Submission 36 Jade McEwen, MA Dis, Adv
Dip Man, Adv Dip H&SC, Dip Com
Serv.
Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
Submission to Inquiry on NDIS Quality and Safeguard Commission
This submission is primarily in relation to reference (c), “The adequacy and effectiveness of … the NDIS Practise standards and audit process”. Overall, it is my view that both the standards and the methods used to determine compliance against them (usually referred to as ‘audits’) do little to reliably monitor service quality in ways which identify good and poor quality support. It is essential that regulatory mechanisms are able to monitor service quality adequately across the disability sector, as they are one of the few mechanisms that can be used to ensure that people with intellectual disabilities are safe and not being mistreated by the staff who support them. Safeguards are particularly pertinent at present, with recent research suggesting that the abuse and neglect of people with intellectual disabilities is ‘rife’ across Australia (Community Affairs References Committee, 2015). In fact, it is believed that people with intellectual disabilities are ten times more likely to experience abuse and neglect than the ‘average citizen’ (Community Affairs References Committee, 2015).
About the Author
I write this submission as a PhD Candidate of the La Trobe Living with Disablity Research Centre who has been researching the way service quality is defined and monitored internationally and in particular, across the Australian disability sector for the past eight years. My research findings have identified both the inadequacies of past and current approaches to monitoring service quality and possible ways in which it can be better monitored in future. I have also worked within disability services for the past 19 years, 15 of which have been within roles designed to ensure service quality and comply with regulatory standards.
The following points summarise my concerns about the NDIS Practice Standards, including the way in which they are used as a mechanism for monitoring service quality within disability service organisations.
1). Standards are written in high level abstract concepts
The NDIS Practise standards are written in high level abstract concepts, with little attention paid to what these concepts actually look like in practise. For example, under the outcome area ‘Privacy and Dignity’ within the Core Module section of the standards, it states ‘Each participant accesses supports that respect and protect their dignity and right to privacy’ (NDIS Quality and Safeguards Commission, p6). However, no further information is provided about what ‘respecting an individual’s privacy or dignity’ actually looks like in practice. Consequently, service providers and the review bodies responsible for monitoring compliance with the standards, have no practical guidance about how ‘good’ or ‘poor’ service quality presents. The lack of information about how practices known to be associated with ‘good’ or ‘poor’ service quality present, may cause service providers and review bodies to focus their attention away from practice and towards the systems and processes that underpin it, contributing to the likelihood of poor service quality or in extreme cases, abuse and neglect going undetected. Consideration should be given to revising the NDIS Practice Standards to include specific, practical information about what ‘good service quality’
looks like within services. Standards should be based on the practices known to contribute to good service quality, which have been identified within relevant contemporary research. Examples, in respect of people with intellectual disability include Active Support, a staff practice designed to improve the quality of life experienced by people with intellectual disabilities through enabling engagement in meaningful activity and social relationships and practice leadership, a practice characterised by Managers and supervisors who ensure that there is a focus on the quality of life outcomes of service users within staff’s day to day practice and team meetings (Beadle-Brown, Bigby & Bould, 2014). The standards also fail to recognise diversity among people with disability and that good support looks different for different groups of people and services. The standards should provide a series of descriptions about what service quality ‘looks like’ amongst particular groups of people, such as people with more severe and profound intellectual disability, or people with high physical support needs but no cognitive impairment.
- A focus on procedures rather than practise Indicators within the NDIS Practice standards describe the way providers must demonstrate compliance with required outcomes. Indicators are general in nature and provide little practical information about the outcomes service providers are expected to achieve and what evidence constitutes compliance against them. Where evidence is specified, it is typically a procedure or record of some kind. For example, the following indicator can be found under the outcome area ‘Violence, Abuse, Neglect, Exploitation and Discrimination: ‘Policies, procedures and practices are in place which actively prevent violence, abuse, neglect, exploitation or discrimination’ (NDIS Quality and Safeguards Commission, p7).
The general nature of the standards coupled with the focus on procedures and records are likely to result in service providers focusing on paperwork rather than staff practice. However it is staff practice that has been found to make the biggest difference to the quality of the support that people with intellectual disabilities receive. For example, research has shown good service quality to be associated with services where staff facilitate Active Support (Flynn, Hastings, Gillespie, McNamara & Randell, 2018). Likewise, the absence of practices such as Active Support has also been associated with services which deliver poor quality support. These and other relevant practices identified within contemporary research could be defined within the NDIS practice standards, including indicators to guide staff and review bodies about what they look like and how they can verify if they have been adequately enacted. In changing the focus of the NDIS Practice standards from general to specific and from a documented approach to one which is practice orientated, ‘compliance’ becomes about how people with disabilities are supported in real time, rather than the documents and records that are written before and after support is provided. Furthermore, in changing the focus of the NDIS Practice standards to the way people with intellectual disabilities experience support, it would be necessary for review bodies to utilise real time observation methods, which have been proven to be a far more adequate and reliable method for monitoring service quality within human service organisations (Mansell, 2011).
- The audit process fails to adequately include service users The audit process typically involves the review of pre-existing records and observations of the way in which processes or systems are enacted, to judge whether or not they match the expectations set out within
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quality standards (Ellis & Whittington, 1993). However, despite government efforts to define and monitor service quality in disability services, abuse, neglect and exploitation of people with a disability is believed to be “rife” across Australia (Parliament of Victoria, 2016, p.40). Research suggests that inadequacies in both the quality standards designed by government (as per previous points 1 & 2 above) and the audit process designed to monitor compliance against them are failing to identify both good and poor quality support within disability services (McEwen, Bigby & Douglas, 2014). Furthermore, they are failing to identify practices and cultures where abuse and neglect are more likely to manifest (McEwen, Bigby & Douglas, in press).
