Part 3: Pathways to wellbeing

Section 3.1: Entry and declining entry

Criterion 3.1.1

Guidance for all providers

  • Information available may include:
    1. service type
    2. location
    3. prioritisation process
    4. referral process and criteria
    5. entry criteria
    6. pre-entry assessment/preparation
    7. related services, where applicable
    8. out-of-hours contact information, where applicable
    9. cost and/or financial assistance available
    10. service review and feedback processes
    11. the use of printed material or material appropriate to the communication needs and style of Māori and other groups of people receiving services
    12. alternative formats such as easy-read, Braille, large print, audio, and translation into the different languages of people who are likely to use the service
    13. information on potential referral sources
    14. email address
    15. website information
    16. the ability to support people with emerging health conditions.
  • Entry criteria meet human rights standards and are devoid of discrimination and stigma on grounds that include:
    1. race
    2. sex
    3. sexual orientation
    4. gender identity
    5. ability
    6. mental health
    7. poverty
    8. age
    9. religion
    10. marital status.

Additional guidance

Fertility services
  • Prompt referral to the Fertility Service Providers for fertility preservation treatment including gamete storage.
  • The Assisted Reproductive Technology service specification describes the requirements for publicly funded assessment and treatment.
Public/private hospital
  • Prompt referral to the Fertility Service Providers for fertility preservation treatment including gamete storage.
  • The Assisted Reproductive Technology service specification describes the requirements for publicly funded assessment and treatment
Abortion services
  • Service providers supply impartial printed resources, web resources, telephone resources, or links to the Ministry of Health for information and advice to support people receiving services. This information may cover:
    1. location of the service
    2. how to access the service
    3. self-referral
    4. referral from another health service
    5. costs associated with pre-assessment, investigation, and travel
    6. travel options to access the service
    7. time frames from initial contact to having the procedure
    8. how to get time off work and school and how to get a medical certificate
    9. how to get post-procedure support in an unsupportive home environment
    10. rights and entitlements and how to access subsidies for costs
    11. contraception
    12. information appropriate for those who do not go ahead with the procedure the service provider is offering
    13. a glossary of relevant medical terms.
  • This information may be available in alternative formats such as Braille, large print, audio-visual, and audio, and may be translated into the different languages of people who are likely to use the service. 

Criterion 3.1.2

Guidance for all providers

  • The documented referral or self-referral process, where relevant, may include:
    1. a system to identify potential risks to the person seeking services and prioritise those referrals. This includes considering a person’s background and their support needs
    2. evidence of communication with the person about the progress of their referral and service time frames
    3. having suitably qualified, skilled, and experienced health care and support workers to perform this function competently.
  • The documented process may include, where applicable:
    1. a needs assessment that aligns with the service level
    2. management of waiting lists, which is clearly communicated to the person receiving services and their whānau
    3. crisis intervention service
    4. a relapse prevention plan
    5. an advance directive/advance care or support planning
    6. a current interRAI assessment.
  • Where services provide dementia or psychogeriatric services, the documented process may include:
    1. specific information on the service’s particular philosophy and practices
    2. noting whether the person with enduring power of attorney, the court-appointed representative, or the welfare guardian has consented to the person being admitted
    3. noting that the person requiring care has a needs assessment that confirms they require a secure unit.
  • Service providers who use telehealth to deliver services must demonstrate an understanding of relevant telehealth guidelines and standards. Where telehealth services are provided offshore, the service provider demonstrates that its agent complies with the requirements of the appropriate New Zealand health regulatory authority.

Additional guidance

Aged care
  • As part of wait list management, service providers have a documented and implemented process that includes, wherever possible, transparent communication. This process may include transparent communication at defined intervals with the person and their whānau.
  • Service providers include information about other support services, such as community support groups, when communicating with the person and their whānau.
Residential disability
  • As part of wait list management, service providers have a documented and implemented process that includes, wherever possible, transparent communication. This process may include transparent communication at defined intervals with the person and their whānau.
  • Service providers include information about other support services, such as community support groups, when communicating with the person and their whānau.
  • Once they have accepted a referral, service providers maintain contact with people until they are transitioned into a home.
  • Service providers demonstrate that they have considered Māori aspects before admission in terms of iwi connections and strengths of whānau connections.
  • Service providers’ entry processes demonstrate:
    1. the person entering services has choice in terms of the homes they will live in, and their flatmates
    2. they have considered the compatibility of people living in a home
    3. they have consulted the people currently living in a home before a new person is moved in
    4. they have developed a contract, service agreement or home agreement for people receiving services in line with contractual requirements.
Residential mental health and alcohol and other drug
  • As part of wait list management, service providers have a documented and implemented process that includes, wherever possible, transparent communication. This process may include transparent communication at defined intervals with the person and their whānau.
  • Service providers include information about other support services, such as community support groups, when communicating with the person and their whānau.
Public/private hospital
  • As part of wait list management, service providers have a documented and implemented process that includes, wherever possible, transparent communication. This process may include transparent communication at defined intervals with the person and their whānau.
  • Service providers include information about other support services, such as community support groups, when communicating with the person and their whānau.
Hospice
  • As part of wait list management, service providers have a documented and implemented process that includes, wherever possible, transparent communication. This process may include transparent communication at defined intervals with the person and their whānau.
  • Service providers include information about other support services, such as community support groups, when communicating with the person and their whānau.
Abortion services
  • Service providers aim to provide the procedure within five (but no longer than 10) working days of request. Where people choose to have more time for decision making, service providers document this.

Criterion 3.1.3

Guidance for all providers

  • A person’s identity could include their:
    1. values and beliefs
    2. culture
    3. religion
    4. disabilities
    5. gender
    6. sexual orientation
    7. relationship status
    8. other social identities or characteristics.
  • Service providers have documented evidence of the person’s entry process.

Criterion 3.1.4

Guidance for all providers

  • Service providers offer feedback to people seeking services and their whānau. The feedback or information about alternative options is in a format appropriate to the needs and condition of the person.
  • When they decline a person entry, service providers:
    1. communicate with the referrer (and, where appropriate, the person and their whānau) the reason for this decision and provide an opportunity to discuss it if requested
    2. inform people of other options or alternative services that may help them
    3. enact warm handovers if their alternative service does not adequately meet the needs of the person and their whānau.

Additional guidance

Aged care
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Fertility services
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Residential disability
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Residential mental health and alcohol and other drug
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Public/private hospital
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Birthing units
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 
Hospice
  • Service providers communicate with a person seeking services where they decline that person entry to their service. 

Criterion 3.1.5

Guidance for all providers

  • Service providers demonstrate routine analysis of entry and decline rates for Māori. Where ethnicity data is incomplete and inconsistent, service providers improve data quality to make such analysis routine.
  • Service providers identify and implement supports to benefit Māori and whānau.

Criterion 3.1.6

Guidance for all providers

  • Service providers make available to Māori and whānau:
    1. kaumātua and kuia support
    2. opportunities to mix with other Māori in the service
    3. Māori health care and support workers.
  • Service providers have information available for Māori, in English and in te reo Māori, on:
    1. the Māori-specific support and community services available to the person entering the service and their whānau
    2. local marae, iwi, and hapū contacts and activities
    3. Māori health professionals available to support the person
    4. types of activities available to support cultural practices and aspirations
    5. how the service supports Māori cultural preferences, such as through: art and craft; leisure activities; sports; exercise; food; outings; spirituality; contact with whānau; and support to attend Māori events, including poukai, tangihanga and hura kōhatu.

