Quality in service delivery: experience necessary!

In services such as disability support and aged care, there are emerging markets, and emerging choice for consumers. But if someone is considering a service, how do they find out whether it is good quality, or whether it will meet their needs? Social services often experience complex regulation, limited consumer choice, and may not have a strong culture of customer service. These are also often not easy environments for consumers to navigate. 

There are many different strategies and systems that help customers of social services, as well as the broader community, to find out about quality.  This isn't always simple, though information technology has opened up new options.  But you don't need to go digital to go the experts: consumers. What are the opportunities?

 
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Audits and assessments

Some service systems include mandatory audits or assessments. In aged care, services are subject to varying levels of announced and unannounced visits from the Aged Care Quality Agency, as well as having regularly to submit documentation about their operations. Most child care operates under the National Quality Standard, with assessments undertaken by regulators, the results being publicly available. The highest possible rating, of excellent, is awarded by the Australian Children's Education and Care Quality Authority. With fewer than fifty services out of the thousands around Australia holding that top rating, this is a system designed to drive high performance, not just assess against a baseline.

These assessments and audits can be powerful tools, but can end up only establishing a baseline. As the Aged Care Quality Agency recently said, "knowing that a service is accredited or meets minimum standards does not help consumers to ascertain whether the provider is delivering high quality care or just passing minimum standards". Audits can also tend to emphasise safety and accountability, rather than consumer experience, though there is a growing focus on consumer needs and expectations. 

The rise of ratings

Spurred on by Trip Advisor and AirBNB, customer ratings have come to be a fundamental way of understanding service quality. In 2014, the Minister responsible for both aged care and disability policy, Mitch Fifield, spoke of the potential for consumer rating to help transform aged care.

That transformation is underway, in fits and starts. Services are emerging, harnessing the power of the digital space. In disability services, these include Clickability in Victoria (and going to be national) and CareNavigator. The path has been rockier in aged care: the NRMA launched its Owl Ratings for aged care, but then put it on hold

Rating systems can be great, but also have lots of challenges. It can be hard for people to know what it is about the service that is being assessed; the rating system can be trolled, with some feeling that reviews can tend to be polarised; and whether a particular service happens to be rated can be a hit-and-miss affair. Some ratings involve self-assessment by services using a tool to guide their rating, such as is used by AgedCareRatings.com.au. This is intended to make rating more systematic, by setting out standard criteria, but may risk the perception of bias, or may struggle to capture the consumer experience. 

Customer feedback

Mostly, the best way to assess quality of a service is to ask an expert, and the greatest experts are customers. This is not as easy as it sounds. Earlier this year, the Australian Aged Care Quality Agency announced it intended to include consumer and carer comments in its published audit outcomes. But the consumer peak body COTA's reaction was lukewarm  because of what they see as the "variable quality of resident and family interviews during the current accreditation process".

There can be other problems too. In some social services, consumers are highly dependent on service providers, and not able to simply switch services if they don't like what they are getting. In these situations, consumers may not feel able to be open about their experience.

However, consumers can be engaged directly, and professionally, to foster quality in service delivery.

Get your organisation checked out

Quality checking brings together the expertise of assessment, the discipline of ratings, and the depth of understanding and lived experience that only service users can offer. 

People who use services have specific expertise that others do not have. Disability expert Sam Connor talks about the kind of thing that in-depth consideration by people who understand services can notice and address:

A service can be clean. The staff professional. The meals can be balanced by a dietician. 

But then the other side of that is that there are only two meal choices, that you order a fortnight in advance. Your door is not shut unless you put a sign on it. People don't knock. There are 'visiting hours'. You can't have a dog. Your coffee is tepid because you might burn yourself. Nobody comes if you press the buzzer unless you know to press it more than once in a row and sometimes you are scolded if it is not an 'emergency'. Sometimes people are only out of bed for three or four hours. 

A casual visitor will not know those things. 

Quality checking requires two things: a checker, and a framework they can use that will help produce assessments and feedback that service users and services can understand.

Checkers will be service users. They might be people with learning disabilities, or with mental health needs, or users of aged care services. Their use of services grounds their understanding of them. They will also have skills in communicating with consumers about their experiences, and may have received training in service assessment.

Quality checkers can use tools like standards, rights frameworks or assessment matrices, to support their work. These can guide the questions that are asked, and help identify areas where services excel, and where they can improve. Examples include the Quality of Life Standards and Toolkit, used in the United Kingdom to support delivery of services that meet the expectations of people with learning disabilities and autism.

The United Kingdom has a national association of quality checkers. As well as being used in social services, quality checking is being used by the NHS and the health system. Some individual services in Australia have been reported as using the approach, though it has not yet taken hold. Adoption of this kind of quality checking - and the culture that supports its use - would represent an important step forward in empowering service users and fostering meaningful quality.