Discussion paper:
A framework for quality improvement
and patient safety capability
and leadership-building for
the New Zealand health system
July 2015
Contents
Executive summary .......................................................................................................................... 3
Introduction ....................................................................................................................................... 5
Background ...................................................................................................................................... 6
Defining quality and safety ................................................................................................................ 7
Benefits of developing health quality and safety capability and leadership ........................................ 8
Developing a New Zealand capability framework .............................................................................. 9
The framework ................................................................................................................................ 10
1
Capabilities of consumers .................................................................................................... 13
2
Capabilities of everyone engaged in the health and disability workforce .............................. 15
3
Capabilities of operational, clinical and team leaders, and other change agents .................. 19
4
Capabilities of senior organisational leaders ........................................................................ 25
5
Capabilities of quality and safety experts.............................................................................. 31
6
Capabilities of governance/boards ....................................................................................... 37
July 2015 Draft Capability Framework
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Executive summary
The Health Quality & Safety Commission (the Commission) has a national mandate to develop and
support capability and leadership in quality improvement and patient safety to ensure that the
delivery of health care is consistent with its overarching framework, the Triple Aim. Building
capability is identified as one of the Commission’s strategic priorities to assist the sector to effect
change.
This document describes a high level framework to guide the development of quality and safety
capability across all levels in the health care sector, including consumers. It has been developed at
the request of the sector and informed by an expert advisory group.
The framework is intended to provide the basis for a common understanding of the expected
knowledge, skills and underpinning values required to achieve better quality and safer patient
centred health care.
Articulating this for each of the broad roles within health care provides a benchmark against which
organisations and individuals can gauge their current knowledge and identify future requirements for
learning and development. It also serves to clarify and deepen understanding of the responsibilities
associated with each role to enable more effective and consistent delivery of quality and safety
expectations for patient care.
Currently, the quality improvement capability of the health sector in New Zealand is reflected in
uneven system performance, with a few centres of excellence and islands of good practice as well
as an over-reliance on the commitment and expertise of individuals to drive the quality and safety
agenda. There is a compliance orientation towards quality and a lack of confidence in the
sustainability of gains.
The serious failures in the Mid-Staffordshire National Health Services Foundation Trust demonstrate
the consequences of not having quality and safety as a central consideration within the systems of
their organisation. One of Berwick’s nine groups of recommendations in response focused on
education, training and capacity building (National Advisory Group on the Safety of Patients in
England 2013) which has also been recognised by many other international health systems.
To date the Commission’s focus on building capacity has been on quality improvement advisor
scholarships, sponsored course attendances, supporting visits by international speakers, and
building capability and leadership as part of all campaigns and collaboratives. The Commission
believes there now needs to be a broader and more integrated approach to address the complex
change challenge involved in achieving and enhancing system wide quality and safety.
Such a strategy needs to include addressing existing workforce needs, sustainably building the
quality improvement capability of the future workforce; developing specialist roles in quality
improvement science; supporting consumer participation; ensuring decision-making based on data
and evidence; and supporting boards to provide leadership that encourages a quality improvement
and patient safety focus throughout the sector.
This capability and leadership framework will provide the basis for a common understanding of the
knowledge, skills and underpinning values required to achieve better quality and safer patient
centred health care, and provides overall direction to the health sector. For each of the groups
identified in the framework, we define who typically belongs within these broad categories, and
July 2015 Draft Capability Framework
Page 3
outline the quality and safety knowledge and actions that could reasonably be expected within the
roles in each group.
The framework also recognises that most health care is delivered within the context of teams and
within services. Quality and safety capability and leadership within and between multidisciplinary
teams and networks is required for the seamless and safe care of patients, as part of the systems of
care within an organisation.
Ultimately, embedding quality improvement and safety within all roles will result in organisations
demonstrating a more mature quality and safety culture, and having in place the requisite systems
and structures to enhance the delivery of better patient outcomes. Making explicit the expected
knowledge, skills and behaviours required across broad roles within health care will enhance
system capability.