Section 3.2: My pathway to wellbeing

Criterion 3.2.1

Aged care: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Home and community: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Service providers undertake assessment according to best practice.
  • Service providers have policies that define time frames for completing care or support plans.
  • Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
  • Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
  • In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.
Residential disability: Guidance
  • Service providers have a documented transition process that:
    1. is developed in partnership with the person entering the service, alongside the people living in the home
    2. demonstrates a partnership approach with the person entering the service and the people currently in the chosen home, including by considering compatibility between people who are living together
    3. enables people moving into a residential home to choose, meet, and engage with the people they will be living with, before they move in
    4. supports the person entering the service to maintain friendships and employment from their previous living situation.
  • Service providers have implemented processes that support people receiving services to:
    1. use a supported decision-making process in determining their preferred supports
    2. have as much influence over decisions as possible
    3. manage their own conflicts within the home
    4. make decisions about their own health care. This can include contacting the ambulance service or attending an annual GP health check.
  • Service providers arrange and provide appropriate support when a person is admitted to public hospitals and when discharged back to their home.
  • Service providers develop an initial care or support plan with the person and their whānau within 48 hours of them entering the home. This initial care or support plan takes account of:
    1. a needs assessment that includes the person’s consent to share results with the provider
    2. other relevant documentation provided.
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Health pathways are implemented and include procedures to support practice.
  • Service providers undertake assessment according to best practice.
  • Service providers have policies that define time frames for completing care or support plans.
  • Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
  • Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
  • In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.
Residential mental health and alcohol and other drug: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Health pathways are implemented and include procedures to support practice.
Public/private hospital: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Health pathways are implemented and include procedures to support practice.
Birthing units: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Health pathways are implemented and include procedures to support practice.
Hospice: Guidance
  • Service providers complete an initial assessment with input from the person receiving services and their whānau.
  • Service providers develop care or support plans for ongoing care and support of the person receiving services.
  • The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
  • Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
  • Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
  • Health pathways are implemented and include procedures to support practice.
Abortion services: Guidance
  • Service providers undertake assessment according to best practice.
  • Service providers have policies that define time frames for completing care or support plans.
  • Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
  • Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
  • In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.

Criterion 3.2.2

Guidance for all providers

  • Service providers have an implemented policy describing the model of care.
  • Service providers consider all other demographic information particular to each person receiving services, such as:
    1. culture
    2. religion
    3. disabilities
    4. gender
    5. sexual orientation
    6. relationship status
    7. other social identities or characteristics.
  • Service providers involve a person’s whānau with that person’s consent.

Additional guidance

Fertility services
  • Service providers include escalation pathways where appropriate.
Home and community
  • Service providers include escalation pathways where appropriate.
Residential disability
  • Service providers include escalation pathways where appropriate.
Residential mental health and alcohol and other drug
  • Service providers include escalation pathways where appropriate.
Public/private hospital
  • Service providers follow current guidelines on care or support plan development; for example, the Ministry of Health’s National Maternity Clinical Guidance, specifically Observation of Mother and Baby in the Immediate Postnatal Period: Consensus statements guiding practice (2012) and National Consensus Guideline for Treatment of Postpartum Haemorrhage (2013).
  • Service providers include escalation pathways where appropriate.
Birthing units
  • Service providers follow current guidelines on care or support plan development; for example, the Ministry of Health’s National Maternity Clinical Guidance, specifically Observation of Mother and Baby in the Immediate Postnatal Period: Consensus statements guiding practice (2012) and National Consensus Guideline for Treatment of Postpartum Haemorrhage (2013).
  • Service providers include escalation pathways where appropriate.
Hospice
  • Service providers include escalation pathways where appropriate.
Abortion services
  • Service providers include escalation pathways where appropriate.

Criterion 3.2.3

Aged care: Guidance
  • Service providers demonstrate:
    1. they have an implemented policy relating to intimacy 
    2. they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
    3. assessment is clearly linked to the care or support plan
    4. the care or support plan identifies key assessed risks, including medical risks
    5. ongoing assessments and reassessments are completed where required
    6. the care or support plan is goal focused and individualised
    7. the care or support plan meets individualised choices and preferences
    8. interventions describe in detail all support required to address assessed needs
    9. cultural, spiritual, and lifestyle needs are identified and addressed
    10. the care or support plan includes multidisciplinary involvement
    11. service providers meet their contractual requirements
    12. the person using services and, if appropriate, their whānau have input into the development of the care or support plan. 
  • Where service providers provide dementia or psychogeriatric services:
    1. interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
    2. service providers meet their contractual requirements
    3. the person using services and their whānau have input into the development of the care or support plan. 
  • Relevant resources: Physiotherapy New Zealand (2022) New Zealand Physiotherapy Guidelines for Aged Residential Care (ARC)
Fertility services: Guidance
  • Service providers support people receiving services and their whānau to access counsellors approved by the Australian and New Zealand Infertility Counsellors Association during the consultation, diagnosis, and waiting times.
  • Point (h) of the criterion does not apply to assisted reproductive technology services.
Home and community: Guidance
  • The care or support plan for the person receiving services clearly articulates agreed variability and flexibility, plus any identified associated risk to the support received. 
  • In developing a care or support plan, people are offered choice in terms of the number and type of support workers engaged for different tasks (for example, reading mail or home support).
  • The care or support plan effectively integrates cultural beliefs, values, and practices. Cultural aspects of a care or support plan may be identified over a period of time.
  • Adequate time is available to develop a person’s care or support plan.
Residential disability: Guidance
  • Service providers follow a supported decision-making process when developing a care or support plan.
  • The care or support plan should:
    1. demonstrate how the person receiving services is being supported to self-determine 
    2. support people to develop and maintain relationships outside of the service that extend beyond whānau 
    3. be in a format accessible to the person 
    4. integrate the person’s identities, cultural needs, values, and beliefs
    5. demonstrate that a proactive approach is taken to make people aware of options, entitlements, and community activities available to them
    6. be agreed to and signed by the person, where possible.
  • The person owns the care or support plan.
  • The care or support plan can include: 
    1. information about how the person wants to be supported and what outcome they want to receive from the service provider. This includes essential information such as personal care and risks
    2. evidence that the person receiving services is offered the opportunity to identify and document their personal aspirations and goals and ways to achieve these. The plan presents the person’s aspirations in a format they prefer. The person has the option to decline this aspect of the care or support plan.
  • Service providers document the person’s choice to participate in and have an aspirational plan. 
  • Service providers demonstrate that people receiving services are informed of other services available to them.
  • Service providers have an implemented policy relating to intimacy.
Residential mental health and alcohol and other drug: Guidance
  • Service providers demonstrate:
    1. they have an implemented policy relating to intimacy 
    2. they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
    3. assessment is clearly linked to the care or support plan
    4. the care or support plan identifies key assessed risks, including medical risks
    5. ongoing assessments and reassessments are completed where required
    6. the care or support plan is goal focused and individualised
    7. the care or support plan meets individualised choices and preferences
    8. interventions describe in detail all support required to address assessed needs
    9. cultural, spiritual, and lifestyle needs are identified and addressed
    10. the care or support plan includes multidisciplinary involvement
    11. service providers meet their contractual requirements
    12. the person using services and, if appropriate, their whānau have input into the development of the care or support plan. 
  • Where service providers provide dementia or psychogeriatric services:
    1. interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
    2. service providers meet their contractual requirements
    3. the person using services and their whānau have input into the development of the care or support plan. 
  • Service providers follow a supported decision-making process when developing a care or support plan.
  • The care or support plan should:
    1. demonstrate how the person receiving services is being supported to self-determine 
    2. support people to develop and maintain relationships outside of the service that extend beyond whānau 
    3. be in a format accessible to the person 
    4. integrate the person’s identities, cultural needs, values, and beliefs
    5. demonstrate that a proactive approach is taken to make people aware of options, entitlements, and community activities available to them
    6. be agreed to and signed by the person, where possible.
  • The person owns the care or support plan.
  • The care or support plan can include: 
    1. information about how the person wants to be supported and what outcome they want to receive from the service provider. This includes essential information such as personal care and risks
    2. evidence that the person receiving services is offered the opportunity to identify and document their personal aspirations and goals and ways to achieve these. The plan presents the person’s aspirations in a format they prefer. The person has the option to decline this aspect of the care or support plan.
  • Service providers document the person’s choice to participate in and have an aspirational plan. 
  • Service providers demonstrate that people receiving services are informed of other services available to them.
  • Service providers have an implemented policy relating to intimacy.
Hospice: Guidance
  • Service providers demonstrate:
    1. they have an implemented policy relating to intimacy 
    2. they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
    3. assessment is clearly linked to the care or support plan
    4. the care or support plan identifies key assessed risks, including medical risks
    5. ongoing assessments and reassessments are completed where required
    6. the care or support plan is goal focused and individualised
    7. the care or support plan meets individualised choices and preferences
    8. interventions describe in detail all support required to address assessed needs
    9. cultural, spiritual, and lifestyle needs are identified and addressed
    10. the care or support plan includes multidisciplinary involvement
    11. service providers meet their contractual requirements
    12. the person using services and, if appropriate, their whānau have input into the development of the care or support plan. 
  • Where service providers provide dementia or psychogeriatric services:
    1. interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
    2. service providers meet their contractual requirements
    3. the person using services and their whānau have input into the development of the care or support plan. 
Abortion services: Guidance
  • Service providers offer people receiving services and their whānau access to appropriate counselling services, which are provided by a workforce holding relevant qualifications or equivalent training in abortion counselling. People can access these services at all stages before, during, and after treatment.

