Building Effective Safety and Quality Systems

Safety and quality training is essential for building workforce capability, cultivating a culture of continuous improvement, and maintaining compliance with relevant health and aged care regulations.

While education and training play a role in meeting relevant standards, achieving compliance requires a broader focus on governance frameworks, systems, and processes that underpin safety and quality outcomes.

Read our article Action 2.9.5 - What is an Effective Training System? for insights into this specific requirement, including how to “regularly review the effectiveness” of training systems by introducing performance metrics and leveraging education for growth.

Using this Training Requirement

This Training Requirement provides guidance on understanding and implementing the specific Safety and Quality Training actions as stated in the National Safety and Quality Health Service (NSQHS) Standards and Strengthened Aged Care Quality Standards.

We will link to specific training and education modules and resources where necessary. Rather than focusing solely on education and training, this Training Requirement also emphasises the systems, processes, and records needed to demonstrate compliance and effectiveness related to safety and quality.

Understanding the Relevant Actions in the Standards

NSQHS Standards:

Strengthened Aged Care Quality Standards:

Accountability for Quality Systems

Safety and quality training sit as key components within clinical governance, aligning with Clinical Performance and Effectiveness in the NSQHS Standards and Standard 2: The Organisation in the Strengthened Aged Care Quality Standards. The placement of these requirements emphasises the organisation’s governing body (Board’s) accountability for establishing systems that support training and workforce development.

Whilst accountability sits with the governing body, implementation relies on Quality, HR, and L&D teams to meet compliance, improve care, and uphold governance standards.

Actions to Meet NSQHS Safety and Quality Training Requirements

The table below lists examples of evidence that may be required during an assessment to demonstrate compliance with each requirement, with a reminder only to share examples of evidence of current initiatives.

Requirement	Action	Staff Training Required (Y/N)	Relevant Resource
Action 1.19	Provide new governing body members with induction training on key systems and responsibilities for safety and quality.	Yes	Clinical Governance (Ausmed) Quality Improvement Systems (Ausmed)
	Provide all new starters with induction training on responsibilities for safety and quality.	Yes	Safety, quality and clinical governance (Ausmed)
	Review orientation policies and programs. Consider whether current modules provide appropriate and effective orientation to safety, quality and clinical governance.	No	Streamlining Induction Video
Action 1.20	Review education and training policies and programs. Consider whether they provide appropriate and effective education and training in safety, quality and clinical governance.	No	Improving Compliance with Training Video
	Review the process and frequency with which the organisation identifies workforce training needs	No	How L&D Teams Can Incorporate Outcomes into Education Planning Video
	Define mandatory education and training requirements for the workforce	No	Mandatory Training Best Practice Video
	Review how the organisation evaluates the outcomes of education and training in safety, quality, leadership and risk	No	The Theoretical Underpinnings of Reporting Best Practices for Learning Evaluation
	Ensure that appropriate records are maintained of education and training undertaken by each member of the workforce	No	Track and report on workforce training programs (Ausmed)
	Provide each member of the workforce with the opportunity (through performance review and development programs) to define their education and training goals, and agree with their manager on opportunities to achieve these goals.	No	Connect staff performance goals with ongoing learning (Ausmed)
	Use external training providers if training cannot be efficiently provided internally.	No	View the Ausmed Library™ of Australian-centric care and clinical resources
	Record and monitor attendance at training sessions to ensure that the workforce maintains skills and competencies.	No	Track and report on workforce training programs (Ausmed)
Action 1.21	Ensure that actions to improve cultural competency are implemented and monitored for effectiveness.	No	Culturally Safe Practice: Healthcare (Ausmed)
	Review the organisation's education and training policies and programs to ensure that they adequately cover cultural competency and monitor workforce participation in training.	No
	Review and maintain the organisation's targets regarding the participation of Aboriginal and Torres Strait Islander peoples in the health workforce across clinical, managerial, support and advocacy roles.	No	Cultural Safety: Fostering Competence in the Workforce and Meeting Clinicians' Support Needs
	Ensuring the workforce participates in cultural competency activities and training.	Yes	Cultural Safety in Healthcare
	Incorporating cultural competency into policies and program development	No	NSQHS Standards User guide for Aboriginal and Torres Strait Islander health

Actions to Meet Strengthened Aged Care Quality and Safety Standards Requirements

The table below lists examples of evidence that may be required during an assessment to demonstrate compliance with each requirement, with a reminder only to share examples of evidence of current initiatives.

