Web viewThe current incident rate nationally is estimated to be between 6 and 8 per 1000 line days....

Chair’s foreword New Zealanders place a lot of faith in their health and disability system, and by and large that faith is justified. We have excellent health services and a very skilled and committed health workforce.

However, there is still significant room for improvement, as demonstrated by the serious and sentinel events reports released each year. For example, one obvious message from the report for 2010/11 is that we need to do more to make sure patients don’t fall and hurt themselves.

The Health Quality and Safety Commission (the Commission) is working with District Health Boards (DHBs) and, increasingly, other health and disability providers, to reduce harm from patient falls, hospital-acquired infections, surgery and medication. We have a number of programmes and projects underway, and more planned for the period covered by this statement of intent.

Our emphasis in all of these is on the substance of change at the workface – rhetoric is one thing; actually improving the care of patients another. The goal is measurable quality improvement, not just quality assurance.

The Commission is focussing on tools and processes that will actually help our clinicians do their job better and more safely. The standardised in-hospital adult medication prescription chart is one example, as is support for advancing electronic prescribing and reconciliation – both steps towards simpler, safer processes.

The Commission was established in November 2010 with an expectation it would reduce deaths, harm and waste from preventable errors while building a culture of constant examination and improvement based on the idea of ‘doing the right thing, and doing it right, first time’. With that in mind, we aim to make sure our work is practical, relevant, future-focused, value for money, and aligned with other work occurring in the sector. These goals are encapsulated in the New Zealand Triple Aim:

improved quality, safety and experience of care improved health and equity for all populations best value for public health system resources.

Initially we are planning to make major progress in four priority areas; patient falls, hospital-acquired infections, surgery and medication. These are also priority areas for the Minister of Health and we are working with DHBs to set quality and safety markers in these four areas. A two-pronged approach will be used – with markers for specific processes shown to improve outcomes, together with measures of outcome which provide context and a clear view of the effects of implementing the changes.

The four priority programmes will be supported by our work with the sector to: develop and support leadership and expertise in improvement science encourage partnerships with consumers and their family/whānau provide robust information that is used to improve quality and safety.

If New Zealand is to make the necessary improvements in quality and outcomes while achieving a financially sustainable health and disability sector, we also need to consider different ways of organising our health and disability services.

Greater integration is needed within health and between health and social services. This implies stronger partnerships with patients, families and communities, more emphasis on

shared values-based decision-making between patients and their providers, increased use of technology and a stronger focus on facilitated networks of care for people with chronic needs.

Technology offers considerable potential to enhance the efficient and effective delivery of services to improve the health of people with chronic needs, at better cost. There are already good examples of this, including the use of evidence based e-therapies for people with mild to moderate mental health problems, and electronic depression management programmes which involve the use of computers, telephone help-lines and text messages.

The key will be the greater empowerment of patients to be more involved in their own care, while ensuring access to the support they really need.

The Commission will continue to maintain an overview of international and national innovations to ensure we are an effective catalyst for change. We are committed to ensuring New Zealand continues to have a world-class, innovative, consumer and family/whānau-centred health and disability support system with continually improving quality and safety.

We are playing our part in assisting Government to get best value for money by focusing very clearly on our priority programmes, continuing to work in partnership with other agencies in the sector and managing our organisational costs effectively.

Professor Alan Merry, ONZMChairHealth Quality and Safety Commission

Board statement In signing this statement, we acknowledge that we are responsible for the information contained in the Statement of Intent for the Health Quality and Safety Commission. This information has been prepared in accordance with the requirements of the Public Finance Act 1989 and the Crown Entities Act 2004 and to give effect to the Minister of Health’s expectations for the Commission. It is also consistent with our appropriations.

Professor Alan Merry Dr Peter FoleyChair Deputy Chair20 June 2012 20 June 2012

ContentsChair’s foreword.............................................................................................................................. iBoard statement........................................................................................................................... iii

Part 1.............................................................................................................................................11.0 Our objectives......................................................................................................................1

1.1 Our legislative mandate..............................................................................................11.2 Strategic context for our work....................................................................................11.3 What we aim to achieve.............................................................................................31.4 How we focus our effort on what matters most..........................................................51.5 Who we work with.......................................................................................................51.6 How we measure our achievements...........................................................................6

2.0 Our plans for 2012/13........................................................................................................102.1 Output class 1: Information, analysis and advice......................................................102.2 Output class 2: Sector tools, techniques and methodologies....................................132.3 Output class 3: Sector and consumer capability.......................................................162.4 Expected revenue/proposed expenses to be incurred in 2012/13 for each output class........................................................................................................................19

3.0 Organisational capacity, capability and development........................................................203.1 The organisation.......................................................................................................203.2 Our people and skills................................................................................................203.3 Good employer practices and equal opportunities....................................................203.4 Meeting our legal responsibilities.............................................................................203.5 Financial management.............................................................................................203.6 Efficient use of organisational resources..................................................................20

Part 2...........................................................................................................................................234.0 Reporting...........................................................................................................................235.0 Prospective statement of service performance for 2012/13...............................................246.0 Prospective financial statements for the three years ending 30 June 2015........................26

6.1 Prospective statement of comprehensive income.....................................................266.2 Prospective statement of movements in equity........................................................266.3 Prospective statement of financial position..............................................................276.4 Prospective statement of cash flows.........................................................................286.5 Declaration by the Board..........................................................................................296.6 Key assumptions for proposed budget in 2012/13 and out-years.............................296.7 Statement of accounting policies..............................................................................296.8 Acquisition of shares.................................................................................................31

Board members...........................................................................................................................32Mortality review committee members..........................................................................................33

Roopu Māori members.................................................................................................................33

Part 11.0 Our objectives1.1 Our legislative mandateThe Health Quality and Safety Commission (the Commission) is a Crown entity under the New Zealand Public Health and Disability Act 2000 and is categorised as a Crown agent for the purposes of the Crown Entities Act 2004.1

We contribute to a world-class, innovative, patient and family/whānau centred health and disability system committed to continually improving safety and quality.

Our objectives, as set out in the New Zealand Public Health and Disability Act 2000, are to lead and coordinate work across the health and disability sector for the purposes of:

monitoring and improving the quality and safety of health and disability support services

helping providers across the health and disability sector to improve the quality and safety of health and disability support services.

The legislative functions of the Commission under Clause 59 C (1) are to: advise the Minister on how quality and safety in health and disability services

may be improved advise the Minister on any matters relating to:

o health epidemiology and quality assurance oro mortality

determine quality and safety indicators (such as serious and sentinel events) for use in measuring the quality and safety of health and disability support services

provide public reports of the quality and safety of health and disability support services as measured against:

o the quality and safety indicatorso any other information the Commission considers relevant for the purpose

of the report promote and support better quality and safety in health and disability support

services disseminate information about the quality and safety of health and disability

support services perform any other functions that:

o relate to the quality and safety of health and disability support serviceso the Commission is for the time being authorised to perform by the

Minister by written notice to the Commission after consultation with it.

1.2 Strategic context for our workThe Commission was established on 10 November 2010 in response to concern that only modest improvements in health quality and safety had been achieved at a national level

1 A Crown agent is required to give effect to government policy when directed by the responsible Minister.

over previous years. Quality experts argued that a strong mandate to drive quality-related activities, greater coordination of appropriate quality interventions at a national level, and strong clinical engagement were pivotal to achieving sustained quality gains and better value for money.

“Good quality is less costly because of more accurate diagnoses, fewer treatment errors, lower complication rates, faster recovery, less invasive treatment, and the minimisation of the need for treatment.”2

New Zealand’s health and disability system rates well internationally, but there is still significant room for improvement. For ‘sicker’3 New Zealanders in 2010:

22 percent experienced a medical, medication or laboratory test error in the past two years

51 percent experienced gaps in hospital or surgery discharge, including arrangements for follow-up visits and what medications to take

31 percent did not have their prescriptions reviewed and discussed in the past year.

In 2001, 12.9 percent of New Zealanders admitted to hospital suffered an unintended adverse event caused in the management of their conditions, rather than the underlying disease and 15 percent of these resulted in permanent disability or death.4 The cost of events deemed preventable was $590 million.5

Outcomes of treatment are not yet distributed equally in New Zealand. For example, nearly 50 percent more Maori than non-Maori/non-Pacific patients suffer an in-hospital preventable adverse event (after controlling for age, deprivation, admission type, length of stay and sex).6

Audits at Counties Manukau District Health Board (DHB) in 2007 identified that 70 percent of patients had at least one medication error on their inpatient medication chart on admission to hospital, when compared with what the patient actually took in the community.7 Between 20 and 43 percent of all electronic discharge summaries undertaken at Waitemata DHB had medication errors; these erroneous summaries were sent to the GPs8 and translated into errors in prescriptions for patients.

The maternal mortality rate in New Zealand in 2009 was 22 per 100,000 maternities, an increase from the previous two years (13.7 in 2008 and 10.3 in 2007). The perinatal-related mortality rate in 2009 was 11.3 per 1,000 total births (10.6 in 2008 and 10.3 in

232 Porter ME, Teisberg EO. 2006. Redefining Health Care: Creating Value-Based Competition and Results. Boston: Harvard Business School Press.3 ‘Sicker’ New Zealanders is defined in the Commonwealth Fund survey as those who were in fair or poor health, had

surgery or been hospitalised in the past two years, or received care for serious or chronic illness, injury or disability in the past year.

4 Davis P, Lay-Yee R, Briant R, et al. Adverse events in New Zealand public hospitals 1: occurrence and impact. New Zealand Medical Journal 115: U271.