Criterion 3.2.4

Guidance for all providers

  • Service providers follow a supported decision-making process where appropriate.

Additional guidance

Aged care
  • Implementation of intervention where appropriate includes: 
    1. monitoring charts and escalation as required
    2. continence management
    3. wound care management
    4. pressure injury prevention and management
    5. nutrition
    6. weight management
    7. falls prevention strategies
    8. maintaining and supporting independence and meeting individualised goals
    9. documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.
  • Where services provide dementia or psychogeriatric services:
    1. behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
    2. the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
    3. the person’s whānau are involved in the process where relevant.
Home and community
  • Where possible, service providers offer people choice over the accessible format of the care or support plan and where it is located.
  • Relevant information about a person receiving services is available and accessible by support workers before they enter the person’s home. This may include the full care or support plan.
Residential disability
  • Implementation of intervention where appropriate includes: 
    1. monitoring charts and escalation as required
    2. continence management
    3. wound care management
    4. pressure injury prevention and management
    5. nutrition
    6. weight management
    7. falls prevention strategies
    8. maintaining and supporting independence and meeting individualised goals
    9. documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.
  • Where services provide dementia or psychogeriatric services:
    1. behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
    2. the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
    3. the person’s whānau are involved in the process where relevant.
  • Where possible, service providers offer people choice over the accessible format of the care or support plan and where it is located.
  • Relevant information about a person receiving services is available and accessible by support workers before they enter the person’s home. This may include the full care or support plan.
Public/private hospital
  • Implementation of intervention where appropriate includes: 
    1. monitoring charts and escalation as required
    2. continence management
    3. wound care management
    4. pressure injury prevention and management
    5. nutrition
    6. weight management
    7. falls prevention strategies
    8. maintaining and supporting independence and meeting individualised goals
    9. documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.
  • Where services provide dementia or psychogeriatric services:
    1. behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
    2. the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
    3. the person’s whānau are involved in the process where relevant.
Hospice
  • Implementation of intervention where appropriate includes: 
    1. monitoring charts and escalation as required
    2. continence management
    3. wound care management
    4. pressure injury prevention and management
    5. nutrition
    6. weight management
    7. falls prevention strategies
    8. maintaining and supporting independence and meeting individualised goals
    9. documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.
  • Where services provide dementia or psychogeriatric services:
    1. behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
    2. the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
    3. the person’s whānau are involved in the process where relevant.

Criterion 3.2.5

Aged care: Guidance
  • Service providers meet evaluation time frames according to aged residential care contracts and other contracts held.
  • Service providers seek multidisciplinary input as appropriate to the needs of a person receiving services.
  • Care or support plan evaluations identify progress to meeting goals.
  • Acute changes in health status are documented on short-term care or support plans or updated on long-term care or support plans.
  • When a person’s needs change, the service provider completes a reassessment. 
  • Where service providers provide dementia or psychogeriatric services, they:
    1. seek a reassessment when a person’s needs change to consider if the person continues to require secure care as the least restrictive option
    2. involve the person’s whānau in the process where relevant.
Home and community: Guidance
  • Service providers meet evaluation time frames according to aged residential care contracts and other contracts held.
  • Service providers seek multidisciplinary input as appropriate to the needs of a person receiving services.
  • Care or support plan evaluations identify progress to meeting goals.
  • Acute changes in health status are documented on short-term care or support plans or updated on long-term care or support plans.
  • When a person’s needs change, the service provider completes a reassessment. 
  • Where service providers provide dementia or psychogeriatric services, they:
    1. seek a reassessment when a person’s needs change to consider if the person continues to require secure care as the least restrictive option
    2. involve the person’s whānau in the process where relevant.
Residential disability: Guidance
  • When reviewing a person’s care or support plan, service providers always follow a supported decision-making process.
  • Service providers conduct a review of a person’s:
    1. care or support plan at least annually or as the person’s support needs change, or when requested by the person
    2. aspiration-based plan within the agreed time frame with the person, and then determine further aspirations in consultation with the person.
  • Where whānau are engaged: 
    1. as much as possible the person being supported should determine the level of whānau engagement
    2. the whānau should be actively involved to the highest degree possible
    3. in situations where the person requires a higher level of substitute decision-making, the service provider demonstrates a high level of engagement with whānau wherever possible.
  • In situations where a person does not have whānau support or external advocacy support (for example, through Auckland Disability Law or the Personal Advocacy and Safeguarding Adults Trust), service providers do everything possible to engage another way of supporting the person using their services to make decisions.
  • Outcome measurements may include: 
    1. a certificate of achievement 
    2. a photograph
    3. a person’s personal agreement
    4. a hui
    5. a daily diary 
    6. a visual chart in the person’s room.

Criterion 3.2.6

Guidance has not been developed for this criterion.

Criterion 3.2.7

Guidance has not been developed for this criterion.

Section 3.3: Individualised activities

Criterion 3.3.1

Aged care: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.
  • Align visiting and social activity policies with the Six Principles for Safe Visiting and Social Activities in Aged Residential Care.
Home and community: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.
Residential disability: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.
  • Service providers consider:
    1. that people receiving services may want time at home alone
    2. more solutions provided by residential disability providers when obstacles are making it difficult to facilitate what the person using services wants to do.
Residential mental health and alcohol and other drug: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.
  • Service providers consider:
    1. that people receiving services may want time at home alone
    2. more solutions provided by residential disability providers when obstacles are making it difficult to facilitate what the person using services wants to do.
Public: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.
Hospice: Guidance
  • People receiving services have input into and provide feedback on what their activity preferences are.
  • Activity assessments and plans identify individual interests and consider the person’s identity.
  • People have access to both group and individual activities. Service providers support this access as needed.

