australian open disclosure governance – closed to cultural voice · 2018-12-06 · introduction...
TRANSCRIPT
Australian Open Disclosure Governance –
Closed to Cultural Voice
Australian Open Disclosure Governance – Closed to Cultural Voice. Critique of Australian Open Disclosure Governance and the Cultural Voice of Australia’s First Peoples
Dr Mark J Lock, BSc (Hons), MPH, PhD
Keywords: Cultural Voice, Healthcare Governance, Open Disclosure, Australia's First Peoples, Cultural Safety
ISBN: 978-0-6483077-0-9 (pdf)
©2018 Committix Pty Ltd
Email: [email protected]
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Citation: Lock, M.J. (2018), Australian Open Disclosure Governance – Closed to Cultural Voice. Critique of Australian Open Disclosure Governance and the Cultural Voice of Australia’s First Peoples. Committix Pty, Ltd, Newcastle. DOI: 10.13140/RG.2.2.10303.56486 Available at: https://committix.com/projects/cultural-voice-and-open-disclosure
Committix Pty Ltd respects Australia’s First Peoples as the traditional owners of Australia.
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Contents
Contents ....................................................................................................................................................... i
Abbreviations ............................................................................................................................................ iv
Executive Summary .................................................................................................................................. 1
Foreword ..................................................................................................................................................... 3
Introduction – A Case Study of Government Governance ............................................................. 4
The Problem - Copying and Pasting “culture” .................................................................................. 5
Culture is more than a variable in communication ....................................................................... 6
What is Open Disclosure?................................................................................................................... 6
Key Message ...................................................................................................................................... 7
Culturally Unsafe Open Disclosure ...................................................................................................... 7
"It tastes like chicken" - the ambiguous flavour of culture soup ............................................... 8
Cultural voice is excluded from healthcare governance............................................................... 8
Australian cultural safety .................................................................................................................... 9
The Williams Definition of Cultural Safety .................................................................................. 10
Bin-Sallik's Moral Obligations in Governance ............................................................................ 10
Open Disclosure and Cultural Safety ............................................................................................. 11
Key Message .................................................................................................................................... 12
Policy Trajectory Methodology .......................................................................................................... 12
Methodology – Constructing a Policy Trajectory ...................................................................... 12
The PRIS Lens ................................................................................................................................ 13
Findings – Open Disclosure Governance and Cultural Voice ...................................................... 15
Blinded Policy Development Trajectories (I) ................................................................................... 15
Cultural Voice Not Caught in the ‘Acts’ (I) ...................................................................................... 15
Key Message .................................................................................................................................... 16
Editing Out Cultural Rights (I) ........................................................................................................... 17
Conflating Australian First Peoples and CALD Communities ................................................ 17
Healthcare rights undercut by definitional complexity ............................................................. 18
No Cultural Statistics (I) ....................................................................................................................... 20
Key Message and Summary of Institution ................................................................................ 21
Disintegrated Governance Leadership (S) ........................................................................................ 22
Boards as Keystone Structures ........................................................................................................ 22
Integrated governance ....................................................................................................................... 23
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A hole-in-governance approach ....................................................................................................... 23
Key Message .................................................................................................................................... 24
Structured out of healthcare Standards (S) ....................................................................................... 24
‘In-Equality’ Assurance Processes (S) ................................................................................................ 26
Excluded from the Accreditation Environment (S) ........................................................................ 27
Key Message .................................................................................................................................... 28
One-way Street Policy Levers (S) ....................................................................................................... 28
The two-way street of cultural safety ............................................................................................ 30
Key Message - Summary of Structures...................................................................................... 31
The White Box of Government Governance (P) ............................................................................. 32
Government Governance .................................................................................................................. 32
Unpacking the invisible backpack ................................................................................................... 33
'MoGed' - A New Variable in Healthcare Epidemiology ........................................................... 33
The 'Secret Governance' variable .................................................................................................... 34
And 'Genuine Partnerships' variable .............................................................................................. 35
Key Message .................................................................................................................................... 36
Cultural Voice Authorised Out (P)...................................................................................................... 36
Keystone Committees ........................................................................................................................ 36
Secret Governance from Secret Committees ................................................................................ 37
Institutionalised Authority ............................................................................................................... 38
A Hierarchy of Authorisation Processes ....................................................................................... 38
A Trajectory of Excluding Cultural Voice .................................................................................... 39
Key Message .................................................................................................................................... 39
Excluded from the Open Disclosure Evidence-base (P) ................................................................. 40
Institutionalised ethic to exclude cultural voice .......................................................................... 40
Stewardship of bias in evidence-gathering processes ................................................................. 40
Disclosing inequity in scientific reviews ....................................................................................... 41
A gap in knowledge governance ...................................................................................................... 41
Key Message - Summary of Processes ....................................................................................... 42
Disclosing Relational Failure in OD Policy Governance (R) ....................................................... 43
Federalism Filtering ........................................................................................................................... 43
Tracking Real Connections .............................................................................................................. 44
Holding Leaders to Account ............................................................................................................ 45
Secret Committee Governance ........................................................................................................ 45
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Culturally Unsafe Relational Governance .................................................................................... 45
Key Message .................................................................................................................................... 46
Medical Associations’ Ineffective Brokerage Role (R) .................................................................... 46
Medical Associations as Knowledge Brokers ............................................................................... 47
Cultural Voice Blocked from EQuIP Governance ...................................................................... 47
Un-EQuIP-ed for Cultural Safety: Brokerage to Blockerage ................................................... 48
Culturally Blind Leadership in Australian Healthcare Accreditation .................................... 49
Key Message .................................................................................................................................... 49
Insincere Consumer Engagement in Open Disclosure Governance (R) .................................... 50
Tokenistic Consumer Engagement ................................................................................................ 50
A Standard for Genuine Partnership? ............................................................................................ 52
Lack of Oral Knowledge Transmission Routes ........................................................................... 52
Key Message and Summary of Relationships ........................................................................... 53
Reprise - Cultural Safety Audit of Australian Open Disclosure Policy Governance14F ....... 54
Discussion – Erasing the ‘Copy and Paste’ approach to Culture ................................................. 57
Guiding Principles for Culturally Safe Open Disclosure Governance ................................... 58
Summary – Who is Governing the Regulator? ........................................................................... 69
Conclusion ................................................................................................................................................. 70
References ................................................................................................................................................. 71
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Abbreviations
ACHCR Australian Charter of Health Care Rights
ACHS Australian Council on Healthcare Standards
ACSQHC Australian Commission on Safety and Quality in Health Care
AHMAC Australian Health Ministers’ Advisory Council
AHSSQAS Australian Health Services Safety and Quality Accreditation Scheme
AODF Australian Open Disclosure Framework
AODF Australian Open Disclosure Framework
ASQFHC Australian Safety and Quality Framework for Health Care
CAEPR Centre for Aboriginal Economic Policy Research
CAEPR Centre for Aboriginal Economic Policy Research
CATSINaM Congress of Aboriginal and Torres Strait Islander Nurses and Midwives
COAG Council of Australian Governments
CRFATSIH Cultural Respect Framework for Aboriginal and Torres Strait Islander Health
NATSIHP National Aboriginal and Torres Strait Islander Health Plan
NIRA National Indigenous Reform Agreement
NISCGID National Integrated Strategy for Closing the Gap in Indigenous Disadvantage
NODS National Open Disclosure Standard
NPACGIHO National Partnership Agreement for Closing the Gap in Indigenous Health Outcomes
NPSEF National Patient Safety Education Framework
NPSEF National Patient Safety Education Framework
NSFATSIH National Strategic Framework for Aboriginal and Torres Strait Islander Health
NSQF National Safety and Quality Framework Consultation Report
NSQHS Standards V1
National Safety and Quality Health Service Standards Version 1 (2011)
OD Open Disclosure
ODSRR Open Disclosure Standard Review Report
OIDF Overcoming Indigenous Disadvantage Framework
PRIS Processes, Relationships, Institutions, Structures
Open Disclosure – Closed to Cultural Voice Dr Mark J Lock
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Executive Summary
1. This critique examines Australian Open Disclosure policy governance through theconcpetual lens of cultural safety. The stimulus for the critique was a ‘copy and paste’approach to ‘culture’ that I detected in the Open Disclosure policy documents from theAustralian Commission on Safety and Quality in Health Care (ACSQHC). As I delvedinto the substance of Open Disclosure policy documents, I wondered why only twosmall paragraphs were devoted to Australia's First Peoples, especially given theirhistory of discriminatory treatment in Australian healthcare system and contemporaryissues of institutional racism and poor health service access and use. I asked a simplequestion, how were Australia's First Peoples voices included in Open Disclosuregovernance?
2. I developed a methodology to interrogate the policy trajectory of Open Disclosuredevelopment by assembling together the published policy documents from theACSQHC and searching for the voice of Australia's First Peoples - their cultural voice.The phrase ‘cultural voice’ denotes the human cultures of Australia’s First Peoples. Itdemarcates space in health policy analysis so that “human culture” becomes visibleinstead of dissolved within the sameness of whiteness.
3. The findings are discussed under the terms of processes, relationships, institutions, andstructures. The concept of ‘processes’ refers to the administrative procedures andprotocols for the conduct of business, like the authorisation processes of committees. Ifound three sub-themes of: the white box of government governance, cultural voiceauthorised out, and excluding the knowledge of Australia’s First Peoples from theevidence base. These provide an overarching theme of culturally-blind processes inAustralian healthcare governance.
4. Relationships refer to the connections between people, organisations, and policydocuments. I found three sub-themes of the ‘relationship’ aspect of goverance for ODpolicy and Australia’s First Peoples of: relational failure, ineffective knowledgebrokering, and insincere community engagement, which support the overarching themeof 'relational incompetence'.
5. The term ‘institution’ refers to hidden social values and norms, which are encoded inActs of parliament, interpreted into legislation and complied with through regulations.What is most apparent is the institutional theme of invisible cultural voice evident inthe sub-themes of: blinded policy development trajectories, cultural needs not caught inthe ‘Acts’, editing out cultural rights, and no cultural statistics.
6. The concept of ‘structures’ refers to the more substantial aspects of governance fromcommittees to performance agreements to quality management to policy levers. I foundthe four sub-themes of: disintegrated federal governance structures, structured out ofhealthcare standards and in-equality assurance process, and one-way street policylevers, which support the overarching theme that the architects of Australian healthcarestructure-out cultural voice.
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7. A major finding is a high degree of ambiguity in healthcare governance documentswhich means that healthcare leaders and stewards can abrogate responsibility todeveloping strong governance standards with Australia’s First Peoples. This signalssome key problems with the governance of the regulator – the Australian Commissionon Safety and Quality on Health Care (ACSQHC).
8. This critique notes that it is the ACSQHC who make Australian healthcare standards,accredit the assessors of healthcare organisations, oversee the Australian Safety andQuality Accreditation Scheme, hold all information as corporate-in-confidence abouthealthcare organisations, and provide policy and strategic advice to healthcare leadersand stewards. In other words, the ACSQHC holds absolute market dominance inhealthcare governance and regulation, an ethic that disempowers the cutlural voice ofAustralia’s First Peoples. This affects the legitimacy of the Australian Commission onSafety and Quality on Health Care in overseeing an Australian health system thatrespects and protects the health rights of Australia’s First Peoples.
9. I argue that the governance of Open Disclosure policy development should include thecultural voice of Australia’s First Peoples through transparent and accountableparticipation and engagement mechanisms. A set of guideing principles are proposed tothat end and would entail improving the coherence of leadership, developing standardsfor the inclusion of cultural voice, developing continuous quality improvementprocesses for cultural safety, including Australia's First Peoples in accreditationgovernance, and improving the two-way flow of information through policy levers.
10. This critique is one way for a First Australian to assert healthcare rights todemonstrate how to go beyond a ‘copy and paste’ approach to culture and to genuinelyengage with Australia’s First Peoples.
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Foreword
The reason for any policy analysis is to understand the values behind it and to see them expressed in the text of rather boring and bland pages of policy documents. Open Disclosure policy does make for plain reading, in-and-of itself, but start interrogating its foundations and its founders and then it becomes an intensely fascinating exercise. Begin with committees, which are the formal way governments engage with their citizens, and investigate the committee members, who want to influence public policy, and then any policy analysis becomes a study in contested values. What is fascinating about Open Disclosure policy is how a painful and emotional process of humanity can become written about with a cold and detached tone. What does it say about those committee members?
The policy context is Australia (a Western Democratic nation) and the audience is Australian policy writers who are anonymously responsible with the difficult task of converting values into text. The topic is about Australia’s Aboriginal and Torres Strait Islander Peoples or Indigenous Australians which I refer to as Australia’s First Peoples. The setting is Open Disclosure Policy which means the process where a health professional openly discloses to a patient that they have been harmed in the healthcare process. This analysis of Open Disclosure is the first performed by a descendent of Australia’s First Peoples and is significant because our voices have been deliberately and systematically excluded from many Australian health policy making processes. Through this analysis I plant a flag in the moon of Australian Open Disclosure policy and declare “this ground includes the cultural voice of Australia’s First Peoples.”
The methodology of this analysis combines an interest about the outcomes of committees with the notion of ‘institution’ as conveying a long period of time. I begin with a policy topic and examine its developmental trajectory by using public corporate documents which contain some information on those people involved in its making. Why committees? They are the way an organisation operationalises its corporate governance processes. The two governance principles that drive my research are transparency and accountability. After all, if I am to trust the architects of the health system then I want to see how they built its foundations and know who is responsible for ongoing oversight of the process. And it begins with committee analysis and that is why Committix Pty Ltd takes committees… seriously.
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Introduction – A Case Study of Government Governance
Leading up to an Open Disclosure (OD) workshop in a Newcastle tertiary health care organisation (in 2014), part of my role was to review the policy and academic literature to find the voice of Australia's First Peoples in the OD policy process.1
In this critique, I disclose the findings of this policy analysis based on authorised publications that are explicitly linked to one another to form a policy trajectory. This allows an analysis of the concept of 'government governance' which here means the stewardship of civil society policy development processes.
And why should an analysis of OD policy matter given Australia's First Peoples' incarceration rates to recognition in Australia's Constitution to children in out-of-home care? Open Disclosure policy is neither headline catching nor grist for the media mill. I propose though, that any Australian health policy should respect the cultures of Australia’s First Peoples. In this analysis I show that the government governance of OD policy reveals an institutional bias against Australia's First Peoples cultural knowledge.
The findings signify an institutional ethos embedded in the corporate governance of the Australian Commission for Safety and Quality in Health Care (ACSQHC) which is a ‘government agency that leads and coordinates national improvements in safety and quality in health care across Australia’.1 This affects its legitimacy in overseeing an Australian health system that respects and protects the health rights of Australia’s First Peoples.
1 Lock, M.J. (26th January 2018), [online], Is Australian Healthcare Open Disclosure Policy Closed to Cultural Safety? [LinkedIn Post]. Retrieved from: https://www.linkedin.com/post/edit/australian-healthcare-open-disclosure-policy-closed-cultural-lock-
Constructing Open Disclosure Policy - A Culturally Unsafe Process?
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The Problem - Copying and Pasting “culture”
In this section I define the problem at the centre of this analysis of Australian Open Disclosure Policy. As implied in the picture, I found that rather than include real people in the discussion, editors prefer to ‘copy and paste’ a paragraph of text written by non-Indigenous people.2
In the decade (2003-2013) of development of Australian Open Disclosure policy, the cultural voice of Australia's First Peoples was edited to just two paragraphs relating to cross-cultural communication. These two paragraphs were subsequently copied and pasted in different policy documents.
The first paragraph, from the 2003 National Open Disclosure Standard (NODS)2 was authorised by the Standards Development Committee (no Australia's First Peoples members).
The second paragraph, from the 2013 Australian Open Disclosure Framework (AODF)3 was authorised by the Open Disclosure Advisory Group (secret membership).
As I read and re-read these two statements, the style and content showed a dismissive tone towards the incredible diversity and complexity of the hundreds of nations of Australia’s First Peoples. Clearly, they were not included in the OD policy development process.
2 Lock, M.J. (1st February 2018), [online], Copying and Pasting “culture” in Open Disclosure Policy [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/copying-pasting-culture-open-disclosure-policy-dr-mark-j-lock-/
Are Australia's First Peoples included in Open Disclosure policy development processes?
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CULTURE IS MORE THAN A VARIABLE IN COMMUNICATION
These two statements pitch culture as relevant only at the point of clinician and patient interaction, but culture is much more complicated. The Nursing Council of New Zealand (2011) defines culture as ‘the beliefs and practices common to any particular group of people’.4 In the context of cultural competency in the United States, Cross et al. (1989) stated that culture ‘implies the integrated pattern of human behaviour that includes thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group’.5 So, culture is more than just a ‘variable’ to consider in communication but embedded in the fabric of everything that we do.
As I delved into the substance of Open Disclosure policy documents, I wondered why only two small paragraphs were devoted to Australia's First Peoples, especially given their history of discriminatory treatment in Australian healthcare system and contemporary issues of institutional racism and poor health service access and use.6-9 I asked a simple question, how were Australia's First Peoples voices included in Open Disclosure governance?
I developed a methodology to interrogate the policy trajectory of Open Disclosure development by assembling together the published policy documents from the Australian Commission on Safety and Quality in Health Care (ACSQHC) and searching for the voice of Australia's First Peoples - their cultural voice. I use the phrase cultural voice to distinguish the notion of 'human culture' from that of 'organisational culture' and 'medical culture' and other forms of 'culture' where humanity is edited-out, as is the case in OD Policy.
WHAT IS OPEN DISCLOSURE?
When a health professional unintentionally causes harm to a patient, it is good professional practice to openly disclose to the patient that an error has occurred. Health services use this definition (from the Open Disclosure Standard: Review Report 2012, p.viii):10
Open disclosure is an individual and health service-level response to incidents of patient harm. It is a process in which healthcare providers communicate with, and support, patients who have been harmed as a result of health care. It is considered an important element of good clinical practice and professional ethics, and is part of effective clinical communication.
My argument is that genuine engagement with human culture means that it is more than a variable in communication but is an essence infusing policy development processes.
