Guide
Integrated Performance and Incentive Framework
PHO Minimum Requirements Self-Assessment
Guide
November 2014
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Guide
Introduction
Tēnā koutou and welcome to PHO Minimum Requirements Self-Assessment Process.
Self-Assessment is a process co-developed and co-designed with DHBs and PHOs to
help PHOs demonstrate compliance against the Minimum Requirements as per
schedule B1 of the PHO Services Agreement.
PHOs’ first self-assessments comes at a time when PHOs have the opportunity to play
an increasing role in the design, delivery and funding of services in their district via the
implementation of the Integrated Performance and Incentive Framework or IPIF.
The IPIF was established following the advice of the Expert Advisory Group. The
ultimate aim of the IPIF is to drive improvement across the health sector by addressing
issues of equity, safety, quality, access and cost of services.
IPIF is a quality improvement programme that begins at a community level. Its goal is
that DHBs, PHOs, general practice teams and other primary care services work
together to plan and provide health services. The journey towards this goal requires an
environment that supports constructive, collaborative professionally driven quality
improvement in front line services.
Completed self-assessments will be reviewed by Peer Review Panels that will provide
an independent appraisal and valuable feedback to your PHO.
The whole process reflects the sector’s focus on collaboration and quality improvement,
and provides an opportunity for PHOs to share ideas for business improvement and
build capability across the health sector.
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Why does the PHO need to do a Self-Assessment?
The Minimum Requirements as per schedule B1 of the PHO Services Agreement are
subject to self-assessments and peer review as per part G sub-clause G.4. SelfAssessment supported by peer review was considered to be the least burdensome
approach for PHOs to show they meet the Minimum Requirements. Peer Review
Panels provide the required level of independent appraisal to increase credibility of the
results.
How does the Self-Assessment process work?
Your PHO will have been sent a link to the self-assessment pack which includes this
guide. Within the pack there are three key documents: a narrative and evidence SelfAssessment Template to be completed for each Minimum Requirement; Prompts to
help with this process, and; Sign-off Templates. The completed Self-Assessment
Templates with attached supporting evidence and Sign-off Templates need to be
returned in accordance with the instructions below by 31 March 2015.
It is anticipated that a wide source of evidence will be required to show how you meet
the Minimum Requirements. To help your PHO with the self-assessment, Prompts have
been provided as an initial reference tool. They are guides only, and not intended to be
an express or implied variation to the Minimum Requirement provisions as per the PHO
Services Agreement. They are not requirements nor are they exhaustive. Your PHO is
welcome to include any other information or evidence as appropriate.
It is also anticipated that a range of staff may need to contribute to the completion of the
Self-Assessment Template. We have therefore also provided an optional Allocation
Tool and Pre-submission Checklist to help track which Minimum Requirement is
allocated to whom and ensure all elements have been included in the submission.
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Some Minimum Requirements are harder to demonstrate than others and we
encourage you use the free text section of the Self-Assessment Template to describe
how your PHO meets each of the Minimum Requirements. It is important that this
narrative is comprehensive, and is supported by good evidence where possible.
Although you know your PHO, the Peer Review Panels will not. The narrative should be
written for an audience that understands the sector but not your particular operations.
We recognise that some Minimum Requirements are interrelated or repeated in parts.
To ensure clarity for yourselves and the Peer Review Panels, we encourage PHOs to
complete separate responses for each component of the Minimum Requirements. You
can cross reference to other sections where necessary, and in some areas the Prompts
document highlights these links already. For example: if you have described the Māori
representation as part of governance arrangements in Minimum Requirement 2(1)(b),
you may wish to cross-reference to the self-assessment for Minimum Requirement
6(2)(b) which explicitly entails Māori participation within the PHO governance.
PHO structures
There are many different structures for PHOs across the country. For the purposes of
self-assessment, each PHO is considered to be the collective of organisations
delivering the PHO’s functions under the Minimum Requirements.
When completing the self-assessment, the response should be appropriate based on
the role the PHO takes for each activity (e.g. funder and/or stewardship and/or service
provider).
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Supporting evidence for Self-Assessments
You will need to provide supporting information as evidence (where possible) for the
self-assessment against the Minimum Requirements. This information will need to be
capable of being submitted in soft copy as inserted attachments in the narrative and
evidence Self-Assessment Template. These should be clearly named to show which
Minimum Requirement it relates to. For example: “evidence that the XYZ PHO is not for
profit is shown in the audited Statement of Compliance for the Financial Statements on
page 47 of the Annual Report as per attachment 1 for 2(1)(a)”. If you are not sure how
to insert the evidence files as attachments in the Self-Assessment Template, please
refer Appendix 1 below.
Supporting evidence should be:

Relevant - Has a logical connection with Minimum Requirement component
being assessed

Reliable - The information is from a credible source and its preparation /
maintenance is good quality. It is expected most of the evidence will be sourced
from your PHOs internal processes. However, where possible it is good to
support this with information that can be externally verified or publically available.

