Part 2: Workforce and structure

Section 2.1: Governance

Criterion 2.1.1

Guidance for all providers

  • People on governance bodies receive appropriate orientation to their governance roles and responsibilities, and are offered governance training.
  • Training for people on governance bodies may cover:
    1. Te Tiriti o Waitangi and tikanga
    2. Government Inquiry into Mental Health and Addiction (2018) He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction
    3. education in lived experience voices at governance
    4. education on the disability sector and priorities
    5. a person-centred approach to service development, implementation, and review
    6. the difference between governance and operational management
    7. influencing organisational culture and behaviour change
    8. quality in the relevant health and disability service
    9. relevant legislation.
  • People with relevant lived experience hold a meaningful proportion of seats on the governance body.
  • Governance bodies work with management to meet the requirements of relevant standards and legislation.
  • Governance bodies use data that reflects the communities they serve in planning and delivering services.
  • Governance bodies have current terms of reference.

Criterion 2.1.2

Guidance for all providers

  • Organisations have documented plans that include their mission, vision, and goals.
  • Documented plans are reviewed at defined intervals. Organisations are set up to deliver on the outcomes identified in the documented plan.
  • Organisational values are person-centred and whānau-focused.
  • Organisational goals aim for integrated service delivery.
  • Values are embedded into all levels of practice.
  • The input of people with lived experience is evident in planning.

Criterion 2.1.3

Aged care: Guidance
  • Managers appointed should have experience in dementia and the special needs of older people.
Fertility services: Guidance
  • Service providers identify a ‘person responsible for activity’, as defined in section 20 of the HART Act, and a ‘practice director’ for communication with the Australian and New Zealand Assisted Reproduction Database.
  • Service providers consider adopting technical bulletins issued by the Reproductive Technology Accreditation Committee (RTAC) or other professional bodies as best practice guidelines.
Birthing units: Guidance
  • Managers appointed are experienced midwives.

Criterion 2.1.4

Guidance for all providers

  • Governance bodies:
    1. at defined intervals receive reports on quality and risk activity and endorse actions
    2. are aware of and understand relevant national guidance on matters that affect the services being delivered (for example, in terms of reducing violence in the workplace)
    3. understand the actions that contribute to patient safety
    4. at defined intervals receive reports framed by Te Tiriti o Waitangi that relate to equity for Māori.

Criterion 2.1.5

Guidance for all providers

  • Strategic and business planning documents align with:
    1. Ministry of Health strategies – in particular, He Korowai Oranga: Māori Health Strategy
    2. the government strategic direction for achieving outcomes for Māori – see Ministry of Health (2014) Equity of Health Care for Māori: A framework.
  • Service providers collaborate with mana whenua in business planning and service development.
  • Where service providers do not have a governance body, they show evidence of taking a meaningful approach to decision making and implementing this criterion so that it is reflected in the services provided.

Criterion 2.1.6

Guidance for all providers

  • Strategic and business planning documents show evidence that they align with:
    1. Ministry of Health strategy – in particular, the Disability Support Services Strategic Plan and Ministry of Health (2018) Whāia Te Ao Mārama 2018 to 2022: The Māori Disability Action Plan
    2. government strategic direction to achieve outcomes for tāngata whaikaha.
  • Tāngata whaikaha have meaningful representation on the governance body.

Additional guidance

Aged care
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.
Home and community
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.
  • Governance body membership includes expertise from people with lived experience.
  • Service providers and their governance bodies report to, and are accountable to, people receiving services.
Residential disability
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.
  • Governance body membership includes expertise from people with lived experience.
  • Service providers and their governance bodies report to, and are accountable to, people receiving services.
Residential mental health and alcohol and other drug
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.
  • Governance body membership includes expertise from people with lived experience.
  • Service providers and their governance bodies report to, and are accountable to, people receiving services.
DHB inpatient/private hospital
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.
Hospice
  • Service providers demonstrate an understanding of the Ministry of Health’s (2016) Healthy Ageing Strategy.
  • Governance bodies may seek:
    1. expertise from people with lived experience
    2. a partnership approach to decision making.

Criterion 2.1.7

Guidance for all providers

Additional guidance

DHB inpatient/private hospital
  • Governance bodies have an understanding of the social determinants of each region. This understanding links to strategic planning and the quality improvement cycle.
  • Universal proportionalism (the principle that those with the greatest need receive the greatest proportion of funding) is included in strategic planning.
  • Governance bodies make proactive funding decisions. 
Birthing units
  • Governance bodies have an understanding of the social determinants of each region. This understanding links to strategic planning and the quality improvement cycle.
  • Universal proportionalism (the principle that those with the greatest need receive the greatest proportion of funding) is included in strategic planning.
  • Governance bodies make proactive funding decisions. 
Hospice
  • Governance bodies have an understanding of the social determinants of each region. This understanding links to strategic planning and the quality improvement cycle.
  • Universal proportionalism (the principle that those with the greatest need receive the greatest proportion of funding) is included in strategic planning.
  • Governance bodies make proactive funding decisions. 

Criterion 2.1.8

Guidance for all providers

  • Governance bodies collaborate with the community on business planning and service development.
  • Service providers consider demographics (for example, the ageing population) in planning.
  • Governance body membership includes expertise from people with lived experience.
  • Service providers and their governance bodies report to, and are accountable to, people receiving services. They have implemented systems to evidence this practice.
  • Service providers have internal advisory groups (or similar) of people who have lived experience of relevant services.

