BRIEFING TO THE INCOMING
MINISTER OF HEALTH
DECEMBER 2011
Health Quality & Safety Commission
PO Box 25496
Wellington 6146
Telephone:
Email:
Website:
04 901 6040
info@hqsc.govt.nz
www.hqsc.govt.nz
Contents
Introduction............................................................................................................................................ 1
Background ........................................................................................................................................... 1
Objectives .......................................................................................................................................... 1
Room for improvement .................................................................................................................... 1
About quality and safety improvement .......................................................................................... 4
The Commission’s place in the health and disability sector .......................................................... 4
The Commission’s work ...................................................................................................................... 5
Patient and family engagement and partnership ......................................................................... 6
Clinical leadership and partnership ............................................................................................... 6
Measurement and evaluation ......................................................................................................... 7
Specific projects ................................................................................................................................... 7
Medication safety ............................................................................................................................. 8
Reportable events ............................................................................................................................ 8
Infection prevention and control ..................................................................................................... 8
Mortality review ................................................................................................................................. 8
Surgical checklist.............................................................................................................................. 9
Falls .................................................................................................................................................... 9
Contestable funds ............................................................................................................................ 9
Building sector capability for quality and safety ........................................................................... 9
How we work ......................................................................................................................................... 9
Moving towards a new future ........................................................................................................... 10
Measuring our achievements ........................................................................................................... 11
Funding ................................................................................................................................................ 12
Board members .................................................................................................................................. 12
Mortality review committee members.............................................................................................. 14
Roopu Māori members ...................................................................................................................... 14
Appendix 1: How New Zealand compares with other countries’ health quality and safety .... 15
References .......................................................................................................................................... 17
Introduction
This briefing provides information about the quality and safety of New Zealand’s health and
disability sector and how health outcomes can be improved and value for money increased
through better health quality and safety. We discuss why the Health Quality and Safety
Commission (the Commission) was established a year ago, along with a brief description of
what we are aiming to achieve, how we partner with the sector, what our work programme is,
how we are funded and what the future holds.
The briefing also provides information about who is involved in improving quality and safety
in New Zealand and provides some international comparisons.
Finally, it introduces our Board members, Chief Executive Officer, mortality review
committee members and Roopu Māori members.
Background
The Commission was established as a stand-alone Crown entity in November 2010 in
response to concern that only modest improvements in health quality and safety had been
achieved at a national level over the previous years. Quality experts argued that a strong
mandate to drive quality-related activities, greater co-ordination of appropriate quality
interventions at a national level, and strong clinical engagement were pivotal to achieving
sustained quality gains and better value for money.
The Commission is also the home of four statutory mortality review committees. The
committees review particular deaths to learn how to prevent these in the future. They work
within the Commission to inform and enable quality and system improvement within health
and other social sectors.
Objectives
The Commission’s objectives, as set out in section 59B of the New Zealand Public Health
and Disability Act 2000, are to lead and co-ordinate 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.
“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.” (Porter and Teisberg 2006)
Room for improvement
New Zealand’s health system rates well internationally, but there is still significant room for
improvement. For example:

for ‘sicker’1 New Zealanders in 2010 (Commonwealth Fund 2011):
o
1
22 percent experienced a medical, medication or laboratory test error in the past
two years
‘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.
1
o
51 percent experienced gaps in hospital or surgery discharge, including
arrangements for follow-up visits and what medications to take
o
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
(Davis et al 2001). The cost of events deemed preventable was $590 million (Brown
et al 2002)

care and outcomes of treatment are not yet distributed equally in New Zealand. For
example, nearly 50 percent more Māori than non-Māori/non-Pacific patients suffer an
in-hospital preventable adverse event (after controlling for age, deprivation,
admission type, length of stay and sex) (Davis et al 2006)

audits at Counties Manukau District Health Board (DHB) 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 (Brkic and Lewis 2007)

between 20 and 43 percent of all electronic discharge summaries undertaken at
Waitemata DHB had medication errors; these errors translated into errors in
prescriptions for patients and were communicated to the GPs (Lee and Park 2008)

