module 1.1 aged care and quality agency overview ...€¦ · web viewthe foundation learning...

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With the exception of the Commonwealth Coat of Arms, this work is licensed under a Creative Commons Attribution 4.0 International license (CC BY 4.0)

Attribution

Material obtained from this guide is to be attributed to the Quality Agency as:© Australian Aged Care Quality Agency 2018.

Third party copyright

Wherever a third party holds copyright in material presented in this guide, the copyright remains with that party. Their permission may be required to use the material.

HDB-EDU-0129 v15.1

Qassist Module 2.2 – Undertaking a self-assessment 2

Contents

Module 1.1 Aged care and Quality Agency overview Facilitator guide....................................2

Copyright..............................................................................................................................2

Attribution..........................................................................................................................2

Third party copyright.........................................................................................................2

Contents...................................................................................................................................3

What is Qassist?......................................................................................................................5

Accessing Qassist learning modules and fact sheets..............................................................5

Foundation modules.................................................................................................................5

Case management modules....................................................................................................5

Foundation modules.................................................................................................................6

Module 1.1 - Aged Care and Quality Agency overview........................................................6

Module 1.2 - Getting to know the Standards........................................................................6

Module 1.3 - Continuous improvement.................................................................................6

Module 1.4 - Understanding risk...........................................................................................6

Module 1.5 – Consumer dignity and choice.........................................................................6

Module 1.6 – Using consumer feedback..............................................................................6

Case management education programs..................................................................................6

Qassist fact sheets...................................................................................................................7

Consumer guides.....................................................................................................................7

Using the Qassist learning modules and fact sheets in the workplace...................................8

Step 1 – Identify learning needs...........................................................................................8

Step 2 – Develop a learning plan based on these identified needs.....................................8

Step 3 – Review the Qassist learning modules and fact sheets, select the ones that will address learning needs, customise for the session, prepare for the learning session and facilitate the session.............................................................................................................9

How to use the facilitator’s guide.............................................................................................9

Layout...................................................................................................................................9

For example........................................................................................................................10

Module 1.1 – Facilitation information.....................................................................................11

Aim.....................................................................................................................................11

Learning outcomes.............................................................................................................11


Target audience..................................................................................................................11

Session overview................................................................................................................11

Facilitator’s resources and references...................................................................................12

Session Plan.......................................................................................................................12

A note about language– care recipients …consumers… residents…clients….elders….citizens..................................................................................................12

Module 2.2 Resources........................................................................................................12

References.........................................................................................................................12

Session plan Module 2.2 Undertaking a self-assessment.....................................................13

Attachments:

Home Care self-assessment tool – Evidence resource guide

Residential Care self-assessment tool – Evidence resource guide

NATSI Flexible Careself-assessment tool – Evidence resource guide

Activity 3 – Undertaking a self-assessment


What is Qassist?

Qassist is our regulatory compliance assistance education program. This program and related learning modules are designed to support the aged care sector to improve compliance and consumer outcomes.

Accessing Qassist learning modules and fact sheets

The learning modules and fact sheets fall into two broad categories that inform our compliance assistance program and resources – Foundation modules and Case management modules.

Foundation modules

These modules are designed to provide the sector with an understanding of the regulatory system and its requirements.

These modules provide the foundation for getting to know the Quality Agency, the aged care standards, continuous improvement, risk in aged care, consumer dignity, choice and feedback. They are targeted at everyone in the sector. While these foundation modules have been designed for compliance assistance purposes as part of our case management responses, they can be used by providers as part of their internal staff training and resource provision as required.

The foundation learning modules include a facilitator guide, presentation resources and associated fact sheets. All of these modules are available for download on our Quality Agency website.

Case management modules

These modules are focused on supporting services to address non-compliance and are specifically designed to support our regulatory case management and monitoring activity.

These modules are only available as Quality Agency facilitated programs through our compliance assistance education program. To apply for compliance assistance education support you can submit an expression of interest (EOI) on our website. Please note compliance assistance education is provided subject to eligibility criteria. Visit the Quality Agency education webpage further about our compliance assistance education.

The case management fact sheets for each module are available for download on our Quality Agency website.


http://www.aacqa.gov.au/


http://www.aacqa.gov.au/providers/education/compliance-assistance


Foundation modules

UNDERSTANDING THE REGULATORY SYSTEM AND ITS REQUIREMENTS

Module 1.1 - Aged Care and Quality Agency overview

Provides the opportunity to explore the big picture and the changing environment of aged care where consumer choice and control is the focus. The module also includes the Quality Agency’s regulatory functions and how quality assessment is undertaken.

