Position Description
Position Title
Lead Coordinator – Adverse event learning programme
Work Role Group
Lead Coordinator
Job Size-Band
Delegated Authority
Organisational Context
The Health Quality & Safety Commission is a stand-alone Crown Entity, established effective November
2010, with a Board responsible to the Minister of Health. The Commission is responsible for assisting
providers across the whole health and disability sector, both private and public to improve service safety
and quality and therefore outcomes for all who use these services in New Zealand.
Improving the quality and safety of care will provide better value for money and more efficient and
effective use of taxpayer funding. The Commission is charged with:
providing advice to the Minister of Health to drive improvement in quality and safety in health and
disability services
leading and coordinating improvements in safety and quality in health care
identifying data sets and key indicators to inform and monitor improvements in safety and quality
reporting publicly on the state of safety and quality, including performance against national indicators
disseminating knowledge on and advocating for safety and quality.
In addition to these functions, the Commission has subsumed the activities outlined in Section 17 of the
New Zealand Public Health and Disability Act 2000 (NZPHD Act), namely:
 Advising the Minister of Health on any health epidemiology and quality assurance matters
 Ensuring to the maximum extent practicable, that there is national coordination in reporting of
relevant health epidemiology and quality assurance matters and that there is a capacity to
improve health outcomes through quality assurance programmes directed to clinical providers.
The Commission also has responsibility for supporting the health system to learn from and prevent
adverse events. New Zealand has an excellent health care system which provides safe and efficient care
to the vast majority of people using its services. However, adverse incidents still occur due to failures in
the system. The Commission guides and supports the New Zealand health care sector in the
management, reporting and analysis of reportable adverse events. All adverse serious or sentinel
events, where significant harm or death may have occurred should be reported, but near misses where
no harm was caused are also encouraged. It is important that all these events are reported so we can
learn from them and improve the way we do things.
Position purpose and responsibilities
The purpose of this position is to provide expert advice to support the further development of the
Adverse Event Learning Programme.
The successful applicant will have an in-depth and expert knowledge of adverse events learning and
prevention and ideally a clinical background. The applicant will offer advice in this area to the
Commission’s staff, advisors, clinical leads and work programmes. The person will also assist in
brokering contact with clinical staff in hospitals around the country, through their network of people
working in this area.
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The successful applicant will use specialist subject matter expertise to guide the design and
implementation of the Adverse Event Learning Programme.
Specifically, this will involve the following:
 Developing / strengthening systems and processes to improve the quality of review systems,
process and practice
 Developing / strengthening systems to share the lessons learnt from the review of adverse
 Management and improvement of the central events repository and data system
 Championing the Adverse Events Learning Programme within the Commission and externally
 Supporting the Trigger Tools (TT) programme
 Participating in team activities
 Displaying cultural competency
 Actively managing risks
Key responsibilities and expectations
These include but are not limited to:
Key Areas
Expert Advice
Performance Expectations
Develop / strengthen
systems and
processes to improve
the quality of review
systems, process and
Develop / strengthen
systems to share the
lessons learnt from
the review of adverse
Provide advice and analysis that is based on the best available
evidence, taking into account the views of relevant stakeholders
Contribute to the preparation and drafting of programme plans, policy
documents, reports and ad hoc advice
Provide advice that will enable the Commission to respond to
requests for information from the Minister’s Office, the public, other
agencies and health and disability providers and supporting the
response to media issues for this Programme
Undertake peer review of documents and material prepared by
colleagues to ensure quality, validity, accuracy and consistency
Provide advice on research, surveys and investigations that may form
the foundation for evidence-based analysis, identifying information
gaps in measuring and data quality, together with analysis issues,
and make recommendations on how to learn from, and prevent,
system failures
Liaise with external researchers, analysts and academics as
Work with Commission staff to ensure the programme is evaluated to
demonstrate impacts, outcomes and learnings that can be applied to
future programmes
Contribute to the identification and mitigation of programme risks
Develop / strengthen systems to help organisations identify adverse
On behalf of the Commission, champion robust review practices
across the sector using appropriate tools
Be involved in the development and delivery of workshops to support
provider organisations to undertake best practice reviews
Develop other initiatives (with the team and opportunistically) to
educate and facilitate the improvement of review practice
Respond to feedback and continuously improve the programme of
learning, in collaboration with the wider team
Share lessons learnt from the review of adverse events through
regular reporting which will include case studies (Open Books) and
public reporting (annual serious adverse event report)
Production of Open Book case studies on a regular/monthly basis
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Management and
improvement of the
central events
repository and data
Champion the
Adverse Events
Learning Programme
within the
Commission and
Support and work with 
the Trigger Tools (TT) 
Participate in team
Display cultural
Actively manage risks
(including Health &
Safety in Employment
Production of annual public report on adverse events and other
publications as required
Undertake speaking engagements and opportunities to represent the
Commission and to share lessons learned from adverse event
reporting and analysis.