Criterion 3.3.2

Aged care: Guidance
  • Service providers:
    1. have implemented procedures for managing community activities or outings, including in terms of transportation safety and medication management
    2. consider activities suitable to the identity of the person receiving services
    3. encourage members of the person’s chosen community and community groups (for example, from local schools or religious institutions) to visit people’s homes.
  • Where service providers provide dementia or psychogeriatric services, they:
    1. take a holistic 24/7 approach to activities and take into account aspects of the person’s life and past routines
    2. offer appropriate activities that provide diversion at appropriate times during the day in line with the needs identified in the person’s care or support plan
    3. provide appropriate access and support to community and external activities.
Home and community: Guidance
  • Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
  • Activities are mainstream first.
  • People have full access to indoor and outdoor activities.
  • Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
  • Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
  • Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
  • Service providers use wheelchair safety belts whenever people are travelling in a van.
  • Service providers support people to be in contact with family and friends.
  • Service providers support people to have groups of friends and to interact with them.
Residential disability: Guidance
  • Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
  • Activities are mainstream first.
  • People have full access to indoor and outdoor activities.
  • Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
  • Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
  • Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
  • Service providers use wheelchair safety belts whenever people are travelling in a van.
  • Service providers support people to be in contact with family and friends.
  • Service providers support people to have groups of friends and to interact with them.
Residential mental health and alcohol and other drug: Guidance
  • Service providers:
    1. have implemented procedures for managing community activities or outings, including in terms of transportation safety and medication management
    2. consider activities suitable to the identity of the person receiving services
    3. encourage members of the person’s chosen community and community groups (for example, from local schools or religious institutions) to visit people’s homes.
  • Where service providers provide dementia or psychogeriatric services, they:
    1. take a holistic 24/7 approach to activities and take into account aspects of the person’s life and past routines
    2. offer appropriate activities that provide diversion at appropriate times during the day in line with the needs identified in the person’s care or support plan
    3. provide appropriate access and support to community and external activities.
  • Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
  • Activities are mainstream first.
  • People have full access to indoor and outdoor activities.
  • Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
  • Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
  • Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
  • Service providers use wheelchair safety belts whenever people are travelling in a van.
  • Service providers support people to be in contact with family and friends.
  • Service providers support people to have groups of friends and to interact with them.

Criterion 3.3.3

  • Service providers should enable Māori using their service to participate in community initiatives and provide opportunities for cultural exploration, participation, and connection. This may require service providers to encourage and enable their workforce to facilitate these linkages through dedicated time.

    For example, if there is a Matariki festival happening in the community and Māori residents are interested in celebrating Matariki, enable them to participate by either bringing your residents to the community event, or bringing the community event to your facility.

    Or, if you know a person belongs to an Iwi, service providers offer resources and support for residents who wish to connect with their Iwi. Different avenues, such as te reo Māori classes, kapa haka should also be available and encouraged for cultural exploration.
     
  • In order to know what options people have to connect with their Iwi, look up their Iwi and marae via these two resources:
  1. Te Kāhui Māngai (Directory of Iwi and Māori Organisations). Overseen by Te Puni Kokiri the Ministry of Māori Development. This directory of Iwi and Māori organisations may be searched alphabetically, by map, or by listed-region.
  2. Māori Maps  -  Overseen by Te Potiki National Trust gathers the information for Māori Maps from public sources and marae community engagement. This resource helps to connect Māori descendants with their marae, and enable visitors to make appropriate contact with these centres of culture - in particular, linking Māori youth with their ancestral identity.
 

Criterion 3.3.4

Aged care: Guidance
  • Opportunities for Māori to participate in te ao Māori include:
    1. activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
    2. local Matariki, kapa haka, and sport events, such as waka ama competitions
    3. leadership training, te reo Māori, and ngā tikanga Māori courses
    4. national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.
Residential disability: Guidance
  • Opportunities for Māori to participate in te ao Māori include:
    1. activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
    2. local Matariki, kapa haka, and sport events, such as waka ama competitions
    3. leadership training, te reo Māori, and ngā tikanga Māori courses
    4. national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.
Residential mental health and alcohol and other drug: Guidance
  • Opportunities for Māori to participate in te ao Māori include:
    1. activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
    2. local Matariki, kapa haka, and sport events, such as waka ama competitions
    3. leadership training, te reo Māori, and ngā tikanga Māori courses
    4. national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.
Public/private hospital: Guidance
  • Opportunities for Māori to participate in te ao Māori include:
    1. activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
    2. local Matariki, kapa haka, and sport events, such as waka ama competitions
    3. leadership training, te reo Māori, and ngā tikanga Māori courses
    4. national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.
Birthing units: Guidance
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.
Hospice: Guidance
  • Opportunities for Māori to participate in te ao Māori include:
    1. activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
    2. local Matariki, kapa haka, and sport events, such as waka ama competitions
    3. leadership training, te reo Māori, and ngā tikanga Māori courses
    4. national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.
Abortion services: Guidance
  • Opportunities for Māori to participate in te ao Māori include following tikanga such as:
    1. kawa
    2. blessing of rooms
    3. rākau rongoā
    4. mirimiri
    5. karakia.

Section 3.4: My medication

Criterion 3.4.1

Guidelines for all providers

Additional guidance

Aged care
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
  • To support their medication management system, service providers can consult the Ministry of Health’s (2011) Medicines Care Guides for Residential Aged Care.
Fertility services
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Home and community
Residential disability
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
  • Where a person cannot manage their own medication, a competent health care or support worker administers it.
  • Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
  • Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.
Residential mental health and alcohol and other drug
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
  • Where a person cannot manage their own medication, a competent health care or support worker administers it.
  • Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
  • Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.
Public/private hospital
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Birthing units
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
  • Where a person cannot manage their own medication, a competent health care or support worker administers it.
  • Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
  • Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.
Hospice
  • Service providers’ medication management systems reflect an end-to-end process.
  • Service providers have implemented policies that describe the medication management system, covering:
    1. prescribing
    2. administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
    3. review
    4. monitoring
    5. adverse reactions
    6. reconciliation on admission and on transfers of care
    7. clinical decision support
    8. procurement
    9. supply
    10. dispensing
    11. safe storage
    12. disposal
    13. management and use of people’s own medication.
  • Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
  • Where a person cannot manage their own medication, a competent health care or support worker administers it.
  • Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
  • Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.

Criterion 3.4.2

Guidance for all providers

  • Service providers demonstrate an understanding of:
    1. the role of the health professional for each aspect of care supporting safe practice
    2. the differences between prescribing and dispensing as defined in legislation (Medicines Act 1981 and Misuse of Drugs Regulations 1977)
    3. reconciliation and review.
  • Service providers use available resources to support medication. This includes the Health Quality & Safety Commission’s medication reconciliation guidance tools and training resources.
  • Service providers prescribe and use all medications for valid therapeutic indications. They never use medications to force compliance or render a person incapable of resistance; use of medications in this way could be classed as chemical restraint and is in breach of this standard.

Additional guidance

Fertility services
  • Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide. 
Public/private hospital
  • Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide. 
Birthing units
  • Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide. 
Hospice
  • Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide. 

Criterion 3.4.3

Guidance for all providers

  • Health care and support worker competency includes understanding and considering cultural and identity-specific needs; for example, needs related to religious beliefs.
  • Service providers adhere to relevant legislation, such as the Misuse of Drugs Act 1975 and the Medicines Act 1981.