Module 1.2 - Getting to know the Standards

Provides an overview of the meaning and intent of the aged care Standards, together with an introduction on demonstrating performance and continuous improvement against the Standards.

Module 1.3 - Continuous improvement

Addresses the importance of continuous improvement being undertaken in collaboration with consumers and staff especially in the areas of demonstrating outcomes for consumers, staff and the service.

Module 1.4 - Understanding risk

Addresses risk management in an aged care context and how to approach managing risk while supporting consumer choice.

Module 1.5 – Consumer dignity and choice

Addresses consumers’ right to privacy, dignity and choice in aged care and provides an overview of the legislation and principles that provide the sector with guidance on consumer dignity and choice.

Module 1.6 – Using consumer feedback

Provides practical strategies to facilitate consumer and representative feedback and how it can be used to support service development, delivery and improvement.

Case management education programs

1. DEMONSTRATING PERFORMANCE AGAINST THE STANDARDS

Modules 2.1 – 2.3. Supporting services with compliance issues. Includes undertaking self-assessment and responding to non-compliance. For example, services that may be experiencing compliance issues or new market entrants. These modules are targeted at management with responsibility for addressing and maintaining compliance and are only available through our case management processes.

2. ADDRESSING CONSUMER FOCUS, AREAS OF PREVALENT RISK AND NEW PROGRAMS

Modules 3.1 – 3.3 Improving the sector and consumer focus.


Includes ongoing assessment and planning and a person centered approach to risk. These modules are targeted at both frontline staff and management and are currently only available through our case management processes.

Qassist fact sheets

Module fact sheets are available to support on the job or workplace based learning for staff.

The fact sheets contain a summary of the key information related to the module topic on the front page and suggested learning activities and questions to support personal exploration of the topic or group discussion on the back page. You can use this in a variety of ways and we encourage you to be creative. Use the factsheets to brainstorm with as many people as you can whether it is through a staff meeting, toolbox talks or in training sessions. More tips on using the resources in the workplace are detailed shortly.

Qassist factsheets are available for all the Qassist modules as listed below:

UNDERSTANDING THE REGULATORY SYSTEM AND ITS REQUIREMENTS

1.1 Aged Care and Quality Agency overview1.2 Getting to know the Standards1.3 Continuous improvement1.4 Understanding risk1.5 Consumer dignity and choice1.6 Using consumer feedback

DEMONSTRATING PERFORMANCE AND CONSUMER OUTCOMES

2.1 Responding to non-compliance2.2 Undertaking a self-assessment2.3 Governance (proposed)

ADDRESSING CONSUMER FOCUS, AREAS OF PREVALENT RISK AND NEW PROGRAMS

3.1 Ongoing assessment and planning with consumers3.2 Person centred approach to risk3.3 Safeguarding vulnerable consumers (proposed)

Consumer guides

In addition to the above factsheets the following consumer guide can be used to support consumer engagement in quality assessment and continuous improvement as a standalone resource or in combination with areas above. These are available on the Quality Agency website.



• Consumer guide to accreditation

Using the Qassist learning modules and fact sheets in the workplace

The ways Qassist can be used are wide and varied. Facilitators are encouraged to be creative when deciding how best to use the resources to meet the learning needs. The following three steps may assist in using the learning modules and fact sheets.

Step 1 – Identify learning needs

Consider the core skills and knowledge required to achieve both individual and organisational goals in the areas of:

• Consumer focus • Quality assessment• Understanding the regulatory framework• Requirements for compliance

Consider the following questions to assist in identifying the learning needs:

• How can effective performance in these areas be achieved? • What skills and knowledge need to be developed and by whom? • Are there specific knowledge gaps that need to be addressed?• Has there been any new legislation, policies or procedures introduced?• Are there any performance or work health and safety issues?• Are there any new staff members

Step 2 – Develop a learning plan based on these identified needs.

This could be individual or group based, job role specific or service/organisation delivered, dependent on the needs.

Consider the following questions when developing a learning plan:

• How does formal and informal learning currently happen in your workplace? • Which of the following is available – on-the-job through buddying and mentoring, off-the-job,

network based, formal workplace sessions (e.g. lunchtime ‘hot topic’ discussions)? • How do people prefer to learn? • What is the priority for learning?• What does the training need to achieve – what will be the impact in the workplace?• How will you determine the effectiveness of the training?