the maternal mortality rate in New Zealand in 2009 was 22 per 100,000 maternities
(13.7 in 2008 and 10.3 in 2007). The perinatal mortality rate in 2009 was 11.3 per
1,000 total births (10.6 in 2008 and 10.3 in 2007). One hundred of the 721 perinatal
deaths in 2009 are considered ‘potentially avoidable’ as well as a number of the
maternal deaths (Perinatal and Maternal Mortality Review Committee 2011).
Many of the adverse events are avoidable and amenable to intervention. The 2009 report of
the Ministerial Review Group identified potential savings of about $60 million per annum
from reducing preventable adverse events in New Zealand hospitals alone (Ministerial
Review Group 2009). More recently a joint DHB/Association of Senior Medical Specialists
report Investing in Clinical Leadership for Quality and Safety Improvement (March 2011)
estimated achievable productivity gains of:

$10 to $12m from reducing falls in hospitals

$10 to $12m from reducing pressure injuries

$10 to $12m from reducing central line infections (central line associated
bacteraemia (CLAB)

$50 to 78m from reducing surgical site infections

$2 to 4m from reducing identification errors.
Examples of successful outcomes from implementation of quality and safety programmes
include:

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 about $200,000 per year

promoting hand hygiene in Starship Hospital’s newborn intensive care unit is paying
off, with greater compliance and fewer infections – over the last three years there has
2
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 result in a 30 percent reduction in patient harm caused by surgery
(Haynes et al 2009)
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 (Healthcare Improvement Scotland 2011).
There is worldwide acknowledgment that improving quality and safety can be a major
contributor to a more sustainable health and disability support system and many countries
have established quality and safety agencies. Government agencies have been established
in Australia, United Kingdom, Scotland, the United States and last year, New Zealand.
There are also many independent quality and safety organisations worldwide.
Common functions of quality and safety organisations are data collection, analysis and
reporting, education, quality improvement programme funding and advocacy. Some, such as
those in Australia and Scotland, also have regulatory and enforcement functions. Others,
including those in the United States, United Kingdom and New Zealand act as catalysts for
change, but are not mandated to carry out regulatory and enforcement roles.
In New Zealand, the separation of these two roles was deliberate. Government recognised
a potential conflict between the role of holding the sector accountable and the role of
facilitating quality and safety improvement. As a result, the Ministry of Health retained
responsibility for accountability and standards.
Appendix 1 provides information about New Zealand’s health quality and safety record
compared with other countries. New Zealand ranks reasonably well internationally on some
indicators eg, fewer patients experience co-ordination problems and more experience
positive shared decision-making with a specialist. However, we rank poorly in relation to
medical, medication and laboratory test errors – and even in those areas where we rank
well, there is significant room for improvement.
3
About quality and safety improvement
Quality and safety are on a continuum….
Quality - increasing the
likelihood of desired
health outcomes for
individuals and
Safety - minimising populations (and
increased participation
harm to individuals
from treatment in the and independence in the
health and disability case of disability)
system
Transformation making the really big
gains in quality and
outcomes, and
achieving a more
sustainable health
and disabilty sector
through innovation,
new ways of
organising services
and use of technology
doing things right
doing even better
doing the right things
Improving quality and safety is not simply about improving performance of individuals
working within the system. More important are improvements in the system itself. Some
simple examples show the importance of system change in improving safety:

wall-mounted soap dispensers in showers resulted in significant reduction in falls in
showers at Lakes DHB Orthopaedic Ward

using red syringe plungers to administer muscle relaxant medications (which make it
impossible to breathe unassisted) reduced incidences of awake paralysis at Waikato
DHB