Additional guidance

Abortion services
  • Where appropriate, service providers establish working relationships with youth-specific health services based in schools and the community.

Criterion 2.1.9

Guidance for all providers

  • Evidence shows meaningful tāngata whaikaha, Māori, whānau, and Te Tiriti partner representation.
  • Evidence shows representatives have time to make decisions. This evidence may include:
    1. board member interviews
    2. minutes
    3. demonstration of the way the policy reflects the views of Māori representatives.

Criterion 2.1.10

Guidance for all providers

Criterion 2.1.11

Guidance for all providers

  • A clinical governance structure is in place that:
    1. includes lived experience and Māori representation 
    2. may be multidisciplinary
    3. looks to national guidance to support development, such as the Health Quality & Safety Commission’s (2017) Clinical Governance: Guidance for health and disability providers.
  • The clinical governance structure, depending on the size and setting, may be a part of the service provider’s governance body.

Section 2.2: Quality and risk

Criterion 2.2.1

Guidance for all providers

  • Service providers demonstrate evidence of:
    1. discussion at executive meetings that review quality and risk indicators
    2. checking progress on key performance indicators
    3. presentation of dashboard data, including Māori health indicators that reflect whānau participation and Māori satisfaction with the service
    4. feedback to health care and support workers and documented links to the governance body
    5. people receiving services having input into the quality and risk management system
    6. a record of outcomes and agreed actions
    7. feedback to people receiving services about outcomes from the quality framework, including experience of care and service feedback from people.
  • Service providers have:
    1. an annual plan that contains specific quality outcomes as advised by a quality agency such as the Health Quality & Safety Commission, and review it quarterly
    2. an understanding of WorkSafe requirements for a ‘person conducting a business undertaking’
    3. an executive presence in project lead roles with a clear link to new developments or initiatives
    4. escalation mechanisms.

Additional guidance

DHB inpatient/private hospital
  • Quality and business planning documents show evidence that service providers:
    1. participate in partnership for mātauranga Māori
    2. include the Accessibility Charter
    3. understand the social determinants of each DHB region 
    4. understand that social determinants help inform quality improvement goals with the aim of improving health outcomes for the communities being served.
Birthing units
  • Quality and business planning documents show evidence that service providers:
    1. participate in partnership for mātauranga Māori
    2. include the Accessibility Charter
    3. understand the social determinants of each DHB region 
    4. understand that social determinants help inform quality improvement goals with the aim of improving health outcomes for the communities being served.
Hospice
  • Quality and business planning documents show evidence that service providers:
    1. participate in partnership for mātauranga Māori
    2. include the Accessibility Charter
    3. understand the social determinants of each DHB region 
    4. understand that social determinants help inform quality improvement goals with the aim of improving health outcomes for the communities being served.

Criterion 2.2.2

Guidance for all providers

  • Service providers take a risk-based approach in order to:
    1. give people receiving services and their whānau leadership roles and influence in decision making at all levels of service provision
    2. focus resources on ‘critical’ aspects
    3. increase safety and legal conformity
    4. address health and safety for people.
    See Australia New Zealand Standard on Risk Management AS/NZS ISO 31000:2009.
  • Service providers use quality domains (see below for a summary) in their quality framework that are:
    1. safe, noting that cultural safety is part of the whole concept of safety for all people receiving health and disability services, ensuring engagement of Māori and Pacific peoples
    2. timely
    3. equitable, which includes equal access, equal experience of care, and equal outcomes of care
    4. effective
    5. efficient
    6. people- and whānau-centred.
  • Service providers’ quality frameworks encompass:
    1. systems thinking
    2. leadership for improvement and positive change
    3. quality improvement and patient safety knowledge
    4. evidence-based improvement and innovation
    5. teamwork and communication. 
  • Service providers’ quality management systems include:
    1. performance evaluation through monitoring, measurement, analysis, and evaluation
    2. a programme of internal audit
    3. a process for identifying and addressing corrective actions.
  • Service providers can refer to the Health Quality & Safety Commission quality domains, which are embedded into a framework that provides a structure to improve and enhance quality of care. This framework consists of four components:
    1. consumer engagement and participation – enabling people and whānau as active members of the health team
    2. clinical effectiveness – evidence-based decision making derived from research and people’s experience to focus improvement
    3. quality improvement and patient safety – increasing the capabilities of everyone participating in the health workforce in quality and safety improvement appropriate to their role and sphere of work
    4. engaged effective workforce – an engaged, effective workforce that works in partnership with people and actively participates in an ongoing process of self and peer review.

Additional guidance

Birthing units

Criterion 2.2.3

Guidance for all providers

  • Service providers are involved in continuous quality improvement activity, planning, and reporting progress on actions.
  • Service providers can evidence:
    1. improvement activity
    2. informed data analysis, including quality safety markers
    3. that quality and safety risk policies and procedures provide indicative time frames for corrective actions and reporting progress.
  • The executive team or clinical quality governance group assures and reports progress to the governance body.

Criterion 2.2.4

Guidance for all providers

  • Service providers use strategic planning to analyse strengths, challenges, opportunities, and threats (SCOT), or threats, opportunities, weaknesses, and strengths (TOWS), or similar. External risks could include national reviews and enquiries. Internal risks could include results from internal reviews, investigations, audit processes, and complaints processes. 
  • A strategic planning technique includes input from health care and support workers and people receiving services.
  • Service providers undertake benchmarking against relevant health performance indicators. 
  • Service providers include business continuity as part of their annual planning processes.
  • Service providers undertake an internal and external risk assessment within defined intervals, or in response to level of risk. 
  • In considering internal and external risks, service providers seek feedback through several mechanisms, such as focus groups and surveys.
  • Service providers demonstrate that quality improvements are made and embedded into practice as a result of incidents, adverse events, complaints, and investigations, among other factors.