• What resources are available? Training facilities, presenters, subject matter experts• Do you have a training calendar?

Step 3 – Review the Qassist learning modules and fact sheets, select the ones that will address learning needs, customise for the session, prepare for the learning session and facilitate the session.

It can be a good idea to consider using a reflective practice model as part of your learning approach. For example, by exploring these three key questions:

Suggestions for implementing Qassist in your workplace:

• Incorporate different Qassist modules into your workplace induction program. • Select modules to meet identified learning needs.• Use different fact sheets as a focused 10-15 minute ‘tool box sessions’.• Schedule modules as an agenda item at staff meetings. These short and focused sessions will

get staff on the same page, quickly and efficiently. • Link discussions specifically to service delivery strategy and consumer outcomes, and identify

opportunities for improvement.• Use real case studies based on consumers ‘lived experience’ or situations that occur in daily

practice. • Provide the resources to mentors and buddies to assist them in supporting workplace learning.• Follow up learning by seeking feedback, providing/identifying relevant resources and further

learning opportunities. • Identify improvements/changes that participants can implement in their workplace as a result of

the learning.

How to use the facilitator’s guide

This facilitator guide includes detailed notes, PowerPoint slides, discussion prompt questions, activity instructions and resources.

Layout


To make it easy for you to follow the content layout is reflected in the following table format.

Slide Time Facilitator information Resources

PowerPointSlide

number

Section duration Content detail, facilitation process, notes for facilitator Links to activity

resources

For example


3 5 mins

ASK participants what they understand is meant by the term “quality care”?

Brainstorm what does “quality” mean?Record responses on a whiteboard or flipchart

Information in italics is for facilitator to use as prompts and/or ensure all information is covered

Fact sheet 1.1Whiteboard or

flipchart


Module 2.2 – Facilitation information

Aim The aim of this session is to assist participants to complete a self-assessment against the applicable standards to demonstrate performance against the applicable standards and identify opportunities for improvement.

Learning outcomesAfter actively participating in this session, participants will be able to:

• Describe the legislative requirements of self-assessment• Explain the benefits of self-assessment• Explain steps in self-assessment and the link to continuous improvement• Practice completing a self-assessment

Target audienceThis session is designed for those who have an understanding of the quality standards that are applicable to the organisation and responsibility contributing to or undertaking self-assessment and continuous improvement activities.

Session overviewDuration approximately 110 minutes

Time Session content/activities/notes

10 mins Welcome and learning outcomes

30 mins What is self-assessment?Activity 1

55 mins Legislative context of self-assessment

65 mins Benefits of self-assessmentActivity 2

90 mins How to conduct a self-assessmentActivity 3

100 mins How does self-assessment link to continuous improvement?

110 mins Next steps


Facilitator’s resources and references

Session PlanThe session plan contains detailed information relating to the topic, discussions and activities. The session plan guides the facilitation of the session and assists the facilitator in relation to content, timing and resources. The PowerPoint presentation is used as guidance for facilitators and does not contain as detailed information as the session plan. Facilitators should refer to the session plan in the first instance to ensure they have a thorough understanding of the topic and delivery method.

A note about language– care recipients …consumers… residents…clients….elders….citizensIn aged care, there are a range of terms used to describe people that access aged care services. In these modules, we use the term ‘care recipient’ when there is a direct reference from the legislation for example in principles of the Standards and the expected outcomes. For all other references, we use ‘consumers’ regardless of the service delivery context. Your service may use other terms that are appropriate to the service delivery or cultural context. Substitute for what is most appropriate for the target audience you are delivering the session to.

Module 2.2 ResourcesEnsure you have the following resources:• Session specific

- PowerPoint presentation – 2.2 Undertaking a self-assessment (The presentation can be printed as notes pages to be provided to participants as handouts if required.)

- Activity 3 – Undertaking a self-assessment (see templates at the back of this guide)- Factsheets

- Home care self-assessment tool evidence guide- Residential self-assessment tool evidence guide- Flexible care self-assessment tool evidence guide

- Applicable Standards handout – Accreditation, Home Care Common Standards, Flexible care quality standards

• Laptop• Post-it notes• Data projector• Flipchart paper• Highlighter pens• Whiteboard markers

References• Aged Care Legislation – https://legislation.gov.au• Department of Health – Aged Care – https://agedcare.health.gov.au• Practices and processes guide, November 2015. AACQA – https://aacqa.gov.au• Results and processes guide, October 2014. AACQA – https://aacqa.gov.au• Flexible care quality review guidelines, December 2015. AACQA - https://aacqa.gov.au


https://aacqa.gov.au/



https://agedcare.health.gov.au/

https://legislation.gov.au/

Session planModule 2.2 Undertaking a self-assessment


0-1 10 mins IntroductionNB: be aware of using acronyms, terminology and/or specific sector language during the session. Some participants may be new to the sector.