July 2015 Draft Capability Framework
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Introduction
Safer and better quality care occurs when those in governance and management, health
practitioners, non-clinical staff and consumers all work together at all levels of the health system
with a common purpose. This common purpose been expressed through the New Zealand Triple
Aim.
The Triple Aim identifies three dimensions that together mean:



providing effective, evidence-based treatments that meet the values and needs of
individuals
ensuring there is improved health and equity for all populations in New Zealand
avoiding harm and waste by doing the right thing first time.
Achieving the Triple Aim requires more than technical knowledge and skills. It requires a capable
workforce that can adapt to meet the changing needs of the complex health care environment
(Bodenheimer and Sinsky 2014). This can only occur in a system where consumer1 safety and their
experience of care is a top priority. Compassionate care, underpinned by openness and
transparency, to engender mutual trust and respect is fundamental to enable consumers and the
health care workforce to work effectively together to co-design a more resilient health care system.
The Health Quality & Safety Commission (the Commission) has a national mandate to develop and
support capability and leadership in quality improvement and patient safety to ensure that the
delivery of health care is consistent with its overarching framework, the Triple Aim (Health Quality &
Safety Commission 2014). The Commission clearly identifies building sector capability as one of its
strategic priorities to assist the sector to effect change (Health Quality & Safety Commission 2014).
This document describes a high level framework to guide the development of quality and safety
capability across all levels in the health care sector, including consumers. It has been developed at
the request of the sector and informed by an expert advisory group.
http://www.hqsc.govt.nz/assets/General-PR-files-images/EAG-representative-Aug-2015.pdf
In this document the words ‘consumer’ and ‘patient’ are considered interchangeable. It is assumed that
these terms embody the broader concept of individuals and/or their whanau/families as applicable.
1
July 2015 Draft Capability Framework
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Background
Currently, the quality improvement capability of the health sector in New Zealand is reflected in
uneven system performance, with a few centres of excellence and islands of good practice as well
as an over-reliance on the commitment and expertise of individuals to drive the quality and safety
agenda. There is a compliance orientation towards quality and a lack of confidence in the
sustainability of gains.
The serious failures in the Mid Staffordshire National Health Services Foundation Trust in 2005–08
demonstrate the consequences of not having quality and safety as central to the systems of an
organisation. One of Berwick’s nine groups of recommendations in response to the Francis Report
(Robert Francis 2013) focused on education, training and capacity building (National Advisory
Group on the Safety of Patients in England 2013), which has also has been recognised by many
international jurisdictions (Lachman 2013, Went 2013, Wales 2014).
The Commission has embarked on building capability as a key strategy for improving health care
quality and safety. To date the focus has been on quality improvement advisor scholarships,
sponsored course attendances, supporting visits by international speakers, and building capability
and leadership as part of all campaigns and collaboratives. The Commission believes there now
needs to be a broader and more integrated approach to address the complex change challenge
involved in achieving system wide quality and safety.
Such a strategy needs to include addressing existing workforce needs, sustainably building the
quality improvement capability of the future workforce, developing specialist roles in quality
improvement science, supporting consumer participation, ensuring decision-making based on data
and evidence, and supporting boards to provide leadership that encourages a quality improvement
and patient safety focus throughout the sector.
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Defining quality and safety
In 2003 in ‘Improving Quality: A systems approach for the New Zealand Health and Disability
Sector’ (Minister of Health 2003) quality was defined as follows:
‘Within a systems approach, quality can be defined as the degree to which the services for
individuals or populations increase the likelihood of desired health outcomes, and/or
increase the participation and independence of people with a disability, and are consistent
with current professional knowledge (adapted from Lohr (1990)). Quality is the cumulative
result of the interactions of people, individuals, teams, organisations and systems.’
The key dimensions of quality include the following:
1. Safe: avoiding harm to patients from the care that is intended to help them.
2. Effective: providing services based on scientific knowledge to all who could benefit, and
refraining from providing services to those not likely to benefit.
3. Patient-centred: providing care that is respectful of and responsive to individual patient
preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
4. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
5. Accessible and equitable: providing care that does not vary in quality because of personal
characteristics such as gender, age, ethnicity, geographic location, and socioeconomic
status.