5 Brown P, McArthur C, Newby L, et al. Cost of Medical Injury in New Zealand: A retrospective Cohort Study. The Journal of Health Serv Res Policy 2002(7): Suppl 1.

6 Davis P, Lay-Yee R, Dyall L, et al. 2006. Quality of hospital care for Maori patients in New Zealand: retrospective cross-sectional assessment. The Lancet 367:1920-25. URL: http://www.thelancet.com.

7 Brkic L, Lewis M. Medication Reconciliation (MR) Safety Programmes at Counties Manukau DHB. 2007 [unpublished].

8 Lee A, Park S. EDS Audit. 2008 [unpublished].

2007). One hundred of the 721 perinatal deaths in 2009 are considered ‘potentially avoidable’ as well as a number of the maternal deaths.9

Many of the adverse events that occur in health care are avoidable and amenable to intervention. In addition to the potential reduction in harm to patients, a joint DHB/Association of Senior Medical Specialists report Investing in Clinical Leadership for Quality and Safety Improvement (March 2011) estimated achievable financial gains of:

$10m to $12m from reducing falls in hospitals $10m to $12m from reducing pressure injuries $10m to $12m from reducing central line infections (central line associated

bacteraemia or CLAB) $50m to $78m from reducing surgical site infections.

There are many examples of successful outcomes from implementation of quality and safety programmes including:

Counties Manukau DHB reduced incidents of infections resulting from CLAB from 6.6 per 1000 line days to 0.9 per 1000 line days over a two-year period with estimated savings of $200,000 per year

promoting hand hygiene in Starship Hospital’s newborn intensive care unit has seen greater compliance with good hand washing practices and fewer infections – over the last three years there has been a reduction of between 20 and 25 percent in late-onset infections for newborns in the unit

adoption of the World Health Organization (WHO) Safe Surgery Checklist overseas has been shown to reduce the rate of complications and death from surgery across a range of health care settings from 11 percent to 7 percent10, and similar gains have been demonstrated using comparable initiatives in high income countries11, 12

in Scotland over a one- to two-year period, the national quality improvement programme achieved a 73 percent reduction in central line infections, a 43 percent reduction in ventilator-associated pneumonia and a 14 percent increase in ward hand hygiene.13

1.3 What we aim to achieveThe Commission’s Triple Aim for the New Zealand health and disability sector is:

improved quality, safety and experience of care improved health and equity for all populations

9 PMMRC. 2011. Fifth Annual report of the Perinatal and Maternal Mortality Review Committee: Reporting Mortality 2009. Wellington: Health Quality and Safety Commission.

10 Haynes AB, Weiser TG, Berry WR, et al. 2009. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine 360: 491-9.

11 Neily J, Mills PD, Young-Xu Y, et al. 2010. Association between implementation of a medical team training program and surgical mortality. The Journal of the American Medical Association 304(15): 1693-700.

12 de Vries EN, Prins HA, Crolla RMPH, et al. 2010. Effect of a comprehensive surgical safety system on patient outcomes. The New England Journal of Medicine 363(20):1928-37.

13 An internal report from Healthcare Improvement, Scotland to their Evidence, Improvement and Scrutiny Committee.

best value for public health system resource

The New Zealand Triple Aim has been accepted by the Ministry of Health (including the National Health Board, the National Health IT Board, the National Health Committee and Health Workforce New Zealand), DHBs, Health Benefits Ltd and PHARMAC. This unification of purpose is central to achieving the goal of improving the quality and safety of health and disability services across the entire sector.

The following diagram shows the Commission’s outcomes framework for improving quality and safety, and ultimately achieving the Government’s outcomes for the sector.

THE HEALTH QUALITY AND SAFETY COMMISSION’S OUTCOMES FRAMEWORK

1.4 How we focus our effort on what matters mostWe could potentially focus our efforts on a large number of issues and opportunities for improvement across the sector. But our resources are limited and we need to be selective about priorities for attention and investment to deliver the best value for money. In deciding where we will focus our efforts we consider a range of factors including:

what size is the potential benefit in terms of improving quality and safety outcomes?

is there a strong evidence base to support intervention? how much can the Commission influence change? what is the likely timeframe to see results?

will Commission involvement help to generate enduring change/benefit? what is the likely investment by the Commission to achieve results – is this value

for money? to what extent does the work leverage off existing activity and leaders within the

sector? how relevant is the work to the Commission and the sector’s own objectives and

priorities?

For the programmes inherited by the Commission (such as the medication safety and mortality review programmes), it has been important to ensure we get the best value for the money already invested.

This prioritisation process is especially important in a constrained economic climate, and at a time when our baseline funding is 10 percent ($1.5 million) less than in 2011/12.

While our priorities will change over time, our specific priorities in the coming few years are:

reducing medication errors and improving medication safety reducing health care associated infections reducing falls in health care settings improving surgical safety.

We will also continue to focus on four central elements that underpin all of our work: building sector capability and clinical leadership facilitating consumer partnerships and values-based decision-making collating, analysing and using reliable information about quality and safety building a culture of quality and safety improvement.

We recently established Roopu Maori, to advise the Board and Chief Executive on strategic issues, priorities and frameworks for Maori and to identify key issues for Maori consumers and organisations. This will enable the Commission to focus more clearly on what is needed to improve equity of health and disability outcomes for Maori.

1.5 Who we work withPartnerships are critical to achieving the improvements needed in quality and safety. All organisations and individuals involved in providing health and disability services have a role in ensuring quality and safety, and their roles cover a broad spectrum including:

quality and safety assurance activities such as legislation, regulation, standards, certification, auditing and credentialing

a wide range of quality and safety improvement activities supported by a range of organisations and networks including the Commission, Ministry of Health, Health Sector Forum, DHBs, Primary Health Organisations (PHOs), professional groups, clinical networks, private and non-government organisations (NGOs).

All health and disability professionals and workers also have an individual responsibility at all times for the quality and safety of their own practice.Given that quality and safety is ‘everyone’s business’, the Commission has an important leadership role as well as a responsibility to build partnerships, maintain an overview and ensure integration of the whole quality and safety landscape.

1.6 How we measure our achievementsIt is important the impact of our work on improved quality and safety is measured to ensure we are achieving our objectives, to monitor and modify our initiatives and to identify and deal with any unintended consequences they might produce. We expect our

work to result in changes in practice as well as outcomes.

The Commission is committed to evaluating the effect of its work and will continue to develop and publish measures of impact (ie, how the delivery of health services has changed as a result of its programmes) and outcomes (ie, how harm to patients and associated costs are reduced).

MEASURING SECTOR OUTCOMES

Responsibility for achieving the outcomes articulated in the Triple Aim is shared by a number of health agencies including the Ministry of Health (the National Health Board, the National Health IT Board, the National Health Committee and Health Workforce New Zealand), DHBs, Health Benefits Ltd and PHARMAC. Some of the relevant measures which will demonstrate progress at this sector level include:

reduction in amenable mortality rates reduction in harm from adverse events reduction in cost associated with avoiding harm from errors and the need for

rework improved value associated with reductions in variation and more effective use of

resources.

MEASURING THE IMPACTS AND OUTCOMES OF THE COMMISSION’S WORK IN THE FOUR PRIORITY AREAS

The impact and outcomes of our four priority programmes will be demonstrated by a variety of measures including:

uptake of good practice (changed practice) higher proportion of appropriate treatments (reduced variation) reduced number of adverse events reduced mortality and harm and reduced costs of unnecessary hospital stays and

treatment.

Most of the expected outcomes in Table 1 have been developed by reference to international literature. The expected outcomes are indicative only at this stage and will be finalised after consultation with the sector on the proposed quality and safety markers for the four priority programmes.

Table 1: How we will measure our achievements

Priority programme Baseline

Expected outcomes 2012/13



1. Medication safety Reducing medication errors (eg, wrong medication or wrong dose) through developing and promoting use of standardised best-practice processes.

1a) Medicine reconciliation

Establish baseline % of high priority patients who receive medicines reconciliation at admission

Baseline increased by at least 25% annually until 90% of high priority patients receive medicines reconciliation at admission14

1b) Prescribing practices

Establish baseline % of audited medicine orders that are legible (including medicine name, dose, route and frequency)

Baseline increased by at least 15% annually until more than 80% of medicine orders are legible15

1c) Standardised process in aged care residential providers

Establish baseline of aged care residential providers using the standardised documentation for prescribing and administering medication in aged residential care facilities

More than 50% of aged care residential providers use the standardised documentation for prescribing and administering medication

More than 75%16 of aged care residential providers use the standardised documentation for prescribing and administering medication

We are currently establishing a measurement and evaluation framework for the National Medication Safety Programme. This will allow us to measure reductions in medication errors and adverse drug events, improved experience of care and value for money

2. Reducing health care associated infections

14 Australian Commission on Safety and Quality in Health Care. 2011. National Inpatient Medication Chart 2009 National Audit Report. Sydney: Australian Commission on Safety and Quality in Health Care.

15 Legibility of medicine orders is reliant on prescribers changing their prescribing practice. This percentage increase is based on the evaluation of the pilot of the national medication chart and the published audit report from the Australian Commission on Safety and Quality in Health Care (after three years of implementation had an improvement from 25 percent to 50 percent in 2009). Once the baseline has been set, the targets for future years will be reviewed.

16 These are goals for implementation and are based on experience of the national medication chart. After 18 months 75 percent of DHBs had adopted the chart. Once it is clear what will be made available for aged residential care the targets will be refined for future years.