• Welcome• Acknowledgement of country - “I would like to begin by acknowledging the Traditional Owners of the land

on which we meet today. I would also like to pay my respects to Elders past and present.”• Introduce topic• Quick Ice Breaker (name, how long people have been working in the sector, how long took to get here,

previous job).

Learning OutcomesGo through the learning outcomes for the session. Clarify what will be covered if needed

• Describe the legislative requirements of self-assessment• Explain the benefits of self-assessment• Explain steps in self-assessment and the link to continuous improvement• Practice completing a self-assessment

PPT and Facilitation guide

2 10 mins Activity 1 – Discussion on the meaning of self-assessmentBegin this session with a group brainstorming activity.to build a shared understanding of what self-assessment means.

PPT, Facilitation guide, and Post-it notes



Give each person/pair a post it note and ask them to think of two different words associated with or meaning the same thing as self-assessment.Ask the pairs or groups to share their words with the whole group.Expect that there will be varied responses.

Key messagesDictionary definition (noun) 1. an evaluation of one's own abilities and failings(Source: Collins English Dictionary. Copyright ©Harper Collins Publishers)

What is self-assessment?Self-assessment is an internal process whereby a service looks at how it does things and what it achieves.

Services can use a wide range of criteria to self-assess, tailored to their own needs and objectives. During the process strengths, weaknesses, and opportunities for improvement are identified. This ensures consumer care and services are always provided at the highest possible standard.

The process helps the service:• Gain an up-to-date picture of its achievements• Identify any gaps or opportunities for improvement

Plan to address the gaps

3-4 5 mins Discuss the link between legislation and self-assessmentChoose the relevant information from the slide to discuss depending on the context you are delivering in.

Slide 3 Residential and home careSlide 4 has NATSI Flexi information.

PPT andFacilitation guide



Before showing the slideASK Does anyone know why we undertaken self-assessment?The Quality Agency Principles 2013 require completion of a self-assessment in preparation for re-accreditation and quality review.

Approved providers may use their own approach or use our self-assessment tool available on our website.

Key messageThere is a legal requirement to undertake a self-assessment as part of re-accreditation for Residential Care or quality review for Home Care/FLEXI care.

Note – Residential aged care – amendments were made in March 2018 to the Quality Agency Principles 2013. These changes a related to Unannounced re-accreditation audits. One of these changes includes the requirement to submit a self-assessment with the application for re-accreditation.

5 10 mins Activity 2 – The benefits of self-assessmentASK• What might be the benefits of self-assessment for the three stakeholders; consumers, staff and

management.• Write responses up on the white board from the group/s.• Top up any additional information following the group discussion using the key message below.

Key messages

Whiteboard



Benefits of self-assessmentSelf-assessment is an opportunity to check:• How the service meets each of the expected outcomes• What the results or outcomes are for consumers• Whether what is intended to happen actually happens (such as whether policies and procedures

are followed)• Whether the effectiveness of past improvements have been evaluated• Whether newly identified improvements are planned and can be managed and implemented

Some of the more holistic benefits of an ongoing and regular self-assessment process for services include:• Being a key driver and informer of continuous improvement, leading to enhanced quality care and

services for consumers• Providing feedback about the service to consumers, representatives, staff and other stakeholders• Informing a shared understanding of the way in which the service functions and performs for all

relevant stakeholders• Contribute to a shared understanding develop and strengthen a sense of shared goals• Assisting the service to be better prepared for re-accreditation site audits, quality reviews and

assessment contacts

6 35 mins Introduce the Quality Agency self-assessment tool as an example of a quality tool and evidence resource guide.

ASK• Has anyone undertaken a self-assessment against the standards before?• How do you think self-assessment should be conducted?• Who should be involved?• When is the best time to do it?

Key messages

PPT,Facilitation guide,

You can also download the word document from the website. Select the right tool for the service.



Self-assessment can be carried out in many ways.The provider and the managers of the service must decide what process is best for them. Involving the staff who carry out the process being assessed is often a valuable way of learning what is really done in the service. Consumers or their representatives, visiting health professionals and other stakeholders should also contribute and learn about the service’s assessment processes, and how the service is run.

