If you're here, you need to understand exactly what training is required for Outcome 2.3 Accountability, Quality System and Policies and Procedures under the Strengthened Aged Care Quality Standards. This outcome establishes the organisational backbone that makes quality care possible—the systems, policies, and accountability structures that ensure good intentions translate into consistent, high-quality care delivery. Getting this training right is critical not just for compliance, but for building an organisation where quality improvement is embedded in daily practice and everyone understands their role in delivering excellence.
Outcome 2.3 sits within Standard 2 - The Organisation, which sets out expectations for how providers must be structured and governed to deliver quality aged care services. This outcome specifically addresses the critical infrastructure of quality systems, accountability frameworks, and the policies that guide practice.
Bottom Line Up Front: Outcome 2.3 requires comprehensive training that ensures the governing body understands and fulfils its accountability for quality care, all workers can effectively use your quality system and contribute to continuous improvement, policies and procedures are current and actually guide practice, and open disclosure is practised consistently when things go wrong. Your workers must demonstrate they can navigate and apply policies, contribute meaningful data to quality monitoring, understand their role in the quality system, and participate in transparent communication about both successes and failures.
Let's walk through exactly what this means for your training programmes and how to build competence systematically across every level of your organisation.
Understanding What Outcome 2.3 Actually Requires
Under the strengthened standards, the governing body is explicitly accountable for the delivery of quality funded aged care services and must maintain oversight of all aspects of the provider's operations. This isn't passive oversight—it requires active engagement, regular monitoring, and responsive action.
The outcome statement makes clear that providers must:
- Use a quality system to enable and drive continuous improvement
- Ensure the governing body maintains oversight of all operations
- Maintain current policies and procedures that guide aged care worker practice
The specific actions break down into seven critical requirements:
Action 2.3.1: Worker Engagement in System Design
Requirement: Providers must engage with aged care workers on the planning and design of systems they're required to use.
What This Means: Training must equip both leaders and workers to participate meaningfully in system development, not just use systems imposed from above. Workers need to understand how to provide input into system design and feel empowered to suggest improvements.
Action 2.3.2: Comprehensive Quality System Implementation
Requirement: Implement a quality system that supports quality services, sets clear accountabilities, establishes expectations, enables monitoring, and drives improvement.
What This Means: Every worker must understand the quality system architecture, their specific role within it, and how their daily work contributes to organisational quality outcomes.
Action 2.3.3: Investment Monitoring
Requirement: The governing body must monitor investment in priority areas to deliver quality services.
What This Means: Board members and senior leaders need sophisticated understanding of resource allocation, return on investment for quality initiatives, and how to track whether investments are achieving intended outcomes.
Action 2.3.4: Quality System Effectiveness
Requirement: Regularly review and improve the effectiveness of the quality system itself.
What This Means: Training must build capability in system evaluation and enhancement—not just operating within the system, but actively improving how the system works.
Action 2.3.5: Performance Reporting
Requirement: Regularly report on quality system performance to individuals, supporters, and aged care workers.
What This Means: Staff at all levels need skills in data interpretation, creating accessible reports for different audiences, and practising transparency about both achievements and areas needing improvement.
Action 2.3.6: Open Disclosure Practice
Requirement: Practise open disclosure and communicate when things go wrong.
What This Means: This fundamental cultural shift requires comprehensive training in difficult conversations, empathetic communication, documentation of disclosure, and follow-through on prevention strategies.
Action 2.3.7: Current Policies and Procedures
Requirement: Maintain and implement policies that are current, regularly reviewed, evidence-based, understood, and accessible.
What This Means: Workers must be able to find, understand, and apply policies in their daily practice. Policies must be living documents that actually guide care, not compliance paperwork gathering dust.
Critical Compliance Requirement: The guidance document emphasises that the governing body's oversight must support continuous improvement and ensure providers meet all quality outcomes. This means your training must create capability at every level, from board to bedside, to contribute to systematic quality improvement.
