Within the residential aged care field, all providers have implemented a quality system consistent with the regulatory requirements of The Aged Care Act (1997), and have completed two cycles of Accreditation. The variation in assessed resident outcome ratings suggested it may be of value to explore possible causative factors of influence, in an attempt to identify the determinants of quality. Avedis Donabedian (1980:82-83), an acknowledged leader in quality in health care, proposed in his quality framework that organisational structure influences process, and process is directly related to outcomes. Further, he theorized that structural characteristics may have a direct influence on outcomes. This study chose to test Donabedian's theory by investigating the impact of organisational structural components on resident outcome ratings, and to explore relationships between those structural elements to determine their relative levels of influence in order to identify whether there was predictive validity for an optimal structural model of care.
The defined scope for the research was a population study of the residential aged care field in Queensland. The study design employed a time-series data collection approach involving secondary data analysis of accreditation reports for the first and second accreditation cycles. Structural elements for investigation were aligned to Donabedian's structural framework, and included levels of centralization or decentralization within the governance structure; provider size in terms of the number of facilities under its control; facility size in terms of numbers of beds; ownership by sector; geographic region of operation; mix of resident dependency ratios; and accessibility by special needs groups.
Statistical analysis found that for both the first and second accreditation cycles, provider size had the greatest predictive power of the structural variables in determining ratings compliance, with the large provider category having the greatest effect. Large providers managing 15-25 facilities, including those from public, private and nonprofit sectors, were found to adhere to a theoretically-based structural efficiency model, and also to achieve the highest levels of total compliance with the Accreditation Standards. Plaudits on the particular success of large providers in demonstrating both efficiency and effectiveness need to be tempered by concerns about the balance between efficiency and equity. The research findings demonstrated that when structural design was directed by technical and allocative efficiency decisions, barriers to access were created for residents who were regionally or culturally disadvantaged, as operations in remote areas, and in planning and delivering culturally appropriate services, incur greater costs.
Donabedian (2003:64) submits that the degree to which standards are specified can be perceived as a continuum, and that not all standards measurements are explicitly stated. It is implicitly understood that the regulations do not require demonstrated effectiveness of outcomes compliance for select segments of the resident population, but rather for the total resident population. Therefore the low incidence of response by large providers to residents living in remote areas, and those with culturally-specific needs, led to exploration of an alternative optimal structure.
In addition to the predicted success of large providers in achieving high effectiveness ratings, the logistic regression equations also predicted small providers managing 2-4 facilities had a statistically significant influence in determining total ratings compliance. Only a small differentiation in the Mean compliance ratings was found between these two most effective provider-size categories. However, the resident benefits offered by small providers included their success in addressing equity of access barriers for residents experiencing regional or cultural disadvantage. Examination of their structural characteristics suggested that in contrast with the efficiency model adopted by large providers, small providers tended to adhere to a structural equity model.
The research findings confirmed that structural design choices do have the capacity to directly influence effectiveness in terms of outcomes, thus validating Donabedians theory of outcome-structure dependence. Moreover, an organisations structural characteristics also influence the scale and scope of its operations, which have a subsequent impact on efficiency and equity. While both large and small provider sizes were found to be highly effective in compliance with the regulated outcome standards, large scale operations with limited scope were more likely to be efficient, while small scale operations with a broad scope were more likely to be equitable. Although the latter model most strongly aligns with regulatory and policy instruments, which are inclusive of principles of equity and access, it is the former model that appears to have garnered greatest political favour.
Analysis of the implications of the research findings confirmed the existence of a policy tension between efficiency drivers and equity principles, and concluded that the regulatory and policy frameworks are currently exerting contradictory pressures on the institutional operating environment of the residential aged care field. The research found that in the pursuit of increased industry efficiency, equity of access is sacrificed. The structural design choices of the most effective service providers focus on either breadth of scale or of scope. Policy makers are therefore faced with the choice of which model should be promoted - one that is efficiency-driven, or one that is equity-driven.