Regular self-assessment ensures up-to-date information about performance is available. The results of self-assessment can be used to plan improvement activities, and in turn the results of these activities can be evaluated and fed into the next self-assessment. So the process continues.A self-assessment record should be a living document. This ensures:

• The service is measuring its performance against the standards and seeking improvements for the benefit of consumers

• A structured approach to self-assessment is being undertaken• Results between self-assessments can be compared to measure progress• Gaps are identified before we visit• The submission of the self-assessment is a simple process, without intensive work being

conducted over a short period.

Activity 3 worksheet –Undertaking a self-assessment

Note: The Evidence guide resources for each of the applicable standards include three expected outcomes where there are high instances of non-compliance. Choose one expected outcome from the relevant standards.Ensure you discuss the context question – What is this all about? For the selected expected outcome.

Brainstorm the three key questions below as whole group, collect responses on white board/ butchers paper or self-assessment tool.

Activity 3 worksheet, Evidence resource guide, and relevant self-assessment tool.Choose the relevant worksheet for the contextResidential Accreditation 1.6, 1.8,



• What practices and processes (evidence) do you have in place to meet this expected outcome?• What results have you demonstrated to show you are meeting this expected outcome• What plans, if any, do you have for improvement in this area?

NOTE: Use the relevant self-assessment tool evidence guide for examples.

Allocate or encourage participants to choose another outcome and repeat the exercise above.Encourage participants to complete the rest of the expected outcomes if they have time or back in the work place with other colleagues.

Top up any further learning from the responses.

2.4, 2.7, 2.13

Home care Home care common standards 1.2, 1.3, 1.6, 2.2, 2.3, 2.4

Flexible care program Quality framework 1.1, 1.3, 1.5, 2.1, 2.3

7 10 mins Link to continuous improvement and self-assessmentWrite up on the whiteboard the headings on a Continuous Improvement planUse the services’ Continuous improvement plans headings if applicable otherwise use the Agency template headings:• Date• Related Standard• Issues identified – Include source for example, consumer/ relative, meeting, internal audit• Planned action – This must include actions, tasks and person responsible for implementing the

improvement Person responsible• Planned completion date• Outcomes – This includes the results, achievement, impact, what you have measured

ASK• Participant to share the identified any areas of improvement and why in either of the expected

outcomes they worked on.• Select one example from the group and use the whiteboard headings to start to populate the CI

plan.• Discuss how the ideas for improvement would be transferred to the CI system/plan.

Whiteboard or use handout two



Use any of these questions to prompt thinking and group discussion:• Who would you tell about the identified opportunity for improvement? Prompt discussion about

systems and processes for capturing opportunities for improvement e.g. forms, committees, meetings, surveys.

• What evidence might you need to provide to demonstrate there is an opportunity for improvement?• Who should be consulted and involved – prompt thinking about consumer involvement – why and

how? What might be the benefits of consumer involvement? (NOTE: Involvement means more than consultation)

• What actions need to be taken, by who and when?• How will success be measured?• How will this be communicated to staff, consumers and representatives?

Key messages• Self –assessment links to all steps in the CI process.• Self-assessment can drive continuous improvement in the service because it helps to:

- Pause and think about the way the service works and what results are being achieved for the benefit of consumers

- Identify the things the service is doing well- Identify areas where the service is not performing well enough for consumers- Identify areas where the service is not performing as well as it would like- Identify the activities to be incorporated into a continuous improvement plan

8 10 mins Learning and reflectionsASKDoes anyone have any questions about what has been covered during this session?Clarify any areas if needed

Revisit learning outcomes:• Describe the legislative requirements of self-assessment• Explain the benefits of self-assessment



• Explain steps in self-assessment and the link to continuous improvement• Practice completing a self-assessment

ASK Participants to name two (2) key things they learnt from their participation in this session.• How can they use this learning in the workplace?

Thank participants for their participation in the session.


PLAN FOR CONTINUOUS IMPROVEMENT

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When deciding on an action, you should consider how the action will improve the care and services provided to consumers, and the sustainability of the action. The Results and processes guide (residential aged care) and Practices and process guide (home care), available on our website, may provide information to assist you.

DateRelated

Standard

Issues identifiedInclude source for example,

consumer/ relative, meeting, internal audit

Planned actionThis must include actions, tasks and person responsible for implementing

the improvement

Person responsible

Planned completion

date

OutcomesThis includes the results,

achievement, impact, what you have measured

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