Systemic Failures in Nursing Home Carecomplete
The purpose of this research is to identify the systemic yet resolvable risks within the residential aged care system that can lead to unintended and unnecessary harm to aged care residents.
This research developed – based on findings in the literature, personal experiences in nursing home care and interviews with core stakeholders – a 3-D system map to represent the structure and the dynamic links within the system. It showed that the system is highly fragmented, dysfunctional and without any evidence of system leadership and transparency of system governance and accountability. The system requires a fundamental redesign – the approach to redesign is illustrated and can serve as a blueprint.