2a) Hand hygiene

Reducing infection rates in health care settings by improving hand hygiene of health professionals

Baseline in January 2011 based on audits: 54% compliance with the hand hygiene programme

Increase in audited compliance rate with the hand hygiene programme in public hospitals to more than 64%

A further increase to more than 70%

Rate of at least 70%17 maintained

Establish baseline rate of hospital-acquired Staphylococcus aureus (S. aureus) bacteraemia infection

Reduction in rate of S. aureus bacteraemiaLiterature suggests that a reduction of between 20% and 50% should be possible18 19

2b) Central line associated bacteraemia (CLAB)

Reducing infection rates that result from central line insertions

The current rate is estimated at between 6 and 8 per 1000 line days

Rate of CLAB reduced to <1 per 1000 line days in all 24 ICUs20

Rate maintained at <1 per 1000 line days in all ICUs

Extend programme to other high risk areas (eg, neonatal, renal) establish baselines and measure reductions

Measurement annually of lives saved based on baseline mortality rate for CLAB (which will be measured during the first year), and estimate of reduced health costs through avoidance of CLAB incidence

2c) Surgical site infection surveillance

Improving patient outcomes and generating savings through reducing surgical site infections

Establish accurate baseline data for surgical infections for high volume procedures (ie, hip joint replacements and knee joint replacement procedures)

Reduction in the percentage of surgical infections for hip joint replacements and knee joint replacement procedures

Literature suggests that a reduction of between 25% and 27% should be possible21 22 23

17 Grayson, et al. 2011. Outcomes from the first two years of the Australian Hand Hygiene Initiative. Medical Journal of Australia 195(10): 615-19.

18 Grayson, et al. 2008. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multi-site hand hygiene culture-change programme and subsequent successful statewide roll-out. Medical Journal of Australia 188(11): 632-40.

19 Harrington, et al. 2007. Reduction in Hospital Wide Incidence of Infection and Colonization with MRSA with use of Antimicrobial hand hygiene gel and Statistical Process Control Charts: Infection control and hospital epidemiology. Vol 28, No 7 p 837-844.

20 Seddon M, Hocking C, Mead P, et al. 2011. Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit. New Zealand Medical Journal 124(1339).

2121Brandt, et al. Reduction of surgical site infection rates associated with active surveillance.

2222Infection Control and Hospital Epidemiology. 2006 27(12):1347-51.

2323 Dellinger, et al. Hospitals collaborate to decrease surgical site infections. American Journal of Surgery 2005 190(1):9-15.





3. Falls reduction

Reducing the number and impact of falls in hospital settings

Establish accurate baseline data for: number of in-

hospital fractured neck of femur (FNOF) per 1000 admissions (age/sex standardised)

mortality following in hospital FNOF – actual lives lost and rate per 1,000 admissions

additional occupied bed days associated with FNOF

cost of additional occupied bed days associated with FNOF

Reduction in number of FNOF over two years and maintained in future years. Literature suggests that a reduction of around 30% should be possible24Associated reduction in mortality and additional occupied bed days and cost will be measured

4. Surgical safety

2424Beasley B, Patatanian E. 2009. Development and Implementation of a Pharmacy Fall Prevention Program. Hospital Pharmacy 44(12): 1095-1102.





Reducing preventable complications of surgery by supporting use of good practice tools and practices

Establish accurate baseline levels for: rates of

surgical harm (or complications) 25

additional occupied bed days associated with patients who suffered surgical harm

costs associated with patients who suffered surgical harm

standardised mortality rates for surgery

Reduction in rates of surgical harm and mortality rates over two years and maintained in future years. Literature suggests that a reduction of around 30% should be possible26

Associated reduction in additional occupied bed days and costs will be measured

To measure the impact of our work on improving equity, our intention is to analyse the measures by ethnicity. Formal evaluation of each programme will also provide further valuable information to assess the outcomes of our work.

2525Data for Auckland City Hospital suggest a pre-checklist incidence of complications (defined by the American College of Surgeons National Surgical Quality Improvement Program) of 13.5 percent.

26 Haynes A, et al. 2008. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360:5.

2.0 Our plans for 2012/13The Commission has grouped its activities into three output classes.

Output class 1: Information, analysis and adviceOutput class 2: Sector tools, techniques and methodologiesOutput class 3: Sector and consumer capability

There is some overlap between these three output classes. Information, analysis and advice, and sector and consumer capability have outputs worth pursuing in their own right, but are also a necessary part of the programme work in output class 2.

Having these three output classes demonstrates that our work in improving quality and safety involves more than programmes – it is also important that we build capability, engagement and momentum and provide information, analysis and advice to support that work and to engender a change in understanding and practice in the sector. Our approach to improving the system overall is to embed these fundamental principles of improvement science in each of our programmes. This will demonstrate to providers at the workface in a practical way, their importance to the improvement of quality and safety.

2.1 Output class 1: Information, analysis and advice

This output class will contribute to:the identification and prioritisation of significant quality issuesuptake of good practicereduction in unwarranted variationimproved equity.

The Commission will: use a variety of information sources to measure the quality and safety of health and

disability support services set markers in priority areas report publicly on quality and safety help to identify priority quality and safety issues at national, regional and local levels identify areas where there is avoidable wastage evaluate the impacts of initiatives designed to reduce harm through adverse events

and improve quality and safety.

Working in association with:Health Sector Forum, DHBs, the Ministry of Health (including the National Health Board (NHB), National Health IT Board (NHITB) and Health Workforce New Zealand (HWNZ)), ACC, the Health and Disability Commissioner (HDC), clinical/health leaders, consumers and families, hospitals (public and private), primary care providers, the aged care and disability sector and NGOs, internal experts and contracted providers.

Cost of output class 1: $6.4m

2.1.1Background and rationale for this output classOne of our key roles, established in legislation, is surveillance or broad assessment of the

quality and safety of the sector, including national and international comparisons to identify areas where improvement is needed. By ensuring effective and transparent reporting and analysis of quality and safety issues, incidents and trends, the Commission can help ensure quality and safety issues are identified and prioritised for action. Publication of information about aspects of quality has, in itself, been demonstrated to drive improvement. The discussions generated in the sector by the information and reports we develop will also be important in stimulating innovation and improvement.

2.1.2Current and planned activity

The Commission will pursue the following activities in 2012/13: setting quality and safety markers in the areas of hospital acquired infection,

medication, patient falls and surgery development of quality and safety indicators reporting health care variation (Atlas of Healthcare Variation) reporting and managing health care incidents reviewing mortality.

We will also continue to support DHBs’ work on measuring consumer experiences, trigger tool surveillance and quality accounts.

SETTING QUALITY AND SAFETY MARKERS IN THE FOUR PRIORITY AREAS

The Commission is working with DHBs and the Minister to set quality and safety markers in the areas of hospital acquired infection, medication, patient falls and surgery. During 2012/13 the Commission will consult with DHBs and the Ministry of Health to create a set of quality and safety markers and test these in DHBs, the Commission and the Ministry of Health. We will work with DHBs to ensure the early achievement of these markers.

Finalised measures and thresholds for patient falls, hospital-acquired infections and surgery will be published by June 2013.

A two-pronged approach will be used – including markers with performance thresholds for specific processes shown to improve outcomes, together with measures of outcome which provide context and a clear view of the effects of implementing the changes.

QUALITY AND SAFETY INDICATORS

Establishing and publishing a small, meaningful and relevant set of national quality and safety indicators was a priority for the Commission in 2011/12, to provide a basis for monitoring progress and identifying priorities for action. In 2012/13 the Commission will continue to engage with clinical and measurement experts to expand and deepen this suite of indicators and to publish these in ways that maximise the likelihood of stimulating clinical improvement and better outcomes.

At least one report against national and international indicators of quality and safety will be published during 2012/13.

HEALTH CARE VARIATION REPORTING (ATLAS OF HEALTHCARE VARIATION)

Health care variation reporting has been shown internationally to be a powerful tool for improving appropriateness of care through highlighting overuse, underuse and misuse of interventions. An example of clinical variation is the still significant variation in the use of statins, aspirin and beta blockers for patients known to be at risk from coronary artery disease. Some low-risk patients are on these medications (which is at the least a waste of resource, but may also subject these people to an unwarranted risk of side effects) while others at high risk are not.

Establishing the process and publishing the first report was a priority for the Commission in 2011/12. The next step is to facilitate open discussion between clinicians, managers, policy-makers and the public and highlight opportunities for improvement. The clear focus of this reporting is to encourage dialogue, as well as to stimulate improved performance. As these measures are specific to individual clinical areas we intend to publish these as ‘domains’ of indicators. These will be released primarily through an interactive web tool which will provide background information and contextual data and commentary.

At least six new Atlas ‘domains’ will be published during 2012/13.

REPORTING AND MANAGEMENT OF HEALTH CARE INCIDENTS

Reporting adverse events in the health system helps service providers to identify and manage the risks of clinical care. Last year the Commission worked with the sector to develop and agree a national policy for reporting and managing health care incidents.27 The policy is designed to help providers identify and address systemic issues in their own organisations that lead to medical errors. This policy requires Chief Executive (or equivalent) sign off, committing management at the highest level to ensuring effective analysis and response to reportable events.

The next steps are to work with the sector to embed the new reportable events policy and improve access to a more comprehensive range of data about reportable events. We are also extending reportable events reporting to the broader health and disability sector including primary care, disability support services, community and private providers and aged care residential services.

Each year the Commission publishes a report on serious and sentinel events in public hospitals based on information provided by DHBs.28 These reports of events that should not happen continue to inform and motivate our programmes to improve patient safety. They also provide an impetus for the health system to learn from the events and take steps to prevent them in future (eg, particular examples from the report can be used as a resource for staff training and education).

In February 2012 we published a well-received and publicised report of 2010/11 events which is being used by the Commission and sector to inform improvement activities, especially around falls in health care settings.