Current - The evidence is from an appropriate time period (preferably no more
than 24 months old)

Precise - It’s clear how the evidence supports the self-assessment against the
Minimum Requirements. For example, highlight specific sections/pages if a large
document is provided.

Sufficient - Quality of evidence is more important than quantity of evidence. Too
much information can become confusing. It is not expected your PHO will need
to provide everything that relates to the Minimum Requirements; usually
examples will be persuasive enough.

Protecting of patient privacy - In using examples, all personally identifiable
information will need to be blanked out prior to scanning and attaching.
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Sources of existing assurance or review
Where your PHO has existing audits or assessments related to the Minimum
Requirements, we encourage you to provide the relevant documents as supporting
evidence. As set out above it is preferable if these reviews can be considered current.
Linkages with Alliance Assessments
It is proposed this self-assessment process will be used to provide background
information to aid the development of a tool to determine what a ‘high performing’
Alliance looks like. With this in mind it will be useful if you are able to differentiate
between activities involving the formal ‘Alliance’ in your area, as opposed to working in
‘alliance’ type arrangements with other partners.
Sign-off of the Self-Assessment
The PHO self-assessment should be completed by staff responsible for the areas within
the Minimum Requirements. The completed self-assessment will require PHO CEO and
Board Chair sign-off.
Lead DHBs and Alliance agencies (where appropriate) play significant roles in PHO
operations. For this reason, the completed PHO self-assessments and supporting
information will need to be provided to your respective lead DHB for endorsement signoff. You may also wish to consider endorsement by your local Alliance. Sign-off
Templates have been provided and must be included in your submission.
When are the Self-Assessments due?
The completed self-assessment including sign-offs are due by Tuesday 31 March 2015.
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How does the PHO submit the Self-Assessment?
Please submit the completed Self-Assessment Templates with all supporting evidence
attached and Sign-off Templates on a memory stick to:
Specialist Audit Advisor – IPIF
System Integration Group
Sector Capability and Implementation
1-3 The Terrace
Ministry of Health
Level 2, Reception
Wellington 6011
What happens next?
As stated above, completed self-assessments will be reviewed by Peer Review Panels
to provide an independent perspective. This review process will draw on relevant sector
knowledge and experience to provide valuable feedback to your PHO, and reflects the
sector’s focus on collaboration and quality improvement.
All PHOs will be given an opportunity to provide members to the Peer Review Panels
and conflicts of interest will be managed.
After the Panels have reviewed all the self-assessments, a national moderation process
will take place to ensure equity and consistency. Results will be provided to your PHO
along with any feedback for business improvement or to highlight examples of good
practise. There will be an opportunity for your PHO to comment and clarify any aspects
of the Panel feedback before the results are finalised and provided to the relevant DHB.
It is intended the self-assessment process will capture good practise initiatives for
sharing with the sector in an anonymous way. However, if your PHO does not want to
contribute towards this collection of shared sector initiatives, there is an opportunity to
indicate this within the Sign-off Templates.
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Any formal disputes will be managed through the standard process within B.30 of the
PHO services agreement.
Where can PHOs get help for their Self-Assessment?
For help with the self-assessments:
 MinRqmts@moh.govt.nz
 04 816 2256
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Appendix 1: How to attach evidence within the template
For ease of peer review, please insert all supporting evidence as attachments into the
evidence table within the Self-Assessment Template. Step by step instructions have
been provided below for Microsoft Word 2010 (however the process will be similar in
previous versions).
1. Click “Insert” tab
2. Click “Object”
3. Click “Create from file”
4. Click “Browse”
5. Navigate to where your file is located
6. Click “Insert”
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7. Tick the “Display as icon” box
8. Optional:
At this point, you have a chance to rename the file by clicking “Change Icon”
Rename by typing into the “Caption” box and then click “OK”
9. Finish by clicking “OK”
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An example of how to fill in the evidence table within the Self-Assessment Template is
shown below:
Insert the
clearly named
attachment:
Click to
select
attachment
type
Describe
relevant
section(s)/
reference(s)
Any other comments
PDF
pages 102-136
The annual report is published on the
Ministry’s website each year as one item
of evidence to demonstrate full and
open public accountability. One aspect
of the financial accountability for public
funding is demonstrated through the
audited financial statements.
Website link
Sections
between
1.05minutes to
2.30minutes
This is a link to a video showing an
example of the Ministry’s
communication with stakeholders about
current health issues.
Image/photo
Whole image
This shows the Ministry’s focus on
Government’s Better Public Services
priorities around vulnerable children.
This event was hosted by the Ministry to
promote awareness of how to create a
safe environment for children.
MOH-annual-report-y
ear-ended-june-2013.pdf
Sample video
link
image-vulnerable
children focused - health promotion.jpg
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