In this paper we do not specify timeliness as a separate dimension as we see this as a component
of other dimensions of effectiveness, accessibility and efficiency. The dimensions above are
underpinned by the foundations of the partnership, participation and protection principles of the
Treaty of Waitangi (Te Tiriti).
While safety is considered a dimension of quality, the inherently hazardous nature of health care
and the high numbers of reported adverse events means safety demands additional consideration.
As defined above, safety is essentially about avoiding harm caused by the process of health care.
To date there has been a strong emphasis on improving safety by learning from past harm. The
causes of patient harm from health care however are seldom simple. In an increasingly complex
health care system, safety needs to be addressed as a system property:
‘Safety does not reside in a person; device or department. Improving safety depends on
learning how safety emerges from the interaction of components’(Cooper, Gaba et al. 2000).
Improving safety requires a focus on what goes right as much as what goes wrong. This
strengthens our understanding of how the system works and how to build system resilience by
ensuring that things go in the right direction (Hollnagel 2014).
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Benefits of developing health quality and safety capability and leadership
Developing workforce capability and leadership offers an important platform for better health care
quality and safety outcomes, and a more systematic and predictable quality and safety response
across the health and disability sector, with the following envisaged medium- and long-term benefits
(Rimmer 2012).
Envisaged medium-term benefits include:




a transparent quality and safety agenda in which everyone has an opportunity to participate
a critical mass of the (technical and leadership) skills and knowledge in quality and safety to
facilitate system-wide spread and change
more consistent application nationally of quality and safety knowledge, tools and techniques,
demonstrated by active projects and improved performance on key quality and safety
priorities
wider engagement and participation by patients/communities in their health and disability
services.
Envisaged long-term benefits include:



a health culture where ‘quality and safety is inherent in everything we do’
a health system that is responsive to patient needs and preferences through effective
partnerships across all levels of health care
reduced harm, waste and unwarranted variation across the system with quality and safety
outcomes matching or better than comparable health systems.
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Developing a New Zealand capability framework
Developing a New Zealand capability framework is important for a number of reasons:




It will provide the basis for a common understanding of the knowledge, skills and
underpinning values required to achieve better quality and safer patient-centred health care.
It provides overall direction to planning and development for capability building across all
levels of the health sector, including consumers.
It is intended to articulate clearly specific leadership expectations for quality and safety at
each level of the health system from all frontline clinical and non-clinical staff to senior
executive teams and Board members.
It will also inform the development of a range of training and education programmes to meet
the needs of the sector, so that there is a coherent approach to building quality and safety
capability in New Zealand.
Ongoing lifelong learning in quality and safety should be supported by a range of education delivery
strategies that are easily accessible to all health care workers throughout their careers, to advance
knowledge and skills, including:



postgraduate pathways in quality and safety that will support a New Zealand evidence base
for quality and safety
a coordinated education programme, using a variety of delivery models and providers with
recognised levels of attainment through New Zealand Qualifications Authority certification,
that will support ongoing education and training for health care workers
the development of a New Zealand College/Association that will support specialist roles in
quality and safety, and provide the necessary leadership to support and sustain excellence
in quality and safety in the New Zealand health care system.
Sustaining a knowledgeable and skilled workforce in quality and safety can only occur in the context
of:




a culture across all levels within the health and disability sector where quality and patient
safety are the central foci
consumer partnership across all levels in the health and disability sector to inform quality
and safety improvement initiatives
effective governance and leadership, both clinical and managerial, across all levels within
the health and disability sector to improve quality and safety
an infrastructure being in place to support and sustain capability in quality and safety across
the sector.
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The framework

The New Zealand framework builds on other frameworks previously described by leading
health care organisations, including NHS Scotland, Kaiser Permanente, (NHS Scotland ,
Scrimshaw and Parisi 2013). Appendix 1: http://www.hqsc.govt.nz/assets/General-PR-filesimages/Sector-full-discussion-paper-appendix-1-Aug-2015.docx
The New Zealand framework has been chosen to describe capabilities rather than competencies.
