 million cases reported globally.
Just over 2000 of the Australian cases(or 7 per cent) have occurred in residential aged care, there’ve been 909 deaths here, 685 (or 75 per cent) of which have occurred in residential care. There have been 221 outbreaks in residential aged care to date – 88 per cent in Victoria, and 12 per cent across NSW, Queensland, South Australia and Western Australia.
From evidence provided in their reviews, Lilly and Gilbert have established what they call the ‘Swiss Cheese’ model, where each line of defence is represented as a slice of cheese – these include leadership and management, effective communication, planning and preparation, infection control, emergency management, pathology testing and workforce – with the analogy of the swiss cheese being, if one considers each individual slice as a ‘line of defence’, many of the holes are in different parts of each of the slices.
The holes can extract and expand, and a Swiss Cheese Moment, is when the holes line up and create what is called an ‘accident trajectory’.
There are a range of lines of defence.
“For example, in leadership and management, what we have found is that clearly when organisations are not reflective and responsive, it means that they’re not amenable to people effectively leaning in to their organisations, and during the course of an outbreak, rightly or wrongly, there are in fact a lot of people leaning in,” Lilly told delegates.
“And not being responsive and not being reflective and taking on board that advice, what we saw in our examination of those outbreaks, there was limited capacity to be reflective and responsive.”
Lilly said the reviews also recognised at the same time, that people were completely and utterly overwhelmed by what was happening around them.
“In terms of effective communication, I’ll use the example of St Basils in Melbourne, we saw severe failures here in communication and engagement with family members.
“Many of you will be aware that the whole workforce were effectively stood down at St Basils – it has a predominantly Greek-speaking population of residents, and the staff that usually work there, many of them were bi-lingual.
“But when they were all stood down, things were really complicated, because, of course, the family members were having trouble getting in touch with their loved ones during lockdown, and even more trouble getting in touch with the staff, because they’d been furloughed.
“Ironically, most of the residents who only spoke Greek, were struggling with many of the surge workforce staff, who actually struggled to speak English.”
To use the Swiss cheese analogy, a number of factors lined up, which actually contributed to the exacerbation of the outbreak at St Basils, including severe failures in emergency management and pathology testing, particularly during the second wave in Victoria.
“So what we see when the lines of defence fail [is] a devastating impact on residents and their families and friends, we saw significant decline in residents’ physical and mental health and sadly we saw deaths as well.
“It takes a severe toll on providers and their staff, and sadly providers have often been demonised during Covid outbreaks, as if the job was not already complicated enough. It has taken a severe toll and that’s something we need to take into consideration when planning for the future.”
Lilly said in the current review much has been made of issues around the design of facilities, in particular shared rooms (bedrooms and bathrooms) and ventilation.
“Shared accommodation for workers from other high risk areas has certainly emerged as an area for us, so understanding the needs of staff members who might want to have safe accommodation away from their family, and to protect their family,” he said.
“But we’ve also become increasingly aware that there are a number of people, despite having the single site working policy, for example, that are also sharing accommodation with people who are also working on single site arrangements, except at a different single site, and in some cases in a different high risk area.
“I think that’s something that we need to look at more closely, in particular, the way we fund those single site working arrangements to the extent that we can create a safer environment for the staff and in doing so, of course, for the residents.”
Staff mental health and wellbeing has ‘absolutely and unequivocally’ emerged as a significant issue, and needs to be addressed moving forward.
“Then of course what we’re also seeing is the longer term impact of COVID risk management on residents and in particular that social isolation from their loved ones, just in terms of risk management and managing the risk, let alone managing an outbreak itself,” Lilly told delegates.
Moving forward, he said the royal commission and the pandemic have really shone a light on some underlying issues that the aged care sector has experienced for a long time, not the least of which has been chronic underfunding.
“We would say that through our reviews collectively, we really need to focus on providing consistent, respectful leadership at all levels – it’s about providers, it’s about government agencies and it’s also about the regulator,” he said.
“But importantly it’s also about the residents themselves, and we’ve seen disrespect shown to many of our residents who’ve not been able to access the healthcare that they or their families wanted them to access, and this is something we want to address in our next report.”
Lilly said improvements needed to be made in local approaches to outbreak management, and that processes need to be refined within and across the nation’s residential aged care services.
“We need to improve the jurisdictional approach to emergency management, so that in my mind is really the intersection between the national aged care plan and the individual jurisdictional response.
“We’ve seen a number of inconsistencies and discrepancies, so that’s something we really need to focus on moving forward.
“We need to ensure that we have sound clinical governance, so that’s understanding how are we providing safe, person-centred and effective care to residents at all times. We have a lot of work to do in that space.”
Lilly and Gilbert have conducted more than 250 hours of interviews with residents, family members, providers, government agencies, consumer and organisation provider bodies, regulators, independent experts and employee organisations – to try to understand what the issues were and to attempt to understand what went wrong.
The pair has also interviewed international experts from Canada, England, Hong Kong, and NZ.
Also included an online survey targeting residential aged care facility managers and online workshops targeting approved providers.