Performing regular system review and making improvements

Article by Christine Grafitti, Senior Consultant

The Commission has now confirmed in a recent webinar that the draft Strengthened Aged Care Quality Standards (SACQS), released in December 2023, will be the final version of the SACQS, with the exception of some minor word or phrasing changes. 

Where the SACQS apply, interesting areas for Registered Providers within the Outcomes of Standards 2: The Organisation and 5: Clinical Care are Actions 2.33, 2.44, 2.56, 2.66, 2.73, 2.95, 5.1 and 5.3 which require providers to ‘regularly review and improve the effectiveness of the following systems’:

  • Information management
  • Feedback and complaint management
  • Risk management
  • Incident management
  • Training
  • Clinical
  • Safe and quality use of medication.

Critical Success Solutions’ (CSS) Consultants have observed that many of our aged care clients will need to upgrade their continuous improvement and quality systems in response to these Actions. Clients are also asking ‘how frequently should I review the effectiveness of these systems?

We believe that a scheduled approach to regular review is warranted whereby a provider might review the effectiveness of these systems annually. However, quality systems must also incorporate triggers and escalation processes to enable the Leadership and Governing Body to understand where these systems are working effectively and when improvements are required. This in turn will enable providers to understand if their systems require an ‘unscheduled pit stop’ for their system in response to quality data.

In order for providers to obtain information about the effectiveness of a system, reworking of forms, operationalising new processes and retraining managers may be required. For example, your incident management system may include reworking of the Incident Form. Our CSS Incident Form includes a section which asks the reviewing manager to evaluate the effectiveness of the incident management system to determine if systems and processes worked well. Where improvements could be made, these improvements are included within the Continuous Improvement Plan, which is then used to evidence how the organisation completed a responsive review of this system or part of the system. Where a number of system failures arise, a full ‘system check’ may be required.

Draft Standard 2: The Organisation, Guidance Material, released 6 February 2024

(Link: also provides the following practical advice to changes that providers can make to meet the new Actions:

  • You need to make sure your incident management system is suitable and developed to help workers use it. Make sure workers understand their role in the incident management system and how to follow it.
  • You also need to assess whether workers are following your incident management system consistently and well (Outcome 2.9). You can do this through performance assessments, audits and system checks

As you navigate these strengthened Standards, CSS are here to help. If you need assistance with your SACQS change management processes, please don’t hesitate to contact us by email or phone to tailor a solution for your requirements and to check your systems.

To obtain further information regarding our suite of education, or discuss how these programs can add value to your organisation please contact me at / 0414 588 795.

Aged Care, Aged Care Workers, education program, Employee, Governance, Governance, Home Care, Statement of Rights, Strengthened Standards, Training

Aged Care Services: Education and Training Requirements Strengthened Standards 2024

Aged Care, Audit Opportunities, Best Practice, Governance, Governance, Governance Audits, Home Care, Statement of Rights, Strengthened Standards

Aged Care Governance Compliance Audits – a Preparation Roadmap to Success

Aged Care, Audit Opportunities, Commission, Governance, Home Care, New Aged Care Act, Non Compliance, Residential Aged Care, Sector Performance Data, Statement of Rights, Strengthened Standards, Strengthened Standards

Sector Performance Data and NEW Strengthened Standards and New Governance Audit Opportunities