Crossing the Aged-Care Compliance Gap

A 3-step template for organisations transitioning to the new aged-care quality standards.

Transitioning to the new aged-care quality standards, which come into effect on the 1st July 2019, should not involve a blind leap of faith. It requires careful planning and execution. One way your organisation can successfully plan its transition is to carry out a compliance gap analysis.

A compliance gap analysis is a self-assessment of your organisation’s systems and processes for the purpose of determining whether they comply with the new standards, and what if any improvements are needed to address identified compliance gaps.

A compliance gap analysis involves answering three simple questions.
1. Where do I need to be?
2. Where am I now?
3. How am I going to get there?

Conducting a regular gap analysis can also provide valuable insight into your organisation’s ongoing compliance performance, and more importantly help identify and fix compliance gaps before they can adversely impact on its accreditation, operating costs and reputation.

1. Where do I need to be?

It’s amazing how many organisations fail to successfully achieve major change initiatives because they didn’t take the time to answer this simple question.

For Australian aged-care providers the answer is clear.  By the 1st July  2019, they must be capable of demonstrating their compliance with and performance against a new quality standards at short-notice, or risk losing their accreditation and funding.

The new standards contain 61 mandatory quality requirements against which each provider must be able to demonstrate their compliance from a consumer, worker and organisational perspective.  That is 183 compliance permutations in total.  A major challenge for any organisation.

To help providers make a successful transition the government has published a guideline which includes examples of suitable compliance evidence for each possible compliance permutation.

2. Where am I now?

Having answered “Where do I need to be?” the next question is “Where am I now?”  A simple self-assessment, or gap-analysis, can help your answer this question.

Start with a spreadsheet, or suitable compliance management solution, that enables you to step through the new standard’s 183 individual compliance permutations; recording the following information as you go.

Example: Compliance Self-Assessment Tool

Only record a “Yes” alongside a quality requirement where you can cite supporting compliance evidence e.g. policy and process documentation, performance data, meeting and worker records, consumer survey results, etc. Otherwise record a “No”.

At the same time record the details of the evidence you cited to make your compliance assessment. A hyperlink to an internal or external cloud directory or website is ideal for this purpose because it will enable you to open and display this information to external accreditation assessors during an unannounced accreditation audit.

Once your self-assessment is completed you will have collected enough information to form a clear picture of where your organisation complies with the new standards and more importantly, where it doesn’t.

Apply some simple analytics to your self-assessment results and you can report this information directly to your governing body; together with improvement recommendations i.e. some compliance management software solutions can help you do this very efficiently.

3.  How am I going to get there?

Having answered “Where do I need to be?” and “Where am I now?” the final step in planning your successful transition is to ask “How am I going to get there?”.

Answer this question by developing a carefully targeted transition plan based on the information gathered from your compliance gap analysis / self-assessment.

Attempting to make a successful transition from one standard to the other without a carefully planning and management oversight plan could have major ramifications for your organisation down the track.

For example, it will be extremely difficult for your governing body and management team to step back and make effective improvements at an organisation level if employees are independently making changes at their level.

Also consider the cost of implementation. Perhaps you don’t have the resources to implement all your improvements right now. So consider the cost and risk of a partial compliance fix, or perhaps partnering with another organisation.

Even though you may be aware of compliance gaps in your systems and processes you can reduce your organisation’s accreditation risk by using your self-assessment tool to record what you are doing to fix them; refer above table.

Also, make sure to include an estimated completion date regular progress updates for each fix, together with a planned reassessment date.

In summary

A compliance self-assessment and gap analysis is a useful first step in preparing your organisation for a successful transition to the new aged-care quality standards.

Selecting the right assessment tool can help reduce the time and effort needed to identify compliance gaps and to quickly demonstrate your organisation’s compliance to internal and external stakeholders; including assessors during unannounced accreditation audits.

If you’d like to learn more about how your organisation can optimise its transition to the new quality standards using FREE aged-care compliance management software click here Link.

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