Additional guidance

DHB inpatient/private hospital
  • Risk mitigation is a continual process that is assessed, reviewed, and updated within defined intervals. 
  • Frequency of review is dependent on the level of risk posed to the service provider.
Birthing units
  • Birthing units and maternity services: see the New Zealand Maternity Clinical Indicators.
Hospice
  • Risk mitigation is a continual process that is assessed, reviewed, and updated within defined intervals.
  • Frequency of review is dependent on the level of risk posed to the service provider.

Criterion 2.2.5

Guidance for all providers

  • The purpose of the National Adverse Event Reporting Policy is to contribute to improved quality, safety, and experience of health and disability services through systems that:
    1. are safe
    2. are people- and whānau-centred
    3. provide for early identification and review of adverse events
    4. verify lessons are learnt
    5. demonstrate public accountability and transparency.
  • The policy supports a national approach to reporting, reviewing, and learning from adverse events and near misses, and is based on the following six key principles. (For more information, see Health Quality & Safety Commission (2017) National Adverse Events Reporting Policy.)
    1. Open communication
      1. Affected people are offered immediate support and an appropriate apology.
      2. Affected people are informed of process and time frames and have the ability to provide comment on the draft review and final report.
      3. A contact person for whānau is provided and there is an agreed regular communication process regarding review progress, and progress with review recommendations once the review is complete.
      4. People receive a copy of the final review report and are appropriately supported.
    2. Consumer participation
      1. People who have been involved in an adverse event will be offered the opportunity to share their story as part of the review process.
      2. Review findings and recommendations will be shared with them.
      3. Independent representatives who have experience using the health and disability service are involved in the review process.
    3. Culturally appropriate review practice
      1. Hui process is followed as appropriate.
      2. Reports have language at a level suitable for all to understand; that is, free of health and disability related jargon.
      3. Service providers demonstrate they use culturally appropriate practices such as restorative practice.
    4. System changes
      1. Service providers demonstrate reviews are focused on system learnings.
      2. Lessons learnt are shared locally and with other providers.
      3. Deidentified copies of adverse event reports are sent to the Health Quality & Safety Commission to support national learnings, and for sharing with others such as the Health and Disability Commissioner and Coronial Services.
      4. Reports state how the implementation of recommendations will be measured.
    5. Accountability
      1. There is evidence of learning, improving safety, and reducing the possibility of adverse events recurring.
      2. Service providers demonstrate that the outcomes of internal reviews are communicated to all parties in an accessible format and the style of feedback is suitable to the person receiving services.
      3. Evidence shows that processes are in place to verify service providers implement and follow up recommendations; for example, providers have a recommendations action plan.
      4. Adverse event review reports state who is the accountable person for the implementation and evaluation of the recommendations.
    6. Reporting must be safe
      1. Service providers identify the immediate actions taken to mitigate risk to people receiving services.  
      2. The review focuses on determining the underlying system failures, and not blaming or punishing individuals.
      3. Service providers update and implement operating policies and procedures to reflect a ‘just and fair’ culture of adverse event reporting and management.
      4. Service providers support health care and support workers throughout the investigation.
      5. Service providers implement a health care and support worker support programme, which may include debriefing.
      6. Service providers understand statutory and regulatory obligations in relation to essential notification reporting and notify the correct authority where required.
  • Where events involve a criminal act, substance abuse by a health care worker, a deliberate unsafe act, or deliberate harm, service providers manage them in a separate process, which may involve regulatory authorities.

Additional guidance

Fertility services
  • Fertility services follow the adverse event process that is outlined in the RTAC Code of Practice.

Criterion 2.2.6

Guidance for all providers

  • Essential notifications are those things that service providers must report.  They include, but are not limited to:
    1. those outlined in legislation, such as Section 31 of the Health and Disability Services (Safety) Act, The Fire and Emergency New Zealand Act 
    2. those required through regulation by other agencies such as WorkSafe, Public Health for notifiable and communicable diseases, or Responsible Authorities.

Criterion 2.2.7

Guidance for all providers

  • Service providers undertake analysis of their health care and support workers’ competencies in the following, and will support workers with training and development in areas with any identified gaps:
    1. te reo and tikanga Māori and ongoing learning
    2. understanding and using Māori models of care, health, and wellbeing
    3. having the capability to use cultural intervention practices and approaches to pae ora
    4. collecting high-quality ethnicity data and understanding the rationale for doing so 
    5. working in partnership and participating with iwi and Māori organisations within and outside of the health sector to allow for better service integration, planning, and support for Māori and whānau.

Criterion 2.2.8

Guidance for all providers

Section 2.3: Service management

Criterion 2.3.1

Guidance for all providers

  • Service providers’ documented rationale for providing culturally and clinically safe services and its implementation demonstrate:
    1. the use of an acuity methodology to estimate health care and support workers’ requirements
    2. how shortfalls in health care and support workers’ capacity and capability are managed
    3. how health care and support workers’ numbers are adjusted to meet changes in people’s acuity
    4. consideration of cultural safety for health care and support workers, Māori and whānau. This could include: cultural independent or group supervision; and working towards best practice tikanga guidelines
    5. a link to the quality and risk management framework that meets the required needs for safe and appropriate levels of service
    6. that rostered workforce levels meet contract requirements for those service providers holding a contract for service.
  • Service providers consider the impact of environmental factors such as the building footprint on health care and support workers.
  • In considering suitability of workforce levels, service providers compare the hours that employed health care and support workers work over and above their contracted hours. Where health care and support workers are exceeding predetermined safe hours, providers implement actions to mitigate potential risk to people receiving services.
  • Service providers consider mental health and addiction peer support for health care and support workers.
  • In determining a safe and effective workforce, service providers have health and safety policies in place that cover:
    1. overtime
    2. workforce levels appropriate to prevent assaults on health care and support workers and other incidents
    3. health care and support worker retention.
  • Workforce engagement surveys may be implemented to receive feedback on levels and skill mix.