Additional guidance

Aged care
  • The responsible registered nurse undertakes annual training and competency assessments of health care and support workers in regard to managing medication.
  • Service providers clearly state the role of support workers in medication management.
  • Training and annual competency assessments determine the breadth of health care and support workers’ role, which may include:
    1. administering pre-packed regular medication
    2. high-risk medication (as outlined in the Ministry of Health (2011) Medicines Care Guides for Residential Aged Care).
  • Service providers have an implemented process for using registered nurse-initiated medication such as that classified as over-the-counter or ‘pharmacy-only’ medication.
  • Service providers orientate agency staff to the facility or home and medication processes.
  • Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
Fertility services
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
Residential disability
  • The responsible registered nurse undertakes annual training and competency assessments of health care and support workers in regard to managing medication.
  • Service providers clearly state the role of support workers in medication management.
  • Training and annual competency assessments determine the breadth of health care and support workers’ role, which may include:
    1. administering pre-packed regular medication
    2. high-risk medication (as outlined in the Ministry of Health (2011) Medicines Care Guides for Residential Aged Care).
  • Service providers have an implemented process for using registered nurse-initiated medication such as that classified as over-the-counter or ‘pharmacy-only’ medication.
  • Service providers orientate agency staff to the facility or home and medication processes.
  • Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
Residential mental health and alcohol and other drug
  • Service providers orientate agency staff to the facility or home and medication processes.
  • Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
Public/private hospital
  • Service providers orientate agency staff to the facility or home and medication processes.
  • Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
  • Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).
Birthing units
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
  • Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).
Hospice
  • Service providers orientate agency staff to the facility or home and medication processes.
  • Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
  • Service providers have implemented policies and procedures that include the management of:
    1. controlled drugs, including register checking and six-monthly reconciliation, where applicable
    2. medication storage and disposal
    3. medication when a person receiving services is on an incremental dosing regimen.
  • Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Criterion 3.4.4

Guidance for all providers

  • Service providers demonstrate medication adverse events are linked to the quality and risk system in their investigation and corrective action implementation.
  • Service providers identify allergies and adverse drug reactions before prescribing medication, or at least before administering it.

Additional guidance

Fertility services
  • Evidence for this process may include the assessment of allergies and sensitivities and consideration of components in culture media used for insemination or embryo transfer.

Criterion 3.4.5

Guidance for all providers

  • Service providers consider the health literacy of people receiving services.
  • Information is available to help people to understand their medications and their side effects.
  • Service providers inform people receiving services and their whānau of medication changes, including changes involving adding, removing, or substituting medication.
  • Service providers provide accessible information to facilitate use of medication that includes:
    1. how and when to take the medication
    2. dose
    3. side effects
    4. when people should get back in touch with the prescriber
    5. supplements and foods to avoid
    6. additional information and resource sheets
    7. name of the medicine
    8. purposes of the medicine.
  • Service providers communicate effectively with the person and their whānau about prescribed medication.
  • Service providers have mechanisms in place to support people with a disability to understand their medication. This may include use of technology, Braille, or tactile labelling.

Additional guidance

Aged care
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Residential disability
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Residential mental health and alcohol and other drug
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Public/private hospital
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Birthing units
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Hospice
  • Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.
Abortion services
  • Service providers inform people about who to contact after hours for medical-abortion-specific advice.
  • Service providers make available contraceptive supplies and any prescriptions given on the day of prescribing.

Criterion 3.4.6

Guidance for all providers (except home and community)
  • Service providers have implemented policy and procedures to support practice. These include:
    1. assessment of the person who is to self-administer medication to determine their competence
    2. training and supervision of the person 
    3. security of the medication.
  • Service providers verify that people who experience difficulties at the time of administration have an emergency contact.

Criterion 3.4.7

Guidance for all providers (except home and community)
  • Service providers manage Standing Orders according to the Ministry of Health’s (2016) current Standing Order Guidelines, Medicines Act 1981 and Medicines Regulations 1984, and the  Misuse of Drugs Act 1975 and Misuse of Drugs Regulations 1977.

Criterion 3.4.8

Aged care: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Fertility services: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Residential disability: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Residential mental health and alcohol and other drug: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Public/private hospital: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Birthing units: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.
Hospice: Guidance
  • Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
  • The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
  • Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:
    1. dosing
    2. interactions
    3. content
    4. side effects
    5. the person’s health condition
    6. pregnancy and breastfeeding.

Criterion 3.4.9

Guidance for all providers

  • Ensure Māori and whānau in your service have the understanding and support to navigate the health system. The identification of health literacy, care of dependents, transport/access, and financial means is extremely important in terms of achieving health equity for Māori and whānau in accessing medication. Have resources and key contacts available who can support Māori to access medication.
  • Provide advice on how to have a conversation with their pharmacist to see if they are eligible for the New Zealand Government’s Prescription Payment Subsidy scheme. More information available on the Ministry of Health website .
  • There are some instances where work and income may cover prescription costs, for more information see: Work and Income website - Prescriptions and health practitioner costs .
  • Ensure staff are familiar with resources on the follow consumer support sites, including Health Navigator on Prescription Charges.

Criterion 3.4.10

Guidance for all providers

  • Service providers work in partnership with Māori to verify that: 
    1. the appropriate support is in place
    2. advice is timely and easily accessed 
    3. treatment is prioritised to achieve better health outcomes.
  • Ensure Māori in your service are supported to access the required medication and blood products. This includes supporting them to know what their medication is for, how to use it, side effects, and may extend to supporting them to take it at the appropriate times.
  • The following resources are accessible to support Māori in their medical appointments: 5 questions to ask about your medications – consumer safety poster (available in te reo Māori and English). Ideally, staff should understand these guidelines and proactively answer  these questions where possible.
  • For some Māori, receiving or donating blood products may have cultural, religious, or spiritual significance. Be sensitive to these possibilities and demonstrate empathy when having conversations about these topics. Work with the person to adjust their care and support pathway that make the process safer for them.  
  • The New Zealand Blood Service provides information relevant to Māori about blood donation and products, which may be useful to share with Māori who are interested in this ahead of relevant specialist appointment.

Criterion 3.4.11

Fertility services: Guidance
  • The principles and requirements of medication management apply.
  • Service providers have implemented policies and procedures that describe blood transfusion and blood management, including: 
    1. prescribing
    2. gaining informed consent for administration
    3. receiving, collecting, and labelling blood samples for pre-transfusion testing
    4. administering the transfusion
    5. managing and reporting adverse reactions 
    6. ensuring traceability through accurately recording all cases of administration 
    7. receiving, storing, handling, and returning blood.
  • Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
  • Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements. 
  • The service provider provides access to the following resources to support blood management: 
    1. clinical information about blood transfusion from the New Zealand Blood Service
    2. for DHB hospitals, the hospital’s blood resource folder on its intranet
    3. information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
    4. information about adverse reaction reporting from the New Zealand Blood Service
    5. information for patients from the New Zealand Blood Service.
Public/private hospital: Guidance
  • The principles and requirements of medication management apply.
  • Service providers have implemented policies and procedures that describe blood transfusion and blood management, including: 
    1. prescribing
    2. gaining informed consent for administration
    3. receiving, collecting, and labelling blood samples for pre-transfusion testing
    4. administering the transfusion
    5. managing and reporting adverse reactions 
    6. ensuring traceability through accurately recording all cases of administration 
    7. receiving, storing, handling, and returning blood.
  • Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
  • Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements. 
  • The service provider provides access to the following resources to support blood management: 
    1. clinical information about blood transfusion from the New Zealand Blood Service
    2. for DHB hospitals, the hospital’s blood resource folder on its intranet
    3. information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
    4. information about adverse reaction reporting from the New Zealand Blood Service
    5. information for patients from the New Zealand Blood Service.
Birthing units: Guidance
  • The principles and requirements of medication management apply.
  • Service providers have implemented policies and procedures that describe blood transfusion and blood management, including: 
    1. prescribing
    2. gaining informed consent for administration
    3. receiving, collecting, and labelling blood samples for pre-transfusion testing
    4. administering the transfusion
    5. managing and reporting adverse reactions 
    6. ensuring traceability through accurately recording all cases of administration 
    7. receiving, storing, handling, and returning blood.
  • Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
  • Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements. 
  • The service provider provides access to the following resources to support blood management: 
    1. clinical information about blood transfusion from the New Zealand Blood Service
    2. for DHB hospitals, the hospital’s blood resource folder on its intranet
    3. information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
    4. information about adverse reaction reporting from the New Zealand Blood Service
    5. information for patients from the New Zealand Blood Service.
Hospice: Guidance
  • The principles and requirements of medication management apply.
  • Service providers have implemented policies and procedures that describe blood transfusion and blood management, including: 
    1. prescribing
    2. gaining informed consent for administration
    3. receiving, collecting, and labelling blood samples for pre-transfusion testing
    4. administering the transfusion
    5. managing and reporting adverse reactions 
    6. ensuring traceability through accurately recording all cases of administration 
    7. receiving, storing, handling, and returning blood.
  • Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
  • Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements. 
  • The service provider provides access to the following resources to support blood management: 
    1. clinical information about blood transfusion from the New Zealand Blood Service
    2. for DHB hospitals, the hospital’s blood resource folder on its intranet
    3. information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
    4. information about adverse reaction reporting from the New Zealand Blood Service
    5. information for patients from the New Zealand Blood Service.
Abortion services: Guidance
  • The principles and requirements of medication management apply.
  • Service providers have implemented policies and procedures that describe blood transfusion and blood management, including: 
    1. prescribing
    2. gaining informed consent for administration
    3. receiving, collecting, and labelling blood samples for pre-transfusion testing
    4. administering the transfusion
    5. managing and reporting adverse reactions 
    6. ensuring traceability through accurately recording all cases of administration 
    7. receiving, storing, handling, and returning blood.
  • Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
  • Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements. 
  • The service provider provides access to the following resources to support blood management: 
    1. clinical information about blood transfusion from the New Zealand Blood Service
    2. for DHB hospitals, the hospital’s blood resource folder on its intranet
    3. information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
    4. information about adverse reaction reporting from the New Zealand Blood Service
    5. information for patients from the New Zealand Blood Service.

