Is Education Always Needed?

Ask any Educator or L&D Coordinator, and they will agree that education is often requested, even emphasised, as the primary tool for enhancing practice and ensuring compliance. This is especially so after an incident. Imagine, there’s a fall. What do we do? Education. Pressure injury rates rising. More education. In fact, let’s make it MANDATORY!

But what if education isn’t always the answer? What if the cause of those incidents was due to low staffing, or a faulty call bell or that a facility had run out of a particular preventative dressing used, and no one had reordered them?

What if there wasn’t actually a need for education in response to any of those situations? What if a careful gap analysis revealed that, actually, there wasn’t a gap in staff knowledge or skill? That they had all completed education activities recently and that, in fact, MORE education might cause training fatigue, poor engagement, and blow out the flame of your bright and shiny stars? Those are the people that do education! Do good, practice well, yet still get more and more education assigned when things go wrong!

What if Education Isn’t Needed?

In this article, I will explore one of my favourite topics! What do you do when education isn’t needed? How can we address gaps in practice that can’t be validated by data to demonstrate they’re caused by knowledge or skill gaps?

I will review the relevant regulatory requirements for organisations to establish, maintain and regularly review the effectiveness of their processes and systems, as clearly described in two sets of National Quality Standards: the strengthened Aged Care Quality Standards and the National Safety and Quality Health Service (NSQHS) Standards.

We’ll explore how policies serve as the key vehicle for translating effective systems and processes into practice. I’ll finish with a practical look at how an effective policy system can ensure safety, compliance and high-quality care, and how when managed effectively alongside education, initiatives can improve quality outcomes.

Why are Effective Processes and Systems Required?

Effective processes and systems underpin the reliability, sustainability and support of the core asset in any organisation: people. Within a health or aged care setting, their need cannot be overestimated. There are 57 mentions of the need for effective systems in the strengthened Aged Care Standards, including in relation to an effective:

• Quality system
• Risk management system
• Incident management system
• Complaints system
• Information management system
• Safe and quality use of medicines system.

Drawing on the Aged Care Quality and Safety Commission’s definition of a ‘system’, policies are critical because they sit alongside the resources, processes and procedures that are organised, integrated, regulated and administered to accomplish a stated goal (ACQSC, 2023).

Policies are intrinsically linked to the core need for organisations to ensure systems are in place within health service organisations to maintain and improve the reliability, safety and quality of healthcare. From a regulatory perspective, policies are described alongside governance, leadership and culture, patient safety, risk management, and quality improvement. These concepts are non-trivial for organisations, highlighting the importance of policies and an effective policy management system (PowerDMS 2020).

Strengthened Aged Care Quality Standards

In the strengthened Aged Care Quality Standards, under Standard 2: The Organisation, outcome 2.3 Accountability and quality system, it’s clearly stated that:

‘The provider maintains and implements policies and procedures that are current, regularly reviewed, informed by contemporary, evidence-based practice, and are understood and accessible by workers and relevant parties.’

National Safety and Quality Health Service Standards

National Safety and Quality Health Service Standards Within the National Safety and Quality Health Service (NSQHS) Standards (2nd edition), the regulatory requirements for policies sit with the Clinical Governance Standard (Standard 1). Action 1.07 states ‘the health service organisation uses a risk management approach to:

• Set out, review and maintain the currency and effectiveness of policies, procedures and protocols
• Monitor and take action to improve adherence to policies, procedures and protocols
• Review compliance with legislation, regulation and jurisdictional requirements.’

(ACSQHC 2021)

What is the Workforce Experience of Policies?

From the perspective of a staff member, policies can often feel like a tedious task to acknowledge, with the real challenge arising when trying to access them at the point of care. I asked a colleague about her recent experience with policies. Her response was:

‘It’s frustrating. You’re in the middle of a busy shift, and you need to quickly check a policy, but it’s buried in a system that’s anything but user-friendly. It’s sometimes easier to find a computer, print out a PDF and use that!'.

The alarming thing my colleague said was challenging was that an outdated policy or procedure was a barrier to translating education into practice.

For managers, policies represent a relentless administrative burden. When I asked another colleague, a quality manager, she said:

'It feels like I’m constantly drowning in paperwork. Just when I think I’ve got things under control, there’s another request for a new policy, or an existing one needs updating. It’s like trying to ride out a wave that never ends.'

The hours spent updating documents, coordinating with IT and ensuring everything is up-to-date can leave them feeling like they’re wasting valuable time that could be better spent elsewhere. ‘Sometimes I wonder if all this time spent on paperwork is really making a difference,’ she admits.

Should we Rethink the Role of Policies?

We need to view policies as the vehicles that translate an organisation's systems and processes into practice. Without an effective policy management system, the very systems and processes designed to guide care and ensure good clinical governance and operations can't be truly effective because they fail to reach the end user - the staff member.

Similarly, policies should be seen as not merely administrative documents or a burdensome task. Policies contribute to a safe environment by mitigating unwarranted clinical variation. Policies aim to prevent clinicians from engaging in areas of practice that vary from best practice. Consistency across an organisation is critical. In healthcare, it’s imeprative.

What is a Policy Management System?