Additional guidance

Aged care
  • Service providers communicate with people receiving services when they are planning changes to staffing levels.
Home and community
  • When support workers do not come to work, service providers inform the people affected of the change of support workers, wherever possible.
  • Service providers’ documented rationale includes:
    1. the required qualifications and experience for different types of support
    2. skill mix (for example, specifying number of registered nurses, enrolled nurses, health care and support workers at level 3 and level 4, and peer support workers) 
    3. adherence to pay equity legislation.
Residential disability
  • Service providers communicate with people receiving services when they are planning changes to staffing levels.
  • When support workers do not come to work, service providers inform the people affected of the change of support workers, wherever possible.
Residential mental health and alcohol and other drug
  • Service providers communicate with people receiving services when they are planning changes to staffing levels.
  • When support workers do not come to work, service providers inform the people affected of the change of support workers, wherever possible.
  • Service providers’ documented rationale includes:
    1. the required qualifications and experience for different types of support
    2. skill mix (for example, specifying number of registered nurses, enrolled nurses, health care and support workers at level 3 and level 4, and peer support workers) 
    3. adherence to pay equity legislation.
DHB inpatient/private hospital
Birthing units

Criterion 2.3.2

Guidance for all providers

  • Service providers embed their organisational values and mission into the culture of the service they deliver.
  • Position descriptions reflect expected positive behaviours and values.
  • Descriptions of roles cover responsibilities and additional functions, such as holding a restraint portfolio or infection prevention portfolio.
  • Recruitment practices meet current best practice, including through actively recruiting and retaining Māori health care and support workers.
  • Service providers proactively support workers to work within their scope of practice and speciality practice.
  • Service providers support access to mandatory and other relevant training.
  • Service providers are aware of requirements in relevant legislation such as the Children’s Act 2014.
  • Those service providers holding contracts for services meet their contractual requirements.
  • Service providers support Māori health care and support workers with targeted cultural and professional development opportunities.
  • Service providers meet the training and qualification requirements in the Support Workers (Pay Equity) Settlements Act 2017.
  • Service providers who are providing dementia and aged residential specialised hospital services meet their contractual requirements.

Additional guidance

Home and community
  • Service providers consider suitability, such as how well someone’s personality or attitude coheres with people receiving services, as an integral factor in determining their service’s workforce.
Residential disability
  • Service providers consider suitability, such as how well someone’s personality or attitude coheres with people receiving services, as an integral factor in determining their service’s workforce.
Residential mental health and alcohol and other drug
  • Service providers verify Addiction Practitioners Association Aotearoa New Zealand qualifications where relevant.
  • Service providers consider suitability, such as how well someone’s personality or attitude coheres with people receiving services, as an integral factor in determining their service’s workforce.

Criterion 2.3.3

Guidance for all providers

  • Service providers consider:
    1. the type of services they are providing and the acuity of people receiving services
    2. contracts they hold and their specific requirements
    3. developing a plan to enhance competencies that may be required when they extend their services. This plan should be linked to current business planning that would include the type of service, equipment required, the workforce, and people receiving services
    4. surveying the workforce and community to determine new requirements
    5. the cultural make-up of health care and support workers and people. This includes actively recruiting and retaining a Māori workforce.
  • Competency records for all health care and support workers are available. The frequency of competency checks will depend on the associated risk.
  • Service providers have a mechanism to determine the percentage of health care and support workers who have completed or maintained the required competency.
  • Service providers require health care and support workers to complete cultural competency training.
  • Service providers consider the cultural make-up of their workforce, which includes considering:
    1. the percentage of Māori health care and support workers
    2. people’s right to speak their own language
    3. tikanga
    4. connections to iwi, hapū, and whānau.

Additional guidance

DHB inpatient/private hospital
  • Service providers incorporate cultural competence into continuing education. Part of this education involves developing an awareness of Māori health models and how they apply to Māori reproductive health. This includes the four domains of Te Whare Tapa Whā: 
    1. hauora hinengaro
    2. hauora tinana
    3. hauora wairua
    4. hauora whānau.
Birthing units
  • Service providers incorporate cultural competence into continuing education. Part of this education involves developing an awareness of Māori health models and how they apply to Māori reproductive health. This includes the four domains of Te Whare Tapa Whā: 
    1. hauora hinengaro
    2. hauora tinana
    3. hauora wairua
    4. hauora whānau.
Abortion services
  • Service providers incorporate cultural competence into continuing education. Part of this education involves developing an awareness of Māori health models and how they apply to Māori reproductive health. This includes the four domains of Te Whare Tapa Whā: 
    1. hauora hinengaro
    2. hauora tinana
    3. hauora wairua
    4. hauora whānau.