introducing a pre-printed decimal point and standardising national medication charts
avoids the ‘classic’ ten-fold errors in dose due to illegible prescribing and
misunderstandings about dosage.
The Commission’s place in the health and disability sector
No single organisation has the mandate and power to control and determine quality and
safety across the sector. 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 including the Commission, Ministry of Health, DHBs, Primary Health
Organisations (PHOs), professional groups, clinical networks, private and NGO
organisations.
And importantly, all health and disability professionals and workers have an individual
responsibility at all times for the quality and safety of their own practice.
4
Given that quality and safety is ‘everyone’s business’, the Commission has an important role
to play in maintaining an overview and ensuring integration of the whole quality and safety
landscape.
The Commission’s work
The Commission worked with the National Health Board to agree a shared overarching goal
for improvement in health services, the New Zealand Triple Aim:

improved quality, safety and experience of care

improved health and equity for all populations

best value for public health resources.
The New Zealand Triple Aim has now been accepted by other key health agencies including
the Ministry of Health (including the National Health Board, the IT Board, the National Health
Committee, Health Workforce New Zealand), DHBs, Health Benefits Ltd and PHARMAC.
This unification of purpose is central to the Commission’s goal of improving the quality and
safety of health and disability services across the entire sector.
QUALITY
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The New Zealand Triple Aim
IMPROVEMENT
SYSTEM
Best value for public
health system resources
To achieve the Triple Aim, the Commission works with the sector to:

reduce deaths, harm and consequent wastage from preventable adverse events and
errors

reduce unwarranted variation (including the use of ineffective or inappropriate
services) and increase the use of effective services

increase value through more efficient service provision

ensure people have efficient access to effective and timely services appropriate to
needs

ensure people obtain those services (and only those services) that are right for them,
and align with their needs and values.
5
Three central elements underpin all our work, both at an operational and strategic level:

patient and family engagement and partnership

clinical leadership and partnership

use of information in a timely and effective way.
Patient and family engagement and partnership
There is growing evidence demonstrating the importance of partnerships between health
services organisations/health professionals, and patients, families, carers and consumers.
Studies have demonstrated significant benefits from such partnerships in clinical quality and
outcomes, the experience of care, and the business and operations of delivering care.
Clinical benefits include fewer deaths (Meterko et al 2010), decreased re-admission rates
(Boulding et al 2011), fewer health care acquired infections (Edgcumbe 2009), shorter stays
in hospital Di Giola et al 2007), improved adherence to treatment regimes (Arbuthnott and
Sharpe 2009) and improved functional status (di Giola et al 2007). Operational benefits
include lower costs per case and increased workforce satisfaction rates (Charmel and
Frampton 2008).
To achieve these partnerships we are supporting programmes which include:

developing a framework for the Commission and providers to work with patients,
family and carers as partners to improve health quality and safety

building the capacity of consumer representative agencies to work with providers as
partners

capturing consumer experiences

consumer literacy (initially on medication safety).
An important element of this work is shared, values-based decision-making. Identifying and
making decisions about the best health treatment or screening option can be difficult for
patients – especially when there is more than one reasonable option, when no option has a
clear advantage in terms of health outcomes, and when each option has benefits and harms
that patients may value differently.
It is important patients and their families can consider the options from a personal view (ie,
how important the possible benefits and harms are to them) and participate with their health
practitioners in making a decision.
Research has found that when patients use decision aids (pamphlets, videos or web-based
tools) they participate more in the decision-making and are able to reach choices that are
more consistent with their values. The effect on actual choices is variable, but the choice of
elective surgery is reduced when patients consider the other options (Stacey et al 2011).
The Commission is considering how it can provide frontline staff with proven tools, skills and
practical ways to work with patients and their families more effectively.
Clinical leadership and partnership
Quality and safety is unlikely to improve unless there is stronger and greater clinical
leadership and clinical engagement throughout the sector. The Commission forms
partnerships with clinical leaders and champions to ensure our work is grounded in the most
up-to-date evidence-based knowledge, translated into tools, techniques and methodologies,
and promoted and implemented across the sector.
6
Strong clinical leadership has been engaged for each of our key projects and we are
developing a broad network of clinical leaders and expert advisors who can be called on as
required for specific programmes, engaged in broad discussions about the Commission’s
work and direction, and provide leadership in the sector for implementation.
The Commission also has a key role in building leadership capability for quality and safety
improvement. We are establishing links with the National Health Services Institute for
Innovation and Improvement (England) and the Institute for Healthcare Improvement (United
States), which have a range of programmes to support implementation of change and
building capacity.
Measurement and evaluation
The use of information and knowledge in a timely and effective way is vital to sustaining a
culture of quality and safety in health care and to the effectiveness of initiatives to improve
quality and safety. The Commission is charged with providing a clear picture of sector
performance over time through national and international benchmarking. We need to provide
information that shows managers and clinicians where they are performing well, and where
improvements can be made. It is also important to know whether programmes are achieving
their outcomes. Establishing a small, meaningful and relevant set of national quality and
safety indicators is a priority, so we can use these to monitor progress and identify priorities
for action.
Information is only helpful if it is available at the right time and in a form that is readily
understood. It must make sense within the context of the clinician/patient relationship or the
services/community relationship. In New Zealand, a lot of data are collected for multiple
purposes. Our role is to focus on turning the key elements of these data into timely and
accessible information that brings greater understanding and wisdom to both clinicians and
consumers.
We are progressing:

