Part 3: Improvements to the Ministry's auditing and certification process since 2009

Effectiveness of arrangements to check the standard of rest home services: Follow-up report.

3.1
In this Part, we discuss the work that the Ministry has done since our 2009 report. In particular, we look at the Ministry's actions to improve:

the quality and consistency of DAA audits;
how it manages risks in the certification arrangements;
certification audit methods; and
how it analyses and shares information.

3.2
We also note that the Ministry reconsidered the design of the certification arrangements and decided to improve the current arrangements.

Our overall findings

3.3
When we carried out our audit in 2009, the Ministry was already addressing the shortcomings that it had identified in the auditing and certifying of rest homes. In 2008, the Ministry had prepared a work programme to improve the effectiveness and efficiency of the auditing and certifying of rest homes. At the time of our 2009 audit, the Ministry had begun work on this programme.

3.4
Since our 2009 report, the Ministry has continued its programme to strengthen arrangements. For example, it has reintroduced third-party accreditation, has updated the DAA Handbook, and is monitoring how well DAAs comply with the good practice auditing standards and audit practices in the DAA Handbook.

3.5
The Ministry has also continued to improve how it manages risks in the certification arrangements. For example, it is better at managing potential conflicts of interest and monitoring risks arising from rest homes selecting their own auditors.

3.6
These changes have improved the consistency and quality of DAA audits. However, the Ministry needs to do more to further strengthen auditors' competence (such as, auditors' use of tracer audit methodology).

3.7
The Ministry has continued to improve auditing methods. For example, DHBs' routine contractual audits have been integrated with the certification audits. Spot (unannounced) audits were introduced in January 2010, and tracer audit methodology at the end of 2010. These improvements have reduced duplication in the certification process and, with the introduction of the tracer audit methodology, the auditors' focus is beginning to shift towards assessing the quality of care.

3.8
The Ministry has continued to improve how it uses auditing and certification information that it has collected from rest homes. It identifies common themes and trends and communicates this information to DAA auditors. It is using this information to improve its guidance to rest homes (for example, the Medicines Care Guides for Residential Aged Care).¹⁰ It is identifying examples of good practice, which are being shared with rest homes. In our view, the Ministry needs to monitor that this information is being used:

by rest homes to improve the quality of care; and
by the DAAs to improve the quality of audits.

The quality and consistency of DAA audits have improved

Reintroducing third-party accreditation has allowed the Ministry to better assess and monitor the capability of DAAs to audit rest homes. Updating the DAA Handbook and monitoring DAAs' compliance with the standards and audit practices in the DAA Handbook have also improved the consistency and quality of audits.

Third-party accreditation has been reintroduced

3.9
Before 2006, accreditation by a third party was required for an agency to be designated as an auditing agency. In 2006, the Ministry removed third-party accreditation as a condition of designation. The Ministry did this in response to two external reports that it commissioned from The Systems 3 Group Pty Ltd (S3G) in 2004 and 2005. The reports by S3G found serious weaknesses common to all or most DAAs. The weaknesses were in management controls, auditing practice, reporting, and auditors' competency. Therefore, the Ministry considered that third-party accreditation was ineffectual.

3.10
The Ministry reintroduced third-party accreditation in 2010. In the new arrangements for accreditation, the Ministry appointed suitable accreditation bodies and better specified the requirements that DAAs had to meet to be accredited. Accreditation bodies audit DAA compliance with international standards for quality auditing. These standards are referenced to the DAA Handbook and check general auditing systems. This had not been done with the previous arrangements.

3.11
DAAs had until December 2010 to gain accreditation. In late 2009 and early 2010, the Ministry signed memoranda of understanding with two third-party accreditation bodies (see paragraph 2.4).

3.12
The memoranda require the third-party accreditation bodies to cover DAAs' capability to audit health services.

3.13
In June 2011, the Ministry evaluated third-party accreditation. This evaluation "indicates that several advantages of third-party accreditation have been realised despite there being no quantitative evidence to support this". The Ministry noted that most DAAs had to improve their systems and processes to gain accreditation, which better supports consistency in auditing.