Criterion 2.3.4

Guidance for all providers

  • Service providers establish a continuing education programme for the workforce.
  • Service providers have implemented policies and procedures that address the need for workers to be released from work for education and learning.
  • Service providers support Māori health care and support workers to meet cultural and professional development needs.
  • Māori health care and support workers are able to learn and work in a culturally safe work environment.
  • Māori health care and support workers have ready access to cultural advisors, mentors, kaumātua, kuia, tohunga, and matakite to support their own cultural and professional development.
  • Service providers follow professional cultural safety guidelines and training; for example, Nursing Council of New Zealand‘s (2011) Guidelines for Cultural Safety, the Treaty of Waitangi and Māori Health in Nursing Education and Practice, Midwifery Council of New Zealand’s (2011) ‘Statement on Cultural Competence for Midwives (PDF, 345 KB)’, and Medical Council of New Zealand’s (2019) ‘Statement on cultural safety’.
  • All health care and support workers attend mandatory training.
  • Service providers seek to embed cultural values in their mandatory training programmes.
  • Credentialling is in place for relevant professionals. See Ministry of Health (2010) The Credentialling Framework for New Zealand Health Professionals.
  • Service providers’ training plans include rights-based framework training and responsiveness training.
  • Service providers maintain a training register.

Additional guidance

Home and community
  • Service providers demonstrate a culture of ongoing professional development for health care and support workers.
  • Training is underpinned by the principles of Enabling Good Lives, is mana enhancing, and focuses on ‘what we are trying to achieve for people’.
  • Training includes:
    1. community inclusion 
    2. strengths-based training 
    3. supported decision-making 
    4. substitute decision-making 
    5. principles of Enabling Good Lives 
    6. positive behaviour support
    7. speaking up for the safety of the person receiving services and their whānau 
    8. cultural training
    9. rainbow (LGBTI+) training
    10. rights-based and responsiveness training
    11. stigma and discrimination training
    12. consumer rights training
    13. Health and Disability Services Consumers’ Code of Rights training.
  • Training is open to whānau, as appropriate.
  • Evidence demonstrates service providers work with organisations that represent the views of people who use the service in developing a learning and development plan.
  • Training materials are in accessible formats.
Residential disability
  • Service providers demonstrate a culture of ongoing professional development for health care and support workers.
  • Training is underpinned by the principles of Enabling Good Lives, is mana enhancing, and focuses on ‘what we are trying to achieve for people’.
  • Training includes:
    1. community inclusion 
    2. strengths-based training 
    3. supported decision-making 
    4. substitute decision-making 
    5. principles of Enabling Good Lives 
    6. positive behaviour support
    7. speaking up for the safety of the person receiving services and their whānau 
    8. cultural training
    9. rainbow (LGBTI+) training
    10. rights-based and responsiveness training
    11. stigma and discrimination training
    12. consumer rights training
    13. Health and Disability Services Consumers’ Code of Rights training.
  • Training is open to whānau, as appropriate.
  • Evidence demonstrates service providers work with organisations that represent the views of people who use the service in developing a learning and development plan.
  • Training materials are in accessible formats.
Residential mental health and alcohol and other drug
  • Service providers demonstrate a culture of ongoing professional development for health care and support workers.
  • Training is underpinned by the principles of Enabling Good Lives, is mana enhancing, and focuses on ‘what we are trying to achieve for people’.
  • Training includes:
    1. community inclusion 
    2. strengths-based training 
    3. supported decision-making 
    4. substitute decision-making 
    5. principles of Enabling Good Lives 
    6. positive behaviour support
    7. speaking up for the safety of the person receiving services and their whānau 
    8. cultural training
    9. rainbow (LGBTI+) training
    10. rights-based and responsiveness training
    11. stigma and discrimination training
    12. consumer rights training
    13. Health and Disability Services Consumers’ Code of Rights training.
  • Training is open to whānau, as appropriate.
  • Evidence demonstrates service providers work with organisations that represent the views of people who use the service in developing a learning and development plan.
  • Training materials are in accessible formats.

Criterion 2.3.5

Guidance for all providers

  • Service providers provide education or training for health care or support workers whose colleagues may be people with lived experience working in the service.
  • Service providers provide supervision, debriefing, and peer support.
  • Health care and support workers receive training about involving people with lived experience in service delivery.

Criterion 2.3.6

Guidance for all providers

  • Service providers:
    1. encourage health care and support workers (at individual and team levels) to participate in learning opportunities that provide them with the most recent literature on Māori health outcomes and disparities, health equity, and quality, and enable them to use this evidence and learn with their peers. For examples, see the website of the Māori Health Review
    2. support the development of expertise in te reo Māori for all health care and support workers
    3. support health care and support workers to build their own knowledge of how they can effectively provide health information for Māori. 
    See Ministry of Health (2015) A Framework for Health Literacy.
  • Service providers give health care and support workers the opportunity to reflect on their own cultural assumptions about Māori, and how these might influence their capacity to provide high-quality care.

Criterion 2.3.7

Guidance for all providers

  • Service providers consider:
    1. assigning professional development support for clinical guidelines and decision-making tools that are focused on achieving health equity for Māori
    2. establishing opportunities to share knowledge within the organisation about initiatives that work toward achieving health equity for Māori.
  • Service providers provide or make equity training available to health care and support workers. This training should include how to:
    1. see and identify inequities
    2. manage inequities for Māori and other groups of people receiving services
    3. identify differences between inequality and inequity
    4. identify policies or service designs that increase inequities for vulnerable populations, including Māori and Pacific peoples.