A policy management system is a way to organise, distribute and record staff acknowledgement of an organisation’s policies. An effective policy management system helps users create and revise policies and procedures to ensure they are informed by current, contemporary, evidence-based practices and regularly reviewed.

An effective system also reduces the administrative burden associated with managing a policy library for both the system's organisational manager(s) and staff required to access, acknowledge and follow the organisation’s policies.

When policies are well-managed, they do more than just ensure compliance. They support the organisation’s broader goals of knowledge translation, competency and capability building, leading to sustained improvements in care quality.

What are the Challenges of Policy Management?

Despite the clear benefits of robust policy management, many organisations need help with its implementation. The challenges are ever-present, from the complexity of regularly changing regulations to the difficulty of engaging staff and ensuring they understand and adhere to policies. Managing a vast policy library can also be overwhelming, leading to what many in the industry refer to as ‘policy overload’. When policies are poorly managed, the consequences can be serious - leading to inconsistent care, increased legal liabilities and a reduction in compliance.

What is an Effective Policy Management System?

Conversely, when policy management is done well, it creates a safer, more reliable environment for both staff and patients, ensuring that care is consistent, standards are met and risks are mitigated. In an effective system, policies are not just documents but living tools that actively guide the actions and decisions of staff, particularly at the point-of-care.

This still requires policies to be regularly reviewed and updated to reflect the latest evidence and regulatory requirements. However, an effective system should enable the process to be streamlined and not overly difficult for the administrator. Less time spent uploading documents and converting them means more time can be spent reviewing current literature to determine the best practice.

The policy management system itself should be user-friendly, allowing staff to easily access, understand and acknowledge the policies that pertain to their roles. It should support remote access, provide evidence of policy acknowledgment, map policies to relevant standards and roles, and track version control. But beyond these technical capabilities, the system must be aligned with the organisation’s education and training initiatives, ensuring that staff are not only aware of policies but also understand how to implement them in their daily practice.

Aligning Education and Policies

Policies (or more broadly, quality management) and education are intrinsically linked functions in an organisation and tools that work together to achieve high-quality care. Staff need specific training to understand and apply policies effectively in their roles, ensuring they meet outlined expectations, procedures and protocols. While policies provide the framework, education equips staff with the necessary knowledge and skills to implement them.

Strategies to align education and quality initiatives and maintaining include:

1. Integrate relevant policy awareness into regular training sessions
2. Ensure educational activities and mandatory training modules are regularly updated to reflect any policy changes, ensuring that education is saying the same thing as the policy
3. Use policy updates and acknowledgement data to inform the focus of educational initiatives
4. When requests for education are made, L&D teams conduct a needs assessment to determine where the gaps lies and validate if education is the right strategy
5. Where education is not needed, use the incident or issue as a prompt to review the organisation’s policy, process or system instead.

Policies Prevent Variations in Care

Policies and good policy management are critical tools to improve the safety, consistency and quality of care. By positioning policies as a vehicle to to translate an organisation's systems and processes into practice, we can reduce unwarranted clinical variation and risk, and improve outcomes. When education initiatives or more mandatory training are not appropriate, it is the policies, and the effective management of these policies, that ensure systems and processes translate into meaningful, high-quality care.

Related Resources

Improving policy management is an ongoing process. Here are some other helpful resources to consider:

• A Guide to Policy Management
• How Organisations Can Create Policies That Actually Improve Care
• The Do's and Don'ts of Policies in Healthcare
• Policies and Procedures in Healthcare

References

• Ausmed 2022, ‘The Do’s And Don'ts of Policies in Healthcare’, Ausmed L&D Toolbox, 7 July, https://www.ausmed.com/publish/organisations/guides/policies-in-healthcare.
• Australian Commission on Safety and Quality in Health Care 2021, National Safety and Quality Health Service Standards, Australian Government, https://www.safetyandquality.gov.au.
• Aged Care Quality and Safety Commission 2023, Final Draft Strengthened Aged Care Quality Standards, Australian Government, https://www.health.gov.au/resources/publications/the-strengthened-aged-care-quality-standards-final-draft?language=en.
• Aged Care Quality and Safety Commission 2023, Provider Governance, Australian Government, https://www.agedcarequality.gov.au/for-providers/provider-governance.
• NDIS Quality and Safeguards Commission 2021, NDIS Practice Standards and Quality Indicators, Australian Government, https://www.ndiscommission.gov.au/sites/default/files/2022-02/ndis-practice-standards-and-quality-indicatorsfinal1_1.pdf.
• iSB Group 2023, ‘HSEQs: How Often Should Health and Safety Policies be Reviewed?’, iSB Group Blog, 16 February, https://blog.isb-group.com/hseqs-how-often-should-health-and-safety-policy-be-reviewed.
• PowerDMS 2020, ‘What is a Policy vs. a Procedure?’, PowerDMS, viewed 5 September 2024, https://www.powerdms.com/policy-learning-center/what-is-a-policy-vs.-a-procedure.
• Youl, Z 2024, ‘A Guide to Policy Management’ Ausmed L&D Toolbox, viewed 4 September 2024, https://www.ausmed.com.au/organisations/toolbox/guides/guide-to-policy-management.

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