How the Quality of Life (QOL-ACC) and Quality of Care Experience (QCE-ACC) surveys can be improved

Elyssia Clark
General Manager, Customer, Insights and Marketing, Benetas

Welcome to the final of three articles outlining outcomes from a pilot Benetas undertook to review the QOL-ACC/QCE-ACC surveys among residents to meet additional National Aged Care Mandatory Quality Indicator Program (QI Program) requirements.

In our first post, we introduced a pilot study we undertook in two of our homes and some hypothesis we had about the QI Program process. In our second article, we outlined some tips for aged care providers in rolling out QOL-ACC and QCE-ACC surveys. In this final article we’ll deep-dive a little more into some of the survey questions, and share our observations and suggestions for improvement.

Observation #1: Residents struggled with the format of the survey questions

Generally speaking, residents struggled with the questions.

Both the QOL–ACC & QCE-ACC surveys follow a consistent format of presenting a statement, then asking participants to indicate to what extent this statement applied to them using a five point Likert scale (always/mostly/sometimes/rarely/ never).

Residents often struggled to connect the “statements” to the scales provided. There was a preference to simply answer ‘yes’ or ‘no’ to each statement.

We understand that both surveys were validated in two studies undertaken with over 1500 older people and family carers received aged care services in the community and in residential aged care. However, this is a very broad cross-section of older people with varying degrees in ability to comprehend information. Undertaking more thorough assessment of the questions just among those in residential aged care could help ensure they are fit for purpose.

Observation #2: The language is fairly advanced (academic) for many

Some residents really struggled to understand the statements.

Take this example from the QCE-ACC survey “I receive services and supports for daily living that are important for my health and wellbeing”.

Some residents struggled to understand what this question was asking. What supports? What’s daily living? How does wellbeing differ to health?

The OECD found that one in eight Australians are illiterate – it’s quite possible that literacy levels may also be impacted by natural declines in mental functioning that happen with age.

Keeping the language short, sharp and simple will be important to ensure the quality of data being collected is an accurate reflection of the intent of questions.

Observation #3: The “interviewer-assisted” version of both QOL-ACC and QCE-ACC surveys is very long

The National Aged Care Mandatory Quality Indicator Program (QI Program) Manual 3.0 – Part A contains two versions of the survey – a streamlined version for residents who are able to do the survey independently, and a more extensive “interviewer-assisted” version of the survey for those residents who require someone to read out the questions to them. The interviewer-assisted version of the survey is significantly longer, requiring the interviewer to read out many words to add context to questions.

Here’s an example. In the self-completion version of the QCE-ACC, the survey simply states:

“For each question, please mark the ONE box that best describes how you feel about your current situation. I have as much independence as I want”. The resident selects from five response options shown to them (all of the time / most of the time / some of the time / a little of the time / none of the time)

Now let’s imagine a resident was having the interviewer-assisted version of the survey read out to them. Here’s what the resident would hear / need to process for this same question:

“The next question is about independence. Independence is about living the life you choose and making your own decisions. This can be decisions about your life or day to day decisions such as how to structure your day, when you take your meals, when and how you undertake care or self-care activities, and when you go to bed.

The independence statement is: I have as much independence as I want

The options are:

• All of the time
• Most of the time
• Some of the time
• A little of the time
• None of the time

So, which of those response options is true for you TODAY in response to “I have as much independence as I want”?”

The challenge we found was that the interviewer-assisted version was so long that by the time it was all read out, the resident had totally forgotten what the question was!

There’s a lot of opportunity to streamline the commentary for the interviewer-assisted surveys, and there is also potential that we could see different responses to the same question, depending on the survey version used. With the additional prompts, you can see that residents might give a different response since they are asked to consider far more defined elements compared to the streamlined version.

Observation #4: Some of the Quality of Life questions are triggering

Asking someone in a wheelchair if they are happy or independent can create emotional anguish for both interviewer and interviewee. Here’s an example:

The third question is about emotional wellbeing. Emotional wellbeing is about living your life without sadness, worry or stress. It is about whether you are generally happy and contented with your life. The statement for emotional wellbeing is: I am generally happy.

This question in particular led to many residents shaking their heads, eyes downcast, and frequent reflections of the fact that they would prefer to be at home. There were instances where interviewers made (good) decisions to discontinue the survey, as they did not believe it was in the residents’ best interests to continue.

We would strongly encourage the government to re-consider the value of the Quality of Life questions, particularly in the context of residential aged care.

Observation #5: The absence of a ‘not applicable/don’t know’ option leads to data wastage

There were two questions which some residents found difficult to answer. They did not feel the response options provided reflected their views, so interviewers had to leave those questions blank. This meant that an overall QOL-ACC or QCE-ACC score could NOT be calculated for those residents, leading to lost time and productivity for an already stretched workforce.

We had at least eight survey participants fall into this category – specific statements which caused issues included:

• I receive care and support from aged care staff who have the appropriate skills and training: Some participants explained they had no idea if the staff had appropriate training, and as such did not want to answer the question.
• When I experience pain, it is well managed: Some residents commented they did not experience pain, and therefore could not answer this question

Observation #6: The surveys are to be conducted quarterly, in addition to the annual My Aged Care star rating independently-administered surveys.

When tracking customer sentiment, different organisations have different cadences. Some measure monthly, others quarterly, others every six months or annually. The decision on how often you measure customer sentiment depends on many factors, but many organisations are realising that measuring too frequently can be as bad as not measuring often enough.

The reality is many aged care providers simply won’t have time or resources to act on the data being collected. Nor, we believe, would government. By asking residents to share with us their views, every quarter, but then not taking actions to address issues raised quickly, we risk seeing response rates to the survey gradually declining over time, as residents lose faith in the process and aged care providers are unable to keep up their side of the deal.

In summary, there’s some work that could be done to streamline both the Quality of Care Experience (QCE-ACC) and Quality of Life (QOL-ACC). The biggest concern is the sheer volume of surveys aged care residents are now being subjected to.

Globally, response rates to surveys are falling because people are tired of being asked to rate everything and provide feedback. We must ensure that we treat those who have given their time to share feedback are treated with respect and dignity, and most importantly, their feedback is heard.