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Unfortunately, there is no public documentation on how this definition was arrived at and who was involved in its development, which is important because definitions are culturally bound constructs and form a touchstone for what is ruled-in and ruled-out of subsequent policy and strategy. The definition of Open Disclosure shows that patient ‘culture’ is reduced to a variable to consider in the communication moment between the clinician and the patient. The contrast is starkly different to the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (2013) where culture is seen in terms of ‘the right to live a healthy, safe and empowered life with a healthy strong connection to culture and country’.11
But how can health service administrators move to embedding cultural voice throughout the health care system – in every aspect of the governance of those systems? I have demonstrated that culturally based concepts such as holistic health are quite difficult for policy makers to engage with and operationalize into policy documents.12, 13 That this is really difficult for policy makers to achieve is that they use a ‘copy and paste’ approach to Australia’s First Peoples’ cultures in Open Disclosure policy development documents.
Key Message
The governance of Open Disclosure policy development should include the cultural voice of Australia’s First Peoples through transparent and accountable participation and engagement mechanisms. In the next section, I explain the relevance of the concept of 'cultural safety' for Open Disclosure policy.
Culturally Unsafe Open Disclosure
This section introduces the notion of “human culture” into OD policy governance. The image shows how cultural voice is talked about as a distant object rather than being integrated within intellectual debates about Open Disclosure.3
The phrase ‘cultural voice’ denotes the human cultures of Australia’s First Peoples. It demarcates space in health policy analysis so that “human culture” becomes visible instead of dissolved within the sameness of whiteness. I suggest that it is time to plant a flag in the
3 Lock, M.J. (1st March 2018), [online], Culturally Unsafe Open Disclosure [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/culturally-unsafe-open-disclosure-dr-mark-j-lock-/
How can cultural voice be included in Open Disclosure policy?
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moon of Australian Open Disclosure policy and declare “this ground includes the cultural voice of Australia’s First Peoples.” As the above image shows, the challenge is to insert cultural voice into a governance environment where the Australian norm assumes sameness of cultures.
"IT TASTES LIKE CHICKEN" - THE AMBIGUOUS FLAVOUR OF CULTURE SOUP
The Australian National Model Clinical Governance Framework (2017) introduces a conceptualisation of culture as 'the values, beliefs and assumptions of occupational groups' (p.8) which is the first time that a definition of culture has appeared in Australian health policy documents. It appears to be an edited version where ‘occupational groups’ replaces ‘people’ for example the Nursing Council of New Zealand’s (2011) limited definition of culture as ‘the beliefs and practices common to any particular group of people.’4 A complex version, in the context of cultural competency in the United States, Cross et al. (1989) state that human culture ‘implies the integrated pattern of human behaviour that includes thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group’.5 While it is difficult to define and measure culture, as noted by one review of the concept,14 I think this needs to be attempted if the concept of 'cultural safety' is to wedge itself into the hard-data, evidence-based world of quality and safety accreditation.
Definitional debates about culture run into its ambiguous meaning in Australian healthcare policy because of the 'cultural soup' phenomena of organisational culture, workforce culture, safety culture, workplace culture, and so on.15-18 As such, the punch of the phrase ‘cultural safety’ could easily be diluted when it is unknown in mainstream healthcare.19, 20 To add to the ambiguity, the Australian Commission on Safety and Health Care published the report Safety Culture Assessment in Health Care: A review of the literature on safety culture assessment modes (2017).21 Thus, easily confounding the phrases 'safety culture' and 'cultural safety'.
CULTURAL VOICE IS EXCLUDED FROM HEALTHCARE GOVERNANCE
An assessment of healthcare governance literature shows that Australia’s First Peoples’ cultural meanings of governance are invisible. For example, in Meredith Edward's (2002) discussion of Australian public sector governance,22 in Donald Philippon and Jeffrey
Should the human cultures of Australia’s First Peoples be an ingredient in culture soup, especially when the chefs are non-Aboriginal people?
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Braithwaite's (2008) comparative review of Australian and Canadian systems of healthcare governance,23 in Lynne Bennington's (2010) Australian review of corporate governance and healthcare literature,24 and in Barbazza and Tello's (2014) international review of health governance25 which referenced Braithwaite, Healy and Dwan's (2005) Australian discussion paper about the governance of health safety and quality.26 This represents an institutional cultural blindness where there is no 'human culture' explicitly considered in healthcare governance, in a multicultural country, whose First Australians have suffered most in the evolution of healthcare.
As Brigg and Curth-Bibb (2017) point out in an article about intercultural governance in Australian Indigenous organisations, ‘Australian governments operate through a European-derived mode of state governance typically conceived, in the dynamics of settler-colonialism, as if it were a form of natural order – a benign and a-cultural framework as opposed to a deeply held set of cultural beliefs.’27 The Australian Indigenous Community Governance Project stated that ‘governance is not culture-neutral’28 and the Institute of Internal Auditors Research Foundation in the United States state that ‘We also recognize that effective governance approaches may be applied in different ways across different cultures’.29 Therefore, a key task is to elucidate how cultural voice affects Australian healthcare governance.
AUSTRALIAN CULTURAL SAFETY
Working out how cultural voice affects healthcare governance is important because of an increasing momentum to include cultural safety in healthcare provisions.30 The concept of cultural safety was raised in 1988 in New Zealand when Ms Hinerangi Mohi stated, ‘You people talk about legal safety, ethical safety, safety in clinical practice and a safe knowledge base, but what about cultural safety?’31 Irihapeti Ramsden (2002), moved by Ms Mohi’s words, subsequently had an enormous influence on nursing practice and cultural safety in Aotearoa/New Zealand. Ramsden's work focussed on nursing practice at the point of engagement between a nurse and a patient and proposed the stages of moving from cultural awareness to cultural sensitivity to cultural safety.32
Much Australian writing about cultural safety draws-on Ramsden. However, the Australian view of cultural safety, while primarily focussed on the nurse/patient interaction, can be expanded to consider governance and systemic levels, echoing the influence of Cross et al. (1989) who pitched competence as congruent to 'all levels' from the individual, agency, and system. Therefore, effecting cultural safety needs to occur through different levels of governance with professions, organisations, governments, and their policy development processes (such as Open Disclosure policy).
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THE WILLIAMS DEFINITION OF CULTURAL SAFETY
Cultural safety also needs to be talked about from different social policy spheres in accord with the social determinants of health. Back in the 1990s, Australian non-Aboriginal educator Robyn Williams heard a presentation from Irihapeti Ramsden about cultural safety. Williams published a personal reflection on Cultural safety – what does it mean for our work practice? (1999).33 Writing about higher education organisations and teaching Australia’s First Peoples, she posed the question: what are the key factors that facilitate effective access, participation and control for Indigenous peoples in the current systems of governance? A relevant question for the health sector and health policy development, as I demonstrate in this critique of Open Disclosure policy.
William's discussed the concept of cultural safety with Aboriginal colleagues including Maryann Bin-Sallik AO (Descendant of the Kija people of the Turkey Creek area) and this resulted in an Australian definition of cultural safety that Bin-Salik credited to Robyn Williams.34
BIN-SALLIK'S MORAL OBLIGATIONS IN GOVERNANCE
Bin-Sallik published Cultural Safety: Let’s Name It! (2003) as a reflective article on cultural safety and Indigenous participation in the Australian higher education sector. She raised a point that is missed in healthcare corporate governance, that higher education institutions ‘have a moral obligation to deconstruct what they are responsible for constructing in the first place.’34 There is no discussion of moral obligations or human rights or the colonial roots of governance in Australian healthcare governance literature (see ‘cultural voice is excluded from healthcare governance’, above). It appears that the so called “old” norm of excluding Australia's First Peoples from policy development survives in obscure policy topics like Open Disclosure.
Cultural safety is an environment that is spiritually, socially and emotionally safe, as well as physically safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience of learning together. - Robyn Williams
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This brings to the fore the notion of ‘government governance’ (the governance of Australian Aboriginal affairs by governments). In the book Serious Whitefella Stuff (2016), Professor Mark Moran observed ‘governments often make decisions on policies and programs with little input from the Aboriginal and Torres Strait Islander Australians on programs and policies designed for them.’35 This statement highlights the need for cultural safety to be considered in contexts other than clinician and patient communication, to touch every aspect of the healthcare system.
OPEN DISCLOSURE AND CULTURAL SAFETY
The implications of these perspectives for Australian Open Disclosure will be further developed in this critique's discussion that I frame as William’s cultural safety governance and Bin-Sallik’s moral obligations. At this point I can say that no existing published journal articles specifically address cultural safety and healthcare governance. The need to address this knowledge gap is important because this quote from the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) makes the link between professional practice to society, systemic, structural, and social determinants of health:36
‘Cultural safety is a philosophy of practice that is about how a health professional does something, not [just] what they do…. It is about how people are treated in society, not about their diversity as such, so its focus is on systemic and structural issues and on the social determinants of health….Cultural safety represents a key philosophical shift from providing care regardless of difference, to care that takes account of peoples’ unique needs. It requires nurses and midwives to undertake an ongoing process of self-reflection and cultural self-awareness, and an acknowledgement of how a nurse’s/midwife’s personal culture impacts on care.’ (p. 4)
The implications are that cultural voice should be allowed into healthcare governance (Williams' cultural safety governance), that an intellectual debate is required on the morality of Australian healthcare governance (Bin-Sallik's moral obligations), and that cultural voice should be evident throughout healthcare governance. However, it appears that Australian OD policy governance is culturally unsafe.
The Nursing Council of New Zealand (2011) state that ‘Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual’.4 The institutional trajectory of the concepts of governance and clinical governance began from – and continue - a point-of-view that Aboriginal and Torres Strait Islander culture has no bearing on those concepts for Australian healthcare.
This recalls the social attitudes of Australian government ministers in the 1965 Native Welfare Conference where they reaffirmed the policy of assimilation which ‘seeks that all persons of Aboriginal descent will choose to attain a similar manner and standard of living to that of other Australian’s’37 which was reiterated in 2000 by former Aboriginal Affairs
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Minister, the Honourable Peter Howson was of the view that ‘the only possible future for Aborigines that makes any sense’ was ‘becoming absorbed in the mores of that civilisation’.38 Could those past blatant discriminatory attitudes be transformed into a contemporary institutionalised norm of excluding cultural voice?
Key Message
Currently (2018), Australian Open Disclosure policy bears the indicators of being culturally unsafe because it denies the identity of Australia's First Peoples, disrespects their cultural voices, and ignores the importance of ‘human culture’ in healthcare policy development. The next section gets into the methodology for the critique, presents a Figure for policy trajectory analysis, and presents the first key finding of 'blinded policy development trajectories'.
Policy Trajectory Methodology
In this section I talk about the methodology behind my analysis of Australian Open Disclosure Policy. As implied in the picture, I use this methodology to scrutinise Open Disclosure governance by the Australian Commission on Safety and Quality in Health Care.4
METHODOLOGY – CONSTRUCTING A POLICY TRAJECTORY
I examined publicly available policy documents because they are ‘totemic objects’ produced by ‘coalitions of elites’ worthy of analysis because ‘beneath their flat surface run the broad currents that underlie aspects of public life.’39 The published documents of OD are the only source of information available where it is possible to eke out a scent of the hidden processes involved in their production. Tracking the scent involved finding OD policy documents published on the internet and then linking them into a policy trajectory because I wanted to see how cultural voice resonated through the trajectory of OD policy development. In a
4 Lock, M.J. (16th March 2018), [online], Tracking cultural voice in Open Disclosure governance [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/tracking-cultural-voice-open-disclosure-governance-dr-mark-j-lock-
Should Open Disclosure governance be closely scrutinised?
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policy trajectory approach, the OD policy documents are ‘themselves political acts’ that ‘carry meanings representative of the struggle and conflict of their production’.40
The linking of documents into a trajectory means that a clear line of sight can be seen from the present to the past. But it is not enough to link one document to another and extract meaning so I used the analytical lens of governance. For me, the very word ‘trajectory’ means that someone was the steward of the OD policy development process, that the steering of a national policy required good governance processes, and this ‘someone’ is the Australian Commission on Safety and Quality in Healthcare (ACSQHC).
Complicating this critique is that the concept of governance is non-standardised as evident in several definitions in use in Australia41-43 and as recognised internationally ‘the health governance function itself remains an elusive concept to define, assess and operationalize’.25 This means that what is ‘good governance’ is open to interpretation and justifiable on vague criteria. What I was trying to find was some concept of governance that respected cultural voice.
The Indigenous Community Governance Project of the Centre for Aboriginal Economic Policy Research (CAEPR) defined governance as 'the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve the things that matter to them'.28 As this definition is built from case study work with Australia’s First Peoples’ organisations, I thought it appropriate to use it as the mirror through which to hear echoes of their voices. The CAEPR work positions governance as inherently a culturally-based concept (page 9 of ‘contested governance’) whereas Australian governance writers write-out any notion of human culture.
The PRIS Lens
With governance as the conceptual magnifying glass in hand, I examined the OD policy trajectory (Figure 1) to detect the points where cultural voice was reflected by using a keyword search (Aboriginal, Indigenous, and Torres Strait Islander) of the OD documents. I translated the CAEPR definition of governance to a PRIS schema of processes (how things are done), relationships (connections between people and organisations), institutions (rules as embedded in Acts), and structures (administrative mechanisms such as committees) to provide an organizing lens for the analysis of the OD policy documents.
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Figure 1: Timeline graphic of policy outputs in Open Disclosure and First Peoples’ Health Policy (©2018 Dr Mark J Lock)
The PRIS box at the centre of Figure 1 is an interrogative lens to attempt to uncover some of the hidden processes that occur in the stewardship of government governance, of which the policy documents are the tangible cultural markers. Within their pages of text are traces of the machinations that lay behind their production – a textscape of signs and symbols. The PRIS lens is ordered as ‘I’ for institution, ‘S’ for structures, ‘P’ for processes, and ‘R’ for relationships to move from the highly conceptual to more concrete aspects of the PRIS white box.
In my terms, the word ‘institution’ refers to the invisible and intangible social norms and values of beliefs in society (think of democracy, marriage, religion, law, and health) while ‘structures’ are more substantial (think of committees and agreements) and ‘processes’ refer to administrative procedures and protocols for the conduct of business. The most concrete domain is that of ‘relationships’ because these are the social interactions between agents that bring into life the institutions and structures and processes of governance.
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Findings – Open Disclosure Governance and Cultural Voice
This critiqe unpacks each finding under the PRIS headings of processes, relationships, institutions, and structures. I ladder the critique from the most abstract concept to the most concrete concept: institutions (I), structures (S), processes (P), and relationships (R).
Blinded Policy Development Trajectories (I)
The documents are chronologically ordered (Figure 1) and show that in the time from 2003 to 2018 alongside of the OD development process (left hand side) occurred concurrently health policy development for Australia’s First Peoples (right hand side). On each side is a series of documents which are linked to each other through explicit mention of one within the other by statements such as ‘this policy builds on’ or ‘this policy is related to’ or simply by direct citation. There is a clear developmental trajectory from one document to the next.
Each of the pathways from each document to the PRIS box represents common thematic lines such as ‘health system effectiveness’, ‘clinically appropriate care’ and ‘quality of care with patients’ as well as ‘governance and accountability’. Thematic links are easy to find through key word searching and they represent a common language used by policy writers in public health.
However, to go beyond thematic signals, I tracked the explicit citations and references to other policies and found the policy documents from both sides did not refer across to each other in contrast to how they pointed to their policy heritage within the same trajectory. This implies a problem with horizontal (across boundary) integration, essentially that policy development processes appeared to be ‘blinded’ to one another. Neither Open Disclosure documents nor Australia’s First Peoples health policy documents mention one another. This is a problem of horizontal integration where vertically developed policy streams do not cross-refer to each other, and occurs through the leadership of the Australian Health Ministers’ Conference and their Australian Health Ministers’ Advisory Council.
Cultural Voice Not Caught in the ‘Acts’ (I)
The cultural voice of Australia’s First Peoples is absent from Australian health legislation. The OD policy documents do not reflect any essence of cultural voice which is consistent with the absence of Australia’s First Peoples from Australian health legislation. In Australia, government statutory organisations are ‘enabled’ into life through laws passed by Australia’s Parliament.
The Australian Health Ministers’ endorsed the operation of the ACSQHC in 2006 which in time became an independent statutory authority by law through the National Health Reform (NHR) Act 2011,44 and it operates under the Public Governance, Performance and
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Accountability Act 2013.44, 45 Both Acts do not give explicit direction to address cultural voice, nor in the eligibility criteria for the ACSQHC Commission Board members or staff of the commission -who are engaged under the Public Service Act 199946 - or in the establishment of committees.46
In an incredibly interesting report, Legally Invisible: How Australian Laws Impede Stewardship and Governance for Aboriginal and Torres Strait Islander Health (2011) Genevieve Howse found that ‘there is no Australian law or series of laws which, taken together, create a legislative structure to secure stewardship and governance for the health of Aboriginal and Torres Strait Islander people’.9, 47 As a result, Australia’s First Peoples cannot rely on institutionalised power to enforce regulatory performance in healthcare safety and quality. The willingness of Australia’s governments to pass motions of sorrow and regret for the past treatment of Australia’s First Peoples appears unmatched by altering legislative structures to enforce, for example, recognition of their cultural voice into corporate health governance standards.48
And the importance of legislative enforcement is highlighted in a recent report, Addressing Institutional Barriers to Health Equity for Aboriginal and Torres Strait Islander People in Queensland's Public Hospital and Health Services (embargoed) the author stated that, ‘The lesson to be learned from this report is that if Aboriginal and Torres Strait Islander health policies are not reinforced in the relevant legislation, then those primarily charged with implementing them, namely the HHS [Hospital and Health Services] boards and their executive management teams, as this audit demonstrates, will invariably ignore them’ (Adrian Marrie, 2017, p.16).49
Key Message
Australian Open Disclosure policy is scrutinised using a specific policy trajectory method, through a governance lens, to see if cultural voice resonates through the textual landscape created by OD policy. At the institutional level, where the analysis is about detecting the moral dimensions (following Bin-Sallik) of governance, OD policy development is blind to cultural voice. Furthermore, this is a norm followed by the Australian Commission on Safety and Quality in Healthcare, whose enabling legislation excludes cultural voice. In the next section, the institutional level analysis continues in the findings of 'editing out cultural rights' and 'no cultural statistics'.