While both competence and capability are required for the ongoing improvement of the quality and
safety of health care, capability reflects a perspective that builds on competence, to include the
ability to adapt to change and generate new ideas and knowledge. It is about staying curious and
open-minded, attributes that are essential for a 21st century workforce (Fraser and Greenhalgh
2001).
The New Zealand Framework takes a whole of system approach as described in the following
definition (Batalden and Davidoff 2007):
‘the combined unceasing efforts of everyone – healthcare professionals, patients and their
families, researchers, payers, planners and educators – to make changes that will lead to
better patient outcomes (health), better system performance (care) and better professional
development (learning).’
It is unique in describing consumer capabilities. Consumers have an important role to play not only
with respect to managing their own health, but also by being actively engaged in the planning and
design of care to improve quality and safety.
The framework also recognises that most health care is delivered within the context of teams and
within services. Quality and safety capability and leadership within and between multidisciplinary
teams and networks is required for the seamless and safe care of patients, as part of the systems of
care within an organisation.
Organisations express capability not only through their systems and structures, but more importantly
through their culture, values and behaviours. Exemplary organisations are those where quality and
safety practices and values are embedded as part of routine practice, resulting in measurable
improvements in the patient experience of care and patient outcomes.
Ultimately, embedding quality and safety within all roles will result in organisations demonstrating a
more mature quality and safety culture, and having in place the requisite systems and structures to
enhance the delivery of better patient outcomes. Making explicit the expected knowledge, skills and
behaviours required across broad roles within health care will enhance system capability.
For our quality and safety framework nine domains have been identified and defined as follows:
July 2015 Draft Capability Framework
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Domain
Description
1. Partnerships with
patients/consumers and their
whānau/families
Establishes meaningful engagement with each
patient/consumer and their whānau/family as the central
participant of the health care team
2. Quality and safety culture
Contributes to and models a culture that values and
promotes quality and safety as top priorities
3. Leadership
Doing what is right and setting an example so that others
follow. In the context of a defined leadership role, leadership
carries the responsibility of setting the direction for improving
quality and safety consistent with organisational and national
goals
4. Systems thinking
Optimises system performance by being aware that a
system is an interdependent group of items, people or
processes, with a common purpose, and working with others
to avoid unintended consequences
5. Teamwork and communication
Works with others across professional and organisational
boundaries to facilitate achieving shared quality and safety
goals.
6. Improvement is evidence-based
and data-driven
Decisions are made on evidence rather than beliefs and
perceptions
7. Quality improvement knowledge
and skills
Applies appropriate tools and methods to improve the quality
of care
8. Patient safety knowledge and
skills
Applies appropriate tools and methods to ensure the delivery
of safe care
9. Managing change
Knows and uses principles of change management to
support effective implementation and sustainability of quality
and safety improvements

In developing domains and grouping knowledge and actions within these domains, we have
taken account of the literature that describes generic capabilities as well as drawing on a
number of sources of information specifically related to competencies in quality and safety.
Appendix 2: http://www.hqsc.govt.nz/assets/General-PR-files-images/Sector-full-discussionpaper-appendix-2-Aug-2015.docx
The New Zealand framework has chosen to identify capabilities by health care groups. These apply
equally across the primary, secondary and aged care sectors. Health care groups have been
broadly classified as follows:
1.
2.
3.
4.
5.
6.
Consumers
Everyone engaged in the health and disability workforce
Operational, clinical and team leaders and other change agents
Senior organisational leaders
Quality and safety experts
Boards
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For each of the groups identified in the framework, we define who typically belongs within these
broad categories, and outline the quality and safety knowledge and actions that could reasonably be
expected as part of that role. We have taken a slightly different approach with the role of consumers
and have not specified domains but summarised the key capabilities more generically.
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1
Capabilities of consumers
The consumer group includes everyone who accesses the health care system, either for their
own purposes, or on behalf of another person (for example, as parents or caregivers). Enabling
consumers to become equal partners in care requires support that builds consumers’ selfefficacy, self-awareness, confidence and coping skills (refer http://www.eupatient.eu/campaign/PatientsprescribE/).