Criterion 2.3.8

Guidance for all providers

  • Training, support, performance and competence of health care and support workers are related to legal obligations for a healthy work environment.
  • Service providers provide safe systems of work for health care and support workers (section 36, Health and Safety at Work Act 2015).

Criterion 2.3.9–2.3.14

Residential mental health and alcohol and other drug: Guidance

Criterion 2.3.9

  • Service providers could appoint a person receiving services to a position of ‘person with lived experience’ or ‘consumer advisor’ or similar.
  • People with lived experience of the service state that they are involved in important decisions about service delivery.

Criterion 2.3.10

  • Service providers recognise people with lived experience of the service and organisations or groups that represent the views of people receiving the service as a valued voice and act on their opinions where appropriate.
  • Position descriptions are clear and provide an appropriate level of responsibility and accountability to people with lived experience.
  • Service providers adequately resource planning, implementation, and evaluation of service activities to involve people with lived experience.

Criterion 2.3.11

  • Policies and procedures may include:
    1. employing people with lived experience of the service, where practicable
    2. services helping with education, training, and support for people with lived experience to maximise their participation in the service
    3. training for service providers in working with people as advisors.
  • Advisors liaise with organisations, networks, or groups that represent the views of people receiving services.

Criterion 2.3.12

  • Service providers could appoint a whānau member to a position of ‘whānau advisor’ or similar.
  • Whānau state that they are involved in important decisions about service delivery.

Criterion 2.3.13

  • Service providers seek advice from whānau advisory groups when developing terms of reference.
  • Roles and responsibilities are clearly outlined and include accountabilities, confidentiality, and conflicts of interest.

Criterion 2.3.14

  • Policies and procedures may include:
    1. employing whānau where practicable
    2. the service helping with education, training and support for whānau to maximise their participation in the service
    3. training for service providers in working with whānau as advisors.
  • Advisors liaise with whānau groups or networks.
DHB mental health and addiction: Guidance

Criterion 2.3.9

  • Service providers could appoint a person receiving services to a position of ‘person with lived experience’ or ‘consumer advisor’ or similar.
  • People with lived experience of the service state that they are involved in important decisions about service delivery.

Criterion 2.3.10

  • Service providers recognise people with lived experience of the service and organisations or groups that represent the views of people receiving the service as a valued voice and act on their opinions where appropriate.
  • Position descriptions are clear and provide an appropriate level of responsibility and accountability to people with lived experience.
  • Service providers adequately resource planning, implementation, and evaluation of service activities to involve people with lived experience.

Criterion 2.3.11

  • Policies and procedures may include:
    1. employing people with lived experience of the service, where practicable
    2. services helping with education, training, and support for people with lived experience to maximise their participation in the service
    3. training for service providers in working with people as advisors.
  • Advisors liaise with organisations, networks, or groups that represent the views of people receiving services.

Criterion 2.3.12

  • Service providers could appoint a whānau member to a position of ‘whānau advisor’ or similar.
  • Whānau state that they are involved in important decisions about service delivery.

Criterion 2.3.13

  • Service providers seek advice from whānau advisory groups when developing terms of reference.
  • Roles and responsibilities are clearly outlined and include accountabilities, confidentiality, and conflicts of interest.

Criterion 2.3.14

  • Policies and procedures may include:
    1. employing whānau where practicable
    2. the service helping with education, training and support for whānau to maximise their participation in the service
    3. training for service providers in working with whānau as advisors.
  • Advisors liaise with whānau groups or networks.

Section 2.4: Health care and support workers 

Criterion 2.4.1

Guidance for all providers

  • Service providers have a documented and implemented recruitment procedure that includes interviewing, reference checking, worker safety checking, criminal record-checking, and providing an employment agreement that complies with relevant legislation. Relevant legislation may include the Children’s Act 2014.
  • Interview panels include Māori representation (across all roles; in particular, clinical midwifery, nursing, allied health, leadership, and medical).
  • See Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development‘, endorsed by National DHB Chief Executives and the Health Workforce Information Programme’s District Health Board Employed Workforce Quarterly Reports for Māori workforce data.
  • Service providers undertake criminal record-checking as part of their recruitment processes.
  • Service providers have transparent recruitment processes and practices that they disclose with applicants, where possible.  
  • Where they use volunteers and bureau staff, service providers have an implemented policy around their recruitment, induction, and ongoing training.
  • Service providers have a policy of inclusion that promotes and supports equal opportunity with inclusive language, recruitment channels, and documentation.
  • Service providers’ employment procedures:
    1. meet the vision and mission statement of the organisation
    2. strive to reflect the communities they serve.