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Editing Out Cultural Rights (I)
This section reveals an Australian norm to exclude cultural voice from OD policy. The image shows Aboriginal people excluded from non-Aboriginal dominated medical forums.5
Tracking cultural voice in policy development processes is about seeing how the voices of Australia's First Peoples are included in government governance. In the last section I introduced a policy trajectory method to see if cultural voice resonates through the textual landscape created by OD policy. At the institutional level, where the analysis is about detecting the moral dimensions of governance, OD policy development is blind to cultural voice. Furthermore, this is a legitimate norm followed by the Australian Commission on Safety and Quality in Healthcare, whose enabling legislation excludes cultural voice (hence the image, above). In this section, I conclude the institutional level analysis for Australian OD policy.
Both policy streams (Figure 1) differ with respect to their takes on ‘culture’. In the health of Australia’s First Peoples, culture and cultural safety has a basis in human rights instruments.50 But this does not translate into Australian healthcare rights. The Australian Charter of Health Care Rights (ACHCR) was developed by the ACSQHC between 2007 and 2008 (during the time of development of the National Indigenous Reform Agreement), and its three principles are the right to access health care, the human right to health care, and acknowledgement and respect of different cultures.51
In all the supporting documents for the ACHCR (see here), the rights of Australia’s First Peoples are not explicitly noted except in the National Patient Charter of Rights: Consultation Report (2008) where, in the section about ‘Respect’ it is noted that ‘there should be more explicit reference to Indigenous Australians and culturally diverse communities’.52 However, the final ACHCR has no explicit reference to Australia’s First Peoples and instead includes them, surreptitiously, with culturally and linguistically diverse communities when it states ‘The care provided shows respect to me and my culture, beliefs, values and personal characteristics’.51
CONFLATING AUSTRALIAN FIRST PEOPLES AND CALD COMMUNITIES
5 Lock, M.J. (3rd April 2018), [online], Australian health norm: exclude cultural voice from Open Disclosure policy [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/australian-health-norm-exclude-cultural-voice-from-open-lock-/
Why does OD policy governance exclude cultural voice?
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The United Nations Declaration on the Rights of Indigenous Peoples (2008) makes a number of points to show why the rights of Australia's First Peoples should be disentangled from the rights of culturally and linguistically diverse communities. Australia's First Peoples are unique because of their: history of colonization, dispossession of lands, territories and resources; the right to self-determination of political status; the right to strengthen their social and cultural institutions; and the right to the dignity and diversity of their cultures, traditions, histories and aspirations. However, the Australian Charter for Healthcare Rights makes invisible Australia's First Peoples in the generic phrase "me and my culture".
Almost ten years later, the ACSQHC 2016-2017 Annual Report (2017)53 noted a publication Consumer Health Information Needs and Preferences: Perspectives of Culturally and Linguistically Diverse and Aboriginal and Torres Strait Islander People (2017) which fails to understand the politics of writing about Australia’s First Peoples and disrespectfully includes them with Culturally and Linguistically Diverse communities.54 This appears to be a norm in Open Disclosure. For example, the New South Wales Clinical Excellence Commission published its Open Disclosure Handbook (2014) where it states that ‘Interactions with the health system for people from culturally and linguistically diverse backgrounds, in particular Aboriginal people and refugees’55 (and it also includes a paraphrase of the ‘copy and paste’ OD statements). This ethic is replicated at a local organisation in the Mid North Coast Local Health District Consumer and Community Engagement Framework (2015-2017) where it states, ‘Proactive engagement with the Aboriginal community and other culturally diverse and marginal groups’.56
At the Australian national health system level, the ACHCR is reaffirmed in the Australian Safety and Quality Framework for Health Care (ASQFHC, 2010), that was developed in 2009 (Figure 1) and which states that an action for people in the health system is to ‘promote healthcare rights’.57 However, in the Proposed National Safety and Quality Framework Consultation Report May 2010 (NSQF, 2010), a suggested strategy was to ‘provide care that is culturally safe’58 which in the final ASQFHC (December 2010) was edited into ‘provide care that respects and is sensitive to different cultures’ (see section 1. Consumer centered – area for action 1.4).57
Based on these examples, it is an Australian norm to conflate the cultures of Australia's First Peoples with those of immigrants and refugees. In the CDAMS Indigenous Health Curriculum Framework (2004), the pedagogical principles state ‘it is important to teach Indigenous cultural safety/awareness separately to multicultural awareness’ (Principle 8).59
HEALTHCARE RIGHTS UNDERCUT BY DEFINITIONAL COMPLEXITY
Furthermore, it is normal to edit-out cultural voice completely in Australian healthcare rights. In the Proposed National Safety and Quality Framework - Consultation Report (2010) the term ‘Aboriginal’ was mostly used with the phrase ‘culturally safe’, but the report noted that ‘culturally safe’ was difficult to define.58 Definitions of cultural safety were
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available such as by Williams (1999) and Bin-Sallik (2003) for Australian perspectives and Ramsden (1990, 2002) for a New Zealand perspective.32, 60 Furthermore, it is also difficult to define health, safety, and quality so ‘difficult to define’ should not be an exclusion criterion. The concepts of safety and quality are not defined in the terminology section of the National Safety and Quality Health Service Standards (2012, 2017),18, 61 but the Royal Australian College of General Practitioners (RACGP) references safety62 as reducing the risk of unnecessary harm to an acceptable minimum level and it is clear that it is about technical, medical, and environmental safety (Mohi: what about cultural safety?).
The RACGP cite the World Health Organisation’s Conceptual Framework for the Classification of International Patient Safety (2009) wherein the ‘drafting group’ realised the importance of universally accepted clear conceptual definitions without which ‘understanding will continue to be impeded’.63 The ensuing document goes to great lengths to define patient safety (not including cultural safety) which contrasts with the authors of the Proposed National Safety and Quality Framework - Consultation Report (2010) who edited out ‘cultural safety’ due to definitional complexity. The point being that a decision was made to cast-off cultural safety and not devote any intellectual and financial effort towards its further elucidation and examination, the obverse occurring for technical and medical quality and safety research.
It appears that promoting health care rights was sacrificed because of definitional complexity. Furthermore, the ACSQHC commissions research on ‘safety culture’64 and 'medication safety'65-67 but not cultural safety. The argument can be made that excluding cultural voice and cultural rights results in exclusion from resource allocation decisions. In 1997, Professor Ian Anderson wrote, ‘moral values and resource allocation cannot be isolated from the social interactions through which these are realised’.68 And Nedelsky (2011) states, ‘What rights do and have always done is construct relationships – such as those of power, responsibility, trust, and obligation’.69 In this light, the copy and paste approach to cultural safety in the OD policy stream (over a decade of development) disrespects the rights of Australia’s First Peoples to a culturally safe health system.
The editing-out of cultural voice in Australia is validated at every level - from the World Health Organisation to Australian healthcare standards to every healthcare organisation - the cultural values of Australia's First peoples are systematically excluded from the institution of health.
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No Cultural Statistics (I)
An implication of editing out cultural rights and cultural voice is that quality assurance process rule-out the collection of statistics. There are ample Figures about the use of hospitals by Australia’s First Peoples people for different health conditions. For example, the New South Wales Clinical Excellence Commission’s Chartbook (2010) for data published in 2010 had - for the first time - a chapter to show the rates of hospitalisation for a variety of conditions.70 However, there is no such discrimination made in its Clinical Incident Management System (2014a),71 and indeed no specific mention of Aboriginal people in the NSW Health Incident Management Policy Directive (2014)72 whereas the NSW Health Open Disclosure Policy Directive (2014)73 includes specific reference to relevant Aboriginal policies. This discrepancy is discombobulating.
On the one hand there is loud statistical noise about high separation rates, disease conditions and readmissions to indicate a high degree of contact by Australia’s First Peoples with public health services,74, 75 but on the other hand, there is statistical silence in incident reporting in the NSW health system. How often do incidents of patient harm occur? In the six months from January to June 2017, there were 94,618 clinical incidents and 7,190 complaints made through the NSW Clinical Incident Management System, where are the incidents reported by and about Australia’s First Peoples?
Not that it has ever been a concern, judging by a 2002 journal article on adverse events in surgical patients in Australia which did not mention Australia's First Peoples.76 This is consistent with the 1995 Quality in Australian Health Care Study77 and activities resulting from that study, which excluded cultural voice. This is made more pointed when the ACSQHC funded research on patient and family member views about the Open Disclosure process (Iedema et al. 2011) that also did not include the views of Australia’s First Peoples.78 The point being that a research gap was noticed between the statistics of patient incidents and the views of patients in the decade of development of OD policy. But the views of patients with the highest rate of contact with hospitals, with the greatest health disadvantage, and history of distrust of hospitals, were left out of the evidence equation.
Furthermore, it was noted in the Proposed National Safety and Quality Framework - Consultation Report (2010), based on consultations conducted by the ACSQHC in 2009 (one year after the Apology to Australia’s Indigenous Peoples) that ‘cultural safety was difficult to define’ (see ‘healthcare rights undercut be definitional complexity’, above). That empirical gap was not addressed as shown by the ‘copy and paste’ approach where no research was commissioned by the ACSQHC on that question, in contrast to research directed towards non-Aboriginal people and gathering their views about Open Disclosure.78 Additionally, the 2017 report Safety Culture Assessment in Health Care: A Review of the Literature on Safety Culture Assessment Modes21 shows that the ACSQHC funds research about safety culture but ignores cultural safety.
The ACSQHC commissions and contributes to research under the mission of ‘knowledge and leadership for safety and quality’ which is noted in annual reports where tables are provided for ‘engagement in research’ and the results are: for the years 2011-12, 2012-2013,
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2013-2014, 2014-2015, 2015-2016: no reported research about or with Australia’s First Peoples.79-83 It is clear that decisions about research expenditure exclude cultural voice to build an OD policy evidence base that is culturally unsafe.
Key Message and Summary of Institution
Analysis of corporate documents about Open Disclosure revealed that the rights of Australia’s First Peoples were edited-out, conflated with culturally and linguistically diverse peoples, and undercut by definitional complexity. This could explain why there are no publicly available cultural statistics to inform quality and safety assurance processes. This section also indicates the institutional norm of excluding the cultural voice of Australia’s First Peoples from the intellectual development of the institution of health.
The term ‘institution’ refers to hidden social values and norms, which are encoded in Acts of parliament, interpreted into legislation and complied with through regulations. What could the four institutional contours indicate about hidden social values and norms? What is most apparent is the institutional theme of invisible cultural voice. This is evident in the blinded policy development trajectories, cultural needs not caught in the ‘Acts’, editing out cultural rights, and no cultural statistics.
The four contours are patterns detected only from the analysis of policy documents linked together into a trajectory that spans fifteen years and, hence, appear to be institutionalized contours. However, that can only be supposition in the absence of more detailed information gained from the actual machinations of policy development processes rather than abstracted solely from document analysis. A sense of those machinations can be gained by looking at the structures involved in operationalizing governance.
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Disintegrated Governance Leadership (S)
The previous section concluded with the assertion that the enabling legislation for the Australian Commission on Safety and Quality in Health Care legitimised the exclusion of cultural voice and, furthermore, this is an Australian cultural norm. In the next sections I shift away from the institutional level of analysis to focus on 'structures' of governance - Boards, healthcare standards, quality assurance mechanisms, and policy levers - which are the more physical manifestations of the ‘health institution’.6
BOARDS AS KEYSTONE STRUCTURES
The concept of corporate governance is physically expressed in the form of committees. In the OD policy development process, as with health policy for Australia’s First Peoples, it is guided by committees. Decisions on the Terms of Reference, the authorisation process, the awarding of contracts for literature reviews, etcetera, are formally endorsed through committees. Unfortunately, there is no publicly available audit trail of these decisions available to be examined. With transparency and accountability key principles of corporate governance standards, because they lead to improved trust with stakeholders, divulging the actual decision-making process would be good practice. What is the role of corporate governance in OD policy development?
The Australian National Audit Office states 'broadly speaking, corporate governance generally refers to the processes by which organisations are directed, controlled and held to account. It encompasses authority, accountability, stewardship, leadership, direction and control exercised in the organisation'(1999).41 Further it states that 'Typically a CAC [Commonwealth authorities and companies] body...is governed by a Board to which the CEO and management are accountable. The Board is in turn accountable to the responsible Minister(s)'.41 The Corporate Governance and Accountability Compendium for NSW Health (2012) states that 'The role of the board is focused on leading, directing and
6 Lock, M.J. (13th April 2018), [online], Disintegrated Leadership in Open Disclosure Policy [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/disintegrated-governance-leadership-open-disclosure-policy-lock-
How can Open Disclosure and Indigenous heath policy trajectories achieve integration?
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monitoring the activities of the local health district' and 'The Board has specific statutory functions, outlined in section 28 of the Health Services Act 1997'.84 Boards are thus keystone structures for corporate governance, and the Australian Commission on Safety and Quality in Health Care (ACSQHC) is a Board governed statutory organisation – a formally constituted organisation of the State.85
INTEGRATED GOVERNANCE
The mission of the ACSQHC is to ‘lead and coordinate healthcare safety and quality improvements in Australia’.79 The concept of ‘coordinate’ means to bring different elements into a harmonious or efficient relationship, and ‘integrate’ means to bring different groups together into equal participation. Both concepts are important principles of healthcare governance and a tool to give them effect is partnerships.25 However, there is an important difference between the OD policy stream (Figure 1) with the emphasis to ‘coordinate’ and the Indigenous policy stream with the focus to ‘integrate’.
In the 2008 National Indigenous Reform Agreement (NIRA, Figure 1) there is a section entitled ‘Integration and Governance’ where it states that ‘Governments propose to take a much more transparent and systematic approach to coordinating services’ by ‘At the highest level, all Governments will be guided by the Service Delivery Principles for Services for Indigenous Australians agreed by COAG in 2008’ (see p.A-21 of the NIRA). One of the those principles is the Integration Principle that states, ‘there should be collaboration between and within Governments at all levels and their agencies to effectively coordinate programs and services’.86 Integrated planning processes were put forth by NSW to the Commonwealth Government in the Overarching Bilateral Indigenous Plan (OBIP) which were first signed in 2005 and continued to 2015.87 Integration is also a key theme in the (2011) NSW Ombudsman’s report Addressing Aboriginal Disadvantage: The Need to do Things Differently (2011) for example in the statement ‘integrated and clearly articulated strategies’88 for more effective resource utilisation.
A HOLE-IN-GOVERNANCE APPROACH
The ‘whole-of-government’ approach was evident in the 2009 National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes (NPACGIHO, Figure 1) in its initiative of 'making indigenous health everyone's business' with the expected outcome for 'improved inter-agency, multi-programme and inter-sectoral collaboration and coordination to meet the needs of Indigenous families and communities' (although there were no performance measures for that outcome).89 This is derived from the 2003 National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH, Figure 1) where the aim was to ‘guide government action over the next ten years through acoordinated, collaborative and multi-sectorial approach supported by Aboriginal and TorresStrait Islander health stakeholder organisations.'90 However, there is no coordination and
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integration between the OD policy and Indigenous health policy trajectories (see Figure 1, above).
Therefore, there are ample thematic statements about the need for integration, coordination, and collaboration to improve the health of Australia’s First Peoples. This implies that all health policies and their oversight committees include cultural voice. However, the lead committee for Australian healthcare – the ACSQHC – has failed to coordinate with Australia’s First Peoples and integrate their cultural voices into OD policy development (see ‘blinded policy development trajectories’, above). Furthermore, the ACSQHC’s mission is authorised by the Australian Health Ministers’ Advisory Council (AHMAC) who authorised the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004-2009 (2004)91 and the follow-up framework for 2016-2026 (2016), 92 which note the need for ‘whole-of-organisation approach and commitment’ and ‘collaboration’.
Key Message
The analysis of 'structures' in Australian Open Disclosure policy, as exemplified by keystone committees, found a “disintegration gap” between the OD and Indigenous health policy trajectories. Keystone committees, whose members are meant to lead coordination and integration in Australian healthcare, should examine how policy development processes can be coherently interlinked so that the cultural voices of Australia's First Peoples are routinely included in policy development trajectories. In the next section, I continue the analysis of 'structures' by looking at healthcare standards and quality assurance processes.
Structured out of healthcare Standards (S)
This section continues the analysis of structures of OP policy by investigating healthcare standards and quality assurance processes. The image indicates how certain types of evidence are used to inform the decisions of keystone committees.7
7 Lock, M.J. (27th April 2018), [online], Structuring Out Cultural Voice in Australian Open Disclosure Policy [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/structuring-out-cultural-voice-australian-open-disclosure-lock-/
There is a disintegration gap between the rhetoric and the reality of integration, a gap overseen by key governance committees in Australian healthcare.
How can cultural voice be structured into Open Disclosure policy design?
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The previous section began the structural level of analysis of Australian Open Disclosure Policy, where I analysed keystone committees and the concepts of ‘integration’ and ‘whole-of-government’. It is important to understand that 'structures' do not refer to a physical scaffold or platform but to the rules and resources used to develop and maintain institutions. Furthermore, institutions refer not to organisations (e.g. a hospital or university are often referred to as institutions) but to those social practices deeply embedded in time and space, and include marriage, religion, health, welfare, democracy, and sport. Institutions are invisible structures of rules and resources93 evident in the use of social norms and values to justify decisions and resource allocation.
I am always interested in how keystone committees make decisions, the effects of those decisions, the decision-making processes, and who was involved, and the information used to justify decisions. They are straightforward questions, but the answers are difficult to divine, as I have shown in this series, because of abject lack of information. Therefore, my analysis of Open Disclosure policy is exploratory and needs further corroboration. It would be helpful if keystone committees would provide Australian citizens with more information. At least they authorise and publish reports to provide a small window into their world of activities. Through that window I saw a disintegration gap between the OD and Indigenous health policy trajectories, and a hole-in-governance to their whole-of-governance approach. In this section, I continue the analysis of 'structures' by looking at healthcare standards and quality assurance processes.