Consumers may participate within all levels of the health care system, not only to achieve
outcomes for themselves and their whānau/families, but also to participate in advisory roles in
the planning, design and delivery of health care services. The increasing focus on building
consumer engagement and partnerships (Carmen, Maurer et al 2013) requires a level of health
literacy that enables consumers to achieve health outcomes as individuals and for the
population as a whole.
Consumers need to feel empowered to ask questions, so they can find, interpret and use
information and health services to make effective decisions about their own and/or their
whanau/family’s health and wellbeing, in partnership with their health care providers.
Consumer engagement also facilitates consumer participation in advisory roles, where
consumers are able to share their experiences and contribute to discussions about planning and
designing care for improved quality and safety.
Consumers need an awareness that they can access information about their rights under the
under the Code of Health and Disability Services Consumers’ Rights Act (1996) and be able to
make a complaint to the provider/health care organisation or the Health and Disability
Commissioner in the event they feel their rights have been breached.
1.1 Consumers interact with healthcare providers in a way that helps them achieve their
desired outcomes
KNOWLEDGE OF
ACTIONS
1.1.1
the concept of partnership and
what that means for consumers
with respect to their own health
and that of their whānau/family
1.1.9
1.1.2
how to formulate questions
relevant to their needs
1.1.3
where to find information and
services relevant to their needs
1.1.10 participate in their care by expressing their
preferences and asking questions to
ensure their needs are met and health care
goals are achieved
1.1.4
how to read and interpret the
information
1.1.5
how to communicate with their
health care provider to express
their needs and preferences
1.1.12 participate in advisory roles by sharing their
experience and contributing to discussions
about planning and designing care for
improved quality and safety
1.1.6
the safety risks that may be
associated with receiving health
1.1.13 work with staff to help redesign care to
apply skills to ask questions, find, interpret
and use information and health services to
maximise their own health and well-being,
or that of their whānau/family
1.1.11 communicate concerns about any quality
and safety where appropriate,
July 2015 Draft Capability Framework
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care
1.1.7
1.1.8
the importance of expressing
concerns to health care providers
and the mechanisms for giving
feedback in their experience of
care
address safety or quality issues for the
future
1.1.14 raise concerns with the provider, health
care organisation or the Health and
Disability Commissioner in the event they
feel their rights have been breached
the Health and Disability Code of
Rights & Complaints process
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2
Capabilities of everyone engaged in the health and disability workforce
At this ‘foundation’ level, everyone requires a basic understanding about the importance of
improving quality and safety in health care by reducing harm, waste and variation.
To do this, they need an appreciation of health care as a process with patients as the central focus.
Berwick cited in (Evans 2014)), described ‘constant curiosity’ as a property of a systems thinker. In
this way, individuals bring their own ‘lens’ to spot ways to make things better and safer for patients
at all levels in the organisation.
There needs to be willingness by every person employed in health care organisations to engage in
quality and safety improvement efforts appropriate to their role and their sphere of work. Simple
quality and safety tools should therefore be part of everyone’s skill set in health care. For some this
can be as simple as identifying and reducing waste, standardising an aspect of care or testing a
small change.
Working collaboratively with others in teams is everyday practice in health care. Relationship skills
are therefore essential. With the move to more network-based care involving multidisciplinary teams
both within and between organisations, effective communication, mutual respect and shared values
are basic competencies that enable teams to achieve optimal outcomes for patients.
Managing information is a critical competency for health care workers in the 21st century. This
means individuals must be able integrate, analyse and critically appraise information in real time so
they can adapt and respond to changing demands. This may include the need at times to innovate
and broaden their scope.