Oversee data management systems for continuous improvement
Collect, code and store data on adverse events for analysis and
Proactively manage the collection and recording of events reporting
data in a timely manner
Identify data quality and analysis issues, identify information gaps and make
recommendations on how to learn from, and prevent system failures
Analyse data and information as required, providing useful reports
Maintain, further improve and develop the process by which adverse
events are reported to the Commission, to ensure they are recorded,
collated and analysed appropriately (RL6 system; Excel and paper,
as appropriate)
Provide internal advice on adverse events learning to the
Commission to support other programmes in the delivery of their work
plans, and to guide Commission in choice of programmes
Provide guidance to sector on questions relating to adverse event
Support the review of national reportable events policy, as necessary
Implementation of annual programme work plan
Represent the Adverse events programme externally as required by
the manager and wider team.
Promote integration with AE programme relationship management
Facilitate integration of trigger tool data with adverse event data to
broaden the perspective on harm
Assist with using TT data to provide internal advice to the
Assist with sharing lessons learnt from TT data across the sector
Maintain and strengthen relationships with key Ministry, DHB, HDC
ACC and other health provider personnel responsible for provision of
events data
Maintain and strengthen relationships with agencies that have a
responsibility to undertake review for the purposes of system
improvement (i.e. DHBs, providers).
Advise other team members on opportunities for progressing team
work programmes
Assist in the development of material for communication with the
Undertake other tasks as allocated by the management
Apply the principles of cultural safety to the projects being managed.
Display respect, sensitivity and cultural awareness in interpersonal
Acknowledge cultural differences by respecting spiritual beliefs, cultural
practices and lifestyle choices
Take responsibility for meeting the Commission’s obligations in workplace
health and safety
Contribute to a healthy and safety working environment and healthy and
safe working practices
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Key relationships
The Board of the
Chief Executive
Executive Assistant
Board Secretary
Manager of Business
Systems & CFO
General Manager
(Deputy CE)
Monitoring & Evaluation
Principal Advisor
Quality Improvement
Partners in Care
Medical Advisor
All Commission employees have a responsibility for managing relationships in some or all of the key
sectors we work with. In this role, the key relationships to be developed are as follows:
Reports to:
Manager, MRC and AELP (who reports to the General Manager
Internal relationships:
Medical advisor (clinical lead of the AELP)
Project Manager AELP and other AELP staff
Communications team
Clinical advisors
Portfolio managers
Members of the programme teams
Mortality Review Committees and their support teams
Advisory groups
Adverse Events Expert Advisory Group (EAG)
EAG Chair
Public sector:
Ministry of Health - the individual business units
SSC and other government departments with related interests
Other key stakeholders
Health and disability
Accident Compensation Corporation, Health & Disability Commission
DHBs, NGOs, PHOs, private health sector, etc.
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Key Selection Criteria
To be considered for this role, the ideal person will need to demonstrate:
Essential experience, skills and qualities
direct experience of management of adverse events in the health system
experience and expertise with Root Cause Analysis and other methods of adverse event review
highly developed written and oral communication skills including the ability to communicate clearly and
succinctly in a variety of communication settings and styles
a tertiary or other relevant qualification preferably in health, social science, or a related discipline and ideally a
Masters degree or similar
substantial experience using a range of analytical frameworks
critical thinking and sound judgement, in particular, the ability to analyse information, develop options and think
proven ability to establish and develop effective networking, interpersonal and relationship management skills.
Desirable experience, skills and qualities
quantitative and qualitative skills applied to policy analysis, research or quality improvement
an understanding and appreciation of effective risk management and quality improvement strategies
an understanding of the health care delivery system in NZ including health and treatment terminologies
established networks across the health and disability sector in NZ.
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Essential experience, skills and qualities