The 2011/12 serious and sentinel events report will be published by 30 December 2012.

MORTALITY REVIEW PROGRAMME

The Commission is the home of four statutory mortality review committees. The committees review particular deaths and identify priorities for preventing such deaths and harm in future. The committees report at least annually and work across agencies to ensure recommendations from their reports are able to be implemented.

There are currently four mortality review committees in New Zealand: the Child and Youth Mortality Review Committee (CYMRC) which reviews deaths

of children and young people aged 28 days to 24 years the Perinatal and Maternal Mortality Review Committee (PMMRC) which reviews

the deaths of babies and mothers in New Zealand the Family Violence Death Review Committee (FVDRC) which reviews all deaths

27 Health Quality and Safety Commission. 2012. The NZ Health and Disability Services National Reportable Events Policy 2012. http://www.hqsc.govt.nz/assets/Reportable-Events/Publications/Reportable-Events-Policy-Mar12.pdf.

28 A serious adverse event is one that requires significant extra treatment but is not life threatening and has not resulted in major loss of function. A sentinel adverse event is life threatening or has led to an unanticipated death or major loss of function.

relating to family violence in New Zealand the Perioperative Mortality Review Committee (POMRC) which reviews all deaths

related to surgery.

During 2011/12, five mortality review reports were published covering deaths resulting from low speed run overs, the involvement of alcohol consumption in the deaths of children and young people in New Zealand, and reports on perioperative, and perinatal and maternal deaths. We also published our first family violence death review report. The reports reviewed those deaths and provided well-received recommendations on how to prevent them in future.

Because mortality review committees focus intensively on specific events they are a powerful tool for improving the quality and safety of services and systems locally and nationally.

During 2012/13 we will publish reports from each of the mortality review committees.

We are reviewing the national mortality review programme to ensure it is of continuing value for quality and safety. This will include looking at expected and actual outcomes from the current approach and alternatives to improve effectiveness and efficiency.

2.1.3Challenges

REPORTABLE EVENTS POLICY AND SERIOUS AND SENTINEL EVENT REPORTING

Our main focus to date has been on the DHB hospital sector. Extending the use of the reportable events policy and serious and sentinel event reporting to the broader health and disability sector is an important challenge. We are actively working with the home care sector and will use the lessons learned to demonstrate the value of this activity to other parts of the sector. We are also publishing web-based training packages to improve the capability of the broader sector to undertake reviews of incidents and serious events.

Our aim over the next few years is to have the reportable events policy used across the whole health and disability sector and to publish serious and sentinel events reports that cover the broader sector. This will play an important role in raising awareness of the key quality and safety issues for each part of the sector, as well as providing a tool for improving management of and learning from, incidents and serious events.

An ongoing challenge is getting improved consistency of reporting from DHBs. Our new reportable events policy provides a good basis for consistent reporting and we will also continue to actively engage with DHBs to assist them in this process.

MORTALITY REVIEW COMMITTEES

One of the key challenges facing the Family Violence Death Review Committee is obtaining information from agencies who are concerned about the security of the information they provide, particularly given its sensitive nature. While we have good systems internally to ensure individuals and families cannot be identified, we need to take the time to build relationships and demonstrate to these agencies our ability to protect confidentiality. This will become easier as we demonstrate the value we can add to their work by presenting the aggregate information in a way that will inform future action to reduce family violence.

MEASURING QUALITY AND SAFETY

The availability of data is our biggest challenge, in particular the balance between imperfect but readily available data and high-quality, very specific data which is difficult

to collect. Wherever possible we use data that are already available and engage actively with the sector to improve the quality of this data. We expect incremental improvements over time as people see their information being used in a way that adds value to their work. Our practice of giving people an opportunity to comment on their information before publication will also result in improvements in data quality.

2.2 Output class 2: Sector tools, techniques and methodologies

This output class will contribute to: reducing the numbers of deaths and harm caused by preventable adverse

events and errors reducing waste and variation in the sector, resulting in better value for

money and savings that can be redeployed within our health and disability services

uptake of good practice.

The Commission will: support key programmes to reduce harm to patients and consumers from errors and

adverse events support new programmes to meet emerging priority quality and safety issues in the

primary, hospital, aged care and disability sectors.

Working in association with:Health Sector Forum, DHBs, the Ministry of Health (including the NHB, NHITB and HWNZ), HDC, ACC, clinical/health leaders, consumers and families, hospitals (public and private), primary care providers, the aged care and disability sector and NGOs, international quality and safety organisations and experts, contracted providers.

Cost of output class 2: $6.1m

2.2.1Background and rationale for this output classProviding good practice tools, techniques and methodologies to help providers improve the quality and safety of services is an important step in ensuring uptake of proven quality and safety practices. Our view across the sector enables us to identify strong improvement initiatives and best practices across the country, understand why things are working well, and work with the sector to extend and disseminate initiatives that are making a real difference. Our broader view also enables us to identify international best practices and work to introduce those relevant to New Zealand.

2.2.2Current and planned activityThe Commission will progress the following four priority programmes during 2012/13:

medication safety infection prevention and control particularly health care associated infections reducing patient falls surgical safety.

As an integral part of these programmes we will: build sector capability and clinical leadership facilitate consumer partnerships and values-based decision-making collate, analyse and use reliable information including the establishment of

quality and safety markers in each priority programme.

We will also support these priority programmes by developing a national campaign.

MEDICATION SAFETY PROGRAMME

In partnership with the National Health Board (including the National Health IT Board) we are developing and implementing the National Medication Safety Programme. We aim to produce a safer and more informed environment for the use of medicines in New Zealand in order to reduce harm, increase productivity and reduce wastage and contribute to the electronic shared care record.

The National Medication Safety Programme is guided by the Medication Safety Strategic Governance Group which is accountable to the Commission and the National Health Board. A Medication Safety Expert Advisory Group29 provides expert technical and clinical advice to the programme and the Medication Safety Steering Group manages and is accountable for project implementation.

Tools

The work ranges from developing and implementing national policies and best practice to addressing the very practical issues faced by consumers and those who prescribe, dispense and administer medications to them on a daily basis. The national adult inpatient medication chart and the paper-based medicine reconciliation process are the foundations of this programme.

By the end of June 2012, 16 DHBs had introduced the medication chart and 20 DHBs were using medicines reconciliation. The tools are being used in hospital settings, but will be extended into the broader health and disability sector as the programme develops. Engagement is already underway with the aged-care sector for implementation of a standardised process for prescribing and administering medication in aged residential care facilities.

During 2012/13 we will implement a prioritisation tool to identify patients most likely to benefit from medicine reconciliation (ie, for high-risk patients).

During 2012/13 we will finalise standardised documentation (medication chart) for prescribing and administering medication in aged residential care facilities.

Electronic medicines management

Technology has the potential to transform the way medicines are managed in the sector. Through our joint work with the National Health Board (including the National Health IT Board) on the electronic medicines management (eMM) programme we are working towards an electronic system that will give all health care providers access to every New Zealander’s medication information and will enable people to manage their medicines more effectively. This includes prescribing, administering, reconciling, dispensing and tracking medicines. An important component of the sector-wide work involves shared electronic care records. During 2011/12 we established the foundations for development of electronic medicines management including agreements with three DHBs who are implementing electronic prescribing and administration and electronic medicine reconciliation. We are working with the National Health IT Board on introducing electronic medicine reconciliation and electronic prescribing and administration to all public hospitals by 2014 (this is a cornerstone of the wider e-health programme).

29 This group replaces the former Safe and Quality Use of Medicines Group.

Section 1.6 outlines how the Commission plans to measure the impact of these programmes.

INFECTION PREVENTION AND CONTROL PROGRAMME

Health care associated infections are one of the most frequent adverse events in health care worldwide. Up to 10 percent of patients admitted to modern hospitals in the developed world acquire one or more infections. In addition to the harm and impact on patients and their families, each case of hospital-acquired infection in New Zealand can cost an additional $20,000 to $45,000 depending on the severity of the infection and the treatment needed.30

The Commission is leading work on infection control including hand hygiene, CLAB and surgical site infection surveillance. The scope of the work includes DHBs, private hospitals, aged care and disability services, primary care and potentially other health and disability providers.

Section 1.6 outlines how the Commission plans to measure the impact of these programmes.

Hand hygiene

This programme aims to improve hand hygiene compliance across all health care worker groups in order to reduce hospital acquired infections. The programme is based on the WHO’s Guidelines on Hand Hygiene in Health Care. Auckland DHB has been contracted by the Commission to lead a two-year programme aimed at leading a culture change and increasing hand hygiene compliance.

The auditing process indicates current compliance with best-practice guidelines in public hospitals is around 54 percent. However the data are poor and the actual rate of compliance is yet to be determined. The Commission and Auckland DHB are aiming for 64 percent compliance in the first year and working towards 70 percent compliance in the next three years. This would make New Zealand’s compliance among the best in the world. Importantly, it would significantly reduce the number and impact of hospital acquired infections.

During 2012/13 100 percent of DHBs will be enrolled and involved in implementing the hand hygiene programme in their public hospitals.

Central line associated bacteraemia (CLAB) programme

CLAB is a serious but preventable complication from a relatively common procedure (insertion of central lines). There is compelling international31 and local evidence to show the effectiveness of initiatives to reduce incidence of CLAB. Counties Manukau reduced incidents of CLAB from 6.6/1000 line days to 0.9/1000 line days over a two-year period with an estimated saving of around $200,000 per year. The current incident rate nationally is estimated to be between 6 and 8 per 1000 line days.

The CLAB programme aims to achieve a sustainable reduction in episodes of CLAB through a national programme of leadership, training and coordination. Ko Awatea, Counties Manukau DHB has been contracted by the Commission to lead this programme.