Criterion 3.4.12

Fertility services: Guidance
  • Service providers follow the principles and requirements for medication management. 
  • Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe: 
    1. gaining informed consent for administration
    2. managing and reporting adverse reactions.
Public/private hospital: Guidance
  • Service providers follow the principles and requirements for medication management. 
  • Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe: 
    1. gaining informed consent for administration
    2. managing and reporting adverse reactions.
Birthing units: Guidance
  • Service providers follow the principles and requirements for medication management. 
  • Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe: 
    1. gaining informed consent for administration
    2. managing and reporting adverse reactions.
Hospice: Guidance
  • Service providers follow the principles and requirements for medication management. 
  • Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe: 
    1. gaining informed consent for administration
    2. managing and reporting adverse reactions.
Abortion services: Guidance
  • Service providers follow the principles and requirements for medication management. 
  • Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe: 
    1. gaining informed consent for administration
    2. managing and reporting adverse reactions.

Section 3.5: Nutrition to support wellbeing

Criterion 3.5.1

Aged care: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
Home and community: Guidance
  • Service providers offer people choice in the meals available.
  • Service providers monitor people for signs and symptoms of dehydration and malnutrition, and implement interventions as needed.
  • Where people require special or modified diets, service providers support them to meet these needs.
  • Service providers with specific training and demonstrated competencies meet the needs of people with enteral feeding tubes.
  • Service providers provide food that has been stored and prepared safely so that people are at no risk of disease caused by unsafe storage and preparation practices, and support workers are oriented to safe food-handling practices.
  • Service providers have a mechanism to consult with health professionals when needed to support the needs of people receiving services.
Residential disability: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers use supported decision making as an integral part of menu planning.
  • Menu planning is individualised, takes likes and dislikes into consideration, and makes alternatives available.
  • Nutritional information of food is available for people receiving services.
Residential mental health and alcohol and other drug: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
  • Service providers have implemented policies and procedures covering:
    1. accessibility, such as to hot drinks
    2. menu development and consultation with people receiving services
    3. strategies to keep food at an appropriate temperature
    4. consideration of environmentally friendly practices for waste management.
  • Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
  • Audit of food services is part of the annual internal audit programme.
  • Service providers can accommodate dietary requirements at short notice.
Public/private hospital: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
  • Service providers have implemented policies and procedures covering:
    1. accessibility, such as to hot drinks
    2. menu development and consultation with people receiving services
    3. strategies to keep food at an appropriate temperature
    4. consideration of environmentally friendly practices for waste management.
  • Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
  • Audit of food services is part of the annual internal audit programme.
  • Service providers can accommodate dietary requirements at short notice.
Birthing units: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers have implemented policies and procedures covering:
    1. accessibility, such as to hot drinks
    2. menu development and consultation with people receiving services
    3. strategies to keep food at an appropriate temperature
    4. consideration of environmentally friendly practices for waste management.
  • Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
  • Audit of food services is part of the annual internal audit programme.
  • Service providers can accommodate dietary requirements at short notice.
Hospice: Guidance
  • Service providers:
    1. demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
    2. adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
    3. consider survey feedback during menu development.
  • Service providers have implemented policies and procedures covering:
    1. accessibility, such as to hot drinks
    2. menu development and consultation with people receiving services
    3. strategies to keep food at an appropriate temperature
    4. consideration of environmentally friendly practices for waste management.
  • Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
  • Audit of food services is part of the annual internal audit programme.
  • Service providers can accommodate dietary requirements at short notice.

Criterion 3.5.2

Aged care: Guidance
  • Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:
    1. baking or similar activities
    2. setting tables before meals
    3. preparing a hāngi or equivalent
    4. supporting people to have culturally appropriate food
    5. growing and preparing vegetables
    6. pre-cooking preparation
    7. preparing for celebrations.
Home and community: Guidance
  • Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:
    1. baking or similar activities
    2. setting tables before meals
    3. preparing a hāngi or equivalent
    4. supporting people to have culturally appropriate food
    5. growing and preparing vegetables
    6. pre-cooking preparation
    7. preparing for celebrations.
  • Where applicable, service providers encourage people receiving services to manage the preparation of food independently or with the support of whānau. 
  • If a person is dependent on food preparation, the service provider offers solutions that may include:
    1. Meals on Wheels options
    2. people being involved in meal planning
    3. pre-cooking preparation
    4. cooking simple nutritious meals
    5. working alongside each person to meet cultural food preferences and preparation practices 
    6. giving people access to food and drink if they wish at any time unless clinically contraindicated
    7. working alongside the person to prepare food.
Residential disability: Guidance
  • Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:
    1. baking or similar activities
    2. setting tables before meals
    3. preparing a hāngi or equivalent
    4. supporting people to have culturally appropriate food
    5. growing and preparing vegetables
    6. pre-cooking preparation
    7. preparing for celebrations.
  • People who live in the house are involved in all aspects of food purchase, meal preparation, and planning. 
  • People who live in the house choose what they eat.
  • Health care and support workers help choose healthy food options.
  • People have access to food and drink when they wish and at any time, unless clinically contraindicated.
  • Service providers offer choices in the person’s preferred communication method. This may include pictures.
     
Residential mental health and alcohol and other drug: Guidance
  • Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:
    1. baking or similar activities
    2. setting tables before meals
    3. preparing a hāngi or equivalent
    4. supporting people to have culturally appropriate food
    5. growing and preparing vegetables
    6. pre-cooking preparation
    7. preparing for celebrations.
  • People who live in the house are involved in all aspects of food purchase, meal preparation, and planning.
  • People who live in the house choose what they eat.
  • Health care and support workers help choose healthy food options.
  • People have access to food and drink when they wish and at any time, unless clinically contraindicated.
  • Service providers offer choices in the person’s preferred communication method. This may include pictures.