3.14
The Ministry noted that the involvement of the third-party accreditation bodies has improved how it monitors and manages actual or emerging issues with DAAs. Accreditation bodies have provided feedback on changes to the DAA Handbook to ensure that it remains consistent with third-party accreditation requirements and best practice approaches to auditing. The Ministry also noted that the accreditation bodies have strengthened its ability to take a firm position when the Ministry and DAAs have disagreed.

3.15
The Ministry is planning another evaluation of third-party accreditation at the end of 2013.

The DAA Handbook has been updated

3.16
The main purpose of the DAA Handbook is to state the Ministry's auditing and audit reporting requirements against which DAAs audit health care services under the Act. DAAs must comply with the DAA Handbook as a condition of designation.

3.17
The DAA Handbook was revised in May 2009 to reflect changes in auditing requirements from the 2008 revision of the Standards. This was the first revision of the DAA Handbook for some time.

3.18
The DAA Handbook was revised further in February 2010 and August 2011. These revisions increased requirements for DAAs and were aimed at improving the quality of, and consistency in, DAA audit practice. Examples include extra guidance on resident sample sizes for the audit team's site-based interviews and the requirement for the DAA audit team to include a registered nurse with an annual practising certificate (and with aged care experience). DAA compliance with the DAA Handbook is monitored by the Ministry (in its review of the certification and spot audit reports) and the third-party accreditation bodies. This monitoring has been introduced since our 2009 report.

3.19
To support compliance with the revised DAA Handbook, the Ministry invited DAA consumer auditors to a training day in November 2010. The training covered:

the role of the auditor;
the Standards and the importance of the Standards and criteria;
the role of the DAA Handbook;
interviewing;
analysing the information collected during the audit;
record-keeping; and
audit report writing.

3.20
We reviewed the course notes and course workbook. We consider that they provide good coverage of the basic audit principles.

3.21
Ongoing training workshops are held for other types of auditors (see paragraphs 3.71-3.73).

Audit reports have been standardised

3.22
Before 2009, the Ministry accepted audit reports from DAAs in various formats. This contributed to a lack of consistency in the reporting of audit evidence and findings.

3.23
A standard electronic reporting template was developed and released in June 2009. It requires DAA auditors to complete mandatory fields against every Standard and every relevant criterion (of which there are currently 206). The template is intended to provide the Ministry with a platform for consistent and comprehensive audit reporting.

3.24
The Ministry completes an internal evaluation form for each audit report received from the DAAs. The evaluation form includes a set of best practice criteria. Six of the criteria assess the quality of the audit,¹¹ and eight assess the quality of the audit report. The results are collated and fed back to the DAAs to help improve quality. Since 2009, the Ministry has also analysed and benchmarked the standard of DAA audit reports. The quarterly benchmark reports are published on the Ministry's website.¹²

3.25
In April 2010, the Ministry published an Audit Report Writing Guide: A guide for writing audit reports to the Ministry of Health to help improve the quality of the audit reports.

The Ministry monitors each DAA

3.26
The Ministry has set up a performance monitoring process for DAAs. The Ministry monitors each DAA by responding to concerns raised:

by DHBs or rest homes;
through assessment of audit reports;
during observation audits carried out by the Ministry;
when issues-based audits or inspections by DHBs are inconsistent with previous DAA audit findings; and
by the annual declarations that DAAs complete and provide to the Ministry.

3.27
The Ministry offers rest homes the opportunity to comment on the audits done by DAAs. Rest homes are emailed a link to an electronic survey after each audit. The purpose of the survey is to allow rest homes to independently offer the Ministry feedback on the audit process. If the feedback directly relates to poor audit performance, the Ministry seeks further comment from the DAA as part of its performance management programme.