The enablement of improvements in healthcare requires not only leadership and stewardship but good evidence. The facts and figures of hospital use can signal to leaders and stewards of an organisation how it is performing according to defined indicators. However, with the absence of cultural voice from health Acts, there are no mandated requirements to establish performance and accountability mechanisms. For example, consider the force of authority in text that ‘Open Disclosure is mandated in the National Safety and Quality Health Service Standards (NSQHS Standards) (Standard 1, Criterion 1.16) and is subject to accreditation’.3 The NSW Health Open Disclosure Policy Directive (2014) states that ‘Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations’ [emphasis in original].73 Compliance is assessed through health services having systemic processes in place to comply with the NSQHS Standards.
Health services organisations are accredited in accordance with the 10 NSQHS Standards, which are ‘a critical component of the Australian Health Services Safety and Quality Accreditation Scheme (AHSSQA, 2010) endorsed by the Australian Health Ministers in November 2010’.61 The AHSSQA Scheme (Figure 1) provides for the national coordination of accreditation processes.94 Both the NSQHS Standards and the AHSSQA Scheme are a way to structure-in considerations of cultural voice. However, it took until 2015 for the ACSQHC to do so.
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In the publication Vital Signs 2015: The State of Safety and Quality in Australian Health Care (2015) it is acknowledged that, ‘racial bias affects the varying access that Indigenous people have to health care’.95 Therefore, the ACSQHC began the project Improving Care for Aboriginal and Torres Strait people in 2015 which, in 2018, was being trialed in the NSQHS Standards (second edition). However, the NSQHS Standards (first edition) were published in 2011 after a decade of pre-development from the 1995 Quality in Australian Health Care study (which had no explicit mention of Australia’s First Peoples).77, 96 It appears that in the foundation period from 1995 to 2012 the voices of Australia’s First Peoples were excluded from influencing the philosophy of Australia’s health safety and quality scheme, standards, and accreditation.
‘In-Equality’ Assurance Processes (S)
Research evidence on the cultures of Australia’s First Peoples was available, and was being conducted during the OD, the NSQHS Standards, and the AHSSQA policy development processes. For example, the aim of the Improving the Culture of Hospitals Project (began in 2008) was to develop an evidence-based quality improvement framework for Australian hospitals.97 It included a range of resources, tools and guidelines to support the design and implementation of continuous quality improvement (CQI) strategies for improving ‘cultural sensitivity’ (Chong et al. 2011).98 The project produced the Aboriginal and Torres Strait Islander Patient Quality Improvement Toolkit for Hospital Staff (2015) in which the authors advocated ‘the CQI method as the vehicle to improve cultural sensitivity and to embed a process of organisational cultural reform.99 Why were these recommendations missed in the evidence base captured into the OD policy stream?
If information is not included in the evidence base then it is not reflected in policy and strategy, or accreditation process. For example, the Australian Council of Healthcare Standards (ACHS) is an official accreditation reviewer (by the ACSQHC) for healthcare organisations to meet the NSQHS Standards. It was in 2011 that Chong et al. (2011) advocated for the inclusion of specific elements for Australia’s First Peoples in the ACHS accreditation process. In fact, in 2002 the VicHealth Koori Health Research and Community Development Unit published an Aboriginal and Torres Strait Islander Hospital Accreditation Project: A Literature Review (2002).100 This research evidence did not permeate into An Introduction to the ACHS NSQHS Standards Program (ACHS 2012),101 or the NSQHS Standards (2012, 2017) or the 2012 Open Disclosure Standard Review Report (ODSRR, Figure 1) as judged through the explicit mention of key words (Aboriginal, Indigenous, Torres Strait Islander) and citation of the ICAHP authors. Why was this evidence for accreditation excluded by the ACHS and the ACSQHC?
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Excluded from the Accreditation Environment (S)
‘The NSQHS Standards form an essential part of the accreditation arrangements under the Australian Health Service Safety and Quality Accreditation Scheme (AHSSQA)’102 and the NSQHS Standards 2 Accreditation Workbook (2017)102 clearly highlights the specific actions for Aboriginal and Torres Strait Islander People (though cultural safety is not defined in the glossary). The AHSSQA Scheme demonstrates how Australian healthcare is interrelated, integrated and coordinated because it contains ‘five inter-related elements’ of: health minister endorsement of NSQHS Standards 2, governments mandating that healthcare organisations be assessed, those organisations implementing actions required to meet the standards, accrediting agencies assess organisations, and the ACSQHC coordination of the Scheme (2017). This statement is an excellent example of the link between keystone committees (health minister endorsement = COAG health council), the force of authority in the word 'mandate', healthcare services accreditation and accrediting agencies. It is through these linkages that cultural voice could influence Australian healthcare governance.
However, there is no recognition of Australia’s First Peoples in the AHSSQA scheme. Furthermore, the nine approved accrediting agencies do not have any Reconciliation Action Plans and rarely note engagement or partnerships with Australia’s First Peoples, none of their methodology is available for independent and public scrutiny, and their corporate governance is largely non-disclosed because they are private corporations. At 2018, the nine accrediting agencies were:
1. Australian Council on Healthcare Standards (no cultural voice)
2. DNV GL Business Assurance Australia Pty Ltd (no cultural voice)
3. BSI Group ANZ Pty Ltd (which as accredited one Aboriginal and Torres StraitIslander Community Health Service, see ATSICHS)
4. AGPAL Group of Companies (the owners of QIP) have a case study of accrediting anAboriginal health service, and the website also has an acknowledgement of Aboriginal andTorres Strait Islander people.
5. Global Mark Pty Ltd note that their staff attended cultural awareness training.
6. SAI Global Certification Services Pty Ltd (no cultural voice)
7. HDAA Australia Pty Ltd have acknowledgement on their home page and highlight theAboriginal experience of staff: Scott Douglas, Terrence O’Brien, and Mary Barram.
8. TQCS International Pty Ltd have a partnership with Yaran Business Services.
9. Institute for Healthy Communities Australia Certification Pty Ltd (no cultural voice).
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If the cultural perspectives of Australian First peoples’ - their cultural voice - is not included in accrediting agencies, then assessors may not be sensitised to consider their needs.
At least, with the publication of the National Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health (2017) (developed by the Wardliparingga Aboriginal Research Unit of the South Australian Health and Medical Research Institute), the process has started for cultural voice to be included in Australia health service safety and quality. The ‘user guide’ notes to ‘Use continuous quality improvement processes to improve the cultural safety of the health service organisation’ and referenced the Improving the Culture of Hospitals Project and included John Willis (lead of the project) on the reference panel for the development of the user guide.
Key Message
The year 2017 marks the point where cultural voice can be formally included in Australian healthcare quality assurance processes, the first time in 67 years since the establishment of publicly funded healthcare in the 1950s.103 However, it is a qualified inclusion because the ‘user guide’ is just one point amongst all the points through which influence is exchanged in healthcare decision-making processes. Considering the history and trajectory of development of Australian healthcare standards, quality assurance processes, and the accreditation environment, I found that cultural voice is structured out of the processes involved in their making. In the next section, I finish the structural level of analysis on the topic of 'One-way Street Policy Levers' where different mechanisms are used to lever healthcare reforms into the healthcare governance environment.
One-way Street Policy Levers (S)
This section concludes the ‘structure’ level of analysis of Australian Open Disclosure policy. The image conveys the idea that cultural diversity needs to be included in OD policy evidence.8
In the previous section, I discussed the absence of cultural voice from the history and trajectory of development of Australian healthcare standards, quality assurance processes, and accreditation environment. At least, with the publication of the National Safety and
8 Lock, M.J. (11th May 2018), [online], Leveraging Out Aboriginal Voice from Australian Open Disclosure Policy [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/leveraging-out-aboriginal-voice-from-australian-open-disclosure/
How can healthcare governance leverage-in more colour
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Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health (2017) the process has started for cultural voice to be included in Australian health service safety and quality.
The Williams and Bin-Sallik definition of cultural safety implies that cultural voice needs to be considered in multiple places. Documents such as ‘the user guide’, and other formal policy and strategic documents, serve as levers to enable relationships between different partners in Australia’s healthcare system and open a two-way dialogue between them. Examples of policy levers are policy directives, agreements, health impact assessment guidelines, and training and education programs. Each operates at macro, meso, and micro levels of the healthcare system.
At the macro-level (where a policy applies to all Australian citizens), the National Open Disclosure Standard (NODS, Figure 1, 2008)2 is carried into the NSW Health system through ‘policy directives’ issued by the Ministry of Health to its organisational entities. For example, the NSW Health 2007 Open Disclosure Policy Directive (2014)73 explicitly cites the principles of the NODS, which is an indicator of the linkage (i.e. explicit mention) and trajectory (the years from 2003 to 2018) of policy documents. The policy lever has been pulled so that OD flows into the NSW Health system. Indeed, Australia’s First Peoples are noted in the NSW Health Open Disclosure Policy Directive, but the term 'considered' - in the case of OD policy - means that Aboriginal people are thought about only at the implementation phase of OD
The NSW Clinical Excellence Commission (NSW-CEC) has corporate ownership of the ‘Open Disclosure Guidelines’73 and because the NSW-CEC is a statutory entity it is required to have a formal agreement – Service Compact Agreement103 – with the Secretary of NSW Health. The former Service Compact Agreement-now called a Performance Agreement (2018)104 establishes the ‘service delivery and performance expectations for the funding and other support’ of the NSW-CEC. One of the performance objectives is ‘to develop effective and working partnerships with Aboriginal Community Controlled Health Services and ensure that the needs of Aboriginal people are considered in all health plans and programs developed by the Organisation’ [emphasis added].105 Therefore, a duty of the NSW-CEC is to ensure that the needs of Aboriginal people are considered in Open Disclosure policy but there is no public or published evidence that this has occurred.
Another policy lever is the meso-level (focussed on policy and strategy) NSW Aboriginal Health Impact Statement and Guidelines (2017)106 which were designed to ‘ensure that the needs and interests of Aboriginal peoples in NSW are integrated into the policy, program and service development process’107 through a series of questions designed to ensure that ‘appropriate consultation’ has taken place with communities of Australia’s First Peoples. The ‘guidelines’ are applied at the development phase of programs specifically designed for Australia’s First Peoples and not at all policies and programs such as OD policy development and implementation. Unfortunately, the 'guidelines' have never been evaluated for effectiveness, and the results of their use are neither public nor published and thus not open to public scrutiny.
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One of the most common policy levers at the micro-level (focussed on interaction level) are training programs. For NSW Health staff there is cultural competence training Respecting the Difference: An Aboriginal Cultural Training Framework for NSW Health (2011)108 and the NSW Hospital Skills Program Aboriginal Health Module (2013).109 It is notable that both the Respecting the Difference and the Hospital Skills Program were developed by the State, have no academic or consultative evidence base (that is publicly available), and do not include reference to Aboriginal community controlled organisations or peak advocacy bodies. Power is solely vested with the State from the philosophy, development, design, implementation, resourcing and delivery of the Respecting the Difference and Hospital Skills training.
The above three examples, a small sample of all health policy initiatives, indicate (because more data is needed) a one-way street approach to policy leverage. That is, the direction of engagement appears to be more about shifting behaviours in the so-called 'target populations' rather than to ‘inward’ organisational behaviour change. To sharpen that point more, I quote a passage from Dr. Gregory Phillip's thesis Dancing with Power: Aboriginal Health, Cultural Safety and Medical Education (2015), 'Cultural awareness assumed that the Crown’s sovereignty would never be challenged, that Aboriginal and Torres Strait Islander people would never have equal say in the decision-making of the parliament, the courts, media or corporate Australia, and that at best, all we could do is hope to influence others and perhaps be rewarded with an advisory post on a government committee'.110 A central principle in cultural safety is acknowledgement of power differentials between clinicians and patients and actively addressing the power imbalance.
THE TWO-WAY STREET OF CULTURAL SAFETY
Recalling the Williams definition of cultural safety and Bin-Sallik's (2003) view of moral obligations, means that ‘power’ is a moral lever in the political relationship between the Australian State and its First Peoples. In OD development and implementation, Aboriginal health impact assessment, and cultural awareness programs, only the State (the socio-political institution of Australian Western democracy) has its hands on the policy lever. While Australia's First Peoples are consulted and participate in policy and training initiatives the ultimate control is vested with the State. Following the decolonising ethic of Australian cultural safety (noted, for example, by Funston 2013)111 power could be divested to organisations controlled by Australia's First Peoples. This would meet a criterion of cultural safety because it extends the ethic of empowerment from the micro-level of clinician and patient to the macro-level of the health system.
I propose that the one-way street phenomenon is a cultural artefact of Australian Western democratic hierarchy where implementation flows downstream from the Minister to Secretaries to Boards and Executives to Staff and then to Citizens. Whilst this is a simple schematic of complex processes, it shows that 'awareness' and 'consideration' and 'consultation' processes occur at the staff and citizen interaction level. Does the resulting awareness about the cultures of Australia's First Peoples flow upstream?
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These different levers should raise awareness in NSW health staff for the perspectives of Australia’s First Peoples to be reflected in, for example, policy development processes. However, there is no (public and published) evidence that this awareness raising resulted in any influence in the development of the Australian Charter of Health Care Rights (2009) and through to the Open Disclosure Standards Review Report (2012), the National Safety and Quality Health Service Standards (2012), or the Australian Open Disclosure Framework (2013). With the NSW health staff who have received OD training, Respecting the Difference training, and Hospital Skills Program training, the cultural awareness that they have acquired does not appear to be applied in the development phase of policy.
Key Message - Summary of Structures
The concept of ‘structures’ refers to the more substantial aspects of governance from committees to performance agreements to quality management to policy levers. For OD policy, each were found to have no resonance of the cultural voices of Australia’s First Peoples. I found the four contours of the structural textscape for OD policy and Australia’s First Peoples show disintegrated federal governance structures, structured out of healthcare standards and in-equality assurance process, and one-way street policy levers. These four contours provide an overarching sense that the architects of Australian healthcare structure-out cultural voice. However, it is a limited sample of all healthcare committees (it does not include all Australian jurisdictions), healthcare and quality assurance activities, and policy levers. Furthermore, it is necessary to consider the processes of government governance and how they might incorporate cultural voice, the topic of the following sections.
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The White Box of Government Governance (P)
This section begins the ‘processes’ level of analysis of Australian Open Disclosure policy. The image conveys the idea that the white box of government governance is at the centre of Australian cultural diversity.9
In the previous section, I argued that the architects of Australian healthcare structure-out cultural voice (the human cultural perspectives of Australia's First Peoples) from the history and trajectory of development of Australian healthcare standards, quality assurance processes, and accreditation environment. In the next sections on the topic of Australian Open Disclosure (OD) governance and cultural safety, I focus on the ‘processes’ aspect of governance.
GOVERNMENT GOVERNANCE
Recall that that ‘processes’ means 'how things are done' and 'government governance' (the phrase first coined in the Overcoming Indigenous Disadvantage Report, 2011) refers to the government administration of Australia’s First Peoples.28 Recall also that the Australian State formally excluded its First Peoples from much of the development of Australian social policy, from 1788 to 1967,112-115 and that overt political pressure (rather than take-for-granted due process) was required to influence decision-making and resource allocation.116,
117 In the Australian healthcare system, the story of participation of Australia’s First Peoples is one of volatility in the constant change of advisory structures and processes.118 While there are many themes to pull-out of that history, I want to highlight the absence of any references or research about organisations as ‘power containers’93 which can be positioned between leaders and citizens.
Organisations, such as government departments of health, have a hidden internal organisational architecture joined by myriad processes referred to as Machinery of Government (discussed further below). The ‘machinery’ can be interrogated through the lens of the PRIS box (Figure 1), which in the context of Australian State and its First Peoples, is a ‘white box’ of processes invisible and secret to the external stakeholder. We can gain a sense of the internal processes of an organisation through hierarchical management maps that show the direct relationships between the executives. Otherwise,
9 Lock, M.J. (25th May 2018), [online], The Government Governance White Box in Australian Healthcare [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/government-governance-white-box-australian-healthcare-dr-mark-j-lock-/
How can we see inside the invisible 'white box' of government governance?
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there is no roadmap that details the processes between the points and pathways from the Board to Executive, then to all an organisation's management units, and eventually through to service provision between the staff and the citizen.
UNPACKING THE INVISIBLE BACKPACK
The PRIS box, a schema derived from the Indigenous Community Governance Project (Hunt et al. 2008)28 based on empirical research with Australian First Nations organisations, positions cultural voice as a lens to interrogate government governance. It is a way to make visible the ‘invisible systems conferring dominance’ (McIntosh 1989)119 such as the internal processes of public administration. In Open Disclosure policy governance, the Australian Commission on Safety and Quality in Health Care is the statutory organisation positioned between leaders and citizens. The question is, what happens within organisations that constrains cultural voice?
For example, the visions and missions of Board and Executive committees (keystone committees) can be moderated through the multiple pathways of diffusion within an organisation to, eventually, affect the way a clinician interacts with a patient. In this uncharted terrain, the stewards (healthcare executives) activate the internal organisational architecture to achieve the mission, vision, and objectives set for it through legislation (by political leaders). How could the processes of governance that operate between the floor (frontline clinicians) and ceiling (executives and Boards) of organisations enable or constrain cultural safety for Australia’s First Peoples?
One way is to simply count the number of leaders and stewards who are required to lead governance reforms. However, it is rare for Australia’s First Peoples to be C-suite members, with most being Anglo Celtic in origin.120 Politically, it is non-Indigenous politicians and Ministers who are responsible for constructing (through parliamentary bills and legislation) and overseeing (through Acts and regulations) government governance and their decision-making is an unacknowledged socio-economic determinant of health because of the changes to government administration).
'MOGED' - A NEW VARIABLE IN HEALTHCARE EPIDEMIOLOGY
Each time, the machinery of government (MoG)121, 122 is changed to restructure social policy to align with the politics of the minister of the day, as reflected in the heuristics of partnership arrangements (see Figure 2, below).87 The 2017 Wentworth Lecture by Dr Martin Parkinson notes that 'In 50 years, Commonwealth administration of Indigenous Affairs has cycled through 21 different ministries, and 11 different structures under them' and where 'relationships of trust and good faith…risk becoming collateral damage in a culture of constant movement'.123
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Figure 2: Indigenous Affairs Arrangements 2012
John Gardiner-Garden (1994) wrote a research paper about the Commonwealth involvement in the administration of Aboriginal affairs Innovation Without Change? Commonwealth Involvement in Aboriginal Health Policy (1994) and stated, 'the cycle of action and inaction, commitment and frustration, structure and restructure needs to be broken'.113 In more recent article by KPMG's Ben Sakker Kelly he asked, 'Here we go again, MoGed within an inch of our lives: Is there a better way?' (2017).124 These two articles indicate a norm of Australian democratic governments – constant political change and governance reforms that destabilise citizen trust in public administration.