Criterion 3.5.3

Aged care: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
  • In relation to the dining experience of people receiving services, service providers should consider:
    1. providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
    2. supplying appropriate equipment to support independence
    3. using respectful processes around assisted feeding
    4. respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
    5. making the menu visible to the people
    6. maintaining a good standard of meal presentation for various food models
    7. making soft or pureed food visually appealing
    8. providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs. 
Home and community: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
Residential disability: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
  • In relation to the dining experience of people receiving services, service providers should consider:
    1. providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
    2. supplying appropriate equipment to support independence
    3. using respectful processes around assisted feeding
    4. respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
    5. making the menu visible to the people
    6. maintaining a good standard of meal presentation for various food models
    7. making soft or pureed food visually appealing
    8. providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs. 
Residential mental health and alcohol and other drug: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
  • In relation to the dining experience of people receiving services, service providers should consider:
    1. providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
    2. supplying appropriate equipment to support independence
    3. using respectful processes around assisted feeding
    4. respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
    5. making the menu visible to the people
    6. maintaining a good standard of meal presentation for various food models
    7. making soft or pureed food visually appealing
    8. providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs. 
Public/private hospital: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
Birthing units: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.
Hospice: Guidance
  • Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
  • Service providers consider the kind of support people need when they eat.

Criterion 3.5.4

Aged care: Guidance
  • Two different levels of nutritional value are considered by service providers:
    1. the overall menu for the facility
    2. specialised dietary requirements for individuals.
Residential mental health and alcohol and other drug: Guidance
  • Two different levels of nutritional value are considered by service providers:
    1. the overall menu for the facility
    2. specialised dietary requirements for individuals.
  • Service providers have implemented a healthy eating policy.
  • Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
  • Service providers consult with appropriately qualified personnel if required.
  • Service providers have a policy that defines the period of review required.
  • An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.
Public/private hospital: Guidance
  • Service providers have a policy that defines the period of review required.
  • An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.
Birthing units: Guidance
  • Service providers have a policy that defines the period of review required.
  • An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.
Hospice: Guidance
  • Service providers have a policy that defines the period of review required.
  • An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.

Criterion 3.5.5

Aged care: Guidance
  • For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.
Public/private hospital: Guidance
  • For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.
Birthing units: Guidance
  • For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.
Hospice: Guidance
  • For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.

Criterion 3.5.6

Residential disability: Guidance
  • Dishwashers are available in the home.
  • Food is stored properly and use-by dates noted.
  • Fridge and freezer temperatures are checked at defined intervals. 
Residential mental health and alcohol and other drug: Guidance
  • Dishwashers are available in the home.
  • Food is stored properly and use-by dates noted.
  • Fridge and freezer temperatures are checked at defined intervals. 

Criterion 3.5.7

Aged care: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Home and community: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Residential disability: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Residential mental health and alcohol and other drug: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Public/private hospital: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Birthing units: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.
Hospice: Guidance
  • Menu development may cover:
    1. sharing of drink and food after formal activities
    2. choices of food available. 
  • The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.
    1. Never pass food over the head.
    2. Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
    3. For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
    4. Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
    5. Use receptacles for drinking water only for that purpose.
    6. Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
    7. Never take food or drink into a room containing a tūpāpaku (deceased person).
      For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.

Section 3.6: Transition, transfer, and discharge 

Criterion 3.6.1

Guidance for all providers

  • Service providers have a policy and procedures for transitioning, transferring, and discharging people using their services.
  • The process includes medication reconciliation and transfer of specialist care if required.

Additional guidance

Aged care
  • Where applicable, discharge planning starts when a person enters a service.
Fertility services
  • Service providers have processes to:
    1. transition people between public and private services (and vice versa) to support them through the change
    2. provide continuous care following a procedure. This process can include people who choose to self-discharge.
Home and community
  • Where applicable, discharge planning starts when a person enters a service.
Residential disability
  • Where applicable, discharge planning starts when a person enters a service.
Residential mental health and alcohol and other drug
  • Where applicable, discharge planning starts when a person enters a service.
Public/private hospital
  • Service providers have processes to:
    1. transition people between public and private services (and vice versa) to support them through the change
    2. provide continuous care following a procedure. This process can include people who choose to self-discharge.
  • Where applicable, discharge planning starts when a person enters a service.
Birthing units
  • Service providers have processes to:
    1. transition people between public and private services (and vice versa) to support them through the change
    2. provide continuous care following a procedure. This process can include people who choose to self-discharge.
  • Where applicable, discharge planning starts when a person enters a service.
Hospice
  • Service providers have processes to:
    1. transition people between public and private services (and vice versa) to support them through the change
    2. provide continuous care following a procedure. This process can include people who choose to self-discharge.
  • Where applicable, discharge planning starts when a person enters a service.
Abortion services
  • People who are completing treatment at home remain under the service provider’s care until documentation confirms that the treatment is complete. The person receiving services understands this arrangement. 
  • Where service providers do not have appropriate facilities for inpatient services, they have an implemented policy for transferring people to an appropriate alternative facility.

Criterion 3.6.2

Guidance for all providers

  • Service providers have transition, transfer, and discharge information available in accessible formats and provide it in a timely manner.
  • Service providers discuss reasons for transition, transfer, or discharge with the person receiving services and their whānau. They record any concerns the person or whānau express in the person’s notes.
  • Service providers allow sufficient time for meetings with the person and their whānau when planning transition or discharge.
  • Service providers confirm all providers that are involved are aware of discharge or transition plans.

Additional guidance

Aged care
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).
Fertility services
  • When no further treatment is planned or likely to be considered, service providers plan further care or support that meets the needs of the person receiving services and, when appropriate, of their whānau. This may include:
    1. referral to counselling
    2. liaising with advocates or lived experience support services
    3. liaising with community support services, including Māori specialist services where appropriate
    4. advising people what to do if they wish to reconsider assisted reproductive technology services later
    5. referral to a different health service
    6. referral for appointments.
Home and community
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).
Residential disability
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).
Residential mental health and alcohol and other drug
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).
Public/private hospital
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).
Hospice
  • Discussions about transition, transfer, or discharge include the person receiving services and whānau and cover an understanding of: 
    1. referral to other agencies
    2. equipment needs
    3. needs reassessment (for example, through a Needs Assessment and Service Coordination service).

Criterion 3.6.3

Guidance for all providers

  • Advice on people’s options to access other services may cover:
    1. specialised therapy services
    2. allied health practitioners
    3. equipment
    4. community resources.

Additional guidance

Fertility services
  • Service providers keep a record of this process. 
Home and community
  • Service providers keep a record of this process. 
Residential disability
  • Service providers keep a record of this process. 
Residential mental health and alcohol and other drug
  • Service providers keep a record of this process. 
Public/private hospital
  • Service providers keep a record of this process. 
Birthing units
  • Service providers keep a record of this process. 
Hospice
  • Service providers keep a record of this process. 
Abortion services
  • Service providers keep a record of this process. 

Criterion 3.6.4

Guidance for all providers

  • Service providers demonstrate that transition, transfer, and discharge plans assess the current needs of the person. This includes documented identification of risks and necessary mitigations. 

Additional guidance

Residential mental health and alcohol and other drug
  • Information is complete to the ‘point of discharge’. For example, if a person is going home to whānau, the information is sufficiently clear and comprehensive to allow the person to receive the appropriate care or support (for example, medication management) from whānau.
  • Service providers’ medication management policy includes discharge risk mitigation and considers time frames and supply of medications (for example, whether daily methadone pickups are necessary, the day of the week on which discharge occurs, and whether the location is rural or urban).
  • Service providers take a risk mitigation approach when returning people’s property. For example, if a person enters the service with sharps and these are removed on admission, a risk assessment determines whether to return them on discharge.
Public/private hospital
  • Information is complete to the ‘point of discharge’. For example, if a person is going home to whānau, the information is sufficiently clear and comprehensive to allow the person to receive the appropriate care or support (for example, medication management) from whānau.
  • Service providers’ medication management policy includes discharge risk mitigation and considers time frames and supply of medications (for example, whether daily methadone pickups are necessary, the day of the week on which discharge occurs, and whether the location is rural or urban).
  • Service providers take a risk mitigation approach when returning people’s property. For example, if a person enters the service with sharps and these are removed on admission, a risk assessment determines whether to return them on discharge.