Additional guidance

Aged care
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.
Home and community
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.
  • People receiving services have a choice of the support workers who work in their home.
  • Service providers demonstrate that Māori health care and support workers are able to work in a manner that is safe for them. 
  • A person with a disability from the service is an integral part of the recruitment process. Ideally the person is involved in recruiting their own support health care and support workers. These people are adequately trained and compensated for their skill and contribution to the recruitment process.
  • Where service providers are having difficulty recruiting health care and support workers, they have mitigation strategies in place to safeguard people receiving services.
  • Service providers inform people receiving services whether the criminal record-checking process is complete for new support workers involved in their care.
Residential disability
  • People receiving services have a choice of the support workers who work in their home.
  • Service providers demonstrate that Māori health care and support workers are able to work in a manner that is safe for them. 
  • A person with a disability from the service is an integral part of the recruitment process. Ideally the person is involved in recruiting their own support health care and support workers. These people are adequately trained and compensated for their skill and contribution to the recruitment process.
  • Where service providers are having difficulty recruiting health care and support workers, they have mitigation strategies in place to safeguard people receiving services.
Residential mental health and alcohol and other drug
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.
  • People receiving services have a choice of the support workers who work in their home.
  • Service providers demonstrate that Māori health care and support workers are able to work in a manner that is safe for them. 
  • A person with a disability from the service is an integral part of the recruitment process. Ideally the person is involved in recruiting their own support health care and support workers. These people are adequately trained and compensated for their skill and contribution to the recruitment process.
  • Where service providers are having difficulty recruiting health care and support workers, they have mitigation strategies in place to safeguard people receiving services.
DHB inpatient/private hospital
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.
  • Service providers use the MERAS Safe Staffing Standards (PDF, 239 KB).
Birthing units
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.
  • Service providers use the MERAS Safe Staffing Standards (PDF, 239 KB).
Hospice
  • Service providers’ policies may include:
    1. how they support the implementation of Te Tumu Whakarae (2019) ‘Te Mahi a Te Tumu Whakarae – Position statement on Māori workforce development’ and associated targets
    2. Te Kuwatawata
    3. exit interviews – either with a manager or with someone else nominated by the person or human resources
    4. strategies that support recruitment of a workforce that reflects the communities they serve
    5. volunteers
    6. unregulated health care and support workers
    7. alignment with the Employment Relations Act 2000
    8. values-based recruitment
    9. progression pathways determined for peer support roles.
  • Service providers demonstrate a commitment to:
    1. succession planning
    2. leadership and workforce development.

Criterion 2.4.2

Guidance for all providers

  • Evidence shows that service providers have:
    1. an identified clinical lead who is responsible for clinical oversight and outcomes for the people receiving services
    2. a clear and documented escalation pathway for health care and support workers in situations where no registered nurse is on duty
    3. position description statements with equity statements about recruiting Māori health care and support workers and those who have competency in te reo Māori.
  • Service providers recognise cultural skills to support different models of care.
  • Service providers may adopt a skills framework.

Additional guidance

Fertility services
  • Service providers mitigate the risk of inexperience by using RTAC (key personnel) for sector guidance.

Criterion 2.4.3

Guidance for all providers

  • Service providers validate professional qualifications as part of the employment process and annually after employing each health care and support worker.

Additional guidance

Birthing units
  • National access agreement requires validation of the applicant or holder’s annual practising certificate and indemnity insurance (under section 88 of the New Zealand Public Health and Disability Act 2000).

Criterion 2.4.4

Guidance for all providers

  • Service providers demonstrate that their orientation and induction programmes incorporate te reo Māori, and actively promote it throughout the organisation and workforce.
  • Service providers demonstrate that the orientation and induction programmes cover their health care and support workers to provide a culturally safe environment to Māori.
  • Where they use volunteers, service providers have an implemented policy on their recruitment, induction, and ongoing training.
  • Where they use bureau staff, service providers have an implemented policy around the use of these staff and the competency requirements that bureau staff must meet before working for the service provider.

Additional guidance

Aged care
  • Service providers embed the principles of Enabling Good Lives in their orientation and induction processes.
Home and community
  • Service providers embed the principles of Enabling Good Lives in their orientation and induction processes.
Residential disability
  • Service providers embed the principles of Enabling Good Lives in their orientation and induction processes.
Residential mental health and alcohol and other drug
  • Service providers embed the principles of Enabling Good Lives in their orientation and induction processes.
DHB inpatient/private hospital
  • Service providers embed the principles of Enabling Good Lives in their orientation and induction processes.

Criterion 2.4.5

Guidance for all providers

  • Service providers have a performance management policy.
  • File notes on health care and support workers may include:
    1. health care and support worker interview
    2. feedback from the person receiving services and their whānau
    3. feedback from cultural supervisors, mentors, cultural advisors, and cultural expert
    4. recommendations arising from events, such as letters of apology, training, or competency review.
  • Appropriately trained people complete performance reviews.
  • In the case of performance management, health care and support workers may have access to independent support.
  • Service providers undertake performance/goal-setting reviews at defined intervals.
  • Service providers use performance reviews to identify and support opportunities for professional development.
  • Professional development opportunities may include:
    1. cultural pathways
    2. organisational culture and expectations.

Criterion 2.4.6

Guidance for all providers

  • Service providers consider reporting workforce information at defined intervals by ethnicity. They organise data by roles, gender, and age range for meaningful analysis and interpretation.
  • Service providers consider reviewing ethnicity data of health care and support workers for quality, including completeness, annually. Service providers use ethnicity data improvement tools to improve quality – for example, the Ministry of Health’s (2013) Primary Care Ethnicity Data Audit Toolkit. If ethnicity data is not recorded for existing health care and support workers,  service providers need to collect it.

Additional guidance

DHB inpatient/private hospital
Birthing units
Hospice

Criterion 2.4.7

Guidance for all providers

  • Service providers have implemented policies related to a debriefing process following incidents.
  • If incidents occur, health care and support workers are actively supported and have access to independent support such as an employee assistance programme.
  • People are encouraged to make full use of available health and legal support.

Additional guidance

Aged care
Residential mental health and alcohol and other drug
  • Health care and support workers have access to supervision.