3.28
A DAA can have its designation cancelled under the Act if it does not meet the requirements of its designation.

3.29
During 2009, the Ministry commissioned a special audit of a DAA that had been consistently underperforming. This resulted in the DAA being required to "show cause" why its designation should not be cancelled. The Ministry closely monitored the DAA while the DAA took the required corrective actions, including a restructure of its organisation. The Ministry observed audits by the DAA in March, July, and September 2010. As a result, it issued a further "show cause" letter in October 2010. The Ministry continued to manage the performance of the DAA. It observed audits by the DAA in January, February, and March 2011. The DAA sold its health services auditing business to another DAA in April 2011.

3.30
The Ministry also commissioned an external audit programme for the other DAAs in early 2010 (before accreditation was reintroduced). Each DAA was given a copy of its audit report and the Ministry worked with the DAAs to prepare action plans to strengthen the DAA's performance. The Ministry monitored the DAAs against these plans and had regular meetings with DAAs.

3.31
DAAs are also required to have an internal audit. The details of what the internal audit covered, the results of the internal audit, and an action plan for the coming year have to be sent to the Ministry by the end of January each year as part of the DAA's annual declaration.

The management of risks in the certification arrangements has improved but auditors' competence needs to be strengthened further

The Ministry is better managing potential conflicts of interest and monitoring risks arising from rest homes selecting their own auditors. However, the Ministry needs to further strengthen the competence of DAA auditors.

Managing conflicts of interest

3.32
The Ministry has implemented a number of strategies to check that DAAs have adequate systems to prevent conflicts of interest.

3.33
The February 2010 revision (and subsequent versions) of the DAA Handbook include:

a requirement for half of the auditors on the auditing team to change after each certification audit;
a requirement for each auditor to complete a conflict of interest declaration for each audit;
an annual declaration by DAAs that a conflict of interest process has been established that prevents auditors (whether staff or contractors) from providing consultancy services or education to a client that has a contract with the DAA for audit services; and
the reintroduction of a code of conduct for auditors (which includes disclosing any current or previous working or personal relationship that may be seen as a conflict of interest or that may influence the auditor's judgement).

3.34
The Ministry's external audit programme of DAAs in 2010 (see paragraph 3.30) checked that each DAA had effective arrangements to avoid or manage any conflicts of interest. Issues raised during the audits were followed up with the relevant DAA.

3.35
The accreditation bodies check these conflict of interest arrangements for compliance with the DAA Handbook during their assessments of the DAAs.

3.36
The Ministry's optional online survey of rest homes after each audit (see paragraph 3.27) includes the question "Does your DAA provide any other services to your organisation and if so what services?"

Selecting the cheapest and most lenient DAA

3.37
To reduce the risk of rest homes choosing the cheapest and most lenient DAA, the Ministry regularly analyses the costs and results of audits. The Ministry has not been able to find a correlation between low-cost audits and fewer partial attainments and non-attainments against the Standards. This suggests that rest homes are not choosing their DAA on the basis of implied leniency.

3.38
The Ministry also monitors the movement of rest homes to different DAAs to ensure that the change is not to achieve more lenient auditing by a DAA. The Ministry is satisfied that movements are not because of the leniency of the DAAs carrying out the audits.

Improving auditor competency

3.39
The Ministry requires each DAA to ensure that the auditors they employ or contract with are capable of auditing quality management systems.¹³ DAA auditors must have gained the New Zealand Qualifications Authority (NZQA) Unit Standard 8086 (Demonstrate knowledge required for quality auditing) qualification or completed an equivalent course recognised by the Ministry. The auditors must be able to show that they are able to carry out audits in keeping with the international standard Guidelines for quality and/or environmental management systems auditing (AS/NZS ISO 19011:2003).

3.40
The DAA also has to assess the competence of its auditors in keeping with another international standard, Conformity assessment – requirements for bodies providing audit and certification of management systems (ISO/IEC 17021:2011). The DAA Handbook says that auditors can show competence by successfully completing NZQA Unit Standard 8084 (Audit quality management systems for compliance with quality standards).