The Six Essential Training Areas You Need
Based on Outcome 2.3 requirements and available Ausmed modules, you need to implement six interconnected training areas that build organisational capability for quality management. All Ausmed modules require a subscription (individual module purchases are not available):
| Training Area | Duration | Content Focus | Key Ausmed Modules | Assessment Requirements |
|---|---|---|---|---|
| Area 1: Quality System Fundamentals | 3 hours initial 1.5 hours annual |
Quality framework components, individual roles and responsibilities, data contribution, improvement methodologies | • Strengthened Aged Care Quality Standards: Home Care (25m) - Specifically includes Outcome 2.3 • NSQHS Standards (25m) - Clinical governance framework • Manual Handling Safety (14m) - Specifically references Outcome 2.3 |
Demonstrate understanding of system architecture and personal accountability |
| Area 2: Open Disclosure Excellence | 2.5 hours initial 1 hour annual |
Disclosure triggers, communication techniques, documentation requirements, follow-through processes | • Holding Difficult Conversations at Work (30m) • Communicating in Aged Care (24m) • Incident Report Writing (30m) |
Role-play scenarios, documentation practice, demonstrate empathetic communication |
| Area 3: Policy Navigation and Application | 2 hours initial Ongoing updates |
Policy access systems, interpretation skills, practical application, version control | • The Code of Conduct for Aged Care (15m) • Work Health and Safety (30m) • Duty of Care (29m) |
Timed retrieval exercises, scenario-based application, explain policies in context |
| Area 4: Data Literacy and Quality Monitoring | 3 hours initial 2 hours annual |
Quality indicators, data collection accuracy, trend analysis, report interpretation | • Documentation in Aged Care (25m) • Comprehensive Care Planning (30m) • Incident Report Writing (30m) • Cyber Security (20m) - Data security |
Accurate data entry, basic analysis, identify trends and outliers |
| Area 5: Governance and Strategic Quality | 6 hours initial 3 hours annual |
Accountability frameworks, clinical governance, strategic planning, investment monitoring | • NSQHS Standards (25m) - Standard 1: Clinical Governance • Duty of Care (29m) - Legal accountability • Strengthened Aged Care Quality Standards: Home Care (25m) |
Case analysis, strategic planning exercises, data interpretation |
| Area 6: Incident Management Systems | 2.5 hours initial 2 hours annual |
Incident recognition, reporting, investigation, learning from incidents | • SIRS: Care Workers (15m) • SIRS: Managers and Administrators (15m) • Mandatory Reporting (25m) • Incident Report Writing (30m) |
Incident classification, reporting practice, investigation techniques |
Breaking Down Each Training Area
Area 1: Quality System Fundamentals - Building the Foundation
The guidance emphasises that workers must understand their role in the quality system and how to use it to tailor and improve aged care services. This isn't about memorising quality theory—it's about practical understanding of how daily work contributes to organisational quality.
Essential Ausmed Modules:
- Start with Strengthened Aged Care Quality Standards: Home Care (25 minutes) for comprehensive standards overview
- Progress to NSQHS Standards (25 minutes) for clinical governance understanding
- Complete Manual Handling Safety (14 minutes) which specifically addresses Outcome 2.3
Your quality system training must address three interconnected levels of understanding:
| System Component | What Workers Need to Know | How It Applies in Practice |
|---|---|---|
| System Architecture | How quality components connect from governance to frontline delivery, where their work fits in the bigger picture | Workers can explain how their documentation feeds into quality indicators that inform board decisions |
| Personal Accountability | Specific quality responsibilities for their role, what "good" looks like in their position | Workers know exactly what quality activities they're responsible for and when they must complete them |
| Contribution Pathways | How to provide input for improvement, escalation routes for concerns, feedback mechanisms | Workers actively submit improvement suggestions and know how to escalate quality concerns |
Area 2: Open Disclosure Excellence - Creating Transparency Culture
Action 2.3.6 requires providers to practise open disclosure and communicate with individuals, supporters, and aged care workers when things go wrong. The guidance provides specific requirements for what open disclosure must include.
Essential Ausmed Modules for Open Disclosure:
- Holding Difficult Conversations at Work (30 minutes) - Core communication skills
- Communicating in Aged Care (24 minutes) - Aged care specific communication
- Incident Report Writing (30 minutes) - Documentation requirements
| Disclosure Component | Training Requirements | Practice Elements |
|---|---|---|
| Acknowledgement | Recognising what went wrong without deflection or minimisation | Practice scripts for different scenarios, emphasise honesty over defensiveness |
| Apology | Genuine expression of regret for impact on the person | Differentiate between admitting fault and expressing empathy for impact |
| Partnership | Working with affected parties to prevent recurrence | Facilitation skills for collaborative problem-solving sessions |
| Documentation | Accurate recording of disclosure conversations and actions | Complete Incident Report Writing module, practice documentation templates |
Area 3: Policy Navigation and Application - From Document to Practice
Action 2.3.7 requires policies and procedures that are current, regularly reviewed, informed by contemporary evidence-based practice, and—critically—understood and accessible by aged care workers.