THE 'SECRET GOVERNANCE' VARIABLE
This brings to the fore the theme of secret governance because there is no way for
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Australian citizens to know how decisions about MoG changes are made, which contrasts to the Australian Health Ministers’ Advisory Council (the stewards) 'This standard [Open Disclosure] will be applied in the interests of a fully open and transparent national health system'. It is unclear to what the members of the Council are referring, as the submissions of Australian healthcare organisations for accreditation against the NSQHS Standards are corporate-in-confidence so that Australian citizens cannot see what their taxpayer funded organisations claim to be doing for them (thus undermining accountability). In effect, the leaders authorise stewards to conduct secret governance in Australian healthcare.
For the stewards of secret governance, located within the PRIS box (Figure 1) there is separation between them and citizen stakeholders, consumers, and patients, a separation that is analogous to the cultural safety distinction between the clinician and the patient. The stewards direct an organisation’s decision-making processes and resource allocation. The stakeholders are configured as external to the organisation and provide advice to the stewards, which is the OD perspective as preferred by the Australian State in its participation structures with Australia’s First Peoples.116, 117 Australian governance literature espouses the principle of stakeholder participation as part of good corporate governance,125, 126 but as noted in the section ‘cultural voice is excluded from healthcare governance’, the participation of Australia’s First Peoples an optional extra.
AND 'GENUINE PARTNERSHIPS' VARIABLE
In the NSW Auditor-General’s Governance Lighthouse (2013) the component of ‘Key Stakeholder Rights’ is at the top of the lighthouse to signify the importance of accountability to stakeholders.125, 126 And in Australia’s National Safety and Quality Health Service Standards (2012, 2017), Standard 2 is ‘Partnering with Consumers’.18, 61 However, there is no published research on the efficacy of such partnerships and their measurement, monitoring and evaluation.
In the NSW Ombudsman’s report Addressing Aboriginal Disadvantage: The Need to do Things Differently (2001) a key finding was that ‘government needs to adopt a very different way of doing business with Aboriginal communities. While for many years there has been rhetoric about ‘partnering’ with communities, too often this has not translated into communities having genuine involvement in decision-making about the solutions to their problems’.88 There was a resulting push to strengthen governance for partnerships with, and accountability to, Australia’s First Peoples’ citizens. This is reflected in the NSW Aboriginal Health Plan 2013-2023 (2012) in ‘Strategic Direction 1: Building trust through partnerships’ wherein it also states to ‘build trust and cultural safety’.127 The intent behind ‘genuine involvement in decision-making’ is to vest power to citizens, a key principle of cultural safety.
The difficulty in measuring, monitoring and evaluating these arguments lies in the fact that the internal decision-making architecture of governments is uncharted. Combine that with the themes: lack of Australia’s First Peoples in C-suite positions, MoGed, secret governance, and genuine partnerships, supports the assertion of a government governance white box.
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Unpacking that box requires more information and administration transparency.
Key Message
The processes of decision-making in the administration of Australia's First Peoples are hidden inside a government governance white box. Unpacking that box could reveal many variables to consider (e.g. MoGed, secret governance, and partnerships) preventing cultural safety in Open Disclosure governance. In the next section, I focus on the variable of 'keystone committees' and how it appears that cultural voice is authorised-out of decision making in Australia's leading healthcare organisations.
Cultural Voice Authorised Out (P)
This section continues the ‘processes’ level of analysis of Australian Open Disclosure policy. The image conveys the idea that the trajectory of OD policy, written by non-Aboriginal people, excludes cultural voice.10
Unpacking the government governance white box could reveal the secret processes of decision-making in the administration of Open Disclosure governance. Important structures for the institutionalisation of secret governance are the numerous keystone committees and how the members of them authorise-out cultural voice in the decision-making processes of Australia’s leading healthcare organisations.
KEYSTONE COMMITTEES
Corporate Governance 'encompasses the mechanisms by which companies, and those in control, are held to account' (ASX Corporate Governance Principles, 2007) and the Australian Health Ministers' Advisory Council (AHMAC) and its committees are the
10 Lock, M.J. (8th June 2018), [online], Keystone Committees Authorise-out Cultural Voice [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/keystone-committees-authorise-out-cultural-voice-dr-mark-j-lock-/
Why is cultural voice excluded from the OD policy trajectory?
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'structures' through which governance occurs for the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026 (CRFATSIH, 2016).92 The Figure above (Figure 3) shows the formal hierarchical relationship between keystone committees and in my view represents a governance chain through which accountability can be tracked. This means that the lead keystone committee – the Council of Australian Governments or COAG - creates the rules for the subcommittee - COAG Health Council - which in turn creates the rules for its subcommittee - the AHMAC, and so on.
SECRET GOVERNANCE FROM SECRET COMMITTEES
The problem with trying to track accountability is that AHMAC's principal committees are secret - there is no publicly available information on either their members or the terms of reference of the committees, not even in an appendix to the CRFATSIH document. See the following link for the AHMAC and its principal committees, which interestingly does not include a link to the sub-committee - the National Aboriginal and Torres Strait Islander Health Standing Committee (NATSIHSC). A Google search (July 2018) for the NATSIHSC committee revealed that it is simply not possible to find out who its members are, but it is known in the industry that the members of the NATSIHSC are civil servants who administer Aboriginal and Torres Strait Islander affairs through government departments. Other than what 'is known' through insider industry knowledge, the NATSIHSC Terms of Reference and full membership are unknown.
Furthermore, as I have noted previously, the decisions of the members of keystone committees are not publicly available and this limits how Australian citizens can see how and what decisions are made for them. The secrecy provision covering the minutes of civil servants arguably 'deprive citizens of information' and 'curtail freedom of expression'128 and limits accountability in Open Disclosure governance.
And the point of this section on 'accountability' is that values are transformed through the governance chain to influence the Open Disclosure (OD) policy trajectory. As for 'accountability', in both policy trajectories (Figure 1), 'governance and leadership' are themes (SCRGSP 2011, COAG 2009a, ACSQHC 2013) that are recursively reproduced in corporate publications.
The Transparency Paradox - Healthcare organisations are required to be accountable to consumers by keystone committees whose decisions are kept secret from Australian citizens.
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INSTITUTIONALISED AUTHORITY
The term 'recursive' means that a value like 'accountability' is repeated in text through different corporate policy documents over time (as in the policy trajectory), is talked about in committees as a principle of governance, is monitored through auditing of corporate records, and occurs in every committee from Australian Parliament to Local Government Councils to project committees. The value of 'accountability' is deeply embedded in Australia's democratic culture, but clearly the practice of it varies depending on many factors such as the concept of 'authority'.
The meaning of authority is 'the right or power to give orders, make decisions, and enforce obedience' (Oxford) and has the twin concepts of 'right' and 'power' at its core. These two concepts are important for keystone committees. While there are different ‘oversight’ committees involved in each of the policy trajectories (Figure 1), and whilst the composition may change due to elections and staff changes, they represent an institutionalised practice whose authority is stamped on the OD policy documents. For example, the 'brand' of the Australian Commission on Safety and Quality in Health Care (ACSQHC) is clearly stamped on all its publications. Its right to power is codified in Australian legislation and for health legislation, Howse and Dwyer (2015) argue that it does not create a legislative basis to protect the healthcare rights of Australia's First Peoples and makes them 'legally invisible'.9,
47 Therefore, the concepts 'right' and 'power' as the basis for authority in keystone committees enables the committee members to authorise-out cultural voice from Open Disclosure governance.
A HIERARCHY OF AUTHORISATION PROCESSES
But what are the actual mechanisms of authorisation processes? As for the ACSQHC, and in all keystone committees, the authorisation processes of public servants (the stewards) play a role in what is ruled in-to or out-of policy processes. Now, AHMAC is a sub-committee (see Figure 3, above) of the COAG Health Council which is one of eight sub-committees to the Council of Australian Governments (COAG) whose members (the political leaders) authorise inter-government coordination, cooperation and partnership in Australia’s federal system. The COAG Health Council is advised by the members of the Australian Health Ministers’ Advisory Council (AHMAC, senior government officials – the stewards of government administration). The COAG Health Council meets to discuss national health issues at the Australian Health Ministers’ Conference. In this hierarchical governance chain, how do authorisation processes work from one committee to the next?
Because of the secrecy provision, it is not possible to obtain the necessary information (e.g., agendas and minutes) to answer that question. This would be important because I would like to see how 'values' are transformed through authorisation processes and why some values are institutionalised, and others are excluded. For example, the value of 'cultural
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respect' was endorsed in 2004 by AHMAC in the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004-2009 (2004)91 and the follow-up framework for 2016-2026 (2016),92 which states as a vision that it, ‘aims to influence the corporate health governance, organisational management and delivery of the Australian health care system to adjust policies and practices to be culturally respectful and thereby contribute to improved health outcomes for Aboriginal and Torres Strait Islander peoples'.91 Logical flaws aside in that statement, there is a way to measure the phrase 'influence corporate health governance' through the policy trajectory method (see ‘Policy Trajectory Methodology’, above).
A TRAJECTORY OF EXCLUDING CULTURAL VOICE
The Open Disclosure Standard Review Report (ODSRR, Figure 1, 2012) states that Australian health ministers endorsed the National Open Disclosure Standard (NODS, Figure 1, 2003) in 200310 which was also the year of endorsement from Australian governments for the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013 (NSFATSIH). The point is, when policy words about ‘system’ and ‘collaboration’ and ‘coordination’ are used, it implies that policies about OD and Australia’s First Peoples should be joined-up through whole-of-government communication (see ‘Disintegrated Governance Leadership’, above).
Instead, the OD process and its trajectory of authorisations effectively legitimised the exclusion of cultural voice from 2003 onwards while cultural respect in corporate health governance was on the agenda of keystone committees. Regarding the internal, and invisible, bureaucratic processes within the government governance white box (PRIS box, Figure 1), what happened during the endorsement processes of the Australian health ministers?
Key Message
Keystone committees in Australian healthcare appear to have an institutionalised norm of excluding cultural voice from Open Disclosure policy governance. A scent of that norm can be tracked in corporate policy documents that are authorised by the Australian Commission on Safety and Quality in Health Care. But its practice reflects deeper Australian cultural norms. The challenge is for healthcare governance leaders and stewards to overcome these values and how they contribute to excluding Australia's First peoples' cultural voice from the right to power and authority in decision-making processes.
As I always say, more information is needed so that decision-making processes can be audited for their cultural safety. In the next section I examine the formal evidence gathering processes underpinning evidence base of Open Disclosure policy, and wrap-up this section on 'processes' before moving onto the 'relationships' aspect of the GGWB.
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Excluded from the Open Disclosure Evidence-base (P)
This section examines the formal evidence gathering processes underlying OD policy. As the image implies, there is a quirky effect between the policy buildings of Open Disclosure and Australia’s First Peoples regarding the inclusion of cultural voice.11
INSTITUTIONALISED ETHIC TO EXCLUDE CULTURAL VOICE
In the previous section, I detailed how keystone committees in Australian healthcare appear to have an institutionalised norm of excluding cultural voice from Open Disclosure policy governance. A scent of that norm can be tracked in corporate policy documents that are authorised by the Australian Commission on Safety and Quality in Health Care. But its practice reflects Australian cultural norms. It is up to healthcare governance leaders and stewards to challenge these values and how they contribute to excluding Australia's First peoples' cultural voice from the right to power and authority in decision-making processes.
STEWARDSHIP OF BIAS IN EVIDENCE-GATHERING PROCESSES
The secret decision-making processes of government stewards can also be seen in the gathering of evidence. The knowledge construction of OD policy documents shows the many evidence-gathering processes taken to inform them, such as workshops, public submissions, consultation documents, and academic literature reviews. One problem with my analysis is that I am not able to obtain the Terms of Reference underlying any of those processes and, therefore, the OD policy documents do not provide the full picture. Nevertheless, what is available provides a hint about the stewardship of bias of the evidence-gathering process.
The Australian Council (it is now the Commission) on Safety and Quality in Health Care (ACSQHC) in 2004 began building a National Patient Safety Education Framework (2005)129 to describe the competencies for patient safety for health care workers. In the article describing the process (Walton et al. 2006)130 the needs of Australia’s First Peoples were not described. Similarly, the article by Iedema et al. (2008a) on the evaluation of the
11 Lock, M.J. 25th June 2018), [online], Excluding Aboriginal Knowledge from Australian Open Disclosure Evidence [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/excluding-aboriginal-knowledge-from-australian-open-disclosure-lock-/
How can Aboriginal peoples cultural voice be included in OD governance?
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National Open Disclosure Pilot did not contain any reference to Australia’s First Peoples.131 There was just one mention of Australia’s First Peoples (only about communication) in the consultation draft of the Australian Open Disclosure Framework (ACSQHC 2012).132 In the Open Disclosure Standard Review Report (ODSRR, Figure 1, 2012) - the 315 references did not contain any about Australia’s First Peoples.10 In fact, the ODSRR did not explicitly state the terms Aboriginal, Indigenous, or Torres Strait Islander, which also occurred in an earlier review of the literature for OD (Iedema et al. 2008b).133
DISCLOSING INEQUITY IN SCIENTIFIC REVIEWS
It is of concern that these evidence-gathering processes missed the needs of Australia’s First Peoples. This is made more pointed due to the abundant political and media attention to Australia’s First Peoples (New Arrangements in Indigenous Affairs in 2004,134 removal of the Aboriginal and Torres Strait Islander Commission in 2005,135 the Northern Territory Intervention in 2007,136 and the development of the Closing the Gap campaign in 2006)137 from the time of the NODS (2003) to the AODF (2013). This broader citizenship noise about the disadvantage suffered by Australia’s First Peoples did not resonate with the Commissioners of the ACSQHC. While more data is needed, there appears to be a pattern to exclude Australia’s First Peoples cultural knowledge from entering the open disclosure policy discourse trajectory.
A GAP IN KNOWLEDGE GOVERNANCE
On the side of Australia’s First Peoples policy trajectory (Figure 1, above), it is also notable that the OD documents were not explicitly cited in either the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013 (NSFATSIH) or the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (NATSIHP) - both stated an aim to, ‘Implement cultural safety and quality of care agendas…across the entire health system’.90 References for how to do so were not offered, reflecting on the stewardship of the oversight committees (the National Aboriginal and Torres Strait Islander Health Council and the National Aboriginal and Torres Strait Islander Health Equality Council) and the evidence-gathering processes that were (they are both disbanded) under their authority.
A gap in knowledge governance by keystone committees highlights the hole-in-governance leadership and stewardship of Australian healthcare.
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On the OD policy trajectory side (Figure 1, above), the ACSQHC commissions and contributes to research under the mission of ‘knowledge and leadership for safety and quality’ which is noted in annual reports where tables are provided for ‘engagement in research’ and the results are: for the years 2011-12, 2012-2013, 2013-2014, 2014-2015, 2015-2016: no reported research about or with Australia’s First Peoples. Decisions about research expenditure exclude cultural voice to build an OD policy evidence base that is culturally unsafe.
Key Message - Summary of Processes
The concept of ‘processes’ refers to the administrative procedures and protocols for the conduct of business, such as the authorisation processes of committees. I found three contours of the ‘processes’ textscape for OD policy and Australia’s First Peoples in the white box of government governance, cultural voice authorised out, and excluding the knowledge of Australia’s First Peoples from the evidence base. These provide an overarching theme of culturally-blind processes in Australian healthcare governance.
Of course, there are many types of processes involved in Australian healthcare that should be audited for their inclusion of Australia’s First Peoples and information from such an audit would prove valuable in informing policy development processes. The very term ‘processes’ signals that the conduits for real influence between leaders, stewards, and stakeholders are ‘relationships’, a concept expanded upon the final section of the analysis of Australian Open Disclosure policy.
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Disclosing Relational Failure in OD Policy Governance (R)
This section begins the ‘relationships’ analysis of OD policy governance. The image conveys the idea of a barrier between keystone committees and cultural voice.12
Relationships are the conduits for exercising real influence between leaders, stewards, and stakeholders. The term 'relationships' is one of four constructs used in this definition of governance as 'the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve the things that matter to them' (CAEPR, 2008, p.9) which is the only definition of governance derived from the cultural voice of Australia's First Peoples.
FEDERALISM FILTERING
Relationships in Australia’s federal system are determined by three levels of government (Federal, State and Territory, and local) and their different departments, which requires much ‘stakeholder engagement’ through informal and formal mechanisms. Committees are a key formal mechanism for relationship formation and management. And this could be a lot of committees, as Australia’s federal system of government results in complex governance structure for Australia’s First Peoples (see Figure 2, below, from the report Australian Government Coordination Arrangements for Indigenous Affairs, 2012).87
12Lock, M.J. (13th July 2018), [online], Disclosing Relational Failure in OD Policy Governance [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/disclosing-relational-failure-od-policy-governance-dr-mark-j-lock-/
How can cultural voice get over the fence and into healthcare governance committees?
Open Disclosure – Closed to Cultural Voice Dr Mark J Lock
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Figure 3: Indigenous affairs governance structure
In the publication Aboriginal Health and Institutional Reform within Australian Federalism (1996), Ian Anderson and Will Sanders asked, ‘Are these institutional arrangements delivering health care to Aboriginal people in an appropriate and effective way, or could they be significantly improved?’.138 One way to assess this question is to track the real connections between the leaders of public health to the stewards of decision-making committees.