3.41
Each auditor has to:

be deemed competent by the DAA they work for before starting any audit or work on behalf of the DAA;
maintain their professional development by regularly participating in audits and completing at least eight hours each calendar year of professional education relevant to quality auditing (including knowledge of legislation and regulation, managing of common medical conditions in the service setting being audited, and knowledge of current nursing care management);
take part in an annual performance review, which includes having at least one audit witnessed by another auditor from the DAA;
comply with the Ministry's code of conduct for DAA auditors (which includes requirements for competence and not acting beyond the scope of their qualifications);
have all audit reports peer-reviewed before sending them to HealthCERT; and
use work documents (for example, interview prompt sheets and tools) to support a standard of auditing consistent with the intent of AS/NZS ISO 19011:2003.

3.42
All newly qualified auditors must be supervised by experienced auditors for their first four audits.

3.43
The third-party accreditation assessment includes checking the DAA's human resource practices, its processes for appointing competent auditors, and its compliance with the DAA Handbook's requirements for individual auditors employed by, or contracted to, the DAA.

Observation audits

3.44
The Ministry carries out observation audits as part of its performance monitoring. These observation audits involve a HealthCERT advisor accompanying a DAA auditor on selected audits. This allows the Ministry to observe and compare audit practices across audits and also to check the competency of the individual auditors. The first two observation audits in early 2010 focused on higher-risk rest homes. Observation audits are now carried out when the DAA auditor is new, the Ministry is concerned about the competence of a DAA or their auditors, or the auditor has not been observed for some time.

3.45
We reviewed 16 of the Ministry's observation audit reports produced between March 2010 and December 2011. These audit reports covered the observation audits of 26 health service providers, 13 of which were rest homes (the rest were certification audits of DHBs and a hospice).¹⁴ At least one certification audit was observed by the Ministry in each DAA during this period. We consider that these audits are a useful part of the Ministry's monitoring and provide useful feedback to help DAAs see where auditors can improve.

Other options to improve auditors' competence

3.46
The Ministry has considered a range of options to further strengthen auditor competence.¹⁵ These include:

An online auditor competence test, with newly engaged auditors required to meet a competence level before the Ministry accepts the auditor on a DAA's auditor register. This option was not pursued because of the amount
of resources required. It was also beyond the scope of the Ministry's role as a regulatory body.
An NZQA 8084 programme, offered by a DAA that is both an auditing and training organisation. The programme includes 45 hours of tutored courses, 20 hours of distance learning, and 25 hours of observed assessment. The programme costs more than $2,000. The Ministry chose not to pursue this option because of the potential conflict of interest for the DAA, as both a training agency and an audit agency.
Working with an external agency to develop a competence programme that is administered by the external agency. At least two international agencies offer this type of service. The Ministry has looked at the programme provided by RABQSA International (an Australian and American partnered organisation). This programme includes an initial knowledge examination, a personal attribute assessment, and a skill assessment. The personal attribute and skill examinations are repeated every fourth year. Although the Ministry preferred this option, it had concerns about stakeholder acceptance of the programme because the costs (estimated to be an average of $140 an audit) would be likely to be passed on to providers.

3.47
The Ministry is still considering how it can further strengthen the competence of auditors.

Audit methods have improved but further training is required in tracer methodology and the reduced criteria project is not yet completed

The Ministry has improved its auditing methods. The routine contractual audit that was carried out by DHBs has been integrated with the certification audit. The frequency of audits is now in line with the Ministry's risk assessment of rest homes and spot audits have been introduced. There is more work to do to ensure that DAA auditors better understand tracer audit methodology. The reduced criteria project needs to be completed.

The integrated audit approach has been introduced

3.48
When we carried out our 2009 audit, we considered that there was unnecessary duplication between certification audits by DAAs and the audit of contract compliance (against the ARRC) by DHBs.

3.49
The Ministry introduced an integrated audit approach in August 2010. This approach incorporates the routine contractual auditing that was done by DHBs into the certification audit by DAAs.

3.50
This integrated approach means that DHBs are more involved at the start and end of the audit process. DAAs contact the relevant DHB 20 working days before the audit, which gives the DHB the opportunity to specify any contract-related issues that it wants to be considered. At the end of the process, the DHB and Ministry jointly evaluate the audit report and, if the rest home meets the Standards, the Ministry will issue a certificate to the rest home.