Essential Ausmed Modules for Policy Training:
- The Code of Conduct for Aged Care (15 minutes) - Understanding foundational policies
- Work Health and Safety (30 minutes) - Critical safety policies
- Duty of Care (29 minutes) - Legal and ethical policy frameworks
Your policy training must bridge the knowing-doing gap:
| Training Component | Skill Development | Competency Measure |
|---|---|---|
| Finding Policies | Navigate policy systems efficiently, use search functions, understand categorisation | Workers can locate any relevant policy within 2 minutes |
| Understanding Content | Interpret technical language, identify key requirements, recognise when policies apply | Workers can explain policy requirements in their own words to colleagues |
| Practical Application | Translate policy requirements into daily practice, adapt to specific situations | Workers demonstrate correct policy application in varied scenarios |
Area 4: Data Literacy and Quality Monitoring - Building Intelligence
The guidance specifically requires monitoring of Quality Indicator data alongside other quality metrics. Every worker contributes to this data, whether through direct data entry or the care they provide that generates outcomes.
Essential Ausmed Modules for Data Management:
- Documentation in Aged Care (25 minutes) - Foundation for accurate data
- Comprehensive Care Planning (30 minutes) - Systematic data collection
- Incident Report Writing (30 minutes) - Quality event documentation
- Cyber Security (20 minutes) - Data security and privacy
Structure your data training by organisational level:
| Organisational Level | Core Competencies | Required Modules |
|---|---|---|
| Direct Care Workers | Accurate documentation, understanding what data is collected and why | Documentation in Aged Care, basic sections of Comprehensive Care Planning |
| Team Leaders/Supervisors | Data validation, identifying gaps, coaching for accuracy | All data modules plus supervisory components |
| Managers | Analysis, benchmarking, report generation | Advanced sections of all modules plus analytics training |
Area 5: Governance and Strategic Quality - Leadership Excellence
The guidance states clearly that "the governing body is accountable for the delivery of quality funded aged care services." This requires sophisticated understanding that goes beyond traditional board governance.
Essential Ausmed Modules for Governance:
- NSQHS Standards (25 minutes) - Includes Standard 1: Clinical Governance
- Duty of Care (29 minutes) - Legal accountability
- Strengthened Aged Care Quality Standards: Home Care (25 minutes) - Standards overview
Governance training must address both oversight and strategic responsibilities:
| Governance Domain | Essential Knowledge | Practical Application |
|---|---|---|
| Accountability Framework | Legal responsibilities, regulatory requirements, fiduciary duties related to quality | Review actual incident reports, practise responding to quality failures |
| Quality Oversight | Clinical governance principles, quality frameworks, performance monitoring | Analyse quality reports, identify concerning trends, set improvement targets |
| Strategic Planning | Setting quality priorities, resource allocation, investment decisions | Develop quality strategies, allocate budgets for improvement initiatives |
Area 6: Incident Management Systems - Learning from Events
While incident management is primarily addressed in Outcome 2.5, the quality system requirements of Outcome 2.3 must integrate incident learning into continuous improvement.