TRACKING REAL CONNECTIONS
The ACSQHC Board is populated by (non-Aboriginal) people who, combined, provide ‘extensive experience and knowledge in the fields of healthcare administration, provision of health services, law, management, primary health care, corporate governance and improvement of safety and quality.’83 A board with this track record should be well aware of the relationship between Australia’s First Peoples and the Australian health system. Furthermore, the ACSQHC supports the Inter-Jurisdictional Committee (a meeting of safety and quality officials) which advises the ACSQHC ‘on the adequacy of the policy
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development process and implementation of policies’,139 and these departmental officials should also have been aware of Australia’s First Peoples health needs. While the ACSQHC reports to the Australian health minister, its activities and outputs need to be authorised by all Australian health ministers upon recommendations from the Australian Health Ministers’ Advisory Council (AHMAC) and endorsed by the COAG Health Council (see ‘cultural voice authorised out’, above). These committee members have an incredible depth and breadth of knowledge which did not empower Australia’s First Peoples’ cultural needs into the OD policy development process.
HOLDING LEADERS TO ACCOUNT
In New South Wales, Ms Elizabeth Koff is the Secretary of New South Wales Health, is a member of the AHMAC, and advises the Honorable Brad Hazzard (New South Wales Minister of Health) who is a member of the COAG Health Council. Furthermore, NSW Health is represented on the Inter-Jurisdictional Committee to the ACSQHC. The NSW Health’s Declaration on Aboriginal Health (2013) states that ‘It calls on NSW Health to look to the future, particularly as we embark on implementing the NSW Aboriginal Health Plan 2013-2023’ which ‘challenges us to take a systems approach by embedding a consideration of the health needs of Aboriginal people in all plans, policies, programs and health service delivery’140 [emphasis added as reference to the definition of OD, above]. It appears that the intent of that declaration by NSW Health lacks carriage into OD policy development through the executive and ministerial relationships.
SECRET COMMITTEE GOVERNANCE As can be seen in Figure 3, above, there are many more direct relational links to examine between committees. That kind of information is not available for audit, in the form of agendas, meeting minutes, and committee decisions, information that would be necessary to analyse to gain a complete Australian picture. However, it appears that Australia’s First Peoples cultural voices are filtered out by the leadership and stewardship connections in Australia’s federal system. Which harks back to the foundation of Australia as a federation, deliberately excluded Australia’s First Peoples in the development of the Australian Constitution 1901.141 As such, it appears to be an Australian cultural norm to exclude cultural voice from formal healthcare governance processes.
CULTURALLY UNSAFE RELATIONAL GOVERNANCE
Recall the Williams and Bin-Sallik Australian definition of cultural safety wherein is the principle of 'sharing' in meaning, knowledge, experience, and respect. Williams (1999) was writing from the perspective of clinician and patient interactions and I suggest that the scope needs to be expanded to be about governance relationships. This means - from one hypothetical angle - that every relational link between keystone committees (e.g. Inter-
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jurisdictional committee > ACSQHC > ACMAC > COAG Health Council > COAG > Australian Parliaments) needs to have a criterion of 'sharing' with Australia's First Peoples. What would that look like?
On the one hand, there is an argument that Australia's First Peoples should be members of keystone committees (none of the committees noted above have members who identify as First Peoples) but there is the perennial issue of who should be the members and which First Peoples' nations do they represent (the issue is of 'representation'). On the other hand, there is an argument that just one member is necessary in the most important decision-making committee - the Council of Australian Governments (COAG) - but the issue of representation becomes more acute because of the twin issues of First Nation’s membership and political party affiliation. These arguments need to be discussed further because of the increasing emphasis on culturally safety (e.g. in Australian Health Practitioner Regulation, 2018)142 and cultural competence (e.g. in National Safety and Quality Health Service Standards 2nd Edition, 2017)18 in clinician and patient interactions that should be extended to institutional arrangements (following Anderson and Sanders).
Key Message
Examining the construct of 'relationships' in Australian Open Disclosure governance has revealed themes of federalism filtering, tracking real connections, holding leaders to account, secret committee governance, and culturally unsafe relational governance. These themes underpin the major theme of relational failure in OD policy governance. The next section will delve into the topic of 'medical associations' ineffective knowledge brokerage role to reveal a relational problem between the medical profession and cultural voice.
Medical Associations’ Ineffective Brokerage Role (R)
This section continues the ‘relationships’ analysis of OD policy governance. The image conveys the idea of ‘blockerage’ between medical profession associations and cultural voice.13
13 Lock, M.J. (24th 2018), [online], Knowledge 'Blockerage' in OD Policy [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/knowledge-blockerage-od-policy-dr-mark-j-lock-/
How can medical profession associations broker cultural voice into OD policy?
Open Disclosure – Closed to Cultural Voice Dr Mark J Lock
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The concept of 'cultural safety' is excluded from governance relationships in Australian Open Disclosure policy because cultural voice is filtered out through Australia's federal political system with its myriad pathways, poor leadership accountability and secret committee governance (as discussed in the previous section). There are many health profession associations that seek to influence Australian government health policy and many of them have special interest groups or advocacy groups devoted to Australia's First Peoples. In this section, I examine the role of medical professional associations whose brokerage role is called into question when examining cultural voice and Open Disclosure policy.
MEDICAL ASSOCIATIONS AS KNOWLEDGE BROKERS
The concept of 'relationships' is important for healthcare governance as indicated in the use of terms of ‘leadership’, ‘stewardship’, ‘stakeholders’, ‘consumers’, ‘patients’, ‘clinicians’, and ‘community’ in governance literature. Health professional associations also form part of the matrix of relations that affect healthcare governance. For example, Professor Ian Anderson (2001) noted the role of the medical profession in ‘the development of institutional structures in health, particularly with respect to their political role in health insurance debates’ had an effect which ‘significantly marginalised Aboriginal people from health care services’.7
Nowadays, the medical profession proactively works with Aboriginal organisations through medical associations, for example the Australian Medical Association,143 the Royal Australian College of Medical Administrators,144 and the Royal Australian College of General Practitioners,145 which are noted as voting members in the development of the 2003 National Open Disclosure Standard (NODS).2 On the face of it, medical associations embrace an advocacy 'brokerage' role between the Australian State and Australia's First Peoples. How effective is that 'brokerage' role for empowering cultural voice?
CULTURAL VOICE BLOCKED FROM EQUIP GOVERNANCE
Those three medical associations are represented on the Council of the Australian Council on Healthcare Standards (ACHS) whose thirty-two members ‘represents governments, consumers and peak health bodies from throughout Australia’ in ‘Australia’s leading health care and assessment provider’.146 However, the ACHS does not have a representative of Australia’s First Peoples on its Board or Council. There is no explicit mention of Australia’s First Peoples through the ACHS website or in its EQuIP National Standards.147 Additionally, the publication of the 40 year history of the ACHS is completely silent about Australia’s First Peoples (2014).148
In a previous section, I noted that evidence gathering process of OD policy did not reflect the broader social and cultural awareness of Australian history and its First Peoples, and the ACHS appears to be intertwined with that governance philosophy. Furthermore, this
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ethic is endorsed by the members of the Council of the ACHS which include medical professional associations with advocacy roles for Australia's First Peoples. The governance linkages between the medical associations and the ACHS do not appear to be effective conduits for the needs of Australia's First Peoples to be considered in 'Australia's leading health care and assessment provider'.
UN-EQUIP-ED FOR CULTURAL SAFETY: BROKERAGE TO BLOCKERAGE
I have argued that the leadership of biased knowledge gathering processes are a part of the Australian Commission for Safety and Quality in Health Care’s (ACSQHC) organisational behaviour (see this ‘disclosing inequity in scientific reviews’, above), and the ACSQHC accredits the ACHS. In a 2006 journal article where the ACHS is framed as the ‘central organisation associated with accreditation in health in Australia’, the team of researchers determined ‘five major variables central to the clinical and organisational performance of an organisation (organisational performance; clinical performance indicators; organisation culture; consumer participation; and accreditation performance on EQuIP)’149 - it is notable that ‘human culture’ is not mentioned especially in a multi-cultural nation whose First Peoples represent one of the oldest known cultures in the world. That is, with ACHS and EQuIP as ‘central to accreditation’ cultural voice is excluded from that philosophy.
In other words, through the powerful medical associations, awareness of the cultural needs of Australia’s First Peoples did not project into the ACHS vision as ‘safe, quality health care for all’,150 its corporate governance structures, or its accreditation standards. It also appears the members of medical profession associations, possessing a depth of knowledge about Australia’s First Peoples, has failed to convey that knowledge into OD policy development. Occupying an important brokerage role between the Australian State and Australia’s First Peoples, noting the limited public information available for analysis, why was knowledge about the needs and cultures Australia’s First Peoples not advocated for in OD policy governance?
Cultural voice is excluded from the philosophy of the ACHS and EQuIP as ‘central to accreditation’
Open Disclosure – Closed to Cultural Voice Dr Mark J Lock
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CULTURALLY BLIND LEADERSHIP IN AUSTRALIAN HEALTHCARE
ACCREDITATION
It is interesting that the ACHS is authorised by the Australian Commission for Safety and Quality in Health Care to accredit organisations against the NSQHS Standards because there is no public transparency and accountability about how organisations are reviewed to receive accreditor status. This is important because a central principle of cultural safety is that patients determine if healthcare is culturally safe. By implication, this means corporate governance processes need to be visible to Australian consumers because of the link between the cultural philosophy of the organisation and the services delivered through it, as implied in Anderson’s (2001) article. That is, the philosophy of the governance of a healthcare organisation is not shielded from the social and cultural norms of society.
It has already been noted that an Australian cultural norm is to exclude cultural voice from healthcare governance philosophy (see ‘culturally unsafe relational governance’, above) as evident in publications about healthcare governance. For example, in Donald Philippon and Jeffrey Braithwaite's (2008) comparative review of Australian and Canadian systems of healthcare governance, and in Braithwaite, Healy and Dwan's (2005) Australian discussion paper about the governance of health safety and quality. Both Canada's and Australia's healthcare systems have priorities to improve the health outcomes of First Nations and yet this issue is silent in both papers, and this is more puzzling because of Judith Healy's engagement with Australia's First Peoples.
Furthermore, Professor Jeffrey Braithwaite’s influence is substantial in healthcare governance because he was also the lead author in the 2006 ‘ACHS and EQuIP as ‘central to accreditation’ paper,149 is recognised as a leader in healthcare accreditation, his research informs the work of the ACSQHC and clinical governance, and because of his development of the Australian Institute of Health Innovation. All these occur without the explicit mention of Australia’s First Peoples.
The significance of leadership in healthcare is important for the implementation of the second edition of the NSQHS Standards with its six specific actions for Australia’s First Peoples. In 2019, healthcare organisations will be accredited with those actions in mind and it is clear that the accreditation agencies lack cultural voice in their organisations (see this Croakey post). This reveals a contradiction of requiring healthcare organisations to partner with consumers but the accreditors and the ACSQHC are not subject to the standards they wish others to abide by.
Key Message
It is important to analyse the relational aspects of healthcare governance to see where reforms could be made so that healthcare accreditation is also culturally safe for Australia's First Peoples. Relationships are the key routes whereby cultural voice cold achieve influence in healthcare governance. However, where healthcare leaders, stewards, and medical professional associations could act as knowledge brokers, rather it appears they act in a
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'blockerage' role that prevents cultural voice from entering healthcare accreditation processes. In the next section, I conclude the 'relational' level of analysis by investigating the oral knowledge links between keystone committees.
Insincere Consumer Engagement in Open Disclosure Governance (R)
It appears that cultural knowledge 'blockerage' is a role of Australian healthcare leaders, stewards, and medical professional associations because of the lack of brokerage of the cultural knowledge of Australia's First Peoples into Australian Open Disclosure policy governance. In this section, I conclude the 'relational' level of analysis on the topic of cultural safety and Open Disclosure governance by investigating the oral knowledge links between keystone committees.14
TOKENISTIC CONSUMER ENGAGEMENT
Knowledge about Australia’s First Peoples and their cultures are transmitted through oral communication such as when participating in 'consumer engagement' mechanisms (e.g. partnering with consumers, NSQHS Standard 2) which is important because both policy streams (Figure 1) are thematically linked by 'patients', 'stakeholders', 'consumers' and the 'Aboriginal community'. This critique of OD policy has found a lack of cultural voice indicated in printed policy documents but it is quite understandable that not every spoken word is communicated in print. That is, it is difficult to capture the knowledge from cultural voice into print when traditional knowledge - with its cultural power based in oral methods - escapes translation into Western English writing and grammatical structures. Byimplication, it is necessary to structure engagement processes to allow oral communicationdue weight such as through, for example, members of Australia's First Peoples on keystonehealthcare committees.
14 Lock, M.J. (6th August 2018), [online], Insincere Consumer Engagement in Open Disclosure Governance [LinkedIn Post]. Retrieved from https://www.linkedin.com/pulse/insincere-consumer-engagement-open-disclosure-governance-lock-/
Can OD governance achieve ‘gold’ for consumer engagement?
Open Disclosure – Closed to Cultural Voice Dr Mark J Lock
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However, gaining membership of keystone committees is structured, I argue, by the philosophy of the organisation and the attitude of its leaders to consumer engagement. I highlight one prominent example with the caveat that more examples are necessary for a complete picture to be obtained (it is a fractured puzzle, as indicated by the above image). The example is the New South Wales Clinical Excellence Commission (NSW-CEC), which is one of the 'pillars' of the New South Wales Health System as described in the NSW Corporate Governance and Accountability Compendium (2012).
The NSW-CEC report Review of the Implementation of the NSW Health Open Disclosure Policy arising from the 2009 NSW Ombudsman’s Report (2012) - and funded by the Australian Commission on Safety and Quality in Health Care (ACSQHC) - resulted in an ‘implementation framework’ developed through one committee ‘which relied on members experience and expertise and a study undertaken by Sorenson et al.’.151 The committee had just two consumer representatives but thirteen NSW government agency representatives. Do I really need to point out the biased ratio?
The NSW-CEC is linked to the ACSQHC through membership of the Inter-Jurisdictional Committee (IJC) by Ms Carrie Marr (CEO of the NSW-CEC) who also reports to the Secretary of NSW Health, Ms Elizabeth Koff (2018-19 Performance Agreement). They have an agreed objective to, 'Improve the patient experience and foster engagement with patients consumers and carers' (Objective 2.3, p. 14, 2018-19 Performance Agreement) and the NSW-CEC Board has a 'Consumer Advisors' committee (of which there is no other information provided). However, I found it impossible to find detailed empirical analysis of the level of consumer engagement such as through a published report or research commissioned by the NSW-CEC: a notable lack of transparency and accountability on consumer engagement.
This also occurs for the ACSQHC and its Consumer Engagement Statement (CES) which ostensibly promotes, 'a culture of consumer involvement in the Commission’s work’. 152 However, the CES available on the website is dated July 2009 and is still watermarked as ‘draft’ nine years later in 2018.153 It appears to be a tokenistic nod to consumers especially compared to the depth of work undertaken with non-consumer experts, health professionals, and government staff. The ACSQHC leads the oversight of the National Safety and Quality Health Service Standards (NSQHS Standards – note the emphasis for healthcare organisations to partner with consumers) and yet fails to report on the degree and extent of consumer engagement through a targeted review or consolidated report to consumers.
The lack of transparency and accountability to consumers about 'consumer engagement' activities and effectiveness signals a cultural norm of tokenistic consumer engagement in Australian Open Disclosure governance.
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A STANDARD FOR GENUINE PARTNERSHIP?
Health policy for Australia’s First Peoples promotes ‘genuine partnership’ (CFFR 2011, COAG 2009b: 6)89, 154 and ‘genuine participation’ (NSW Ministry of Health, 2012). This is indicated in the governance structures where committee members are majority Australia’s First Peoples and are represented by peak advocacy organisations. Oral transmission of culturally-based concepts (such as holistic health) is a culturally appropriate strategy to counter-balance a lack of Western scientific empirical research.12, 13 The voice of Australia’s First Peoples is prominent in the membership of committees such as the National Aboriginal and Torres Strait Islander Health Equality Council (disbanded 2014), the National Aboriginal Community Controlled Health Organisation, the Australian Indigenous Doctors Association155 and the Aboriginal Health & Medical Research Council of NSW (AH&MRC).
Signaling the power shift to the patient implied in cultural safety,32 the Aboriginal community sector has de facto veto rights on the authorisation of Aboriginal health policy. Note the veracity of endorsement by the AH&MRC (NSW peak body representing the community health service sector) in the NSW Aboriginal Health Plan 2013-2023 (2012) about ‘meaningful partnerships’ as ‘critical to effecting positive change’.127 Indeed, the 2018-19 Performance Agreement (2018) between the NSW-CEC and the NSW Ministry of Health has the specific objective 'To develop effective and working partnerships with Aboriginal Community Controlled Health Services and ensure the health needs of Aboriginal people are considered in all health plans and programs developed by Support Organisations'104 but it is not measured, monitored, evaluated, or reported on to Aboriginal consumers.
As this case study shows, there is no demonstrated consumer engagement or cultural voice in Open Disclosure policy governance. Therefore, it is incumbent on the ACSQHC and organisations such as the NSW-CEC to devote resources to engaging with Australia's First Peoples consumers and set measurable benchmarks for healthcare organisations to reach when 'partnering with consumers' (see also, ‘no cultural statistics’, above).
LACK OF ORAL KNOWLEDGE TRANSMISSION ROUTES
Currently, the benchmark is at ground zero for providing evidence on public record for partnering with Australia's First Peoples consumers and their peak advocacy organisations. One criterion for the assessment of ground zero is a lack of connectivity between the committee structures of the ACSQHC/the ACHS/the NSW-CEC and the AH&MRC. Another criterion is that the ACSQHC’s publications do not reference peak Aboriginal community controlled organisations when they are the acknowledged community and consumer representatives of the health needs of Australia’s First Peoples.
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Therefore, there are no formalised transmission routes between keystone committees that would enable oral communication of the cultural knowledge of Australia’s First Peoples.
Further, in the NSW-CEC report Review of the Implementation of the NSW Health Open Disclosure Policy arising from the 2009 NSW Ombudsman’s Report (2012) the reliance on the single study by Sorenson, Iedema et al. (2008) speaks to problems of ‘excluded from the evidence base’, as noted above, and this study only referred to culture in ‘service’ and did not include specific mention of Australia’s First Peoples.156 And there is a dearth of in-depth studies which have measured the actual experiences of patients and families with the disclosure process.78 In my literature search I could not find published empirical research of Australia’s First Peoples experience with Open Disclosure. Therefore, there is lack of evidence derived from the oral traditions of Australia’s First Peoples as patients, community members, and policy advisors.