2.1 Partnerships with patients/consumers and their whānau/families
Establish meaningful engagement and partnerships with patients/consumers and their
whānau/families as the central participants of the health care team
KNOWLEDGE OF
ACTIONS
2.1.1
the core values associated with
patient centred care
2.1.4
applies the principles of patient centred care
as part of their everyday practice
2.1.2
the concept of patient engagement
and patient partnership across the
spectrum of health care as a key
strategy for improving health
outcomes
2.1.5
partners with the patient/consumer and their
whānau/family so that their care is tailored to
meet their expressed needs and preferences
2.1.6
identifies the health literacy of their patients
and adapts communication style to ensure
the patient/consumer and their whānau/family
understand key information and are
supported to ask questions
2.1.3
the principles of health literacy and
cultural competency
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2.2 Quality and safety culture
Contribute to and model a culture that values and promotes quality and safety as top priorities
KNOWLEDGE OF
ACTIONS
2.1.1
what a good quality and safety
culture is and the links with better
patient outcomes
2.1.4
fosters a quality and safety culture within their
own work environment
2.1.5
is open and transparent in words and actions
2.1.2
the value of openness and
transparency in health care and the
implications for quality and safety
2.1.6
recognises and reports quality and safety
concerns
2.1.3
the importance of reporting and the
mechanisms for reporting in their
own organisation
2.3 Leadership
Doing what is right and setting an example so that others follow. In the context of a defined
leadership role, leadership carries the responsibility of setting the direction for improving quality and
safety consistent with organisational and national goals
KNOWLEDGE OF
ACTIONS
2.3.1
2.3.2
demonstrates leadership appropriate to their
role
2.3.3
models doing the right thing in both words
and actions
2.3.4
motivates and leads others to do the right
thing in words and actions
2.3.5
delivers safe and effective care every time for
the right patient in the right place at the right
time
the broad principles of leadership
and the implications for their own
role within the team
2.4 Systems thinking
Optimise system performance by being aware that a system is an interdependent group of items,
people or processes with a common purpose; and work with others to avoid unintended
consequences
KNOWLEDGE OF
ACTIONS
2.4.1
2.4.4
demonstrates an awareness of where their
role fits in the context of the wider system
2.4.5
works within their team or department and
ensures that actions taken don’t have
unintended consequences for other areas
the New Zealand health care
context- both the structure and
function of national, regional and
local organisations
2.4.2
health care as a complex system
2.4.3
local systems and processes
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2.5 Teamwork and communication
Work with others across professional, organisational and cultural boundaries to facilitate achieving
shared quality and safety goals
KNOWLEDGE OF
ACTIONS
the basic principles of:
2.5.5
effective communication skills
including active listening
demonstrates understanding of the purpose
of the team
2.5.6
team building skills including
individual member traits and how
they contribute to team functioning
demonstrates understanding of their roles,
strengths and responsibilities as well as that
of each team member
2.5.7
ensures written and verbal communications
to exchange information are clear, respectful
and logical\
2.5.8
plans and manages time and responsibilities
to achieve team objectives
2.5.9
adapts and adjusts own behaviour and
strategies to meet team objectives
2.5.1
2.5.2
2.5.3
conflict management and resolution
2.5.4
giving and receiving constructive
feedback
2.5.10 shows trust and respect for others in the
workplace
2.5.11 applies active listening and effective conflict
management skills
2.5.12 gives, receives and acts on constructive
feedback in the context of an open team
culture
2.6 Improvement is evidence-based and data-driven
Decisions are made on evidence rather than on beliefs and perceptions
KNOWLEDGE OF
ACTIONS
2.6.1
how to source evidence
2.6.3
2.6.2
simple measurement concepts to
establish the facts
uses best practice evidence to inform their
own practice
2.6.4
uses facts rather than beliefs and perceptions
to substantiate decisions and identify
opportunities for improvement
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2.7 Quality improvement knowledge and skills
Apply appropriate tools and methods to improve the quality of care
KNOWLEDGE OF
ACTIONS
2.7.1
the history and current context of
health care improvement
2.7.5
participates in quality improvement projects in
their local environment
2.7.2
the key drivers of poor quality care:
harm, waste and variation
2.7.6
identifies and defines problems, especially in
relation to harm, waste and variation
2.7.3
the principles of improvement
2.7.7
sets a simple goal for improvement
2.7.4
how to apply simple Quality
Improvement tools
2.7.8
is able to develop a simple measure to
evaluate an aspect of care or service delivery
2.7.9
applies simple tools for improvement
2.7.10 knows where to ask for help
2.8 Patient safety knowledge and skills
Apply appropriate knowledge, tools and methods to ensure the delivery of safe care
KNOWLEDGE OF
ACTIONS
2.8.1
the nature and extent of patient harm
2.8.5
complies with organisational safety practices
2.8.2
the basic principles of human factors
including human error
2.8.6
is risk aware
2.8.7
reports safety concerns
2.8.3
how to report and learn from adverse
events and near misses
2.8.8
anticipates future threats and take steps to
minimise risk
2.8.4
the importance of openness and
transparency and the principles of
open disclosure
2.8.9
participates in adverse event reviews when
required
2.9 Managing change
Know and use principles of change management to be supportive of the effective implementation
and sustainability of quality and safety improvements
KNOWLEDGE OF
ACTIONS
2.9.1
how change can impact on self and
others
2.9.3
participates in and supports change
processes
2.9.2
the importance and value of
implementing sustainable quality and
safety improvements
2.9.4
adapts own behaviour and attitudes to
accommodate change
2.9.5
empowers change within the local work team
2.9.6
actively communicates successful change
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3
Capabilities of operational, clinical and team leaders, and other change
agents
Operational and clinical leaders are in positions that require them to facilitate and lead change
within teams and services. This identifies them as champions for quality and safety with a
responsibility to foster innovative practices and creativity within team and service areas in order to
bring about changes to improve the quality and safety of care.
