Introduction

While some organisations are achieving high levels of compliance, there is still significant room for improvement across the health, aged and disability care sectors.

In health and aged care, non-compliance can lead to fines, harm an organisation’s reputation, and affect the quality of care. What practical strategies can organisations and L&D teams implement to ensure their workforce is adequately trained and compliant?

This guide provides an overview of compliance training, its necessity, and strategies to improve compliance outcomes. We want to share practical and actionable strategies to maximise compliance and learning outcomes.

Understanding Compliance Training

What Is Compliance Training in Healthcare?

Compliance training is the mandatory, regulation-driven training that staff must complete within a specific timeframe to meet essential standards, such as mandatory training and induction training. In healthcare, this means meeting the requirements of National Quality and Safety Standards through providing training in areas like workplace health and safety, infection control, and basic life support (BLS).

In contrast, training not required by law but encouraged for staff development is often known as “mandatory (Non-compliance)” or simply optional training.

How Compliance Is Measured

Compliance is assessed through compliance requirements, also referred to as compliance records, which request users to complete specific compliance training by a due date.

Each compliance requirement outlines who must complete the training, what is required, and the timeframe. These requirements are created automatically or manually through a training plan.

Compliance Terminology

Basic terminology related to compliance is essential for accurately describing and measuring it.

Term	Description
Met	Requirements are currently successfully completed
New	Requirement is currently assigned for the first time and has not yet passed its first due date
Unmet	Requirement is past its due date and incomplete
Extended	The user is currently on an extended period to complete the learning
Waived	A manager has actioned the requirement

Benefits of Compliance

Compliance with training is essential for several reasons, including:

1. It upholds legal and regulatory standards.
2. Helps organisations avoid costly penalties and consequences.
3. Reflects a moral and ethical commitment to safe, high-quality care, as people generally want to "do the right thing."
4. Avoids costs associated with non-compliance.
5. May lead to a positive reputation and retention of staff.

A positive reputation for compliance may attract and retain staff, as studies note that reputation inspires people to join an organisation, while quality care encourages staff to stay (Jarden et al., 2021).

Challenges and Risks of Non-Compliance

Australian healthcare regulators typically employ a risk-based approach to addressing non-compliance issues among care providers. The response and management of non-compliance vary depending on the problem identified during an audit.

Low to Medium Risk Non-Compliance

When the risk of non-compliance is low to medium, actions may include directions, information requests or mandatory re-assessment.

Severe Non-Compliance Risks

When risks to patients or clients are medium to severe or if a provider fails to address non-compliance despite initial regulatory action, enforceable actions range from notices to remedy actions to civil penalties, injunctions, and sanctions. Potential consequences include funding restrictions or revoking approvals.

Unique Risks in Disability Care

Disability care providers face unique compliance challenges under the NDIS framework, as non-compliance directly impacts participant rights and well-being. Non-compliance involves failing to adhere to NDIS rules and regulations, which are crucial for safeguarding participants' rights and well-being.

There are 6 categories of non-compliance:

1. Error or mistake
2. Misuse
3. Conflict of interest
4. Dishonest behaviour
5. Fraud
6. Corruption

Read more about fraud and non-compliance on the NDIS website.

Benchmarking Compliance Rates

Maintaining focus on compliance is essential for continuous improvement. It demands constant vigilance. To benchmark effectively:

1. Monitor your sector’s performance and know where compliance issues commonly arise.
2. Use this insight to address similar concerns within your organisation to improve compliance proactively. This is good risk management.

Comparing Compliance and Performance Across Sectors

Aged Care Compliance Data

Quarterly sector performance reports, complaints reports, star ratings, and National Aged Care Mandatory Quality Indicator Program (QI Program data) are helpful benchmarking tools in aged care.

Explore Ausmed’s guide on how The Aged Care Quality and Safety Commission responds to and manages non-compliance.

Aged Care Compliance Challenges

Based on these critical documents: Complaints about Aged Care Services Year in Review 2023–24 and the Sector Performance Report Q3 2024, key areas of concern include:

• Medication administration and management: High complaint levels regarding correct timing and accuracy.
• Personal and oral hygiene: Repeated issues with maintaining resident hygiene standards.
• Staffing levels and suitability: Consistent complaints about inadequate staffing, particularly on weekends.
• Falls prevention and management: Ongoing concerns about fall management protocols.
• Food and nutrition: Growing dissatisfaction with meal quality and variety.
• Communication and consultation: Home services report frequent complaints about poor communication and lack of consultation.
• Financial management: Transparent billing and financial management in home care settings need improvement.

