Introducing "The Great Divide"

How well do quality and education initiatives align within your organisation? Are education and quality initiatives rolled out in sync? Does an education-led initiative to combat a sharp increase in falls occur simultaneously with a quality-led update to the organisation's post-falls management policy? Or is there a six-month gap between two core activities that are ultimately focusing on the same issue: improved falls management knowledge, skills, response and care by staff?

Essentially, are these core functions effectively collaborating to implement regulatory standards and ensure staff competence, or do they function in separate spheres? To put it brutally, I am calling it out. There’s a divide between education or learning and development (L&D) and quality teams.

I've long observed the need to bridge the gap. However, I have recently been reflecting that this age-old divide does need to be closed or narrowed. Aged care providers, in particular, will be heavily focused on meeting the new regulatory demands of the strengthened Aged Care Standards, especially over the next six months. For Quality and Education teams, which I describe as standards ‘implementation champions’, this alignment is imperative. This piece explores the theoretical and practical aspects of aligning quality and education. It is underpinned by recent evidence and enriched with my own and my peers’ anecdotal insights, which I am sure will resonate with many of you.

Before I begin, I should say that any article written under the ‘thought leadership’ handle needs an asterisk, disclaimer, asterisk, asterisk, asterisk. That is why many organisations, teams and people may not experience this!

Unpacking the Silos

In many organisations, quality and education offices are located close to each other, but on organisation charts, they sit within different departments. Often, education or L&D sits within people and culture, whereas quality, with responsibilities centred around assurance, control, improvement, risk management and compliance, often sits within an operational division. This is entirely appropriate, and I am not advocating for a total reshuffle, but the irony never ceases to amaze me.

Why, indeed, do silos exist between Quality and Education teams when both aim fundamentally to enhance care quality and safety? It's a perplexing scenario, considering their shared objectives.

Historically, these divisions may stem from differing operational focuses: reactive versus proactive. Quality teams are often driven by compliance and immediate safety outcomes. Quality activities are often rolled out in quite a reactionary manner in response to an issue. On the other hand, L&D or education departments typically aim to proactively cultivate long-term staff development, competence, skill proficiency and overall capacity in the workforce. Rapid-response education is still required in certain instances, such as during educational emergencies, but it’s often not the core method that an L&D team uses to deliver learning. An example of this was during COVID-19, where large instances of learning were required quickly to address pressing needs such as education on donning and doffing PPE correctly, recognising symptoms of COVID-19 and correct use of rapid antigen tests.

Examples of the Great Divide

How might this divide manifest at an operational level? A common example is that when Quality identifies a compliance issue that requires immediate rectification, L&D may not be looped in quickly enough to adapt education or training plans in sync to align with the organisation meeting these urgent needs. Conversely, education initiatives might only sometimes align with the most pressing quality concerns, leading to gaps where staff may be well-trained but not in the areas of highest compliance risk.

My experience from working as a clinician in an Intensive Care Unit (ICU) centres around audits. Quality team members often conduct important audits to obtain data on whether correct evidence-based practices and policies are being adhered to. Typically, though, the representative only interacted with the Nurse Unit Manager, not the frontline staff who were being audited. The Quality team member stood in a corner and recorded activities meticulously on an iPad. Often, I didn’t know what aspect of clinical care was being audited, the name of the person conducting it, or how we went. It truly felt like surveillance. This approach, granted, may be rooted in ‘audit best practices’. Still, I felt it limited the opportunity to educate the entire clinical team on quality measures, reinforcing the division between quality assurance and clinical education.

I asked a colleague and senior healthcare manager about her experience. She shared an example highlighting the divide that existed not just on the floor but in department head meetings: During these meetings, despite the presence of highly experienced leaders, there needed to be more acknowledgement and communication among them. This absence of basic interaction between teams created an uncomfortable atmosphere, contrasting starkly with the collaborative spirit expected in our workforce and in clinical settings.

Bridging the Gap to Achieve a Shared Goal

The challenge, then, is to bridge these divides, encouraging constant communication and collaboration to ensure that both departments coexist and that the systems, processes, plans and tools used to coordinate both core functions are aligned. When this occurs, we can work towards the shared goal of improving care outcomes and staff competency. Such alignment is essential, not just for implementing new or meeting existing regulatory standards but for fostering a workforce and workplace where continuous improvement is part of the everyday culture.

Evidence of Need for Collaboration

Benefits of strategic alignment

Let’s start with the evidence. Recent studies highlight the critical need for strategic alignment between quality and education to address gaps in knowledge, skills, practice and policy implementation. For instance, a systematic review published by Atkins et al. in 2023 states that quality improvement collaboratives significantly enhance the implementation of evidence-based practices when there is effective collaboration between Quality and Educational teams. The review showed that effective collaboration between facilities and within organisations leads to better adherence to evidence-based guidelines (Zamboni et al. 2020). This involves both intra-organisational mechanisms, where change happens within a single facility, and inter-organisational mechanisms, where collaboration across facilities drives improvement​. This is the holy grail: implementing evidence-based practice across a complex adaptive system where multi-sites and many teams exist.

Improved adherence and experience

Aligning educational initiatives with quality improvement (QI) measures ensures that training directly contributes to enhanced quality of care and adherence to regulatory standards and best-practice guidelines (Hempel et al. 2022). Additionally, we can involve the person, patient or client to achieve alignment (Bombard et al. 2018). Given all health and aged care roles revolve around the person being the centre of care, studies suggest that engaging patients can significantly improve the quality of care. This engagement ranges from consulting on care to active co-design of health services, which has been shown to produce tangible quality improvements and enhance patient experience.