During 2012/13 the national CLAB tool for insertion and maintenance will be implemented in all 24 public hospital ICUs.

30 Evaluation of the Middlemore Hospital ICU’s implementation of the standardised checklist of interventions “the Central Line Bundle” to prevent catheter-related blood stream infection.

31 Pronovost P, Needham D, et al. 2006. An intervention to decrease catheter-related bloodstream infections in the ICU. The New England Journal of Medicine 355: 2725-32.

Surgical site infection surveillance and response

Surgical site infections (SSIs) are the second most common form of hospital-acquired infection, are costly to treat, are associated with increased mortality and have an impact on quality of life.

A national SSI surveillance programme has been shown internationally and through a cost-benefit analysis (Sapere, 2011), to improve patient outcomes as well as generate savings to the health sector. The joint DHB/Association of Senior Medical Specialists report32 estimated achievable productivity gains of $50m to $78m from reducing surgical site infections.

The Commission is implementing a systematic national SSI surveillance programme to facilitate comparisons between providers and to motivate and support teams to reduce rates of SSIs by implementing evidence-based changes to surgical practice. This will include contracting a lead agency for the programme, developing a system for standardised collation and reporting of SSIs and developing advice on best practice responses.

During 2012/13 we will establish a national surgical site surveillance and response system and collection of baseline information. A lead agency will be selected and the software solution and paper-based data collection commenced.

SURGICAL SAFETY

Recent cost-benefit analysis indicates that, in New Zealand, potentially preventable complications arise in 10 to 15 percent of all surgical procedures. We are working to improve patient safety by:

increasing and improving the use of the WHO surgical safety checklist - international evidence has shown dramatic (over a third) reduction in patient harm through adoption of the checklist and similar approaches; however, effective use of the checklist requires the engaged participation of all members of the operating team, and this is at present variable. We will work to enhance the effectiveness of this potentially very powerful tool.

supporting the introduction by DHBs of the ‘productive operating theatres’ programme designed to improve the patient experience of care and outcomes of care.

During 2012/13 we will collect baseline data of the percentage of operations where the surgical checklist is used properly.

Section 1.6 outlines how the Commission plans to measure the impact of this programme.

FALLS REDUCTION

Falls in public hospitals remain the largest category of serious events reported by hospitals. DHBs reported 195 falls in the 2010/11 year that were classified as a serious or sentinel event. This figure represents 52 percent of the total number of serious and sentinel events reported.

Taking steps to reduce the number and harm from falls is therefore one of our priority areas in the next few years in hospital inpatient settings and aged residential care. The Commission will lead the national approach to reducing harm from falls and is currently driving the establishment phase as a multi-agency partnership. Partners include DHBs,

32 Investing in Clinical Leadership for Quality and Safety Improvement (March 2011).

ACC, the Office of the Chief Nurse in the Ministry of Health, the aged residential care sector, the NZ Home Health Association and others. Potential approaches the Commission may adopt include:

increasing the profile of the problem and potential solutions through an awareness and education campaign which will be aimed at all four priority programmes, including falls reduction in health care settings.

developing a national policy statement to guide improvement in the sector identifying and promulgating a toolkit to implement changes based on what

works supporting Releasing Time to Care, a programme focused on improving ward

processes and environments to help nurses and therapists spend more time on patient care, thereby improving safety and efficiency

supporting sector training. During 2012/13 we will collect accurate baseline information about the prevalence of falls and harm from falls in health care settings.

Section 1.6 outlines how the Commission plans to measure the impact of this programme.

2.2.3ChallengesAsking funders and providers to invest in improving quality and safety at a time of fiscal restraint will require good evidence of the value of the investment. Our commitment to having robust evidence to support our programmes and being clear about the costs and benefits (human and financial) of the programmes should enable us to mitigate this challenge. Having early adopters helps considerably and to date we have always been able to find willing DHBs and providers to test some of our programmes. This enables us to demonstrate the benefits that accrue from uptake of the programmes.

There is a risk that a few DHBs may decide not to implement the national standardised paper-based medication chart and medicines reconciliation system on the basis that they plan to move directly to an electronic system within a few years. The paper-based systems are important because they can be implemented much more quickly, with earlier improvements in patient safety. Furthermore they establish the practice changes that drive the improvements in quality and thus provide a sound foundation for electronic systems – these changes in practice are needed irrespective of whether the system used is paper-based or electronic. Over the next few years paper-based systems will also be important as a back-up system when electronic systems fail, or where there is handover to a provider who does not have an electronic system.

2.3 Output class 3: Sector and consumer capability

This output class will contribute to: an improved quality and safety culture where there is constant examination

and improvement consistent use of information and tools to improve practice improved partnerships between consumers and health and disability

practitioners where consumers are partners in decisions relating to their care and participate in decision making at all levels.

The Commission will: support programmes to increase health literacy and improve consumer participation in

decisions relating to their care support and develop clinical leadership identify and develop core competencies, identify the extent of the gap in current

capability and work to close that gap engage and communicate with the sector to share learnings, align information and

sector activities and reduce duplication seek peer review and commentary from international partners on quality and safety

and investigate successful international initiatives provide advice on frameworks and regulatory settings within the health and disability

system to ensure they align with quality and safety improvement support and advise on education and skills training.

Working in association with:Health Sector Forum, DHBs, the Ministry of Health (including the NHB, NHITB and HWNZ), HDC, consumers and families, clinical/health leaders, international quality and safety organisations and experts, hospitals (public and private), primary care providers, the aged care and disability sector and NGOs.

Cost of output class 3: $1.7m.

2.3.1Background and rationale for this output classDeveloping the quality and safety capability of the sector is a key element in delivering better sector quality and safety outcomes and a more systematic and predictable quality and safety response across the system. Our aim is to achieve and surpass internationally accepted quality and safety outcomes for every New Zealander.

Benefits in the longer term include: a health culture where quality and safety is inherent in everything we do greater confidence and consistent achievement of the right standard of safety

and quality across New Zealand’s health and disability services wider engagement and participation by patients/communities in their health and

disability services an affordable system – a high quality system is more efficient and reduces costs.

More immediate benefits of building capability include: a critical mass of the technical and leadership skills and knowledge to facilitate

system-wide spread of our quality and safety programmes delivery on key quality and safety programmes and local projects based on better

access to expert knowledge more consistent application, nationally, of quality and safety knowledge, tools

and techniques developed by active projects and improved performance on key quality and safety priorities.

2.3.2 Current and planned activityThe Commission will progress the following priority programmes during 2012/13:

developing the capability of people in the sector developing consumer and family/whānau engagement and partnership.

We will also continue to raise the profile of the Commission to increase our influence with the sector through promoting understanding of the role of the Commission and of the potential of our work to enhance clinical practice. We will promote key quality and safety messages via our website, newsletters, meetings and conferences, and disseminate information to frontline staff on individual programmes.

DEVELOPING PEOPLE CAPABILITY IN THE SECTOR

The Commission is developing a strategy and action plan for building quality and safety capability in the New Zealand health and disability sector. Actions that are likely to be taken over the first few years include the following.

Clinical leadership Working with the DHBs and the National Health Board on a programme to assess

progress with implementing In Good Hands. The first step is a survey of DHB health professional employees to learn more about what is effective for encouraging greater clinical leadership in DHBs’ decision-making processes. The results will inform both internal DHB processes and national efforts to strengthen clinical leadership.

Working with the New Zealand Centre of Excellence in Health Care Leadership33 on how the Centre’s programmes could support leadership for quality and safety.

Engaging with the Colleges and professional associations. For example, these organisations are helping us distribute and promote the key messages from the serious and sentinel events report in ways that are relevant to their memberships, and working with us in other areas of mutual interest, supporting Commission programmes and initiatives.

Improvement science Identifying the competencies DHB clinicians currently have to participate in, and

support the implementation and sustainability of the Commission’s four priority programmes.

Developing a framework and describing the competencies in improvement science required of clinicians in order to sustain ongoing programmes to reduce harm in the four priority programmes.

Describing the competencies required of leaders, managers and those in governance roles to understand the system or organisational changes required to successfully improve quality, focussed initially in the four priority programmes.

Assessing individuals and groups in DHBs against the agreed competencies to inform the planning of future education, training or development programmes.

Investigating a number of education, training or development programmes and expected outcomes to address gaps found.

During 2012/13 we will develop a set of core competencies in quality improvement science which initially relate to the Commission’s four priority areas.

DEVELOPING CONSUMER AND FAMILY/WHĀNAU ENGAGEMENT AND PARTNERSHIP

Our health and disability services exist for the patients and consumers they serve. There is growing evidence demonstrating the importance of partnerships between health services organisations/health professionals, and patients, families/whānau and carers.

33 This has been established by Health Workforce New Zealand and is hosted by the University of Auckland.

Potential benefits have been demonstrated in improved outcomes, enhanced experience of care, lower costs per case and increased workforce satisfaction. One way to ensure excellent health care with limited resource lies in greater engagement of patients with decisions about their own health care.

We are particularly interested in promoting values-based decision-making. For example, a third of patients with accepted indications for knee replacement will chose not to have this procedure if fully informed about the risks, the time associated with recovery, and the extent of potential benefit. In essence, patients who participate more in the decision-making are able to reach choices that are more consistent with what is important to them as individuals.

The Commission has developed a Partners in Care framework and action plan which focuses on raising awareness and leading by example. It has three streams. These aim to increase health literacy, improve consumer participation and develop leadership capability for providers and consumers. The theme for the first year is leadership and awareness-raising about the framework and the role the Commission plays.

