The contribution of electronic health records to risk management through accreditation of residential aged care homes in Australia

In accordance with the international themes in health and personal services [5], a risk management approach has to be established in RAC homes to effectively control the risk factors for resident safety and wellbeing so as to comply with the legislative requirements in Australia. The process of risk management includes identifying and assessing risks, developing risk management plans, implementing risk management actions and re-evaluating emerging risks in the care processes [6].

An important objective of RAC homes is minimising risks to the individual care recipients, their families and society [7], which requires managing the risk factors related to residents’ health conditions. The classical nursing process model, which has been widely used as a theoretical framework for nursing practice and documentation in RAC homes in Australia, is a risk management approach to resident safety. This model is comprised of five stages: nursing assessment, nursing problem or diagnosis, planning, implementation and evaluation [8, 9]. Each stage of the model echoes the relevant stage in the risk management cycle. In the context of aged care nursing, ‘risk management’ encompasses many of the activities undertaken by qualified and non-qualified nursing staff [10]. An important objective of risk management in nursing practice is to reduce adverse events and incidents that under optimal conditions are not a normal consequence of a resident’s nursing and personal care.

To ensure the effective implementation of the risk management system to protect resident safety, Australian government has implemented a compulsory aged care accreditation program. This guides and monitors a risk management approach in registered RAC homes, similar to those in other OECD and European Union countries [11]. Aged care accreditation drives the risk management system in RAC homes in Australia, within six states and two territories: New South Wales (NSW), Victoria (VIC), Queensland (QLD), Western Australia (WA), South Australia (SA), Tasmania (TAS), Northern Territory (NT) and the Australian Capital Territory (ACT).

Aged care accreditation is a process that assesses quality of care and services provided in RAC homes, and gives recognition that providers are competent, comply with regulations and meet service quality standards [11]. It encourages quality and safety through a mix of compliance and quality elements, which can extend to continuous quality improvement. To ensure the effective function of the RAC risk management system and resident safety, the aged care accreditation system is implemented through the government-operated Australian Aged Care Quality Agency (AACQA), which determines whether the services provided by an RAC home meet the relevant safety standards. The AACQA commenced operation on January 1, 2014, superseding the Aged Care Standards and Accreditation Agency (ACSAA).

The AACQA makes use of the same four accreditation standards as its predecessor, both followed the Quality of Care Principles 2014 [12], made under the Aged Care Act 1997 [13]. An accreditation report is organised under four RAC accreditation standards: (1) management systems, staffing and organisational development; (2) health and personal care; (3) resident lifestyle; and (4) physical environment and safe systems [12]. The four standards include 9, 17, 10 and 8 expected outcomes, respectively, a total of 44 [12]. Common to all four standards are the outcomes of continuous improvement, regulatory compliance and education and staff development.

The process of aged care accreditation in Australia includes self-assessment by each RAC home against the accreditation standards and submission of an application for accreditation. This is followed by a desk audit and a site audit by a team of registered aged care quality surveyors. Then the AACQA publishes an official report, and makes the decision about whether the home met the standards. If the AACQA found that a service did not meet one or more outcomes under the relevant standards, it would require the service to rectify the non-compliance. Finally, an accreditation certificate is issued, when appropriate, and an accreditation report published on the AACQA’s web site [14].

Information management is fundamental to healthcare delivery. A variety of information systems, covering client registration, billing and client health records, have been established in Australian RAC homes to support a variety of organisational purposes and functions. These include administrative, financial, regulatory compliance, care delivery and quality assurance. As the communication tool for information exchange between nursing staff and with outside health service providers [15], the client health record system, either in paper or electronic format, is the most important information system in RAC homes. It supports the delivery of aged care services and risk management for client safety, promotes effective communication between caregivers, and facilitates continuity and individuality of care of clients, and regulatory compliance [8, 9].

By the end of 2014, 37.4% (1031 of 2756) of the accredited RAC homes in Australia had introduced electronic health records (EHR) to manage client health and lifestyle information and to improve effectiveness and efficiency in information management [4]. Although EHR is a major technology to support the delivery of aged care services and risk management for client safety in RAC homes, its rate of adoption appeared to have stagnated since 2014 according to our analysis of the publicly - available aged care accreditation reports.

The study described here aims to research the effectiveness of EHR in risk management for accreditation in RAC services in Australia. In order to provide contextualised and valid explanations of the findings, the following research questions were addressed.

A convenience sample of 5560 aged care accreditation reports published from 2011 to 2018 was sourced from the AACQA website (www.​aacqa.​gov.​au). The first collection was conducted in 2015. All 3607 reports published between March 7, 2011 and March 7, 2015 were downloaded. The second collection was conducted in 2019. A stratified sample of reports were downloaded for each state or territory. The simple random sampling method, i.e., randomly picking a number, was applied to select half of the reports that were published between March 8, 2015 and December 31, 2018. After removing those reports that could not be opened or did not contain actual findings, 1953 reports were collected. Each report was about 20–30 pages.