It is noticeable in the annual reports of the ACSQHC that its staff organise, conduct, and participate (i.e. through oral knowledge) in an enormous range of activities about safety and quality in healthcare (see, ‘a gap in knowledge governance’, above). These are ‘intervention’ points where the cultural safety of Australia’s First Peoples could be integrated and diffused into Australian safety and quality philosophy. Instead, as the ACSQHC Annual Reports show, there is silence about the quality and safety needs of Australia’s First Peoples. This appears to be a violation of the Australian Safety and Quality Framework for Health Care’s statement ‘to promote healthcare rights’.57
Key Message and Summary of Relationships
Relationships refer to the connections between people, organisations, and policy documents, evident as the individual leader of an organisation, the committee level power of experts, as group level power in associations, and as documents or agreements between different parts of the health system. I found three contours of the ‘relationship’ textscape for OD policy and Australia’s First Peoples of relational failure, ineffective knowledge brokering, and insincere community engagement. These provide the overarching theme of 'relational incompetence'. As for all sections of this critique, this section would be better informed by more information about the leadership links between committees, the role of other health professions in health policy development, and an analysis of inter-links between different committees.
This section on relationships was the last of four sections (institutions, structures, processes, and relationships) that defined the textscape of OD policy development. It appears that while promoting healthcare rights, patient-centred care, and consumer engagement as core principles of Australian healthcare, there are no formalised structural mechanisms that enable cultural voice to influence OD policy governance. In the discussion section, I aim to draw the themes together into a coherent narrative that provides some clear guidelines for how to restructure government governance to be safer for the cultural voices of Australia’s First Peoples.
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Reprise - Cultural Safety Audit of Australian Open Disclosure Policy Governance15
Remember, in the cultural safety literature it is the patient who defines the experience33, 157 but in an Open Disclosure event every aspect of it is controlled through keystone committees by health experts, mainstream healthcare organisations, and the Australian State. The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (2017) state that ‘cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgement of white privilege’.158 The following suggestions (in the discussion) would mean a substantial shift in current OD policy development processes to allow a greater influence of cultural voice.
A cultural safety audit of Australian Open Disclosure policy governance revealed that healthcare agencies, their keystone committees, and their leaders and stewards have a normative value of excluding the cultural voice of Australia's First Peoples. This finding comes through the development of a methodology using the 'policy trajectory' technique, detection and linking of corporate governance documents, an analytical lens of an Indigenous-informed governance definition, and sensitised by the concept of cultural safety. The findings of the audit are noted above (and through fourteen LinkedIn posts) to demonstrate the principles of transparency and accountability to Australia's First Peoples.
I argue that the governance of Open Disclosure policy development should include the cultural voice of Australia’s First Peoples through transparent and accountable participation and engagement mechanisms. These questions could be used as sensitising questions for any organisational audit:
1. Constructing Open Disclosure Policy - A Culturally Unsafe Process?
The opening question for the audit makes a clear statement of the sensitising concept used, 'cultural safety', and implies the point that cultural safety needs to be thought about at different levels (e.g. macro, meso, and micro) of the healthcare system.
2. Are Australia’s First Peoples included in Open Disclosure policy developmentprocesses?
The second question references Australia's First Peoples as a deliberate strategy to move away from the colonising terms Aboriginal, Indigenous, and Torres Strait Islander.
3. How can cultural voice be included in Open Disclosure policy?
15 Lock, M.J. (23rd August 2018), [online], Cultural Safety Audit of Australian Open Disclosure Policy Governance [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/cultural-safety-audit-australian-open-disclosure-policy-lock-/
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The third question combined the 'how' with 'cultural voice' to show that I wanted practical guidelines for policy makers to include the human cultural values of Australia's First Peoples - their cultural voice.
4. Should Open Disclosure governance be closely scrutinised?
Question four shows that the methodology has to be clearly articulated and transparently presented to stakeholders to encourage scrutiny and accountability.
5. Why does Open Disclosure policy governance exclude cultural voice?
Question five shows that I think audit methodology needs to include a 'why' because of my desire to understand the conflict between 'open communication' and 'excluding cultural voice'.
6. How can Open Disclosure and Indigenous heath policy trajectories achieveintegration?
There needs to be a baseline reference point for policy analysis and question 6 directs analysis to the linkages between different social policy areas.
7. How can cultural voice be structured into Open Disclosure policy design?
While policy has a component of scientific evidence, the analyst needs to assess the inclusion and exclusion criteria for evidence selection and how they can be culturally biased - the point of question 7.
8. How can healthcare governance leverage-in more colour privilege?
Question 8 includes the terms 'leverage' and 'colour privilege' that direct analysis to the leverage points in healthcare governance and if people at those points reflect the diversity of Australia's First Peoples.
9. How can we see inside the invisible 'white box' of government governance?
The phrase 'government governance' refers to the internal administration of public agencies which is a part of the quality and safety equation in healthcare. The 'white box' invokes the notions of 'white privilege' and 'colonisation' (question 9).
10. Why is cultural voice excluded from the OD policy trajectory?
Policy analysis should be about the long arc of institutional time, which means a methodology that detects multiple points linked together in a chain, and not only focus on one point in the chain (question 10).
11. How can Aboriginal peoples cultural voice be included in OD governance?
I advocate that health policy analysts need to assess the policy AND the governance of its development, implementation, and evaluation. I see policy documents as a product of keystone committees whose governance also needs to be audited (question 11).
12. How can cultural voice get over the fence and into healthcare governancecommittees?
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Keystone committees are a physical cultural object of the Western institution of governance. There are many keystone committees in healthcare whose cultural norms form chain-link barriers to inclusion and diversity. Policy analysis need to assess the inter-links between different keystone committees - implied in question 12.
13. How can medical profession associations broker cultural voice into OD policy?
The term 'brokerage' means to assess the organisations that are voting members in keystone committees. I assess what they propose in policy releases and if their brokerage actions reflect their policies (question 13).
14. Can OD governance achieve ‘gold’ for consumer engagement?
The consumer engagement question (14) is about 'cultural voice evidence' because oral cultures prefer this culturally valued mode of communication compared to the sole reliance on quantitative information and the ‘experts’ in the interpretation of it.
Cultural safety audits should be conducted on the governance of Australian Open Disclosure policy. Audits of healthcare organisations are standard practice for their accreditation to ensure a high level of quality and safety in the delivery of care to patients. However, accreditation agencies and government statutory authorities remain unscrutinised for how their governance processes are implicated in poor quality and safety outcomes of Australia's First Peoples. In the next section, I begin the discussion of the findings of this cultural safety audit and provide performance indicators for OD governance leaders to guide their stewards and organisations on a course to be more culturally safe.
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Discussion – Erasing the ‘Copy and Paste’ approach to Culture
This critique set out to investigate why the cultural voice of Australia’s First Peoples is excluded from Open Disclosure policy development processes by a statutory government organisation charged with overseeing reforms in Australian healthcare quality and safety culture. The critique relied on publicly available documents which provide only limited information about the machinations underlying their
development. Information from other sources – meeting agendas and minutes, observations of meetings, participant interviews, Terms of Reference of committees, and draft policy documents – would provide richer information for this research. Nevertheless, the official publications of the Australian Commission on Safety and Quality in Health Care are the touchstones for the leaders and stewards to refer to when justifying their organisation’s mission in Australian healthcare.16
The policy documents form an explicitly linked trajectory signalling the long arc of institutional time. Rather than the term ‘institution’ being equated to ‘organisation’, institutional time refers to the unconscious development of modes of practice (in this case, healthcare governance) underpinned by subconscious values and norms over a long period to time. Each point in that trajectory, a point being a policy document, contains traces of how it presents the cultural voice of Australia’s First Peoples throughout its different sections. A search of relevant terminology in different sections - from the summary, introduction, committee membership, body text, recommendations, discussion and conclusions, and references and bibliography – revealed a systematic lack of explicit mention of Australia’s First Peoples.
As a reference point, consider the way Australia’s First Peoples are respected throughout the different sections of the Fifth National Mental Health and Suicide Prevention Plan (2017) where it is stated that, ‘Governments also recognise the importance of Aboriginal and Torres Strait Islander leadership in building better mental health services, underpinned by the Gayaa Dhuwi (Proud Spirit) Declaration’.159 That plan also includes an action for ‘improving cultural safety across all service settings’ through the National Suicide Prevention Implementation Strategy (2017 draft).160
This thematic link reflects the emphasis on cultural safety in the National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and Social and Emotional Wellbeing 2017-2023 (2017) where three commonwealth government ministers state, ‘By ensuring cultural considerations are embedded in practice, Aboriginal and Torres Strait Islander peoples will have much better access to culturally safe,
16 Lock, M.J. (14th September 2018), [online]. Apologising for Institutional Harm in Australian Open Disclosure Policy, [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/apologising-institutional-harm-australian-open-disclosure-lock-
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responsive, person-centred services provided by a culturally competent and confident workforce.’161 A stark contrast to the treatment of cultural voice in Open Disclosure policy.
However, the mental health documents show that Australian government ministers and the Australian Health Ministers’ Advisory Council endorse and authorise the integration of Australia’s First Peoples cultures in mental health policy and strategy. It begs the question, why is that perspective authorised-out of Open Disclosure?
Such questions can be investigated through a policy trajectory methodology. The significance of the methodology and the textscape is to force policy makers to think beyond cultural safety as only occurring at the clinician and patient interface – it is relevant at every point and pathway of healthcare governance where interactions occur. This is profound because of the scope for healthcare quality and safety improvements lies not only with clinician competency but also with non-clinical staff from general personnel to managers to directors to executives to Board members to politicians– all personnel in the governance chain. As such, this critique addresses a gap in the critical analysis of government governance.
It was noted in the 2011 Overcoming Indigenous Disadvantage Framework that the high-level group of 'Governance and leadership' is one of the 'strategic areas for action' because of a 'general view that improving governance remains critically important - including the governance of governments, as well as governance of Indigenous organisations and communities'.42 In the following section, I provide some ‘guiding principles’ for how to improve government governance in Australian Open Disclosure policy.
GUIDING PRINCIPLES FOR CULTURALLY SAFE OPEN DISCLOSURE
GOVERNANCE Leaders and stewards of keystone committees can use the audit questions (above) to review their corporate governance processes. This would help to uncover answers that Williams (1999) asked of higher education organisations, ‘what are the key factors that facilitate effective access, participation and control for Indigenous peoples in the current systems of governance?’ Furthermore, an audit process would help to delve into the moral obligations of governance following Bin-Sallik (2003) who stated that higher education organisations, ‘have a moral obligation to deconstruct what they are responsible for constructing in the first place’. These could be reformulated into two overarching guiding questions in the textscape of OD policy governance: do Australia’s First Peoples have effective access, participation, and control in healthcare governance? Does healthcare governance philosophy and practice consider the moral obligations to Australia’s First Peoples?
Underlying these two guiding questions are fifteen thematic contours placed within the PRIS (processes, relationships, institutions, and structures) framework derived from the governance definition used in the Indigenous community governance project by the Centre for Aboriginal Economic Policy Research. This is done so that the notion of ‘human culture’ (with multitudinous definitions14) is brought into the governance literature of Australian healthcare in the phrase ‘cultural voice’ (to disambiguate the term ‘culture’ from its use as
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organisational culture, service culture, etc.). However, advocating for cultural voice to be an explicit consideration of healthcare governance means providing a set of guidelines for leaders to chart a course for their stewards to steer organisations towards improved cultural safety with Australia’s First Peoples.
Processes17 refer to the administrative procedures and protocols for the conduct of business. The theme, ‘culturally-blind processes’ in Australian Open Disclosure governance can be addressed by the objective to become culturally diverse:
1) The white box of government governance > Reduce secret governance processesto reveal where cultural voice could influence decision-making structures.Relevance:a. The Open Disclosure Standard (2008) states, ‘Ensuring that communication
is open and honest, and that it is immediate is important to improvingpatient safety.’2
b. The ASX Corporate Governance Principles and Recommendations (2014)state, ‘A listed entity should respect the rights of its security holders byproviding them with appropriate information and facilities to allow them toexercise those rights effectively.’43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017) states, ‘WhenAboriginal and Torres Strait Islander people are marginalised and notengaged in decision-making, the result is ineffective use of resources, bothhuman and financial, with limited improvement in outcomes.’162
d. The NSW Corporate Governance and Accountability Compendium (2012)states, ‘Standard 6: Involve stakeholders in decisions that affect them’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015)states, ‘Public sector agencies are accountable and should have a culture ofestablishing and publicly reporting on their performance across the fullservice delivery chain – inputs, outputs, processes and outcomes.’126
2) Cultural voice authorised-out > Include a formal provision that each keystonecommittee should include cultural voice in their authorisation processes.Relevance:a. The Open Disclosure Standard (2008) states, ‘The need for involvement of
consumers and health care professionals in developing policies andprocesses.’2
b. The ASX Corporate Governance Principles and Recommendations (2014)state, ‘Board renewal is critical to performance. To promote investorconfidence, there should be a formal, rigorous and transparent process forthe appointment and reappointment of directors to the board.’43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017) states, ‘Partnershipscan be strengthened when they are developed at all levels of theorganisation and include decision-making bodies.’162
17 Lock, M.J. (9th October 2018), [online]. Guiding Principles for Culturally Safe Open Disclosure Governance (No.1). [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/guiding-principles-culturally-safe-open-disclosure-governance-lock
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d. The NSW Corporate Governance and Accountability Compendium (2012)states, ‘Openness – processes must be transparent; people have a right toknow how and why decisions are made, and who is making them’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015)Principle 6. Ethical Framework – Act ethically and responsibly – integrity,service and trust.126 Refers to the Ethical Framework of the NSWGovernment (2014) wherein the ‘trust principle’ for example, ‘Public officialshave an overarching obligation to act in the public interest. They mustperform their official functions and duties, and exercise any discretionarypowers, in ways that promote the public interest that is applicable to theirofficial functions.’163
3) Excluded from the Open Disclosure evidence base > Direct that any knowledgegathering process should formally have an objective to include knowledge of andabout Australia’s First Peoples. Relevance:a. The Open Disclosure Standard (2008). Principle 7. Good Governance,
where, ‘Open disclosure requires the creation of clinical risk and qualityimprovement processes through governance frameworks where adverseevents are investigated and analysed to find out what can be done to preventtheir recurrence. It involves a system of accountability through theorganisation’s chief executive officer or governing body to ensure that thesechanges are implemented and their effectiveness reviewed.’2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 3: Act ethically and responsibly, because, ‘Acting ethically andresponsibly goes well beyond mere compliance with legal obligations andinvolves acting with honesty, integrity and in a manner that is consistentwith the reasonable expectations of investors and the broader community’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 2.13: Workingin partnership. For example, ‘Relationships that are respectful of cultureshould [inter alia] – respect Aboriginal and Torres Strait Islanderknowledge’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 5: Maintain high standards of professional and ethical conduct. Forexample, Boards and chief executives lead by example in order to ensure anethical and professional culture is embedded within their organisations,which reflects the CORE values of the NSW Health system’ (CORE-Collaboration, Openness, Respect, Empowerment).84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 17 – Respect the rights of key stakeholders (accountability)through a key stakeholder management program because, ‘thisacknowledges that agencies need to be transparent and be held to accountfor their performance’.126
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Relationships18 are the conduits for exercising real influence between leaders, stewards, and stakeholders. The theme relationally incompetent could be addressed by becoming relationally competent:
1) Disclosing relational failure > Each point in governance structures, and thepathways between them, explicitly include a rule for the inclusion of culturalvoice. Relevance:
a. The Open Disclosure Standard (2008). Principle 7. Good Governance,where, ‘It involves a system of accountability through the organisation’schief executive officer or governing body to ensure that these changes areimplemented and their effectiveness reviewed.’2
b. The ASX Corporate Governance Principles and Recommendations (2014).Definition of corporate governance, ‘the framework of rules, relationships,systems and processes within and by which authority is exercised andcontrolled within corporations. It encompasses the mechanisms by whichcompanies, and those in control, are held to account’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 1.21: Improvingcultural competency. Suggested strategy: Develop, review, and implementan ongoing program of cultural awareness and cultural competency training.Suggested approach, for example, ‘Considers what steps need to be taken atorganisational, systemic and individual levels’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 7: Establish sound audit and risk management practices, where‘Each public health organisation must establish and maintain an effectiveinternal audit function that is responsible for overseeing the adequacy andeffectiveness of the organisation’s system of internal control, riskmanagement and governance’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 3: Clear accountability and delegations (lay solid foundations formanagement and oversight – accountability and service). For example, ‘Arethe responsibilities between Ministers, governance committees andmanagement clear and understood?’.126
4) Ineffective knowledge brokerage > Representatives of medical associationsadvocate for the inclusion of cultural voice in Open Disclosure governance.Relevance:a. The Open Disclosure Standard (2008). Principle 5. ‘Staff support – Health
care organisations should create an environment in which all staff are ableand encouraged to recognise and report adverse events and are supportedthrough the open disclosure process’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 6: Respect the rights of security holders. Recommendation 6.2: ‘A
18 Lock, M.J. (31st October 2018), [online]. Guiding Principles for Culturally Safe Open Disclosure Governance (No.2). [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/guiding-principles-culturally-safe-open-disclosure-governance-lock--1c/
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listed entity should design and implement an investor relations program to facilitate effective two-way communication with investors’. For example, ‘A listed entity’s investor relations program may also run in tandem with a wider stakeholder engagement program involving interactions with politicians, bureaucrats, regulators, unions, consumer groups, environmental groups, local community groups and other stakeholders’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 2.13: Workingin partnership. Agree on the structure, mechanisms and responsibilities ofpartnerships, for example, ‘Developing a set of principles for working inpartnership that cover issues such as reciprocity (that is, the Aboriginal orTorres Strait Islander community involved gains value from the partnershiparrangements), communication, involvement, and sharing of knowledge’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 5: Maintain high standards of professional and ethical conduct. Forexample, ‘Members of the board must be aware of their roles andresponsibilities and lead by example (e.g. fiduciary duties, duty of care anddiligence)’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 3: Clear accountability and delegations (lay solid foundations formanagement and oversight – accountability and service). For example, ‘Doall staff know what they are to do, for whom, when and to what level ofperformance – including their obligations under the Ethical Framework forthe NSW Government sector?’126
5) Insincere consumer engagement > Develop a value of genuine engagement withhealthcare consumers whereby they are empowered to use their culture voice.Relevance:a. The Open Disclosure Standard (2008). Principle 4: ‘Recognition of the
reasonable expectations of patients and their support person.’2b. The ASX Corporate Governance Principles and Recommendations (2014).
