Factors impacting clinical data and documentation quality in Australian aged care and disability services: A user-centred perspective

Abstract

Abstract Background: Research has highlighted a need to improve the quality of clinical documentation and data within aged care and disability services in Australia to support improved regulatory reporting and ensure quality and safety of services. However, the specific causes of data quality issues within aged care and disability services and solutions for optimisation are not well understood. Objectives: This study explored aged care and disability workforce (referred to as ‘users’) experiences and perceived root causes of clinical data quality issues at a large aged care and disability services provider in Western Australia, to inform optimisation solutions. Methods: A purposive sample of n=135 participants comprising aged care, disability, (including community-based and residential-based), staff in clinical, care, administrative and/or management roles participated in user consultations. Data collection was undertaken through semi-structured interviews and web-based surveys. Data were analysed using an inductive thematic analysis method, where themes and subthemes were derived. Results: Eight overarching causes of data and documentation quality issues were identified: 1) staff-related challenges, 2) education and training, 3) external barriers, 4) operational guidelines and procedures, 5) organisational practices and culture, 6) technological infrastructure, 7) systems design limitations, and 8) systems configuration-related challenges. Conclusion: The quality of clinical data and documentation within aged care and disability services is influenced by a complex interplay of internal and external factors. Coordinated and collaborative effort is required between service providers and the wider sector to identify behavioural and technical optimisation solutions to support safe and high-quality care and improved regulatory reporting.