the first report against national and international measures and indicators of quality
and safety. This will provide the starting point for time series information to track
performance and demonstrate and motivate success across the sector

the first health care variation report. This will identify unwarranted health care
outcomes and practices. Variation reporting is designed to encourage discussion by
clinicians about good practice and contributes to consumers getting appropriate
treatment regardless of who their practitioner is or where they live

the use of trigger tool surveillance to assist in identifying harm and injury to patients
and to help organisations to track and learn from their behaviours over time

the use of quality reports (also known as quality accounts) which requires leaders of
an organisation to consider the quality of their services, their priorities for
improvement, the actions they intend to take to secure improvements, and to make
this information available to the public

evaluating the effectiveness and efficiency of our key programmes.
Specific projects
The Commission inherited several existing health quality and safety projects when it was
established. These projects form the core of our current project work. Many of the projects
were focused on the hospital sector and we are increasingly widening our scope to include
the broader sector (including primary care, aged care and disability)
7
Medication safety
In order to reduce preventable medication errors and consequently reduce harm and cost
and increase patient confidence, we are leading the national Medication Safety Programme.
There is potential, over time, for substantial reductions in patient harm and in costs to free up
valuable resources. Our initial focus is on implementing:

the national adult medication chart which is a simple but effective way of reducing
medication errors

the medicine reconciliation process which ensures patient medicines are checked at
critical handover times, such as when patients are admitted to, transferred within or
discharged from hospital

the eMedicines programme in partnership with the National Health IT Board (this is a
cornerstone of the wider e-health programme).
Reportable events
We have worked with the sector to develop and agree a national policy for reporting and
managing health care incidents which will assist providers to identify and address systemic
issues in their own organisations that lead to medical errors.
Our annual serious and sentinel events report assists in identifying and promoting
understanding of systemic quality and safety issues and provides New Zealand case studies
of successful interventions.
Infection prevention and control
In order to reduce the harm and cost of avoidable infections acquired during health care, we
are leading work on infection control including:

the national Hand Hygiene Programme

the CLAB Programme

the Surgical Site Infection Surveillance Programme.
Mortality review
The Commission’s four mortality review committees report annually on mortality and
morbidity, and identify priorities for preventing such deaths and harm in future.
The Child and Youth Mortality Review Committee and the Family Violence Death Review
Committee also work locally and regionally to find and implement interagency solutions to
some of the priority issues highlighted by their work.
Current work of the committees includes:

Child and Youth Mortality Review Committee: implementing awareness campaigns
and prevention resources for sudden unexpected death in infancy (SUDI), and
addressing youth suicide in the Pacific community

Perinatal and Maternal Mortality Review Committee: identifying and targeting
perinatal deaths that can be classified as ‘potentially avoidable’

Family Violence Death Review Committee: implementing a network of regional local
review panels and reviewing family violence deaths from 2010 and 2011

