Participation, equity and inclusiveness

There must be avenues for men and women to participate in the decision making at all levels of governance in the organisation. This includes the board, advisory committees, managers and staff. The way in which communication occurs from the staff to the board and back again must enable all those involved in the organisation to feel they are listened to and valued for their contribution. Workers’ inclusiveness gives people a sense of ownership and engenders pride in the organisation. Proper representation of all constituents involved must be evident and minutes kept for decisions made at all levels.

Laws and legislation

The aged care sector is one of the most legislatively controlled areas of human services. In residential care the rights and responsibilities, standards of care, monitoring and auditing and funding systems are tightly managed by the Commonwealth Government (Commonwealth Government 1997). At state and territory level there are also regulatory systems for buildings, occupational health and safety, food service delivery and complaints. Monitoring of all these areas is by government agencies and independent arbitrators. All levels of governance must be aware of the systems they operate under and be conscious of their legal obligations to their stakeholders.

Transparency

Transparency in governance means that all decisions made are well documented and communicated to all involved, that there are no underhand business dealings and that all follow legal requirements. It also means clear dealings with the local community around the service and consideration is given to the effects of decision making on local planning and service delivery.

Responsiveness

Issues arising must be seen to be dealt with within a reasonable timeframe by action of those in governance positions. Complaints, staff issues and accounts payable are some of the areas where to maintain relationships and demonstrate good governance, responses should be given promptly and directly to those concerned. The credibility of the organisation is at stake when decisions are not made in time or delayed for some unknown reason. Sometimes there are legitimate reasons for a delay in a decision but these reasons should be made known to those concerned.

Consensus-oriented

There are many reasons for people to participate in governance activity. People join boards and committees usually because they are interested in the work of the organisation. Differences of opinion are healthy and give options for organisational governance decision making. However, to progress in good governance there must be a sense of strategic planning that everybody is happy to follow. Without a clear pathway for the future, the organisation will flounder. This consensus model must flow from board level to clinical care levels, or else policy and procedural documents given for staff to follow are useless.

Effectiveness and efficiency

Good governance will produce both effective business and care outcomes. Without efficient budgetary control and a willingness to try different methods of cost-effectiveness the organisation will not be able to deliver quality care. Benchmarks can be set by industry standards but they only give guidance for the attainment of satisfactory outcomes, not diverse excellent outcomes that are making a difference. Good governance weighs the element of risk taking against possible gains and will always follow the criteria of non-malfeasance and beneficence in ethical decision making.

Accountability

Good governance demonstrates accountability to all the stakeholders of the organisation.

In aged care stakeholders will include the people who receive services, their families and the community in which the service is delivered. Staff who are directly employed and those who operate as consultants are equally important. The success of the organisation is measured by the way it is accountable for all decisions made and their outcomes.

Corporate governance also includes the management of adverse events and risk assessment and management. Whilst adverse events are usually well documented in health care settings through the quality systems employed, aged care organisations are just developing these systems and risk management is not well documented. Kohn and colleagues (1999) suggest that although 60–80% of adverse events involve human error, the major cause of the error does not lie within the individual but rather the structures and processes that are intended to support the provision of care.

Aged care organisations have had to develop quality systems to meet the Standards and Accreditation Agency requirements. However, the nature of the care being delivered is becoming more complex as the population longevity increases, but with more complex comorbidities. This has led to a range of comorbidity factors in care that were once dealt with in acute hospital settings and rehabilitation units. Neurological disorders are often the major reason for admission to care and have the most complex symptomatology. Alzheimer’s disease, other forms of dementia, motor neuron disease, Parkinson’s disease, stroke, post-trauma brain injury, post-traumatic stress disorders and alcoholic neurological problems, together with the younger onset diseases such as multiple sclerosis, are becoming more apparent in the reason for admission to residential care.

At the same time as the population presents with these chronic health issues, the nature of the workforce in aged care has changed. Registered nurses are avoiding working in aged care and those who do are ageing themselves (Australian Institute for Health and Welfare [AIHW] 2008). The average age of registered nurses working in residential care services now in Australia is over 45 years. Provision of care is reliant on a less skilled workforce with minimal supervision. General practitioners (GPs) are also finding it difficult to maintain geriatric care and residential care coverage, especially in rural areas. Allied health practitioners are in short supply and specialist geriatricians and psychogeriatricians are becoming more and more difficult to access (AIHW 2008).

Existing risk management and quality systems in residential services are not keeping up with the complex organisational processes, clinical decision making and potential environmental hazards that now exist. Other ways of utilising workers, managing risks and providing cost-effective safe care outcomes are needed.