Essential Ausmed Modules for Incident Management:
- Serious Incident Response Scheme (SIRS): Care Workers (15 minutes) - Frontline responsibilities
- Serious Incident Response Scheme (SIRS): Managers and Administrators (15 minutes) - Management oversight
- Mandatory Reporting (25 minutes) - Reporting requirements
- Incident Report Writing (30 minutes) - Documentation skills
Implementation by Role
The key to successful Outcome 2.3 implementation is ensuring everyone receives role-appropriate training while maintaining system coherence:
| Role Category | Priority Ausmed Modules | Additional Requirements | Timeline |
|---|---|---|---|
| Governing Body Members | NSQHS Standards (25m), Strengthened Standards (25m), Duty of Care (29m) | Strategic planning workshops, data interpretation training | Within 3 months of appointment |
| Senior Leadership | All governance modules plus SIRS Managers (15m), Mandatory Reporting (25m) | Change management, investment analysis | Within first month |
| Quality/Compliance Staff | All modules with emphasis on Documentation (25m), Incident Report Writing (30m), NSQHS Standards (25m) | Advanced analytics, audit techniques | Comprehensive initial plus ongoing |
| Managers/Team Leaders | SIRS modules (30m total), Holding Difficult Conversations (30m), Documentation (25m) | Performance management, team coaching | Within first 2 months |
| Direct Care Workers | Strengthened Standards (25m), Code of Conduct (15m), Documentation (25m), SIRS Care Workers (15m) | Policy application, basic data entry | During orientation, reinforced in first 90 days |
Building Your Evidence Portfolio
Auditors will look for specific evidence that demonstrates your Outcome 2.3 training translates into effective quality systems and accountability:
| Evidence Category | Required Documentation | What Auditors Look For |
|---|---|---|
| Training Records | Individual completion of Ausmed modules, competency assessments, refresher schedules | Systematic approach, role-appropriate training, regular updates |
| Module Application | Examples of how Ausmed training content is applied in practice | Translation of online learning to workplace implementation |
| System Effectiveness | Quality reports showing improvement trends, governance meeting minutes | Active quality monitoring, responsive improvement |
| Policy Management | Policy access logs, evidence of workers completing policy-related modules | Current knowledge, regular engagement with policies |
| Open Disclosure | Documentation showing completion of communication modules, disclosure records | Consistent practice, comprehensive approach |
Training Frequency and Ongoing Requirements
While the strengthened standards don't mandate specific frequencies, best practice based on Ausmed module recommendations includes:
Initial Training Package:
- Complete all role-relevant Ausmed modules within 3 months of employment
- Minimum 2-3 hours of foundational modules for all staff
- Additional role-specific modules as outlined above
Annual Refresher Requirements:
- Review key modules annually (Strengthened Standards, NSQHS Standards, relevant SIRS modules)
- Update training when policies change significantly
- Complete new modules as they become available
- Minimum 2 hours annual refresher training
Trigger-Based Training:
- Following incidents: Review relevant SIRS and Incident Report Writing modules
- After complaints: Complete Holding Difficult Conversations refresher
- Policy updates: Targeted training on affected policies
- System changes: Training on new quality processes
Measuring Success
The guidance emphasises that providers must analyse quality data to identify issues and report to the governing body and Quality Advisory Committee. Your training effectiveness measures should align with this requirement:
| Measurement Domain | Specific Metrics | Target Indicators |
|---|---|---|
| Module Completion | Percentage completing required Ausmed modules | 100% within specified timeframes |
| Knowledge Application | Policy compliance rates, quality data accuracy | >90% compliance with key processes |
| System Engagement | Improvement suggestions, incident reporting rates | Increasing engagement trends |
| Quality Outcomes | Quality indicator performance, incident reduction | Continuous improvement demonstrated |
Critical Success Factors
The guidance emphasises several elements essential for Outcome 2.3 success that your Ausmed training programme must address:
Investment Monitoring: Complete the NSQHS Standards module to understand clinical governance and how the governing body monitors investment in priority areas and demonstrates return on quality investments.
Stakeholder Reporting: The Communicating in Aged Care module helps develop skills to report quality performance to different audiences—governing body, older people, and supporters.
Systems Integration: The Strengthened Standards modules emphasise connections between different standards and how quality systems enable comprehensive compliance.
Contemporary Evidence: Regular module updates ensure training remains aligned with contemporary, evidence-based practice as required by the standards.
Remember the Foundation
Outcome 2.3 creates the organisational infrastructure that makes all other standards achievable. The combination of systematic Ausmed training modules and practical workplace application builds the quality capability your organisation needs. When your quality systems work effectively, when policies genuinely guide practice, when open disclosure becomes natural rather than feared, and when everyone understands their quality responsibilities, you create an environment where excellence becomes systematic rather than accidental.
This training isn't about creating quality specialists—it's about building quality capability throughout your organisation. Every person, from board members to personal care workers, has a role in your quality system. The Ausmed modules provide the foundational knowledge, but it's the application of this learning in daily practice that creates real quality improvement.
The governing body's accountability, emphasised throughout this outcome, means quality training must be championed from the very top of the organisation. When board members complete their NSQHS Standards and Duty of Care modules, when they ask informed questions based on that training, and when they demonstrate commitment to continuous improvement, it sends a powerful message that quality is everyone's responsibility and everyone's priority.