During 2012/13 we will implement the first year of the Partners in Care action plan.

ENGAGEMENT AND COMMUNICATION

We aim to: raise the profile of the Commission and promote understanding of its role as a

catalyst for invigorating change, and its focus on four priority areas ensure the Commission has consistent and continued visibility in the sector help establish the Commission as the ‘go to’ body for the health sector for

support and advice to improve the quality and safety of New Zealand health and disability services

ensure stakeholders are familiar with, and understand the role of the Commission and how it relates to their work and interests

promote the benefits of increasing health quality and safety to the sector and encourage the sector to ‘own’ health quality and safety.

In 2012/13 there will be a strong focus on the development and implementation of initiatives to raise awareness of the Commission’s four priority areas – in terms of harm currently caused in those areas, how that harm can be reduced, and the benefits of reduced harm. Initiatives will be targeted to both the health sector and the public.

There will also be a strong focus on stakeholder engagement. Meaningful and ongoing engagement is critical to assist the Commission to lead, contribute to and support a sector-wide environment in which a shared health quality and safety agenda is created, and acted upon.

There will be a continued focus on ensuring: the Commission has an up-to-date website that is useful to the sector publications such as reports and newsletters are of a high standard, and mindful

of health literacy requirements the Commission has a professional and recognisable presence at conferences

and events media issues are managed, and the Commission’s key messages are proactively

promoted through media communications risks are identified and managed.

2.3.3Challenges

CONSUMER AND FAMILY/WHĀNAU ENGAGEMENT AND PARTNERSHIP

The health and disability sector generally struggles to engage with and enable effective participation by consumers and their families in their care. There is sometimes a lack of acceptance by providers of the role of patients and their families and health professionals often perceive they don’t have sufficient time to engage in this way. There is a lack of training and education for health professionals and patients on how to engage, low health literacy and lack of patient knowledge.

The Commission can add value in this area, in collaboration with others within the sector, including consumers and their families.

IMPROVEMENT SCIENCE CAPABILITY

There is a view in the sector that we do not have sufficient expertise in improvement science across the sector to lead and implement the major changes that are needed to improve quality and safety across New Zealand. Our immediate challenge is to test this assumption against an agreed set of core competencies and to work with the sector to close any gaps.

2.4 Expected revenue/proposed expenses to be incurred in

2012/13 for each output classNote: Numbers are rounded

Output class 1 Output class 2 Output class 3 Total

Information, analysis and

advice$000’s

Sector tools, techniques and methodologies

$000’s

Sector and consumer capability

$000’s $000’s2011/12 2012/13 2011/12 2012/13 2011/12 2012/13 2011/12 2012/13

IncomeCrown revenueInterest incomeOther income

4,20357 0

6,38439

0

7,321133411

4,962310

2,952510

1,630100

14,476241411

12,976800

Total income 4,260 6,423 7,865 4,993 3,003 1,640 15,128

13,056

ExpenditureOperational and Internal programme costsExternal programme cost

1,822

3,205

3,058

3,365

3,402

3,919

2,710

3,363

851

2,430

542

1,198

6,075

9,554

6,310

7,926

Total expenditure

5,027 6,423 7,321 6,073 3,281 1,740 15,629

14,236

Surplus/(deficit) (767) (0) 544 (1,080)

(278) (100) (501) (1,180)

See Section 6.6 for key assumptions and 2012/13 deficit explanations.Figures for 2011/12 are forecast.

3.0 Organisational capacity, capability and developmentTo ensure we can achieve our outcomes, impacts and outputs we need a strong foundation of skilled people working together in a well-run organisation and strong partnerships with others in the sector.

3.1 The organisationThe Commission is led by a Board of seven members appointed by the Minister of Health. The work of the Commission is carried out by up to 35 staff (including clinical leaders for each programme area) and a number of expert committees. We are a relatively small agency and rely heavily on partnerships within the health and disability sector to provide expertise, implement programmes and change the quality and safety culture of our health and disability services. By working in this way, the Commission can remain connected to people and the workface, adaptive and responsive to achieving our outcomes.

We put a great deal of emphasis on collaboration and coordination between different parts of the sector – New Zealand is a small country and we all have to work together to the agreed common end. Of particular importance are our partnerships with clinical leaders, consumers and consumer groups and a developing partnership with Maori. We also have strong international links, so that we are well-connected to innovation, evidence and advice from our colleagues overseas.

3.2 Our people and skillsOur core expertise is in the science of patient safety and quality improvement, programme management, stakeholder engagement, the collection and use of information and evaluation.

Staff are encouraged to identify required competencies and future training needs and to undertake relevant training. The Commission has a dedicated staff training budget. All staff have a personal development plan which is reviewed annually.

3.3 Good employer practices and equal opportunitiesThe Commission wishes to ensure it attracts and retains productive, talented staff. We will meet our good employer obligations under Part 3, Section 118 of the Crown Entities Act 2004. These obligations are addressed through our recruitment and employment policies which are made available to all staff. There is a specific policy relating to equality and diversity which outlines the Commission’s commitment to the principles of equal employment opportunity and to ensuring no discriminatory policies or practices exist in any aspect of employment. The Commission encourages the achievement of work-life balance and is a family-friendly workplace. Technology allows some staff to work from home when necessary.

Our recruitment programme aims to attract and appoint the best people, who have the appropriate skills, values and attributes to meet the Commission’s needs, objectives, and strategic direction.

3.4 Meeting our legal responsibilities

We ensure we meet our good employer requirements, the Public Finance Act, the Public Records Act, the State Services and Crown Entities Acts and other applicable Crown entity legislation through our governance, operational and business rules. We have implemented the ComplyWith legislative compliance information, monitoring and reporting programme which is used by over 60 Crown-owned or funded entities, departments, companies and by the Office of the Auditor-General. The first ComplyWith survey showed a high level of overall compliance and identified some areas for further development. Our aim during 2012/13 is to comply with all legislative requirements (or have in place a process to remedy any non-compliance).

3.5 Financial managementWe maintain sound management of public funding through our compliance with relevant requirements under the State Sector and Public Finance Acts and applicable Crown entity legislation. We are building on the recommendations of the 2010/11 audit review by Audit New Zealand. This is being overseen by the Commission’s Finance and Audit Committee.

3.6 Efficient use of organisational resourcesDuring our establishment, we used the All of Government procurement processes for most of our office and IT purchases. We will continue to use All of Government procurement processes unless there is a compelling reason not to. We will also seek opportunities to share backroom functions with other similar agencies wherever it is possible and where it would result in significant savings. We continue to strive for good value for money in our overhead and other costs.

Every project has a clear focus on its value proposition, both human and economic.

Part 24.0 ReportingWe will provide the Minister and the Ministry of Health with information that enables monitoring of our performance and will comply with the reporting requirements of the Crown Entities Act 2004.

This includes a statement of intent and annual report as well as quarterly reporting against our statements of financial and service performance.

5.0 Prospective statement of service

performance for 2012/13 Background to these measures is included in Part 1 of this statement of intent.

Quantity Timeliness Quality Link to impacts and outcomes

Quality and safety markers for the sector

Finalised set of measures and thresholds for patient falls, hospital-acquired infections and surgical harm

Finalised with the sector by 30 December 2012

Report published by 30 June 2013

Measures are tested internally in DHBs, the clinical community and the Ministry of Health

Improved quality and safety culture

Measuring health quality and safety

At least one report against national and international measures of quality and safety

At least six new Atlas ‘domains’ are published

One serious and sentinel events report published

By 30 June 2013

By 30 June 2013

By 30 December 2012

Within six months of the reports being published a survey of stakeholders shows that at least 80% consider that the report was useful and well presented. For the report against national and international measures and the health care variation report the survey will relate to the 2011/12 report


Reduced unwarranted variation

Reduced deaths, harm and wastage

Mortality review reports


At least one review of child and youth mortality published

Review of perinatal and maternal mortality published

Review of family violence deaths published

Review of perioperative deaths published

31 March 2013

30 June 2013

31 March 2013

31 March 2013

All reports include priorities for action

Within six months of publication stakeholder feedback indicates that at least 80% consider that the report was useful and well presented


Review of the national mortality review committees completed

30 June 2013 The review identifies how outcomes for mortality review can be maximised locally, regionally and nationally

Improved efficiency

Best value from public health system resources

Medication safety

Prioritisation tool implemented in at least four DHBs

By 30 June 2013 Tool is independently evaluated to ensure high-risk patients are identified

Uptake of good practice.Reduced deaths, harm and wastage

Standardised process for prescribing and administering medication in aged residential care medication chart finalised

By 30 June 2013 Developed in partnership with a representative cross section of the aged care sector

Uptake of good practiceReduced deaths, harm and wastage

Milestones in the Commission’s contracts with the three DHBs implementing phase 2 of the eMedication Management programme are met

By 30 June 2013 A formal evaluation is undertaken with results available for the next phase of development of the programme


Hospital acquired infection

100% of DHBs enrolled and involved in implementing the

By 30 June 2013 Increase in audited compliance rate with the hand hygiene

Uptake of good practiceReduced deaths,


hand hygiene programme

programme in public hospitals to 64%

harm and wastage

National CLAB process for insertion and maintenance is implemented and sustained in all ICUs and HDUs

By 30 June 2013 Reduction in CLAB rates to <1 per 1000 line days

Uptake of good practice.