Training and education can assist organisations in improving compliance with various areas, including the high-risk clinical and care areas listed above. Switch to Ausmed and gain access to our full range of aged care learning resources from the Ausmed Library™.

Acute Care Compliance Data

For acute care, National Safety and Quality Healthcare Services (NSQHS) Standards assessment outcomes provide data by standard, showing assessment completion rates and areas needing improvement.

Acute Care Compliance Challenges

According to NSQHS Standards assessment data, Clinical Governance is a critical area for improvement in acute care. This standard had the lowest compliance rate, with only 38% of initial assessments fully meeting the requirements. Key issues include:

• Inadequate staff training: Leads to gaps in safety and quality practices.
• Lack of effective risk management systems: To identify and manage clinical risks.
• Poor monitoring and evaluation: Of safety and quality performance metrics.

Disability Care Compliance Data

Sector-wide compliance reports are more challenging for disability care providers to find. Review the compliance and enforcement section on the NDIS website regularly and monitor the news and events section for updates on compliance trends and provider concerns.

Learning from High-Performing Organisations

High-performing organisations, especially larger ones, often set a target compliance rate of 80% for mandatory training. However, tracking compliance can be challenging. Many organisations need help identifying the number of unmet requirements, total active requirements, or the percentage of staff meeting specific training standards. Organisations can strengthen their compliance efforts by using an effective reporting system to identify unmet and active requirements accurately.

Data from Ausmed’s platform shows average training compliance rates across sectors:

• Aged care: 74%
• Acute care: 68%
• Disability care: 51%

These benchmarks reveal sector-specific challenges, guiding organisations on where to focus improvement efforts.

Effective Compliance Management

There are 3 pillars to effective compliance management:

1. Set up core compliance settings.
2. Accurate ongoing monitoring.
3. Reporting on compliance.

1. Set up core compliance settings

Take the time to set up your organisation’s core compliance settings according to your needs.

• Determine the impact of extended requirements on your compliance rates.
• Be familiar with reporting terminology.

2. Accurate ongoing monitoring

Monitor and manage accurate user compliance on an ongoing basis.

• Schedule monthly tidy-ups of users, job roles and teams.
• Know how to change your organisation’s structure, such as adding new facilities or locations.
• Ensure your learning management system (LMS) and user HR lists match.

3. Reporting on compliance

The need for quick and accurate audit reports can be stressful, especially when a key person responsible is unavailable, such as during a holiday.

• Know what reports are available from your system and choose the correct reports for your needs.
• Create visual aids as required to communicate your progress.
• Build audit capability.
• Reduce key person risk.

Tools for Effective Compliance Reporting

Reporting on compliance is essential to tracking training progress, promptly addressing gaps effectively, and communicating important metrics to relevant teams. The frequency and detail of reporting depend on the accessibility and capabilities of your system and your reporting needs.

Types of Compliance Reports

Depending on your system, you can generate many reports to suit your needs. There are many available via the Ausmed LMS™, including:

• All learning records
• Standards report
• Extended requirements
• Feedback report
• Time spent learning
• Learning analytics
• Passport holders
• Suggested by users

Effective reporting offers important information at the team and board level and, most importantly, during an audit. Three types of reports available through Ausmed Intelligence™, support high-performing organisations, include:

1. Audit
2. Team
3. Board

1. Audit Reports

Audit reports help organisations prepare for and pass audits, reducing the risk of failing regulatory requirements. They also allow anyone to quickly and easily communicate learning requirements to auditors.

Audit reports are generated in 3 easy steps to reduce stress and key person liability. Anyone can do it.

1. Identify the scope of the audit
   • Is it an individual team or location (facility)?
   • Select the team and relevant job roles being audited.
2. Select the relevant requirements being audited:
   • Training Plan Title or Individual Learning Record.
   • Add selected requirements to your report.
3. Review the report before publishing
   • Add insights to clarify any requirements.
   • Download as a PDF or copy link and share.

2. Team Reports

Team reports enable facilities, managers, and operations teams to see where things are going well quickly or if action is required. They help to:

• Identify and address compliance issues in specific teams or locations.
• View the percentage of users that have met all their mandatory (compliance) learning requirements at the end of each month.
• Manage users with unmet learning or policy requirements easily.
• View time spent learning each month.