3.51
If necessary, the rest home submits a corrective action plan for the DHB to approve. The DHB then monitors progress by directly sourcing progress reports from the rest home. This is a change from the DAA submitting progress reports. The aim is to allow DHBs to focus on quality improvement in the rest homes rather than auditing processes.

Spot audits have been introduced

3.52
The Ministry introduced spot audits from 1 January 2010. These audits occur within a three-month period either side of the midpoint of the rest home's certification period. The audits focus on the delivery of care and include the relevant contractual requirements for the ARRC.

3.53
DAAs liaise with DHBs and the Ministry before and after the audit, using a defined process.

3.54
The audits are unannounced so that providers cannot prepare for the visits. The audits are intended to check the rest home's compliance with the Standards during the rest home's normal day-to-day business. However, during our audit, we were told that the spot audits were not as effective as they could be because rest homes are aware of the "window" when the audits would happen. We support the Ministry's use of spot audits as a method of ensuring that the Standards are maintained in rest homes.

There are more audits when risks are assessed as higher

3.55
Although rest homes can be certified for up to five years, the Ministry decides how long the certification period will be for based on an assessment of the rest home's risk. HealthCERT assesses that risk by using a risk matrix. This matrix has been improved in the last two years. Certification can be for only a year when the assessed risk is higher.

3.56
The Standards are grouped according to the consequence that the risk has for a rest home resident. For example, high risks are abuse and/or neglect, inadequate staffing levels, poor medicine management, and unsafe restraint use. General risks include quality and risk management systems, governance procedures and systems, and operational systems. The number of Standards and criteria that are partially attained or not attained and their associated risk ratings determine a "score" on the matrix.

3.57
The Ministry considers other information that it receives – for example, the outcomes of any complaints to the Health and Disability Commissioner, information provided through the DHB's issues-based audits (see paragraph 4.20), changes in the management or ownership of the rest home, past issues and reports, and whether past issues have been corrected.

3.58
The matrix score and the Ministry's assessment of the other information determine the length of the certification period. The lower the matrix score, the shorter the certification period. Because spot audits are required to be carried out halfway through the certification period, the higher-risk rest homes are audited more frequently. For example, a rest home that gained a one-year certification is audited every six months, while a rest home with a four-year certification is audited every two years.

3.59
HealthCERT can conduct further spot audits as a condition of certification at any time if it considers the rest home has been performing poorly. For a new rest home, if HealthCERT has concerns about potential risks that cannot be evaluated before the service is fully operational, HealthCERT can require a spot audit as a condition of the provisional one-year certificate. There is a defined process that HealthCERT must follow to assess whether a condition of this type will be added to the certificate.

Tracer audit methodology has been introduced

3.60
As part of revising the DAA Handbook at the end of 2010, the Ministry introduced tracer audit methodology. Tracer methodology training was provided at the September 2010 and June 2011 workshops for DAA auditors.

3.61
Tracer audit methodology is an evaluation method that selects individual residents to test the care and services provided to them. Using this method, the auditor retraces specific care pathways that the resident has experienced by observing, talking with others, and reviewing records to assess compliance against the Standards. The method allows the auditor to follow processes to gain a clear sense of day-to-day issues affecting the care of individual residents. It is designed to shift the auditor's focus from examining written policies and procedures to include the quality of care delivered to residents.

3.62
The auditor is able to look for trends that might point to potential system-level problems within a rest home.

3.63
In March 2012, more than a year after tracer audit methodology was introduced, the Ministry reviewed a small sample of audits (one audit from each DAA) where this methodology had been used. This review of six audits highlighted several issues:

important members of staff were not always interviewed;
care planning was reported in only four of the six audits;
residents' assessments were not recorded in one of the six audits; and
only one DAA auditor was checking the observed practice against the rest home's policies and procedures.