These reports were published in Microsoft word or pdf formats. The word documents were converted to pdf files, which were further converted to text files using custom-built software operating in conjunction with Adobe Acrobat XI Version 11.0.23. Errors generated during conversion, i.e., mis-spelling, broken line and unnecessary symbols, were fixed manually in comparison with the original pdf documents. The incorrect character encoding was concentrated on list characters like ‘•’ in pdf format. As all errors did not influence reading the content, they were converted to ‘?’ or ‘????’ in the text files.

A computer program was developed to automatically extract data using keywords. For example, to extract data on whether an RAC home used EHR, the keywords used included ‘electronic clinical plan’, ‘electronic clinical documentation’, ‘electronic clinical information’ and ‘electronic care plan’. To identify whether the home failed an expected outcome, the keywords ‘not met’ and the title of that outcome were used.

The accuracy of the computerised conversion function was tested by manual comparison with human judgement for a set of 100 reports randomly selected from the first batch of 3607 reports. As no difference in results was found between the two methods, the program was effective to extract the data, thus was applied to all the reports.

Data items extracted from each report included (1) the jurisdiction where the RAC home was located. (2) reporting year; (3) size of the RAC home (large, ≥ 60 beds or small < 60 beds); (4) type of information system used by the home (EHR or paper); (5) accreditation outcome of the RAC home (failed or passed); and (6) accreditation result of each of the 44 expected outcomes (labelled by 0 [not met] or 1 [met]). Ownership, whether not-for-profit, private or government owned, of the RAC homes that failed the accreditation was identified by manually searching online.

The extracted data were stored in a Microsoft Excel spreadsheet. Each row stored the data extracted from one accreditation report. Therefore, there were 5560 rows plus one header row in this spreadsheet.

In total, fifteen indicators were used to assess the accreditation outcome 1.8 Information Systems. Further details of the findings for these indicators are provided in Additional file 1.

Ten indicators were used in the accreditation reports to determine that an RAC home did not meet the accreditation outcome 1.8 and 14 for outcome 2.4 (Table 1). Failure in monitoring mechanisms was a common reason for RAC homes to fail seven accreditation outcomes (Table 2). There were four major reasons for RAC homes failing medication management accreditation outcomes (Table 3).

Comparison of details for the two series of reports is shown in Table 4. The failure rate for RAC homes was higher in the AACQA than the ACSAA reports, while mean numbers of outcomes failed were similar. There were significantly higher failures rates in the AACQA series for 28 of the 44 accreditation outcomes considered, and no significant difference from the ACSAA reports for the remainder. Four of the five most frequently failed outcomes were common to both series of reports. The number of reports recorded failure of each of the 44 accreditation outcomes is presented in Additional file 1.

There was no significant difference in the failure rate between the RAC homes using an EHR system (2.8%, 55/1988) and those using a paper-based system (3.1%, 111/3572). The failure rate varied over the years, increasing from 2014 to a highest value of 12.1% in 2018. As indicated in Table 5, there did not appear to be a clear relationship between failure rate and the proportion of reports for homes that used EHR. Increased use of EHR did not seem to bring a clear risk management benefit through decreasing accreditation failure rates.

For those RAC homes that used EHR, large homes had a significantly higher failure rate than small ones. For large homes, the failure rate was lower for those with EHR than those using paper. For small homes the difference between failure rates for EHR and paper was less (Table 6).

There was some variation between jurisdictions in the failure rates for their RAC homes, with QLD having a higher rate and VIC a lower rate than the others (Table 7).

The 166 reports that recorded failure were from 155 RAC homes. Of these, 61.9% were not-for-profit, 29.7% were private and 8.4% were government - owned. 93.5% of these RAC homes failed accreditation outcome once, 5.8% failed twice and one failed three times (Additional file 1).

Across the OECD countries, external regulatory control over RAC services is typically focused on controlling input (physical and human resources) by setting minimum acceptable standards and enforcing compliance [11]. Typically, accreditation requirements involve benchmarks for structure, workforce and safety. These aspects are reflected in Australian aged care accreditation by the structural component Information Systems and the workforce component Human Resource Management. These had always been among the top five failed accreditation outcomes.

However, aged care accreditation in Australia appears to fall short in assessing safety. There was only one safety-related indicator for the accreditation outcome 1.8 Information System: “Residents and representatives are satisfied with the information management of the home”, and one for 2.4 Clinical Care: “Residents and representatives are satisfied with the clinical care provided”. These two outcome measurement statements are subjective, vague and difficult to quantify. This echoes the observation of Nies et al. [11] that enforcement of external accreditation regulatory controls might be lenient in the OECD countries, therefore quality assurance needs to transfer to outcome-based measures that are supported by robust data infrastructure and clear guidance.