Perioperative Mortality Review Committee: publishing its inaugural report on
perioperative mortality ie deaths after an operative procedure or while under the care
of a surgeon in hospital.
8
Surgical checklist
In order to reduce avoidable surgical errors (for example wrong patient, site or procedure
and retained instruments or swabs) and to improve teamwork and communication in the
operating room (which are very important factors determining outcome) the Commission is
working to improve the effectiveness of the use of the WHO Safe Surgery Checklist. The
checklist is widely used in New Zealand, but the engagement of clinicians in its use is
variable (as it is in most other countries).
We are working with Dr Atul Gawande’s unit at the Harvard School of Public Health to
implement an initiative to ensure the checklist is used ‘every time, in every theatre,
effectively’. Dr Gawande led the development of the checklist and has been running a
parallel initiative in South Carolina. This work will reinforce and interlink with the ‘productive
theatre’ work of the Ministry of Health.
Falls
In order to reduce the number and impact of falls in inpatient, residential and community
settings, the Commission is working with the DHB shared services organisation to gather
information and scope the work required.
Contestable funds
There are many exciting and effective local initiatives in different hospitals, practices, and
other health and disability organisations. Identifying and advancing those that have national
potential has long been recognised as an important but challenging opportunity to reduce
harm and make the best use of the health dollar.
The Commission has therefore provided seed funding for a selected number of health and
disability providers to test and trial new ideas. Selected providers cover a broad range of
services including disability support, older people, primary care and the community sector.
Evidence of successful initiatives will be shared with the wider sector.
Building sector capability for quality and safety
The Commission aims to assist the spread of innovation and good practice, and to introduce
the sector to leading local and international quality and safety initiatives and experts.
Education and relevant skills training is fundamental to this. Initially, we have worked with
other organisations to support their programmes, and we plan to hold at least one quality
forum each year. We are currently developing a comprehensive plan for building sector
capability into the future, focusing on the use of improvement tools, and on creating a
learning system through which frontline staff improve their knowledge and gain tools and
resources that can be applied across programmes to improve the quality and safety of their
practice.
More detail about our programmes can be found in our 2011–2014 Statement of Intent which
is attached and is also available at www.hqsc.govt.nz.
How we work
We are a 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.
We are determined to achieve the substance of change rather than merely adding to the
already excessive rhetoric in this area. This requires participation in all steps of the relevant
health and disability processes. Change must be successfully and affordably implemented
and it must be enduring. The focus must remain on the objectives of saving lives, reducing
harm and improving value for the available resource (our Triple Aim).
9
The Commission puts a great deal of emphasis on collaboration and co-ordination 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 Māori. We also have strong international links, so
that we are well-connected to innovation, evidence and advice from our colleagues
overseas.
Moving towards a new future
The Commission’s initial focus is necessarily on ‘first order changes’ aimed at improving
patient safety and service quality directly. This is reflected in our programmes to:

ensure we reduce harm

identify and address unwarranted variation

build a culture of constant examination and improvement around ‘doing the right
thing, right, first time’.
By focusing on this work, we will continue to reduce harm and achieve better value for
money from our services.
In addition the Commission needs to provide the direction and co-ordination within the sector
to:

develop and support sector leadership

develop a culture where partnerships with patients and families are the norm and
where patients and their families are able to make the values-based decisions that
mean they get those treatments (and only those) that they actually need and want

provide an overview of the whole health quality and safety landscape, make sense of
what is happening and set the quality and safety agenda

be a reliable source of information of quality and safety for the sector and develop a
sector where improvement is information driven

provide commentary and help the sector have conversations about the difficult issues
that underpin substantial wastage in health care so that we can make changes to
align our processes to the real needs and values of our patients

provide expert assistance to organisations and people implementing quality and
safety change programmes