3.64
The findings from the review indicate that DAA auditors need further training in, and guidance with, the use of tracer audit methodology.

3.65
The Ministry acknowledges that not all auditors attend the workshops and that DAAs are responsible for transferring knowledge to those in their audit team who do not attend the workshops. The Ministry notes that more work is needed to ensure that "train the trainer" approaches are effective and that third-party accreditation agencies monitor new methods.

3.66
In our survey of DHB planning and funding managers, one DHB noted its support of tracer audit methodology. The DHB noted, as a general comment, that this audit methodology provides a very useful tool for seeing whether policies and procedures are followed. The DHB would like to see this methodology used more widely – to cover the spectrum of residents, different levels of care, and different issues (for example, falls, wounds, clinical care, and palliative care).

A project to reduce the number of audit criteria is under way

3.67
DAA auditors currently assess rest homes against 206 criteria. Our 2009 report identified that it was a significant challenge for auditors to consistently check more than 200 criteria thoroughly on every rest home audit in the time allocated. In November 2011, the Ministry began a project to reduce the number of criteria audited within the Standards. The Ministry has made progress with the reduced criteria project but improvements and efficiencies could have been achieved earlier.

3.68
In January 2012, an Information and Discussion Document proposed a process for new certification and recertification audits from 1 January 2013. The new process would include:

First, a document review (a "stage one audit"), which would involve the DAA completing a simple checklist and making it available to the rest home. This could reduce the time needed for reviewing policies and procedures on site.
Secondly, an on-site audit (a "stage two audit"), which would involve auditors auditing at the Standard level, not at the criteria level. However, auditors will consider the highly relevant criteria that sit under each Standard.

Reducing the number of criteria subject to audit ... is expected to allow auditors to take a more resident centred and holistic view of services. This approach is consistent with tracer methodology.
Finally, reporting on the audit results would be at the Standard level and against all relevant criteria.

3.69
The Ministry has identified a number of potential benefits of this approach:

a reduction in the number of criteria by 50%;
a time saving of 20% associated with having to audit fewer criteria;
an improved focus on quality-of-life outcomes for residents;
a time saving of 50% on reporting because of reduced reporting requirements;
streamlined audit reports because of a focus on relevant criteria; and
removal of duplication of evidence from audit reports.

3.70
The Standards must be reviewed within five years of their introduction. Therefore, the Ministry is planning to review the Standards by 2013. In our view, the timing of the Standards review and introducing the revised audit process that incorporates the reduced number of criteria in January 2013 presents the Ministry with an opportunity to further improve rest home audits. As discussed in Part 5, instead of compliance checking, the focus can be on connecting clinical and audit information to continuously improve the quality of care provided in rest homes.

Analysis and sharing of information is improving and needs to lead to changes across the rest home sector

The Ministry is beginning to use auditing and certification information from the rest home sector to identify common themes and trends. It has more work to do to ensure that this information is improving the quality of care, auditing, and certification.

DAA workshops have been held regularly

3.71
The Ministry has held workshops for DAA auditors about every three months. The workshops have covered a variety of topics. These topics include:

dementia care;
auditing informed consent and advanced directives;
the tracer audit methodology;
DAA Handbook changes;
an update on the integrated audit process;
publication of audit summaries; and
guides for nutrition, safe food, and fluid management.

3.72
The DAA staff we spoke to generally support the workshops. They considered them a useful forum for introducing changes, disseminating information to DAAs, and clarifying any common issues arising in the certification audits.

3.73
The Ministry evaluated the DAA workshops in June 2011. Twenty-three workshop participants responded to the Ministry's survey. Generally, the results were positive, with:

65% of the participants finding the workshops generally useful and a good opportunity to network and clarify issues; and
61% of participants thinking that the frequency of the workshops was appropriate.

The HealthCERT Bulletin has been published regularly

3.74
HealthCERT publishes a newsletter (HealthCERT Bulletin) about every four months and sends it to DAAs. The HealthCERT Bulletin provides auditors with updates (for example, DAA Handbook updates and changes in the sector), news about research, and answers to commonly asked questions.