It can help to save team reports or use a system that auto-generates them each month as they allow for ongoing assessment and management of learning compliance.

3. Board Reports

Board reports provide a board or governing body with visual, digestible information to reduce risk and liability. Typically, data is presented as an overall learning compliance rate (%) for your organisation, with a KPI and progress towards achieving it. Benefits include:

• Presenting the governing body with visually summarised compliance data.
• Showning reports at monthly or quarterly Board meetings.
• Help the governing body understand and mitigate organisational risks.

Request a quote today to transform your compliance data into actionable insights in seconds. Ausmed Intelligence makes audits, executive presentations, and manager updates fast, easy, and effective.

Strategies to Improve Compliance

There are a range of strategies to improve compliance rates with training. They can be broken down into:

1. Addressing common challenges.
2. Implementing practical strategies.

Addressing common challenges with compliance

Meeting current needs and future compliance trends begins with addressing common challenges with compliance.

Challenge	Solution
Unclear training requirements	Follow mandatory training best practices and conduct an annual gap analysis or needs assessment to map exact training requirements to standards. Implement compliance training plans tailored to mandatory and induction needs.
Varied certification or trainer requirements	Create in-house training champions by certifying key team members to deliver sessions, reducing reliance on external trainers.
Difficulty in reporting	Automate training records and avoid manual spreadsheets by leveraging platforms like the Ausmed LMS™ for quick, accurate, and comprehensive compliance reporting.
Low engagement in training	Combat training fatigue with staggered scheduling, targeted role-specific training, and balanced use of optional training. Focus on relevance to job roles to minimise overload and maximise impact.
Policies do not align with training	Ensure policies are organised, distributed, and acknowledged through the same system used for education and training. This helps align policies with learning content seamlessly.
Compliance across multiple sites/sectors	For recruitment agencies, develop centralised training strategies adaptable to diverse requirements across sites, sectors, and standards.

Practical Strategies to Improve Compliance

These 5 practical strategies can improve compliance with training and help demonstrate conformance with the Standards:

1. Link learning to an outcome.
2. Document and reflect on initiatives.
3. Build audit capability.
4. Align systems, processes, and people through leadership and culture.
5. Empower learners to improve compliance.

1. Link Learning to an Outcome

Linking learning initiatives to tangible outcomes is a powerful strategy for demonstrating compliance and conformance. For example:

• Connect training completed 2 months ago to measurable improvements today, such as reduced infection rates or fewer falls.
• During an audit, showcasing how interventions or new processes directly contributed to better outcomes is invaluable.

Document these achievements in your continuous improvement plan, aligning them with internal priorities or external quality indicators, such as those for aged care or acute care.

This approach evidences success and strengthens the link between compliance, learning and organisational strategy.

2. Document and Reflect on Initiatives

Effective documentation and reflection connect compliance and continuous improvement. Record basic details: name, date, participants, topics covered, and learning objectives. Then, importantly, reflect on the initiative. For example

• Describe why it was selected.
• How learning outcomes align with practice.
• Potential barriers to application.
• Ask how staff will implement what they learned.

Attach evidence demonstrating the training’s impact, such as performance data or success stories. Organisations can refine training approaches and ensure measurable progress by combining thorough documentation with thoughtful reflection.

3. Build Audit Capability

Building audit capability minimises risks and ensures consistent performance. Relying on one or two people for audit preparation increases vulnerability, especially during unexpected absences.

Mitigate this by:

• Equipping a team with the tools and skills for quick, accurate reporting.
• Provide repeated exposure and practice to create “muscle memory” for audits.
• Consider informal “training audits” twice a year to identify gaps and build confidence.

Strong audit capability supports proactive compliance, reduces stress, and ensures readiness for formal evaluations, even under tight timelines.

4. Align Systems, Processes and People

Achieving compliance isn’t just about passing audits; it’s about fostering a culture of providing excellent person-centred care and continuously improving. Moving beyond a “tick-box” approach requires on strong leadership to align systems, processes, and people.

Practically, leaders can start by:

• Reviewing their organisational processes for redundancies.
• Look for opportunities to improve efficiency.
• Quick wins can include removing duplications.
• Ensure systems work seamlessly together.

Leadership is critical in building intrinsic and extrinsic motivation across teams, inspiring staff to consistently deliver their best. When systems, processes, and people are aligned, organisations can achieve compliance and sustainable, high-quality care.