As ‘middle managers’, operational and clinical leaders are the ‘bridge’ between the senior
leadership and the frontline. Ensuring organisational objectives are actioned at the front line
requires strategic thinking and planning skills and a degree of organisational awareness to create
an environment for change.
To effect change, leaders need a sound working knowledge of improvement science and safety
science methods, including an understanding of measurement for improvement to monitor the
quality and safety aspects of patient care and to identify problems. In developing solutions, they
need to use an evidence-based approach to inform decision-making and then test, evaluate and
refine the impact of selected interventions.
Leaders also need to be able to lead and work with teams and consumer groups in the co-design
and redesign of care. By modelling desirable behaviours and their ability to communicate effectively,
they should be able to create a culture that has a focus on improving the quality and safety of care
for patients. Leadership and management skills at this level will enable them to execute a number of
portfolios effectively.
Team leaders, nurse educators, and intern supervisors may also lead local quality and safety
projects at a unit or service level. Providing learning opportunities for staff on both a formal and
informal basis not only improves knowledge and skills, but creates the momentum that keeps staff
engaged and curious about how they can ‘take the next step’ to improve quality and safety.
Anyone in health care can be a ‘change agent’, however some have formal roles in leading service
and organisational change to improve the quality and safety of health care. Other change agents in
the organisation include those who are not in formal leadership roles, but who also cause a change
in the way things are done or the way ideas are viewed. These are not the formal change agents
such as quality improvement advisors who are ‘experts’.
July 2015 Draft Capability Framework
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3.1 Partnerships with patients/consumers and their whānau/families
Establish meaningful engagement and partnerships with patients/consumers and their
whānau/families as the central participant of the health care team
KNOWLEDGE OF
ACTIONS
3.1.1
the core values associated with
patient centred care
3.1.5
3.1.2
the concept of patient engagement
and patient partnership across the
spectrum of health care as a key
strategy for improving health
outcomes
model and ensure that staff apply the
principles of patient centred care as part of
their everyday practice
3.1.6
model and ensure that staff adapt their
communication style to ensure
patient/consumer and their whānau/family
understand key information and are
supported to ask questions
3.1.7
facilitate active participation by consumers of
healthcare in the co-design of care across all
levels of health care
3.1.3
3.1.4
the principles of health literacy and
cultural competency
the concept of co-design in health
care as a way of involving patients in
co-producing health at the individual,
organisational and policy levels to
improve the experience of care for
patients
3.2 Quality and safety culture
Contribute to and model a culture that values and promotes quality and safety as top priorities
KNOWLEDGE OF
ACTIONS
3.2.1
3.2.5
champion an ideal quality and safety culture
within their own work environment
3.2.6
ensure their words and actions model and
uphold the values of openness and
transparency
3.2.7
measure safety culture and use the results to
inform improvement
3.2.8
receive and act on quality and safety
concerns raised and escalate where
appropriate
3.2.9
manage safety risks using a systems-based
approach
3.2.2
what an ideal quality and safety
culture is and the links with better
patient outcomes
the value of openness and
transparency in healthcare and the
implications for quality and safety
3.2.3
how to measure the safety culture
3.2.4
balancing system versus individual
accountabilities and approaches to
improving the safety and reliability of
healthcare
July 2015 Draft Capability Framework
Page 20
3.3 Leadership
Doing what is right and setting an example so that others follow. In the context of a defined