Gap in teamwork

Despite the positive outcomes associated with collaboration between these core functions in a health or aged care organisation, Rosen et al. (2018) identified a noticeable gap in how teamwork impacts safety and quality measures directly, suggesting a more integrated approach could yield better outcomes. The evidence indicates that collaboration between Quality and Education teams in healthcare settings is crucial for improving outcomes but often presents challenges due to varying levels of integration and communication.

So, the key point is that the strategic integration of clinical education with QI initiatives, such as coordinating the dissemination of the latest clinical guidelines and related policies, reduces risks and increases the likelihood of improved care if that new knowledge, policy, activity or initiative being implemented is sustained. When the patient or person at the centre of care informs that change, their experience and outcomes also improve.

Cross-team collaboration is our tool to unlock these benefits.

Practical Examples of Alignment

Here's how a stronger integration between Quality and Education can be practically applied across any sector. I am using an example within aged care to ensure the effective implementation of the new strengthened Aged Care Quality Standards, as this is currently a key priority for the sector.

Example 1: Using Quality Indicator Data to Validate the Need for Education

Mandatory quality indicator (QI) data can significantly guide L&D teams in prioritising educational content. By using this data as a key input within a needs assessment, L&D teams can identify specific areas where training is most needed, ensuring that education directly addresses the highest-risk or weakest areas in service provision.

The process involves mapping out which standards are underperforming based on the QI data and then aligning educational activities (and quality initiatives) to address these gaps. This approach ensures that training is not just delivered as a formality but is targeted to improve areas identified as needing the most attention at the right time.

More training and education won’t solve systemic issues.

When using mandatory QI data in ongoing or rolling training needs assessment, care must be taken if data shows repetitive quality issues. In this case, it may not always be appropriate for this data to lead to training responses. We need to address underlying systemic or procedural problems. For example, what happens if the quality indicator data inputted into each needs assessment demonstrates the need for education on the same topic? This scenario is not unlikely as audits have very specific focuses, and the data collection is mandatory. What this may result in is ongoing education every month on the same topic, such as pressure injury prevention, leading to training fatigue, burnout, disengagement and ongoing compliance issues. In this case, L&D teams could work closely with Quality teams to explore the deeper systemic issues that may be causing the persistent clinical issues. Activities such as discovery with staff (just talking!), structured interviews or surveys are essential to identify issues that training alone is not able to address.

Example 2: Aligning Quality and Education Frameworks

A robust Quality Framework in any aged care organisation encompasses quality assurance processes and clearly defined staff roles and responsibilities. Similarly, an Education Framework should outline learning objectives, resource allocation and intervention strategies that an organisation is prioritising. I contend that the Education Framework is in sync with the Quality Framework to ensure cohesive service delivery and improvement. I am not suggesting that we merge documents; distinct frameworks are very much required. But has Quality reviewed the Education Framework and vice versa? Have they been developed and released at similar times?

Aligning these frameworks through review and collaboration ensures that quality assurance and educational efforts are not only aligned but also mutually reinforcing. For instance, changes in policies or the introduction of new procedures should trigger updates in training materials and methods, ensuring that staff education is current and relevant. Simply documenting and sharing updates on when those changes are planned to take place will assist in annual resource planning. Regular communication and collaboration are critical throughout the year. What are the core policy updates, and what clinical changes within them do staff need to know? This collaboration ensures that reviews of policies or updates to processes translate to staff clinical practice changing, leading to sustained improvements rather than temporary fixes.

Conclusion

Integrating clinical education and quality initiatives has numerous strategic, regulatory and operational benefits. When we work together, we achieve the minimum level of compliance that organisations require. More importantly, though, we lay the critical foundations of effective intra-organisational systems and processes that enable all teams to build staff knowledge, skills, competence and capability to provide safe, quality care.

References

Bombard, Y, Baker, G, Orlando, E et al. 2018, ‘Engaging Patients to Improve Quality of Care: A Systematic Review’, Implementation Science, vol. 13, no. 98, viewed 21 August 2024, https://doi.org/10.1186/s13012-018-0784-z

Zamboni, K, Baker, U, Tyagi, M et al. 2020, ‘How and Under What Circumstances do Quality Improvement Collaboratives Lead to Better Outcomes? A Systematic Review’, Implementation Science, vol. 15, no. 27, viewed 21 August 2024, https://doi.org/10.1186/s13012-020-0978-z

Hempel, S, Bolshakova, M, Turner, BJ et al. 2022, ‘Evidence-Based Quality Improvement: A Scoping Review of the Literature’, Journal of General Internal Medicine, vol. 37, pp. 4257-4267, viewed 21 August 2024, https://doi.org/10.1007/s11606-022-07602-5

Atkins, E, Birmpili, P, Glidewell, L et al. 2023, ‘Effectiveness of Quality Improvement Collaboratives in UK Surgical Settings and Barriers and Facilitators Influencing Their Implementation: A Systematic Review and Evidence Synthesis’, BMJ Open Quality, vol. 2, no. 2, viewed 21 August 2024, https://doi.org/10.1136/bmjoq-2022-002241

Rosen, MA, Diaz-Granados, D, Dietz, AS et al. 2018, ‘Teamwork in Healthcare: Key Discoveries Enabling Safer, High-quality Care’, American Psychologist, vol. 73, no. 4, viewed 21 August 2024, https://doi.org/10.1037/amp0000298

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