reduce fragmentation and duplication by sharing ideas and information nationally and
providing a more systematic way to learn from each other.
Over the next few years our focus on these broader roles will increase, although our work
will always be underpinned by effective programmes to improve the safety and quality of our
health and disability services. Change occurs at the workface by participation in effective
initiatives to improve practice, not by rhetoric. It is by demonstrating to practitioners and
administrators that improving quality is both possible and worthwhile that we can best
change the quality and safety culture.
Our longer term strategy must also encompass ‘second order change’. If New Zealand is to
make the really big gains in quality and outcomes and achieve a financially sustainable
health and disability sector, we need to actively consider different ways of organising health
services.
10
Clearly greater integration is needed within health and between health and social services.
This implies stronger partnerships with patients, families and communities, a far greater
emphasis on shared values-based decision-making between patients and their providers,
increased use of technology (including information technology) and a much stronger focus
on facilitated networks of care for people with chronic needs.
There are already good examples of the use of technology to improve health outcomes of
people with chronic needs (at a lower cost). These include the use of e-therapies for people
with mild to moderate mental health problems, and the electronic depression management
programme which involves use of computers, telephone help-lines and text messaging.
Emerging technology and methods of communication have enormous potential to improve
outcomes and generate saving in the management of chronic illness. The key will be the
greater empowerment of patients to engage more effectively in their own care, while
ensuring access to the support they really need.
For example, in one programme in the United States, people with congestive heart failure
are provided with scales that send their weight wirelessly to a nurse. In one instance when a
woman put on a significant amount of weight in 24 hours, the nurse was able to ring her
within 30 minutes of getting the wireless weight reading and give her instructions on
increasing her medications, thus avoiding further deterioration and possible hospitalisation.
Shifting health care from hospitals to the community in this way reduces costs and improves
the patient experience.
The Commission will maintain an overview of international and national innovations to
ensure it is an effective catalyst for change. We are committed to ensuring New Zealand
continues to have a world-class, innovative, patient and family/whānau centred health and
disability support system with continually improving quality and safety.
Measuring our achievements
Over the next few years we will develop a clear picture of quality and safety in the sector,
and of the impacts of our work. All of our key programmes will be evaluated and monitored.
This will include an assessment of each programme’s impact on:

reducing avoidable deaths, harm and wastage

improving health outcomes

improving equity and reducing inappropriate variation

improving value for money.
We will also measure consumer satisfaction with their health and disability care experiences
and treatments.
Currently we are evaluating the Medication Safety Programme. We will measure whether the
programme is achieving its long-term goal of reducing potential and actual adverse drug
events (ADEs) resulting in improvements in:

ADE associated morbidity and mortality

ADE associated health care costs

medication safety and patient confidence in the use of medicines.
Our evaluation activity along with our time-series reports against indicators of quality and
safety will assist the Ministry of Health with its 2015 report back to Cabinet on the impact of
the Commission’s activities.
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Funding
The Commission receives annual funding of $14.5 million for its activities. Fifteen percent is
allocated to operational support costs and 85 percent to programme costs. We do not
currently receive any third-party funding.
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.
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Dr Peter Jansen
Dr 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 Martin
Geraint 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 100 lives” campaign in Wales, which used clinical
quality improvement across an entire national health care system to drive patient safety.
Mrs Anthea Penny
Anthea 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 Officer: Dr Janice Wilson
13
Mortality review committee members
Perinatal and
Maternal Mortality
Review Committee
Perioperative
Mortality Review
Committee
Child and Youth
Mortality Review
Committee
Professor Cynthia
Farquhar (Chair)
Professor Lesley
McCowan
Dr Vicki Culling
Dr Stephanie Palmer
Mrs Anja Hale
Dr Beverley Lawton
Ms Susan Bree
Dr Alec Ekeroma
Dr Margaret Meeks
Dr Graham Sharpe
Professor Iain Martin
(Chair)
Dr Digby Ngan Kee
Dr Jonathan Koea
Ms Teena Robinson
Dr Philip Hider
Dr Catherine (Cathy)
Ferguson
Dr Leona Wilson
Dr Anthony Williams
Ms Rosaleen
Robertson
Dr Nicholas
Baker (Chair)
Dr Anganette Hall
Professor Edwin
Mitchell
Dr Sharon Wong
Ms Susan Matthews
Ms Anthea Simcock
Mr Eruini George
Mr Paul Nixon
Family Violence
Death Review
Committee
Associate Professor
Julia Tolmie (Chair)
Associate Professor
Dawn Elder
Ms Ngaroma Grant
Ms Miranda Ritchie
Professor Barry Taylor
Ms Fia Turner-Tupou
Judge Paul von
Dadelszen
Associate Professor
Denise Wilson
Roopu Māori members