A national surgical site surveillance system is piloted in at least one DHB health care provider

By 30 June 2013 Data from the pilot are validated and can be used to inform the next phase of the programme


Surgical harm reduction

Data collected on the percentage of operations where the surgical checklist is used properly and a baseline established to inform the next phase of the programme

30 December 2012 Data are collected using a proven methodology

Uptake of good practice

National falls prevention programme

Accurate baseline information about prevalence of falls and harm from falls

30 December 2012 Accuracy is assured by triangulation of information from internal reporting, serious and sentinel events reports, ACC and the National Minimum Data Set

Uptake of good practice

Building quality and safety capability

A set of core competencies in quality improvement science is developed which initially relates to the Commission’s four priority areas

30 June 2013 The set of competencies is informed by people identified by DHBs and other large providers as experts in improvement science and/or who have expertise in particular areas or methods



80% of the milestones for 2012/13 in the Partners in Care action plan are implemented

30 June 2013 A survey of a cross section of health and disability sector providers shows at least 60% are aware of the Commission’s role in supporting consumer/provider partnerships

Partnerships between consumers and health and disability providers

6.0 Prospective financial statements for the three years ending 30 June 2015 6.1 Prospective statement of comprehensive income

Planned12

months to 30

June 2012($000)

Forecast12

months to 30

June 2012($000)

Planned2012/13

($000)

Planned2013/14

($000)

Planned2014/15

($000)

RevenueMinistry of HealthInterest incomeOther income

14,47647

0

14,476241411

12,97680

0

12,976450

12,976450

Total operating revenue 14,523 15,128 13,056 13,021 13,021

ExpenditureSalariesTravelConsultant and contractorsBoard/fees/committeesPrinting/communicationOverhead and IT expensesOther expenses

3,31815364360920135214

3,028283

1,107524295716

12

4,06227756846023958410

4,123258278452238572

10

4,185258225452238561

10

Total operating expenditure 5,290 5,965 6,200 5,931 5,929

Quality and safety programmesMortality review programmes

7,8862,248

7,2042,350

5,5562,370

4,9602,370

4,7972,370

Total programme expenses

10,134 9,554 7,926 7,330 7,167

Depreciation and amortisation

87 110 110 110 110

Total expenditure 15,511 15,629 14,236 13,371 13,206

Operating surplus/deficit (988) (501) (1,180) (350) (185)

Note: Numbers are rounded.

6.2 Prospective statement of movements in equityPlanned

12 months to 30

June 2012($000)

Forecast12

months to 30

June 2012($000)

Planned2012/13

($000)

Planned2013/14

($000)

Planned2014/15

($000)

Opening balance 2,578 3,097 3,096 1,916 1,566

Equity injection 0 500 0 0 0

Total comprehensive income:Net surplus / (deficit)

(988) (501) (1,180) (350) (185)

Balance at 30 June 1,590 3,096 1,916 1,566 1,381


6.3 Prospective statement of financial positionPlanned

12 months to 30

June 2012($000)

Forecast12

months to 30

June 2012($000)

Planned2012/13

($000)

Planned2013/14

($000)

Planned2014/15

($000)

Accumulated funds 1,590 3,096 1,916 1,566 1,381

Represented by current assetsCash and cash equivalentsGST receivableDebtors and other receivablesInventory

1,993197

00

3,846242

00

2,347127

00

2,057116

00

1,780113

00

Total current assets 2,190 4,088 2,474 2,173 1,893

Non-current assetsProperty, plant and equipmentIntangible assets

28034

29378

20655

11932

17259

Total non-current assets 314 371 261 151 231

Total assets 2,504 4,459 2,735 2,324 2,124

Current liabilitiesCreditorsEmployee benefit liabilitiesOther payables

801113

0

1,28380

0

666153

0

605153

0

590153

0

Total current liabilities 914 1,363 819 758 743

Total liabilities 914 1,363 819 758 743

Net assets 1,590 3,096 1,916 1,566 1,381


6.4 Prospective statement of cash flowsPlanned

12 months to 30

June 2012($000)

Forecast12

months to 30

June 2012($000)

Planned2012/13

($000)

Planned2013/14

($000)

Planned2014/15

($000)

Cash flows used in operating activities

Cash provided from:Ministry of HealthInterest receivedOther income

Cash disbursed to:Payments to suppliers and employeesNet goods and services tax

14,476470

(14,853)

(161)

14,476241411

(17,875)

(33)

12,976800

(14,670)

115

12,97645

0

(13,322)

12

12,97645

0

(13,111)

3

Net cash flows from (used in) operating activities

(492) (2,780) (1,499) (290) (87)

Cash flows used in investing activities

Cash disbursed to:Purchase of property, plant, equipment & intangibles

0 (481) 0 0 (190)

Net cash flows (used in) investing activities

0 (481) 0 0 (190)

Cash flows used in financing activityEquity injection 0 500 0 0 0

Net cash flows (used in) finance activities

0 500 0 0 0

Net increase / (decrease) in cash and cash equivalents

(492) (2,761) (1,499) (290) (277)

Plus projected opening cash and cash equivalents

2,485 6,607 3,846 2,347 2,057

Closing cash and cash equivalents

1,993 3,846 2,347 2,057 1,780


6.5 Declaration by the BoardThe Board acknowledges its responsibility for the information contained in the Commission’s forecast financial statements. The financial statements should also be read in conjunction with the statement of accounting policies set out in section 6.7.

6.6 Key assumptions for proposed budget in 2012/13 and out-yearsIn preparing these financial statements, we have made estimates and assumptions concerning the future, which may differ from actual results.

Estimates and assumptions are continually evaluated and are based on limited historical experience (given this is a relatively new organisation) and other factors, including expectations of future events that are believed to be reasonable under the circumstances.

Key assumptions are: while personnel costs have been assessed on the basis of expected staff mix and

seniority, this may vary as a number of staff are still to be recruited. However, we will maintain total expenditure within our appropriations, even if individual line items vary. In particular, there may be movements between salary, contractor and programme costs

out-year costs in the operating budget are based on a general inflationary adjustment

the timing of the receipt of Crown revenue is based on quarterly payments paid at the beginning of the quarter on the 4th of the month

minimum ongoing equity requirements from 2012/13 for the Commission have been estimated between $1.0m to $1.5m to cover approximately one month’s worth of operating and programme expenditure and/or any contingencies

salaries include a 1.5% p.a. increase provision offset by reduction in expenditure on contractors and consultants

the 2012/13 deficit of $1.18m is mainly driven by:o $350k management fee for eMedicines management programmeso $436k for completion of phase 2 of the eMedicines management

programmeo $100k for completion of the mortality review committee reviewo $400k for completion of the Surgical Site Infection Surveillance

Programme activity originally planned for 2011/12 2013/14 and 2014/15 deficits relate to the management costs of $350k and

$185k respectively for phase 3 of the eMedicines management programme hardware and other software replacement is planned for 2014/15.

6.7 Statement of accounting policiesREPORTING ENTITY

The Health Quality and Safety Commission is a Crown entity as defined by the Crown Entities Act 2004 and the New Zealand Public Health and Disability Act 2000 and is domiciled in New Zealand. As such, the Commission’s ultimate parent is the New Zealand Crown.The Commission’s primary objective is to provide public services to New Zealanders, as opposed to that of making a financial return. Accordingly, the Commission has designated itself as a public benefit entity for the purposes of New Zealand Equivalents to International Financial Reporting Standards (NZIFRS).

BASIS OF PREPARATION

Statement of Compliance

These prospective financial statements have been prepared in accordance with the Crown Entities Act 2004. This includes the requirement to comply with New Zealand generally accepted accounting principles (NZGAAP).

The financial statements comply with NZIFRS, and other applicable financial reporting standards, as appropriate for public benefit entities. This includes New Zealand Financial Reporting Standard No.42: Prospective Financial Statements (FRS-42).

The prospective financial statements have been prepared for the special purpose of the 2012 to 2015 Statement of Intent (SOI) of the Commission to the Minister of Health and Parliament. They are not prepared for any other purpose and should not be relied upon for any other purpose.

These statements will be used in the annual report as the budgeted figures.

The preceding SOI narrative informs the prospective financial statements and the document should be read as a whole.

The preparation of prospective financial statements in conformity with FRS-42 requires management to make judgments, estimates and assumptions that affect the application of policies and reported amounts of assets and liabilities, income and expenses. Actual financial results achieved for the period covered are likely to vary from the information presented and the variations may be material.

Measurement system

The financial statements have been prepared on a historical cost basis.

Functional and presentation currency

The financial statements are presented in New Zealand dollars. The functional currency of the Commission is New Zealand dollars.

SIGNIFICANT ACCOUNTING POLICIES

The accounting policies outlined below will be applied for the next year when reporting in terms of section 154 of the Crown Entities Act 2004 and will be in a format consistent with generally accepted accounting practices. The following accounting policies, which significantly affect the measurement of financial performance and of financial position, have been consistently applied.

Budget figures

These prospective financial statements were authorised for issue by the Commission in May 2012.

The budget figures have been prepared in accordance with generally accepted accounting practice and are consistent with the accounting policies adopted by the Commission for the preparation of the financial statements. The Commission is responsible for the prospective financial statements presented, including the appropriateness of the assumptions underlying the prospective financial statements and all other required disclosure. It is not intended to update the prospective financial statements subsequent to publication of these statements.

Revenue

Revenue is measured at fair value and is recognised as income when earned and is reported in the financial period to which it relates.

Revenue from the Crown

The Commission is primarily funded through revenue received from the Crown, which is restricted in its use for the purpose of the Commission meeting its objectives as specified in this SOI. Revenue from the Crown is recognised as revenue when earned and is reported in the financial period to which it relates.

Interest

Interest income is recognised using the effective interest method.

Operating leases

Leases that do not transfer substantially all the risks and reward incidental to ownership of an asset to the Commission are classified as operating leases. Lease payments under an operating lease are recognised as an expense on a straight-line basis over the term of the lease in the prospective statement of financial performance.