There was an improvement in the consistency of use of measurement indicators for quality assessment after the transition of the accreditation authority from ACSAA to AACQA in 2014. This was indicated by a significantly increased use of 33.3% of the measurement indicators to assess accreditation outcome 1.8 Information Systems and 47.1% of the indicators for outcome 2.4 Clinical Care. However, there remained a huge variation in the implementation of more than half of the indicators. This suggested a big variation in the implementation of quality standards by accreditation surveyors across the country. This might reflect a lack of robust data infrastructure and clear guidance to the quality surveyors on which indicator data to capture and how to accurately and fully use clear indicators to assess the quality of RAC services.

Failure in monitoring mechanism is the key factor for RAC homes to fail many accreditation outcomes. In our previous study, six risk indicators to fail the information system accreditation outcome were summarized for the RAC homes that used paper records [4]. In this study, nine risk indicators were extracted, including five of those identified in the previous study. As many more RAC homes have failed the accreditation outcome 1.8 Information Systems since 2015, it is reasonable to expect this increased identification of risk indicators for information system failure.

There were fourteen risk indicators for RAC homes to fail the Clinical Care accreditation outcome. Five revealed deficiency in nursing process. The close proximity of the nursing process model to the risk management cycle supported a failure of risk management for clinical care. Two risk indicators suggested information system failure: information was not always current, accurate and consistent; and information systems and communication processes were not effective to support the provision of appropriate clinical care. This echoes the importance of the information system for clinical care.

Of the 5560 aged care accreditation reports published in 8 years, only 3% (166) reported failure of one or more accreditation outcome. Failure rate was the lowest in 2014 when AACQA took over from ACSAA. Over the following 4 years the failure rate then increased to reach 12.3% in 2018. There were also more failed accreditation outcomes in the AACQA reports than in the ACSAA reports.

What is concerning is a continued increase in the failure rates in the core safety areas of Clinical Care, Medication Management and Behavioural Management over the years. Large RAC homes had a significantly higher failure rate than the small ones. Failure rates varied between jurisdictions The RAC homes in QLD had a higher failure rate, and those in VIC a lower rate, than homes in other jurisdictions. Possible explanations for these variations are that the implementation of measurement indicators was different across the years and locations, or that the quality of RAC services was indeed different.

Meeting accreditation standards is a mandatory requirement for the RAC homes in Australia to acquire registration and to receive government subsidy for care services. Accreditation drives the risk management approach in RAC homes to providing safe care for their residents. Our findings suggest that the effect of accreditation on driving and monitoring the risk management approach in RAC services was sub-optimal.

A risk-based approach to accreditation needs to take proper account of relevant history and current risk profile of a facility, to seek the true views of care recipients and their representatives, and to ensure that quality surveyors have adequate competency for the job [16]. In the period covered by this study, the Australian aged care regulatory system has been fragmented [16]. Responsibility was split between the Department of Health, the Quality Agency and the Complaints Commissioner, creating opportunity for miscommunication or discoordination between the three organisations. There was a lack of mechanism for Aged Care Accreditation Agency to identify ‘at risk’ RAC services.

In this study, the unit of analysis was an individual accreditation report. There were cases where several reports were produced for one RAC home. 5.8% of the 155 RAC homes that failed the accreditation outcomes were sampled twice and one was sampled three times. As the rate of repetitive failure in accreditation for an RAC home was minimal, it did not appear that the accreditation took adequate account of the relevant history and risk profile of an RAC home in the previous accreditation audit.

Another factor that may reduce the rigor of accreditation was that some RAC services became adept at providing the quality surveyors with “the look and feel” and information that the surveyors would expect, instead of presenting a true profile that the care recipients experienced on daily basis [16].

Only a few OECD countries have well-established information systems for care quality in RAC homes. Australia appears to be advanced in that respect, with 31 to 52% of the sampled RAC homes using EHR in the last 5 years. However, there was a similar level of accreditation failure rates in RAC homes using EHR and those using paper records. This might be due to a failure of accreditation in assessing outcomes, particularly a lack of coverage of safety outcomes. Accreditation may not be robust enough to identify the performance difference brought about by the use of EHR to replace paper records. Another possibility is that both EHR and paper records were weak in documenting measurable and concrete resident outcomes and nursing processes [17], and thus of limited quality [18‐20].

Observational studies in Australian RAC homes have found that oral communication was the most frequent activity and the major communication channel between nursing staff, with residents and with outside service providers [2, 21‐23]. About two-thirds of activities of nursing staff had a duration of 1 minute or less [2]; therefore nursing staff rarely had time to consult nursing records in the care delivery process [1]. Even in conducting high risk activity of medication management that requires clear information, the nursing staff only spent one to 2 minutes on reading residents’ records in a three-hour round [24]. EHR systems may not be adequately used in RAC homes to support nursing staff delivering care services, nor risk management to ensure resident safety.

In order to effectively fulfil the role of guiding and monitoring risk management practices in RAC homes, aged care accreditation in Australia needs to transform to outcome-based measures that are supported by robust data infrastructure and clear guidance. The EHR system and its use may also need to be improved to truly support risk management for accreditation in RAC homes.