Tu Williams (Chair)
Rees Tapsell
Riripeta Haretuku
Leanne Te Karu
Rachel Thompson
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.
14
Appendix 1: How New Zealand compares with other countries’ health quality
and safety
The most recent Commonwealth Fund International Health Policy Survey of Sicker Adults in
Eleven Countries (2011) focused on people in fair or poor health, who had undergone
surgery or been hospitalised in the past two years, had received care for serious or chronic
illness or had an injury or disability in the past year. The survey covered Australia, Canada,
France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United
Kingdom and the United States.
The survey showed that New Zealand ranks reasonably well internationally on some
indicators, eg, fewer patients experienced co-ordination problems in the past two years, and
more experienced positive shared decision-making with a specialist. It ranks poorly in
relation to medical, medication and laboratory test errors. However, even in those areas
where we rank well, there is significant room for improvement.
Area measured
Percentage
Ranking
out of 11
countries
measured
(best = 1st)
Experienced co-ordination problems in the past two years (Test
30%
3rd
51%
5th
22%
9th
31%
6th
72%
3rd
results/records not available at time of appointment, doctors ordered
test that had already been done, providers failed to share important
information with each other, specialist did not have information about
medical history, and/or regular doctor not informed about specialist
care).
Experienced gaps in hospital or surgery discharge in the past
two years (did not receive instructions about symptoms and when to
seek further care, know who to contact for questions about condition
or treatment, receive written plan for care after discharge, have
arrangements made for follow-up visits and/or receive clear
instructions about what medicines they should be taking).
Experienced a medical, medication or laboratory test error in
the past two years.
Did not have their prescriptions reviewed and discussed in the
past year.
Experienced a positive shared decision-making experience
with specialists (Specialist always/often gives opportunities to ask
questions about recommended treatment, tells you about treatment
choices and involves you as much as you want in decisions about
your care).
The 2011 Organisation for Economic Co-operation and Development (OECD) Health at a
Glance report notes that for procedural or post-operative complications New Zealand has
rates higher than the OECD average. New Zealand is in the top four for ‘foreign body left in’
during procedure, the top three for accidental puncture or laceration and in the top three for
postoperative sepsis.
On the other hand, admission rates for asthma and Chronic Obstructive Pulmonary Disease
(COPD) have reduced significantly over the past few years and New Zealand has the
second lowest rate of avoidable admissions for uncontrolled diabetes.
15
International comparisons relevant to the work of the Commission’s mortality review
committees.



Among the industrialised nations, New Zealand has the highest rate of death from SUDI.
The burden of this problem falls disproportionately in the Māori community and amongst
families living in deprived circumstances. In New Zealand, the total mortality rate is 1.1
deaths per 1000 live births. The Māori rate is at 2.3 deaths per 1000 births while the rate
for other ethnicity is 0.52 deaths per 1000 births.
International comparisons show that New Zealand has the highest rates of youth suicide
in the OECD for both men and women aged between 15 and 19 years according to the
OECD 2009 report Doing Better for Children. Caution needs to be taken when making
international comparisons of suicide rates because many factors affect the recording and
classification of suicide and can result in undercounting of suicide in other countries.
However, it is a significant concern that too many young people die by suicide in New
Zealand.
Results of a 2003 UNICEF study of child maltreatment deaths in rich countries in the
1990s showed that New Zealand had the third highest child maltreatment death rate in
that period (1.2 deaths per 100,000 children under the age of 15 years).
16
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18