Cash and cash equivalents

Cash and cash equivalents include cash on hand, deposits held at call with banks and other short-term, highly liquid investments, with original maturities of three months or less.

Debtors and other receivables

Debtors and other receivables are measured at fair value and subsequently measured at amortised cost using the effective interest method, less any provision for impairment.

Bank deposits

Investments in bank deposits are initially measured at fair value plus transaction costs. After initial recognition, investments in bank deposits are measured at amortised cost using the effective interest method.

Inventories

Inventories held for sale are measured at the lower of cost (calculated using the First In First Out basis) and net realisable value.

Property, plant and equipment

Property, plant and equipment asset classes consist of building fit-out, computers, furniture and fittings and office equipment.

Property, plant and equipment are shown at cost, less any accumulated depreciation and impairment losses.The cost of an item of property, plant and equipment is recognised as an asset only when it is probable that future economic benefits or service potential associated with the item will flow to the Commission and the cost of the item can be measured reliably.

Gains and losses on disposals are determined by comparing the proceeds with the carrying amount of the asset. Gains and losses on disposals are included in the prospective statement of financial performance.

Costs incurred subsequent to initial acquisition are capitalised only when it is probable that future economic benefits or service potential associated with the item will flow to the Commission and the cost of the item can be measured reliably.

The costs of day-to-day servicing of property, plant and equipment are recognised in the prospective statement of financial performance as they are incurred.

Depreciation

Depreciation is provided using the straight line (SL) basis at rates that will write off the cost (or valuation) of the assets to their estimated residual values over their useful lives. The useful lives and associated depreciation rates of major classes of assets have been estimated as follows:

Building fit-out 10 years 10% SLComputers 3 years 33% SLOffice equipment 5 years 20% SLFurniture and fittings 5 years 20% SL

Intangibles

Software acquisition: Acquired computer software licenses are capitalised on the basis of the costs incurred to acquire and bring to use the specific software.

Costs associated with maintaining computer software are recognised as an expense when incurred.

Costs associated with the development and maintenance of the Commission’s website are recognised as an expense when incurred.

Amortisation: Amortisation begins when the asset is available for use and ceases at the date that the asset is derecognised.

The amortisation charge for each period is recognised in the prospective statement of financial performance. The useful lives and associated amortisation rates of major classes of intangible assets have been estimated as follows:

Acquired computer software 3 years 33% SL

Impairment of non-financial assets

Property, plant and equipment and intangible assets that have a finite useful life are reviewed for impairment whenever events or changes in circumstances indicate the carrying amount may not be recoverable. An impairment loss is recognised for the amount by which the asset’s carrying amount exceeds its recoverable amount. The recoverable amount is the higher of an asset’s fair value less costs to sell and value in use.

6.8 Acquisition of sharesBefore the Commission subscribes for purchase, or otherwise acquires shares in any company or other organisation, it will first obtain the written consent of the Minister of Health. There are no current plans to acquire such shares.

Board members Professor Alan Merry (Chair) Professor Alan Merry is head of the University of Auckland’s School of Medicine. He is a practising cardiac anaesthetist and chronic pain specialist, and works with patients in routine surgical settings (in public and in private), in life-threatening medical emergencies and in managing chronic illness. He currently chairs the Quality and Safety Committee of the World Federation of Societies of Anaesthesiologists, and worked with the WHO as the anaesthesia lead of the Safe Surgery Saves Lives initiative. He is involved with a follow-on project with these (and other) organisations to improve the safety of anaesthesia world-wide through enhanced standards, technology and education. Professor Merry has a long-standing interest in safety and quality in health care: he co-chaired the New Zealand Medical Law Reform Group in the 1990s, and has conducted research into various aspects of safety in anaesthesia and surgery. He co-authored the book Safety and Ethics in Healthcare, A Guide to Getting it Right.

Dr Peter Foley (Deputy Chair) Dr Peter Foley brings a valuable mix of experience to this role. He is experienced at dealing with health systems at a ‘big picture’ level, while also continuing to work as a GP, based in Hawke’s Bay, where he is the DHB Chief Medical Officer – Primary Care. Dr Foley is the immediate past Chair of the New Zealand Medical Association (NZMA) – a role which required high-level abilities in planning and managing systems, while working in close affiliation and alignment with other key medical organisations such as the Royal New Zealand College of General Practitioners and the New Zealand Council of Medical Colleges. He was recently conferred an NZMA Fellowship in recognition of many years

spent advancing health policy in New Zealand. He has a particular interest in the Commission’s future aged care work.

Mrs Shelley Frost A registered nurse with significant experience in primary health care, Shelley Frost is the current Deputy Chair and Executive Director (Nursing) of General Practice New Zealand, and also a member of the General Practice Leaders’ Forum, and the Canterbury General Practice Group. Her involvement in those roles builds on her strong clinical governance and leadership skills. She is the Director of Nursing at Pegasus Health, an executive role with responsibility for the provision of professional and clinical nursing leadership. She is also Deputy Chair of the Canterbury DHB’s Clinical Board, and a trustee of Partnership Health Canterbury PHO.

Dr David Galler Dr David Galler is an intensive care specialist at Middlemore Hospital in Manukau City. Prior to this he was Principal Medical Advisor to the Minister of Health at the Ministry of Health, and Clinical Director of Acute Care at Middlemore Hospital. A past President of the Association of Salaried Medical Specialists, Dr Galler has worked extensively on quality and safety issues in recent years through a close involvement in the Ministry of Health’s Quality Improvement Committee – the predecessor of the current Commission.

Dr Peter JansenDr Peter Jansen, of Ngati Raukawa descent, is a senior medical advisor to ACC. He has extensive experience as a teacher, researcher and health management advisor for Mauri Ora Associates, experience as a GP in Papakura and Whangamata, and was a former Medical Director of Boehringer Ingelheim (NZ) Limited, a multinational pharmaceutical company. He has published a number of papers relating to cultural competence in health care, and led the development of guidelines on Cultural Competence for health-related organisations in New Zealand. He received the award of Distinguished Fellow of the Royal New Zealand College of General Practitioners for his work in this area. Dr Jansen’s previous appointments have included deputy chairperson of Counties Manukau DHB and a board member of MidCentral Health. He was also an inaugural director of ProCare IPA, a director of Quality Health NZ (formerly the NZ Council of Healthcare Standards), and was clinical director of Te Kupenga o Hoturoa PHO.

Mr Geraint MartinGeraint Martin has more than two decades of experience in health management, and is the current CEO of Counties Manukau DHB, a role he has held since 2006. He has extensive experience in key health governance roles – and has held posts as Director of Health and Social Care Strategy for the Welsh Assembly Government and Chief Executive of Kettering General Hospital in Northamptonshire. Mr Martin has developed and implemented clinical quality improvement programmes in both the UK and New Zealand. At Counties Manukau DHB he leads the clinical leadership team which is developing whole-of-system changes to the way hospitals work. He has established a Centre for Health Services Innovation led by New Zealand’s first chair in health innovation and improvement. He also helped lay the foundations of the Saving 1000 lives campaign in Wales, which used clinical quality improvement across an entire national health care system to drive patient safety.

Mrs Anthea PennyAnthea Penny is a qualified health professional, an experienced chief executive in the New Zealand health sector and a management consultant. She is director of R H Penny

Ltd, Australasia, and Australasian agent for the NHS Institute of Innovation and Improvement, (Service Transformation) responsible for the NHS Institute’s commercial affairs and relationships in New Zealand and Australia. She is also the inaugural recipient of the 2004 New Zealand Institute of Health Management Silver Fern Award for Excellence in Health Service Management. Since 1993, Anthea Penny has worked as a management consultant, with national and regional funders and service providers of health care, aged care and rehabilitation in New Zealand and Australia. Her main role has been to review and improve organisational performance and to develop health policy and strategy across the service delivery spectrum.

Chief Executive OfficerDr Janice Wilson is the Commission’s Chief Executive Officer.

Mortality review committee members

Perinatal and Maternal Mortality Review Committee

Perioperative Mortality Review

Committee

Child and Youth Mortality Review

Committee

Family Violence Death Review

Committee

Professor Cynthia Farquhar (Chair)Dr Beverley LawtonMs Susan BreeDr Alec EkeromaDr Margaret MeeksDr Graham SharpeDr Sue BelgraveDr Suzanne CrengleMs Gail McIverMs Linda PenlingtonMs Alison Eddy

Dr Leona Wilson (Chair)

Dr Digby Ngan KeeDr Jonathan KoeaMs Teena RobinsonDr Philip HiderDr Catherine (Cathy) FergusonDr Anthony WilliamsMs Rosaleen RobertsonTwo additional members to be appointed

Dr Nicholas Baker (Chair)Professor Edwin MitchellDr Sharon WongMrs Susan MatthewsMrs Anthea SimcockMr Paul NixonDr Pat TuohyThree additional members to be appointed

Associate Professor Julia Tolmie (Chair)Associate Professor Dawn ElderMs Ngaroma GrantMs Miranda RitchieProfessor Barry TaylorMs Fia Turner-TupouJudge Paul von DadelszenAssociate Professor Denise Wilson

Roopu Māori membersTu Williams (Chair) Denise Wilson (ex-officio)Riripeta Haretuku Leanne Te KaruRees TapsellOne further member is being appointed.

Roopu Māori provides advice to the Board and Chief Executive of the Commission on strategic issues, priorities and frameworks from a Māori world view and identifies key quality and safety issues for Māori patients and organisations. Advice from this group can assist in the gathering and interpretation of data on quality and safety and also prioritise or shape new programmes to ensure the Commission’s aim to improve health and equity for all populations can be achieved.

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