Principle 6: Respect the rights of security holders.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 2.13: Workingin partnership.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 6: Involve stakeholders in decisions that affect them.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 17 – Respect the rights of key stakeholders (accountability)through a key stakeholder management program because.126
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Institutions19 are the invisible and intangible social norms, values and beliefs in society. The theme of invisible cultural voice could be addressed through an objective to improve the visibility of cultural voice:
6) Blinded policy development trajectories > Link the policy developmenttrajectories of different policy processes so that there is explicit overlap betweenthem. Relevance:a. The Open Disclosure Standard (2008). Principle 6: Integrated risk
management and systems improvement. Where ‘health care organisationsshould ensure that they – [inter alia] – have in place integrated riskmanagement and quality improvement processes.’2
b. The ASX Corporate Governance Principles and Recommendations (2014).The corporate governance definition implies a level of ‘system-ness’ which isa conceptual key for connecting different processes in an organisation: ‘Thephrase ‘corporate governance’ describes ‘the framework of rules,relationships, systems and processes within and by which authority isexercised and controlled within corporations. It encompasses themechanisms by which companies, and those in control, are held to account’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 1.4:Implementing and monitoring targeted strategies. Suggested strategy:adopt a whole-of-organisation approach. Suggested approach: ‘Implementpolicies, procedures, strategies and protocols using a whole-of-organisationapproach to change management, with support from clinical and non-clinicalleaders.162
d. The NSW Corporate Governance and Accountability Compendium (2012).NSW State Health Plan: Toward 2021, ‘Keeping people healthy. Provideworld class clinical care. Delivering truly integrated care’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).‘Transparency and performance reporting can be improved. Public sectoragencies are accountable and should have a culture of establishing andpublicly reporting on their performance across the full service delivery chain– inputs, outputs, processes and outcomes’. 126
7) Cultural voice not ‘caught’ in the Acts > Include cultural safety principles inhealth Acts because they structure a governance ethic throughout all Australianhealthcare organisations. Relevance:a. The Open Disclosure Standard (2008). Principle 4: Recognition of the
reasonable expectations of patients and their support person. Where, ‘Thepatient and their support person may reasonably expect to be fully informedof the facts surrounding an adverse event and its consequence, treated withempathy, respect and consideration and provided with support in a mannerappropriate to their needs’.2
19 Lock, M.J. (13 November 2018), [online]. Guiding Principles for Culturally Safe Open Disclosure Governance (No.3). [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/guiding-principles-culturally-safe-open-disclosure-governance-lock--2c/
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b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 2: Structure the board to add value. Commentary: ‘A highperforming, effective board is essential for the proper governance of a listedentity. The board needs to have an appropriate number of independent non-executive directors who can challenge management and hold them toaccount, and also represent the best interests of the listed entity and itssecurity holders as a whole rather than those of individual security holdersor interest groups’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Addressing the sixspecific actions to meet the needs of Aboriginal and Torres Strait Islanderpeople. Whereby, ‘To provide safe and high-quality care to Aboriginal andTorres Strait Islander people, the health service organisation must have aknowledge of the community’s needs and priorities. This can only beachieved by working in respectful and meaningful partnership with theAboriginal and Torres Strait Islander community (Action 2.13)’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 1: Establish robust oversight and governance frameworks. Forexample, ‘Health organisations should ensure that [inter alia] – ‘The legaland policy obligations of the organisation are identified and understood; andresponsibilities for compliance are allocated’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015). Thestatement about ‘good’ governance includes statements about the ‘legal way’and ‘rights of stakeholders’: ‘Good governance sets a clear direction, a wayto get there and tracks progress. There is independent assurance thatmanagement is achieving this direction in an ethical and legal way. Risksand opportunities are recognised and addressed. The rights of stakeholdersare respected with open and transparent information on organisationalactivities and performance. And importantly, the organisation and its leadersembrace a governance culture that focuses on achievement, accountabilityand ethical behaviour’.126
8) Editing out cultural rights > Embed cultural rights into editing corporatedocuments to ensure the fidelity of cultural safety philosophy. Relevance:a. The Open Disclosure Standard (2008) does not acknowledge ‘human rights’,
‘patient rights’, or the Charter of Healthcare Rights, but implies theirconsideration in implementing Open Disclosure where, ‘each organisationwill operate – [inter alia] – within its own policies, procedures andprocesses’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 6: Respect the rights of security holders.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 2.13: Workingin partnership. Suggested strategy: Ensure representation of Aboriginal andTorres Strait Islander communities on the health service organisation’sdecision-making bodies. Example of supporting evidence: ‘Safety and quality
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action plans that incorporate Aboriginal and Torres Strait Islander communities’ strengths-based approach and key principles of the United Nations Declaration on the Rights of Indigenous Peoples.’162
d. The NSW Corporate Governance and Accountability Compendium (2012).Standard 6: Involve stakeholders in decisions that affect them. Activity:Respect the rights of stakeholders. Requirement [inter alia]: ‘A patientservice charter must be established to identify the commitment of thedistrict to protecting the rights of patients in the health system’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 17 – Respect the rights of key stakeholders (accountability)through a key stakeholder management program because. For example, ‘Arethere policies and practices that adequately address open governmentrequirements – publication of key policies and access to information?’126
9) No cultural statistics > Gather statistics of incidences of cultural harm to informquality improvement. Relevance:a. The Open Disclosure Standard (2008). The Open Disclosure Process:
Incident Detection or Recognition, ‘The open disclosure process commenceswith the recognition that the patient has suffered unintended harm duringtheir treatment. Hospitals must develop appropriate mechanisms to identifyadverse events’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 5: Make timely and balanced disclosure. This is where, ‘A listedentity should make timely and balanced disclosure of all matters concerningit that a reasonable person would expect to have a material effect on theprice or value of its securities’,43 which implies mechanisms and measures arein-place to detect irregular matters.
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 1.2: Addressinghealth needs of Aboriginal and Torres Strait Islander people. Suggestedstrategies: set safety and quality priorities. Consider [inter alia]: ‘Currentorganisational performance against key safety and quality measures forAboriginal and Torres Strait Islander patients’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Accreditation through the National Safety and Quality Health ServiceStandards where, ‘In addition to undergoing assessment against the NSQHSStandards by the accrediting agency, a health service is required, at eachassessment, to provide to its accrediting agency evidence to demonstrateimplementation of the NSQHS Standards. This evidence comprisesinformation in response to measures relevant to the Standards’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Under the heading ‘How to use the governance lighthouse checklist’ thereare several suggestions where ‘government agencies and universitiesshould…pay particular attention to ensuring [inter alia] – performanceinformation on key metrics, inputs, outputs, processes and outcomes isregularly disclosed and benchmarked’.126
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Structures20 are the more physical manifestations of the health institution. The theme of structured out of healthcare standards can be addressed through the objective to structure in cultural voice:
10) Disintegrated governance leadership > Improve the coherence of leadershipwithin current Boards and between different Boards. Relevance:a. The Open Disclosure Standard (2008). Coherence could be implied in
Principle 7: Good Governance, where ‘Open disclosure requires the creationof clinical risk and quality improvement processes through governanceframeworks where adverse events are investigated and analysed to find outwhat can be done to prevent their recurrence. It involves a system ofaccountability through the organisation’s chief executive officer orgoverning body to ensure that these changes are implemented and theireffectiveness reviewed’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Coherence is implied in Principle 1: Lay solid foundations for managementand oversight. For example, ‘monitoring the effectiveness of the entity’sgovernance practices’,43 which implies a system of integrated performancereporting.
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Coherent leadership isimplied through Action 1.4: Implementing and monitoring targetedstrategies. Suggested strategy: adopt a whole-of-organisation approach.Suggested approach: ‘Implement policies, procedures, strategies andprotocols using a whole-of-organisation approach to change management,with support from clinical and non-clinical leaders.162
d. The NSW Corporate Governance and Accountability Compendium (2012).This notes the NSW Health Performance Framework,164 where coherentleadership is implied in the ‘integrated’ key attribute: ‘the Frameworkincorporates NSW Health Strategic Priorities and links the objectives ofsafe, effective, patient centred and efficient health service delivery’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Coherence is implied through Principle 3: Clear accountability anddelegations (lay solid foundations for management and oversight –accountability and service). For example, in ‘1. Leadership and strategicbusiness plans [inter alia]: ‘Do senior executives actively connect staff withthe organisation’s purpose (e.g. through forums, attendance at meetings,walking the floor, performance agreements and connecting day-to-day workwith purpose)?126
11) Structured out of healthcare standards > Develop standards for the inclusion ofAustralia’s First Peoples in healthcare governance. Relevance:
20 Lock, M.J. (22 November 2018), [online]. Guiding Principles for Culturally Safe Open Disclosure Governance (No.4). [LinkedIn Post]. Retrieved from: https://www.linkedin.com/pulse/guiding-principles-culturally-safe-open-disclosure-governance-lock--3c/
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a. The Open Disclosure Standard (2008). Appendix A Glossary references adefinition of ‘standard’ that, ‘Sets out agreed specifications and/orprocedures designed to ensure that a material, product, method or service isfit for the purpose and consistently performs the way in which it wasintended’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 1: Lay solid foundations for management and oversight. Forexample, Recommendation 5 about gender diversity policy implies the samefor cultural diversity, ‘The measurable objectives the board sets infurtherance of its diversity policy should include appropriate and meaningfulbenchmarks that are able to be, and are, measured and monitored foreffectiveness in addressing any gender imbalance issues in an organisation’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 1.2: Addressinghealth needs of Aboriginal and Torres Strait Islander people. Suggestedstrategy [inter alia]: set safety and quality priorities. Suggested approach[inter alia]: Recommend to the governing body priority areas to beaddressed, including timelines, targets, deliverables, and accountabilities forsuccess.’ For example, ‘Endorse performance indicators, and monitoring,reporting and evaluation processes’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Notes the relevance of ‘standards’ of ethical behaviour, ‘The governmentsector core values are consistent with the standards contained in the NSWHealth Code of Conduct’, which, ‘ensures a clear and common set ofstandards of ethical and professional conduct that apply to everyoneworking in NSW Health, the outcomes we are committed to, and thebehaviours which are unacceptable and will not be tolerated.84
e. The Governance Lighthouse - Strategic Early Warning System (2015),notes the importance of tracking progress which implies developingmeasurable standards, ‘Good governance sets a clear direction, a way to getthere and tracks progress’.126
12) The ‘in-equality’ assurance process > Develop continuous quality improvementprocesses for healthcare governance. Relevance:a. The Open Disclosure Standard (2008). Appendix A Glossary: Systems
Improvement-‘the changes made to dysfunctional operational methodsprocesses and infrastructure to ensure improved quality and safety’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Systematic and disciplined approach noted for Principle 7: Recognise andmanage risk – ‘a listed entity should establish a sound risk managementframework and periodically review the effectiveness of that framework’ andin Commentary it notes, ‘An internal audit function can assist a listed entityto accomplish its objectives by bringing a systematic, disciplined approach toevaluating and continually improving the effectiveness of its riskmanagement and internal control processes’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 1.2: Addressing
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health needs of Aboriginal and Torres Strait Islander people. Suggested strategy: Align safety and quality priorities at the national, state and territory, local, and Aboriginal and Torres Strait Islander community levels.162
d. The NSW Corporate Governance and Accountability Compendium (2012).The stakeholder engagement Figure states the purpose, ‘Healthier people,fairer access, quality care, better value’ for example, ‘active engagement withcommunity organisations and groups to promote positive health, qualityintegrated and co-ordinated care and the open exchange of information’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Where quality assurance processes are implied in Principle 8: Complianceframework (which falls under the section ‘act ethically and responsibly-integrity, service, trust’) that asks, ‘Have all key compliance obligations(relevant laws, regulations and government directions) been identified alongwith their risk ratings and appropriate mitigation?’.126
13) Excluded from the accreditation environment > Improve the explicit presence ofAustralia’s First Peoples in accreditation agencies and their accreditationdevelopment governance. Relevance:a. The Open Disclosure Standard (2008). Include representative organisations
for Australia’s First Peoples in standards development committees, ‘Thefollowing organisations were voting members of the StandardsDevelopment Committee who participated in the development andendorsement of this standard’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).The ASX Corporate Governance Council ‘It brings together variousbusiness, shareholder and industry groups, each offering valuable insightsand expertise on governance issues from the perspective of their particularstakeholders’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). ‘The AustralianCommission on Safety and Quality in Health Care (the Commission)acknowledges the development of this guide by the WardliparinggaAboriginal Research Unit of the South Australian Health and MedicalResearch Institute, and the significant contribution made by the Aboriginaland Torres Strait Islander Health Project Working Group’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).There is a distinct lack of transparency about the governance process forthis publication, ‘It will however be regularly updated as relevant legislation,government policy and NSW Health Policy Directives are issued andrevised and as the NSW Health Governance review progresses’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).There is no disclosure of the governance process for the development of thelighthouse, ‘This guide presents an updated version of the Audit Office’seight principles and 17 key governance components, published in 2011’.126
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14) One-way street policy levers > Improve the two-way the flow of information andadvice within hierarchical governance processes. Relevance:a. The Open Disclosure Standard (2008). ‘Ensuring that communication is
open and honest, and that it is immediate is important to improving patientsafety’.2
b. The ASX Corporate Governance Principles and Recommendations (2014).Principle 6: Respect the rights of security holders. Recommendation 6.2, ‘Alisted entity should design and implement an investor relations program tofacilitate effective two-way communication with investors’.43
c. The National Safety and Quality Health Service Standards user guide forAboriginal and Torres Strait Islander Health (2017). Action 2.13: Workingin partnership, ‘Communication strategies need to be clear and interactive toenable culturally appropriate ways of working and sharingunderstandings’.162
d. The NSW Corporate Governance and Accountability Compendium (2012).Enterprise-wide risk management framework: Governance and risk, ‘Aresponsive, open and consultative approach benefits the organisation and itsstakeholders through active consultative processes, clear communication andeducation in risks, effective risk controls and the responsible management ofrisks at all levels of the organisation’.84
e. The Governance Lighthouse - Strategic Early Warning System (2015).Principle 6-Ethical framework (act ethically and responsibly-integrity,service and trust), ‘Do senior management have an open door policy wherestaff feel safe and comfortable to openly raise questions, concerns or statetheir views?’126
I argue that the norm of 'structured out of healthcare standards' displayed in Australian Open Disclosure policy governance could be addressed by improving the coherence of leadership, developing standards for the inclusion of cultural voice, developing continuous quality improvement processes for cultural safety, including Australia's First Peoples in accreditation governance, and improving the two-way flow of information through policy levers.
SUMMARY – WHO IS GOVERNING THE REGULATOR?
The relevance of these guiding principles needs to be critically investigated through more availability to corporate information, as I have noted throughout the critique. What was interesting in developing the guiding principles is how it was necessary to search through the cadre of corporate governance documents (the Open Disclosure Standard, ASX Corporate Governance Principles and Recommendations, National Safety and Quality Health Care Standards, and the Governance Lighthouse) and fit-in my findings (rather awkwardly) to the current information. Each of the governance documents were very differently structured and indicated an ad-hoc approach to corporate governance and health governance philosophy and development. As a result, there is a high degree of ambiguity in
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healthcare governance which means that healthcare leaders and stewards can abrogate responsibility to developing strong governance standards with Australia’s First Peoples. This signals some key problems with the governance of the regulator – the Australian Commission on Safety and Quality on Health Care (ACSQHC).
The Organisation for Economic Cooperation and Development (OECD) produced a report The Governance of Regulators. OECD Best Practice Principles for Regulatory Policy (2014) and stated that, ‘Governments are responsible for the delivery of public policies, but the achievement of many key social, economic and environmental goals is the task of regulatory agencies’.165 This report notes the principle of ‘independence’ and how it can be variously interpreted in different ways for different purposes and the significance of this for the value of ‘trust’. This OECD report was noted in the report, Australia's Health Workforce: Strengthening the Education Foundation. Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme for health professions. Draft Report September 2017 (2017) which talked about independence and autonomy of accreditors and health professions166 but this is not noted in the corporate governance of the ACSQHC.
Regarding independence and autonomy, this critique notes that it is the ACSQHC who make Australian healthcare standards, accredit the assessors of healthcare organisations, oversee the Australian Safety and Quality Accreditation Scheme, hold all information as corporate-in-confidence about healthcare organisations, and provide policy and strategic advice to healthcare leaders and stewards. In other words, in terms of power sharing with Australia’s First Peoples (a principle of cultural safety), the ACSQHC holds absolute market dominance in healthcare governance and regulation. This, arguably, compromises the principle of independence and therefore, the trust in which Australia’s First Peoples can have in the Australian Commission on Safety and Quality on Health Care to lead reforms in healthcare quality and safety.
Conclusion
Just as there are different ways to construct geographical maps of landscapes, so it is also for the qualitative methods used to develop a discursive map of textscapes. That was a task of this critique, where the headings, subheadings, themes, and subthemes constitute a textscape of Australian Open Disclosure Governance and the cultural voice of Australia’s First Peoples. This is one way for a First Australian to assert healthcare rights to demonstrate how to go beyond a ‘copy and paste’ approach to culture and to genuinely engage with Australia’s First Peoples.
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Australian Open Disclosure Governance – Closed to Cultural Voice. Critique of Australian Open Disclosure Governance and the Cultural Voice of Australia’s First Peoples
Dr Mark J Lock – Founder and Director Committix Pty Ltd ABN 786 146 747 34 Email: [email protected] ¦Website: https://committix.com