3.75
The topics covered in the DAA workshops are reported in the HealthCERT Bulletin. This is done so that DAA auditors who were not able to attend the workshops have access to the information provided.

3.76
We have reviewed the newsletters and consider that they provide useful information. The usefulness of the HealthCERT Bulletin was tested as part of the June 2011 evaluation of the DAA workshops. Of the attendees at the June workshop, 78% thought that the HealthCERT Bulletin was useful.

Common themes are identified from available information

3.77
In our 2009 audit, we had concerns about how the Ministry was using the available information to improve aged-care residential facilities.

3.78
The Ministry now analyses the information in the audit reports to identify common problem areas. This involves analysing the number of partial attainments and non-attainments against each criterion and Standard. The analysis has identified areas that need to be improved and has led to three projects: publishing the Medicines Care Guides for Residential Aged Care (see paragraph 3.8), the continuous quality improvement project, and the continuum of service delivery project.

Medicines Care Guides for Residential Aged Care

3.79
In November 2009, the Ministry analysed the results of 320 audits. In 140 of these audits (117 of which were of rest homes), the provider received a partial attainment for medicine management.

3.80
The Ministry contracted a gerontology nurse practitioner/senior lecturer to write a guide on safe management of medicines for residential aged care and residential disability services. The guide was published in May 2011 and provides a quick clinical reference to common conditions and topics encountered in the care of older people.

3.81
A hard copy of the guide was sent to every rest home provider. The guide is available on the Ministry's website.¹⁶

Continuous quality improvement project

3.82
The Ministry intended that the continuous quality improvement project would identify examples of innovation and improvements made by rest home providers. A panel of experts has already selected examples of good practice, which are published on the Health Improvement and Innovation Resource Centre website.¹⁷

3.83
The Ministry provided us with several examples of innovative practice that it had identified. The rest home providers have an access code and password for the site. The Ministry told us that it would make the good practice examples available to all providers of health and disability services soon.

Continuum of service delivery review

3.84
The Ministry analysed the issues identified in rest home certification audits between March 2009 and July 2011 (636 audits of 493 facilities). It published the results of this review in December 2011.

3.85
The review established that the highest levels of non-compliance (noted in at least 30% of the reports) involved five criteria of the Standards.

3.86
The review identified the following main themes within those five criteria:

time frames for care planning and reviews were not met;
a lack of documented assessments;
all needs were not recorded in the care plans;
some interventions documented in the care plans were insufficient or not clearly documented;
some care plans were not complete;
care plans were not updated to reflect changes in residents' needs; and
short-term care planning was insufficient.

3.87
The Ministry noted that this analysis identified a number of opportunities for improvement and change throughout the sector. It has presented the findings to rest homes as part of a general awareness-raising activity. However, the extent to which rest homes have acted on these opportunities is unclear. Therefore, we cannot determine how much positive change has resulted from this awareness-raising activity.

The Ministry reconsidered the design of the certification arrangements

3.88
In our 2009 report, we recommended that the Ministry reconsider the design of the certification arrangements by examining alternatives and evaluating whether the alternatives would be more effective and more reliable.

3.89
The Ministry has considered this recommendation and decided to strengthen the current arrangements rather than redesign them.

10: See "Medicines Care Guides for Residential Aged Care", at www.health.govt.nz.

11: These criteria are the composition of the audit team, triangulation of audit evidence, rest home resident or relative interviews, that statements about the Standards match the criteria, that the evidence matches the level of attainment awarded, and that the sampling methodology included tracer methods.

12: See "Evaluation of auditing agencies", at www.health.govt.nz.

13: "Quality auditing" compares the auditee's activities against the auditee's quality management systems and applicable quality standards.

14: An observation audit may cover more than one health service provider.

15: This includes auditors' knowledge, skills, personal attributes, and the qualifications of an auditor to ensure that they meet the scope of certification.

16: See "Medicines Care Guides for Residential Aged Care", at www.health.govt.nz.

17: See www.hiirc.org.nz.

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