Section 2.5: Information

Criterion 2.5.1

Guidance for all providers

  • Service providers meet whole-of-government standards for collecting disability data.
  • Records are uniquely identifiable, legible, timely, signed, and dated, and include the name and designation of the service provider, following professional guidelines and sector standards.
  • Service providers write notes in partnership with the person, as much as possible.
  • Service providers only hold information about people that is relevant for safe support. 
  • Sometimes the use of a person’s previous name can be psychologically harmful. Service providers record people’s preferred names and pronouns on documents related to the services they receive. Records of previous names people were known by are kept private. See Stats NZ standards and policies: Sex – Classification and Statistical Standard, Gender Identity – Classification and Statistical Standard, Data Protection and Use Policy.  
  • People receiving services are able to request and review their records in accordance with privacy laws, and service providers give them their records in a format accessible to the person concerned.
  • Service providers have consent processes in place for data collection. 
  • Service providers collect, record, and use ethnicity data in accordance with HISO 10001 2017: Ethnicity Data Protocols.
  • Service providers include an ethnicity audit as part of the internal audit programme, using a tool such as the ethnicity data auditing tool (EDAT).   
  • Service providers explore person-centred methods of managing health records, such as:
    1. personal health records as a web-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it
    2. an integrated and comprehensive view of health information, including information people communicate themselves, such as symptoms and medication use, information from doctors, such as diagnosis and test results, and pharmacy data. 

Additional guidance

Fertility services
  • Service providers maintain appropriate levels of documentation and management of health records, according to relevant legislation and standards, including the New Zealand Standard on Health Records NZS 8153:2002. For information about the requirements of the New Zealand Connected Health Information Services, see Connected Health Information Services. Permanent records are kept of:
    1. clinical and laboratory results of investigations undertaken
    2. the outcome of every attempted fertilisation
    3. every insemination
    4. every embryo transfer
    5. the fate of every embryo
    6. conceptions arising from treatment involving in vitro sperm, eggs, or embryos.
  • Service providers collect information required by the HART Act on the donors of children conceived using donated gametes or embryos, including:
    1. physical characteristics – name; gender; date, place and country of birth; height; eye and hair colour
    2. ethnicity and any relevant cultural affiliation
    3. for a Māori donor, whānau, hapū, and iwi, to the extent the donor is aware of these
    4. family medical history
    5. social history.
Residential mental health and alcohol and other drug
  • Service providers will write notes in collaboration with the person receiving services, unless there are good reasons not to. 
DHB inpatient/private hospital
  • Service providers will write notes in collaboration with the person receiving services, unless there are good reasons not to. 
Birthing units
  • Service providers will write notes in collaboration with the person receiving services, unless there are good reasons not to. 
Hospice
  • Service providers will write notes in collaboration with the person receiving services, unless there are good reasons not to. 

Criterion 2.5.2

Guidance for all providers

  • The information management system complies with the:
    1. New Zealand Public Health and Disability Act 2000
    2. Health Act 1956
    3. Health Information Privacy Code 1994
    4. Privacy Act 2020
    5. Official Information Act 1982
    6. Cancer Registry Act 1993 and Cancer Registry Regulations 1994
    7. Public Records Act 2005 
    8. Health (Retention of Health Information) Regulations 1996.
  • An overarching policy and related procedures govern a service provider’s information management system.
  • Service providers keep private information in a secure manner, ensuring it is unable to be publicly accessed or observed. 
  • Service providers implement guidance relating to managing electronic information including social media, use of images, and emails. For one resource, see the Nursing Council of New Zealand’s (2019) Guideline: Social Media and the Nursing Profession: A guide to maintain professionalism online for nurses and nursing students (PDF, 490 KB).
  • Service providers follow the required procedures for the minimum duration of storage of people’s records, as regulated under the Health Information Functional Disposal Authorities (FDA) (Department of Inland Affairs – National Archives).
  • Service providers maintain high-quality, complete ethnicity data consistent with HISO 10001 2017: Ethnicity Data Protocols.
  • Service providers use ethnicity data audit tools such as the Ministry of Health’s (2013) Primary Care Ethnicity Data Audit Toolkit.
  • Service providers capture data on gender that goes beyond male and female options to include gender diverse people, with at least either a wide variety of culturally appropriate gender options or a write-in field for a gender that is not listed. See Stats NZ (2020) ‘Sex and gender identity statistical standards: Consultation’.
  • Service providers use optional data fields to recognise the identities of people from rainbow communities to support equitable and high-quality health and support outcomes for people from these communities.
  • Service providers use data fields to recognise iwi affiliation whakapapa. 

Additional guidance

Fertility services
  • The minimum duration of storage of people’s records is regulated under the Health Information Functional Disposal Authorities (FDA) (Department of Internal Affairs – National Archives). That minimum duration is: 
    1. 10 years from the date of treatment not leading to the birth of a child
    2. 26 years from the date of treatment leading to the birth of a child (allowing for 20 years for the child to reach maturity, 3 years for ACC claims and 3 years for ACC appeals)
    3. 50 years for information about donors or children conceived using donor gametes or embryos, as described in the HART Act.
DHB inpatient/private hospital
  • Service providers have a data use policy.
  • Local lead maternity carers can access service providers’ information management systems for information sharing.
Birthing units
  • Service providers have a data use policy.
  • Local lead maternity carers can access service providers’ information management systems for information sharing.

Criterion 2.5.3

Guidance for all providers

  • Service providers maintain active, updated, and archived records in a suitable order and condition so that they may be retrieved when required, and enable records to follow people when needed.
  • Service providers undertake procedures to test back-up records at defined intervals, and update their disaster recovery strategy and the business continuity plan as required.
  • As part of their internal audit programme, service providers regularly monitor their records as to the quality of the documentation and the effectiveness of the information management system.
Back to top