5. Empower Learners to Improve Compliance

Improving compliance training is a collaborative effort. It’s a partnership between an organisation’s Learning and Development (L&D) team and its learners. Compliance training can evolve from a tick-box requirement to a more positive learning experience by empowering learners, building community, and fostering personal connections.

Read this Ausmed Guide on Empowering Learners to Improve Compliance for helpful, practical strategies to support learners.

Emerging Trends in Compliance Training

Examining the latest updates to the National Quality Standards provides insights into current and emerging trends in compliance. For example, the strengthened Aged Care Quality Standards, indicate a shift in how compliance will be viewed and managed across all sectors.

Shift from Compliance to Conformance

A fundamental change is the shift from "compliance" to "conformance" in the sector’s new regulatory model and audit methodology. While both terms involve meeting standards, they emphasise different scopes:

• Compliance: Focuses on meeting legally mandated standards to operate.
• Conformance: Conformance demands more than just meeting a standard, but providing evidence that a change in practice or improvement occured as a result of a particular action or initiative.

This terminology shift signals a movement beyond the bare minimum, focusing on continuous improvement and enhanced quality outcomes. It encourages organisations to build competence and capability, striving to provide the highest standard of care.

Building Compliance and Workforce Capability

Ready to transform your approach to compliance training?

Join Ausmed’s free four-part webinar series designed for educators, L&D professionals, HR teams, and anyone involved in staff induction, onboarding, and training.

In the final webinar, we challenge traditional training methods and explore innovative ways to rethink the impact of education programs. Learn how to use insights to build a capable workforce and drive continuous improvement across your organisation.

Watch the Compliance Capability Webinar Series Now.

Related Guides

• Guide to Empowering Learners to Imrpove Compliance
• Guide to Navigating Compliance Chaos
• Guide to Mandatory Training
• A Guide for Managers: Mandatory Training in Aged Care
• Guide to Induction Training
• Induction Training - FAQs
• A Guide to Policy Management
• Creating an Education Framework

References and Useful Resources

Aged Care Quality and Safety Commission, 2024, 'Complaints about aged care services report', Aged Care Quality and Safety Commission, viewed 18 November 2024, https://www.agedcarequality.gov.au/news-publications/reports/complaints-about-aged-care-services-report.

Aged Care Quality and Safety Commission, 2024, 'Sector performance', Aged Care Quality and Safety Commission, viewed 18 November 2024, https://www.agedcarequality.gov.au/news-publications/reports/sector-performance.

Australian Commission on Safety and Quality in Health Care, 2024, 'NSQHS Standards assessment outcomes', Australian Commission on Safety and Quality in Health Care, viewed 18 November 2024, https://www.safetyandquality.gov.au/standards/nsqhs-standards/nsqhs-standards-assessment-outcomes.

Australian Commission on Safety and Quality in Health Care, 2024, 'NSQHS Standards lessons learnt', Australian Commission on Safety and Quality in Health Care, viewed 18 November 2024, https://www.safetyandquality.gov.au/standards/nsqhs-standards/implementation-nsqhs-standards/nsqhs-standards-lessons-learnt.

Australian Government Department of Health and Aged Care, 2024, 'Star ratings for residential aged care', Department of Health and Aged Care, viewed 18 November 2024, https://www.health.gov.au/our-work/star-ratings-for-residential-aged-care.

Ausmed, 2023, 'Understand compliance requirements', Ausmed Knowledge, viewed 18 November 2024, https://knowledge.organisations.ausmed.com.au/en/knowledge/understand-compliance-requirements.

Ausmed, 2023, 'Understand learning records', Ausmed Knowledge, viewed 18 November 2024, https://knowledge.organisations.ausmed.com.au/en/knowledge/understand-learning-records.

National Disability Insurance Scheme (NDIS), 2021, 'Fraud and non-compliance', NDIS, viewed 18 November 2024, https://www.ndis.gov.au/about-us/fraud-and-non-compliance.

National Disability Insurance Scheme (NDIS), 2021, 'Provider compliance', NDIS, viewed 18 November 2024, https://www.ndis.gov.au/providers/provider-compliance.

Jarden, RJ, Jarden, A, Weiland, TJ, Taylor, G, Bujalka, H, Brockenshire, N & Gerdtz, MF 2021, 'New graduate nurse wellbeing, work wellbeing and mental health: A quantitative systematic review', International Journal of Nursing Studies, vol. 121, 103997, viewed 18 November 2024, https://doi.org/10.1016/j.ijnurstu.2021.103997.

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