Criterion 3.6.5

Guidance for all providers

  • Where possible, service providers confirm arrangements for discharge.

Additional guidance

Residential mental health and alcohol and other drug
  • Service providers make reasonable efforts to follow up with the person receiving services. 
  • Service providers make reasonable efforts to verify their referral is acknowledged.
Public/private hospital
  • Service providers make reasonable efforts to follow up with the person receiving services. 
  • Service providers make reasonable efforts to verify their referral is acknowledged.
Abortion services
  • Service providers make reasonable efforts to follow up with the person receiving services. 
  • Service providers make reasonable efforts to verify their referral is acknowledged.

Section 3.7: Electroconvulsive therapy

Public/private hospital: Guidance

Criterion 3.7.1

  • National standards prescribe acceptable practice for ECT.
  • In reference to ECT, the Mental Health (Compulsory Assessment and Treatment) Act 1992, the Health and Disability Services Consumers’ Code of Rights, and the National Mental Health Sector Standard require that service providers deliver care to Māori with proper recognition of and respect for cultural and/or ethical beliefs. 

Criterion 3.7.2

  • The Ministry of Health established baseline data on the quality of ECT delivery in New Zealand. It conducted this audit mainly to determine whether the technical standards of ECT delivery in New Zealand are as high as is practicable. 
  • While existing guidelines do not specifically address the needs of Māori, service providers need to give New Zealanders the assurance that if they or their whānau receive ECT, treatment will be delivered in a way that is as safe as possible while giving the treatment the highest chance of success.

Criterion 3.7.3

  • Service providers listen to people with lived experience of ECT treatment. They give people with lived experience and their whānau/carers an opportunity to discuss their concerns. They use concerns raised to help to address stigma associated with ECT as a treatment.
  • Service providers provide information on ECT. This includes information about the type of ECT to be administered (including electrode placement) and expected outcomes. Service providers acknowledge concerns and any risks associated with ECT and include whānau and/or carers in the discussion. Psychiatrists should do everything possible to minimise adverse effects of ECT.
  • Service providers seek consent before undertaking any procedure, treatment or providing a report for legal or other purposes.
  • Service providers deliver ECT services in an appropriate environment that safely manages people receiving therapy.
  • Clinical decisions follow approved guidelines and protocols. A trained professional team delivers best practice ECT care. Service providers use the knowledge gained from patient experience to improve ECT services.
  • The experience of patients and whānau/carers informs improvement of ECT services. Service providers apply learning to inform future best practice. For more information, see Ministry of Health (2009) Electroconvulsive Therapy (ECT) in New Zealand. What you and your family and whānau need to know, The Royal Australian and New Zealand College of Psychiatrists (2020) ‘Electroconvulsive Therapy (ECT): Your health in mind’ (consumer information), and Health Navigator’s information for consumers on depression and ECT.

Criterion 3.7.4

  • Where whānau want to be more closely involved in and consulted on specific cultural preferences and concerns, service providers carefully consider the indications for ECT and all aspects of the process and explain them in a culturally sensitive manner. Te Whare Tapa Whā and other Māori models of care are relevant. Information should also include alternative treatment options.
  • Service providers could use the Takarangi Competency Framework to guide best practice in culturally safe care.

Section 3.8: Obtaining and caring for gametes and embryos

Fertility services: Guidance

Criterion 3.8.1

  • Service providers use a minimum of three types of identifying information to verify the traceability of all people receiving services and biological material. This identifying information can include: 
    1. full name
    2. date of birth
    3. address
    4. mobile phone number.
  • Service providers use a minimum of three identifiers, one of which is a unique identifier, to verify the traceability of all biological material. 
  • Service providers undertake risk assessment to minimise identification error.
  • Service providers undertake two independent checks of people or biological material during assisted reproductive procedures, using the Reproductive Technology Accreditation Committee’s technical bulletins as sector guidance.
  • People providing semen samples confirm, in writing and on each occasion, that the sample is theirs.
  • At a minimum, service providers undertake an annual audit of the patient, gamete, and embryo identification processes and associated digital and manual records.

Criterion 3.8.2

  • Service providers undertake risk assessment to manage people’s safety, covering: 
    1. documented pre-admission instructions
    2. informed consents for treatment
    3. pre-existing medical conditions
    4. safe, appropriate levels of sedation or anaesthesia 
    5. post-procedure and treatment support, such as written information and emergency contact information
    6. safe discharge after the procedure
    7. the education and competence of the personnel, emergency trolley, emergency response, and the number and skill mix of health care and support workers during procedures
    8. management of clinical emergencies.
  • Service providers develop and implement policies and procedures to manage clinical emergencies that may arise, including policies and procedures on moving a person to another service provider and on training health care and support workers in advanced life support.
  • Service providers use the Royal Australian and New Zealand College of Anaesthetists (2019) Safe procedural sedation competencies (PDF, 152 KB).

Criterion 3.8.3

  • All buildings, plant, and equipment are fit for purpose.
  • Service providers maintain all buildings, plant, and equipment in reliable and safe working order.
  • The facility layout and design are clinically appropriate; contribute to safe service delivery; and maintain safety for people receiving services, their whānau, and service providers.
  • Relevant equipment is calibrated and validated.
  • All equipment necessary to provide the service is available when required, and service providers have a contingency plan to follow if such equipment becomes unavailable.
  • The environment is suitable for the procedures carried out to minimise the risk associated with particulate material and volatile organic compound.
  • Where service providers are storing critical material (for example, medication or culture medium), they may monitor temperatures or other critical parameters and demonstrate that these are in line with the manufacturer’s instructions.
  • Facilities are secured against entry of unauthorised personnel.

Criterion 3.8.4

  • Service providers have a written procedure that defines specifications for transporting human gametes, embryos, or other biological samples.  
  • Service providers maintain security of system and of storage vessels.
  • Service providers have implemented policies and procedures that comply with the HART Act.

Criterion 3.8.5

  • Service providers undertake a risk assessment.
  • Service providers have documentation of working through scenarios.

Criterion 3.8.6

Guidance has not been developed for this criterion.

Criterion 3.8.7

  • When a fertility service closes, the service provider sends any relevant information that Births, Deaths and Marriages usually holds to the Registrar-General.
  • Service providers have policies and procedures in place detailing arrangements for the ongoing storage of  cryopreserved gametes, embryos, or other biological samples.
  • Service providers record details of the number of people with cryopreserved embryos, gametes, or other biological samples in storage and details of the location of the material.
  • Where the service provider is transferring storage of the  cryopreserved  gametes, embryos, or other biological material to another organisation, it obtains and records:
    1. the name and address of the organisation agreeing to accept storage
    2. the name of the medical director responsible for the storage of the material
    3. a letter from the medical director accepting responsibility for storage
    4. copies of the communication with people who have material in storage, outlining their options and costs for future storage
    5. a copy of procedures for consenting to the transfer of embryos and gametes sent to the new organisation, including the consent forms.
  • Service providers have an implemented policy for providing for the ongoing storage of medical records.
  • Service providers maintain a copy of procedures for consenting for the transfer of medical records to another doctor, and the consent forms.
  • Service providers demonstrate confirmation that someone from the organisation has notified the Director-General of Health of closure under section 81 of the HART Act within the required time after closure of the organisation.

Criterion 3.8.8

  • Service providers are Māori-centred. For example, they provide sufficient information focused on Māori needs, sharing the experiences of Māori with fertility treatment.
  • Service providers monitor access of their services by ethnicity to verify service provision is appropriate and achieves equitable access and outcomes for Māori.
  • Service providers have suitable processes and procedures to verify their day-stay services are culturally and clinically safe.
Part 2: Workforce and structure Up to First page Part 4: Person-centred and safe environment

Page last updated: 25 March 2024

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