Requirement	Action	Staff Training Required (Y/N)	Relevant Resource
Action 2.9.4	Put in place a training system.	No	Action 2.9.5 - What is an Effective Training System?
	Put in place training strategies and a ‘training matrix’ (or equivalent).	No	Request a copy of Ausmed’s Gap Analysis Tool to understand the training requirements of the strengthened Aged Care Quality Standards.
	Regularly analyse training needs.	No	The Educational Implications of Strengthened Aged Care Standards
	List the skills needed for each role and what training can build these skills.	No	Mandatory Training Best Practices
	Make sure training is based on contemporary, evidence-based practice.	No	Evaluating Content Integrity
	Conduct training to fill any competency gaps.	No	Assess, track, develop and manage the competencies of your workforce (Ausmed)
	After training, include processes to check that workers have the right skills and capabilities for their roles.	No	Demonstarting Training and Education Outcomes
Action 2.9.5	Regularly review the effectiveness of the training system. Look for ways to improve the system.	No	Action 2.9.5 - What is an Effective Training System? Switch to the Ausmed LMS to plan, assign, track and report on workforce training.
Action 2.9.6	Provide competency-based training in relation to core matters.		Assess, track, develop and manage the competencies of your workforce (Ausmed)
	Deliver training in line with any identified training needs.	Yes	Person-centred care Culturally safe / trauma-informed care Dementia Palliative and end-of-life care Responding to medical emergencies Code of Conduct for Aged Care Serious Incident Response Scheme (SIRS) Aged Care Quality Standards
Action 2.9.7	Put in place strategies to regularly assess, monitor and review the performance of workers.	No	Connect staff performance goals with ongoing learning (Ausmed)
	Use feedback from older people and performance reviews to improve training.	No	Connect staff performance goals with ongoing learning (Ausmed)

Evidence of Compliance

The table below lists examples of evidence that may be required during an assessment to demonstrate compliance with each requirement.

Only demonstrate evidence for activities that are currently in use.

Requirement		Evidence of Compliance - Examples
NSQHS Standards	Action 1.19	Orientation and induction documents that detail the safety and quality roles and responsibilities of the workforce and the governing body.
		Attendance records for orientation and induction training.
		Reports on evaluation of orientation and induction training content.
NSQHS Standards	Action 1.20	Policy documents about orientation and training of the clinical workforce.
		Employment records that detail the skills and competencies required of the position, as well as the safety and quality roles and responsibilities.
		Evidence of the assessment of clinicians’ needs for education and competency-based training
		Schedule of clinical workforce education and competency-based training that includes the requirements of the NSQHS Standards.
		Orientation manuals, education resources or records of attendance at workforce training.
		Audit results of the proportion of the workforce with completed performance reviews.
		Skills appraisals and records of competencies for the workforce, including the locum and agency workforce.
		Feedback from the workforce about their training needs.
		Reviews and evaluation reports of education and training programs.
		Communicate with the workforce about annual mandatory training requirements.
NSQHS Standards	Action 1.21	Evidence of assessment of the workforce’s needs for cultural competency and cultural awareness training.
		Training documents on Aboriginal and Torres Strait Islander cultural awareness and cultural competency.
		Policy documents in which the needs of Aboriginal and Torres Strait Islander patients are recognised.
		Review and evaluation reports of cultural awareness education and training programs.
		Committee and meeting records in which the cultural needs of Aboriginal and Torres Strait Islander patients are discussed, and strategies to meet their needs are monitored or evaluated.
		Employment documents that detail the roles and responsibilities of Aboriginal support officers.
		Strategies for increasing employment opportunities for Aboriginal and Torres Strait Islander peoples in the organisation.
		Data analysis and evaluation of feedback from the workforce and consumers about the workforce’s cultural competency and cultural awareness.
Strengthened Aged Care Quality Standards	Action 2.9.4 Action 2.9.5 Action 2.9.6	Sample of training records for all workers, including contractors, including records that show they have completed training and the competency they need to perform their role.
		Policies and processes for training and induction management.
		Processes for monitoring and improving the training management system.
		A policy or procedure that includes training strategies to ensure that workers have the necessary skills, qualifications and competencies to effectively perform their role.
		A policy or procedure that includes core and non-core training requirements for all workers.
		Process for monitoring worker qualifications, competency and training.
		Processes for monitoring and improving the training management system.
		Provider-level training needs analysis and training matrix or similar.
		Evidence of improvements adopted after review of the training management system.
		Induction manuals, education and training resources
		Service-level plans for continuous improvement.
		Process for incorporating worker feedback, complaints, incidence and staff performance goals with training.
Strengthened Aged Care Quality Standards	Action 2.9.7	Policies and processes for worker performance assessment, monitoring and reviews.
		Sample of worker performance reviews.

The Importance of Safety and Quality Training

Good clinical governance is the foundation of an organisation’s ability to build workforce capability, achieve compliance, and deliver safe, high-quality care. While training and education are critical for the workforce and governing body, compliance relies on robust governance frameworks, clear processes, well-defined policies, and accurate record-keeping. Evidence of compliance may include attendance records, performance reviews, training evaluations, and documented improvements to training systems.

To meet these standards, organisations must also establish and regularly review processes, policies, and records that underpin compliance efforts and drive continuous improvement.

References and Useful Resources

• The Great Divide? - Aligning Quality and Education
• A Guide to Policy Management

References and Useful Resources

• Strengthened Aged Care Quality Standards - Aged Care Quality and Safety Commission
• Strengthened Quality Standards Provider Guidance - Aged Care Quality and Safety Commission
• Evidence Mapping Framework - Aged Care Quality and Safety Commission
• Clinical Governance Standard (NSQHS Standards) - Australian Commission on Safety and Quality in Health Care

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