The audit process was modelled from quality assurance processes over three decades ago, but remains the dominant way in which compliance against quality standards are monitored today (McEwen, Bigby & Douglas, 2014). Originally designed for the engineering and manufacturing sectors, the audit process focuses on paperwork held by organisations such as their policies and procedures. However, research suggests that an organisations policies and procedures do not necessarily represent staff actions, including the adequacy of the support they provide to people with disabilities (Community Affairs References Committee, 2015). For example services with excellent policies and procedures may provide poor quality support and services with poorly written policies and procedures may provide excellent support (McEwen, Bigby & Douglas, 2019).
Further compounding the ‘documented approach’ used within the audit process, is the fact that there are very few stipulated methods for reviewing staff practises or the quality of frontline service provision (e.g. observation and interview). The only information provided in relation to these tasks was specific to the number of service users who should be engaged in these activities. For example, the Joint Accreditation System of Australia and New Zealand (the organisation responsible for accrediting organisations as “competent” to perform audits) requirements for consultation stipulate that “the sample size for service user consultation must be twenty-five percent of the square root of the number of people accessing services, rounded up, for certification and recertification audits” (Joint Accreditation System of Australia and New Zealand, 2013 p. 11). Under this formula, within one large service supporting 200 people with disabilities in one location (such as a day service), a minimum of 4 people would be required to participate in consultation activities during audits. Such a small proportion of people is inadequate for making accurate determinations about the quality of the supports people with intellectual disabilities receive. Significantly larger cohorts of service users should be engaged in the evaluation of the supports they receive, because findings are more likely to be accurate and to minimise the risk of inaccurate data due to the high prevalence of acquiescence amongst people with intellectual disability (Williams, 2011). Consideration should be given to revising the audit process, to adopt methods known to be more adequate for monitoring service quality within human service settings such as observation and interview (McEwen, Bigby & Douglas, 2014). Until this is achieved, the audit process will continue to reflect the adequacy of service providers systems, processes and records, rather than the lived experience of people with a disability.
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Conclusion
I would welcome the opportunity to present and discuss further this submission to a hearing of the Committee. It is my belief based on 8 years of research, that in addressing the inadequacies identified within the NDIS Practice standards and associated audit process, there will be a much higher chance that poor quality services and in extreme cases abuse and neglect will be identified across the disability sector. Furthermore, I believe that the changes I propose are far more likely to elevate practise within disability service organisations and encourage service providers to focus their efforts on practises known to improve the quality of the support people receive.
Thank you for your consideration and please feel free to contact me any time.
Sincerely
Jade McEwen
PhD Candidate
La Trobe University
References
Bigby, C., Knox, M., Beadle Brown, J., & Bould, E. (2014). Identifying good group homes for people with severe intellectual disability: Qualitative indicators using a quality of life framework. Intellectual and Developmental Disabilities.
Community Affairs References Committee (2015). Violence, abuse and neglect against people with disability in institutional and residential settings, including the gender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people with disability, and culturally and linguistically diverse people with disability. Canberra: Commonwealth of Australia.
Ellis, R., & Whittington, D. (1993). Quality assurance in healthcare, a handbook. Great Britain: Edward
Arnold
Flynn, S., Hastings, R, P., Gillespie, D., McNamara, R., & Randell, E. (2018). Is the amount of exposure to aggressive challenging behaviour related to staff work-related well-being in intellectual disability services? Evidence from a clustered research design. Research in Developmental Disabilities.
Joint Accreditation System of Australia and New Zealand. (2013). Human services scheme, Part 4 additional requirements for bodies certifying human services in Victoria.
Mansell, J. (2011). Structured observational research in services for people with learning disabilities. The London School for Economics and Political Science online. London: School for Social Care Research.
McEwen, J., Bigby, C., & Douglas, J. (2014). What are Victoria’s disability service standards really measuring? Research and Practice in Intellectual and Developmental Disabilities.
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McEwen, J., Bigby, C., & Douglas, J. (2019). Moving on from Quality Assurance: Exploring Systems that Measure both Process and Personal Outcomes in Disability Services, Journal of Policy and Practise in Intellectual Disabilities.
McEwen, J., Bigby, C., & Douglas, J. (In Press). What is good service quality? Day service staff’s perspectives about what it looks like and how it should be monitored.
National Disability Insurance Scheme Quality and Safeguards Commission (2020). NDIS Practise
Standards, NDIS Practise Standards and Quality Indicators. Retrieved on the 25th of July, 2020 from https://www.ndiscommission.gov.au/sites/default/files/documents/2019-12/ndis-practice-standards-and quality-indicators.pdf.
Parliament of Victoria (2016). Inquiry into abuse in disability services. Final report. Retrieved from: https://www.parliament.vic.gov.au/images/stories/committees/fcdc/inquiries/58th/Abuse_in_disability_ser vices/FCDC_58-02_Abuse_in_disability_services_-_Final_report.pdf.
Williams, V. (2011). Disability and discourse: Analysing inclusive conversation with people with intellectual disabilities. West Sussex: Wiley-Blackwell.
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