leadership role, leadership carries the responsibility of setting the direction for improving quality and
safety consistent with organisational and national goals
KNOWLEDGE OF
ACTIONS
3.3.1
transformational leadership theory
and practice
3.3.5
3.3.2
the application of organisational
theory and management in health
care (including strategic planning)
set and lead the strategic direction for quality
improvement in collaboration with the senior
executive team and board
3.3.6
methods and tools for clinical and
operational risk assessment and
management
chair or participate in organisational
committees that have a key influence on
quality and safety within the organisation
3.3.7
lead continuous quality improvement by
working with key stakeholders and across
boundaries to create effective strategies for
organisational change to reduce waste,
improve capacity and flow, streamline
processes and enhance the patient
experience of care
3.3.8
lead, motivate and support teams in the
design of patient centred care and manage
organisational implementation and spread
3.3.9
coach and mentor to improve capability in
quality and safety leadership
3.3.3
3.3.4
giving and receiving constructive
feedback
3.4 Systems thinking
Optimise system performance by being aware that a system is an interdependent group of items,
people or processes with a common purpose, and work with others to avoid unintended
consequences
KNOWLEDGE OF
ACTIONS
3.4.1
the New Zealand health care context
including both the structure and
function of national, regional and local
organisations
3.4.7
demonstrate an awareness of the various
roles they undertake and/or manage in the
context of the wider system
3.4.8
3.4.2
the New Zealand Triple Aim and
managing resources appropriately to
achieve best value outcomes for
individuals and population
demonstrate awareness about the complex
interplay between patients, health care
workers and the work environment, and can
explain the implications for the quality and
safety of care
3.4.3
health care as a complex adaptive
system
3.4.9
3.4.4
quality as a systems feature
use a multidisciplinary approach to analyse
system quality and safety gaps and prioritise
strategies for actions
3.4.5
the application of systems theory and
operational management in health
3.4.10 coordinate quality and safety improvement
locally and across service and organisational
boundaries to ensure the integrity of the
July 2015 Draft Capability Framework
Page 21
care
3.4.6
system
systems and processes in key
services and organisations they
interact with
3.4.11 build capability to improve team and system
resilience
3.5 Teamwork and communication
Work with others across professional, organisational and cultural boundaries to facilitate achieving
shared quality and safety goals
KNOWLEDGE OF
ACTIONS
the basic principles of:
3.5.7
foster a team culture that supports quality
and safety
3.5.8
model communication that is clear, respectful
and logical
3.5.9
model trust and respect for others in the
workplace
3.5.1
3.5.2
effective team work and impact on
patient outcomes
team building skills including
individual member traits and how they
contribute to team functioning
3.5.3
effective communication skills
including active listening
3.5.4
conflict management and resolution
3.5.5
negotiation skills
3.5.6
giving and receiving constructive
feedback
3.5.10 demonstrates understanding of their roles,
strengths and responsibilities as well as that
of each team member
3.5.11 adapt and adjust their own behaviour and
strategies to meet team objectives
3.5.12 use active listening, effective conflict
management and negotiation skills for quality
and patient safety
3.5.13 give and receive constructive feedback in the
context of an open team culture
3.6 Improvement is evidence-based and data-driven
Decisions are made on evidence rather than on beliefs and perceptions
KNOWLEDGE OF
ACTIONS
3.6.1
evidence-based practice methods
and tools
3.6.8
3.6.2
types of data, sampling
methodologies, data collection and
management
use evidence and industry benchmarks to set
performance standards and inform
continuous performance improvement to get
the best value for health care resources at
population and individual levels
3.6.3
the reliability validity and limitations of
metrics for measurement
3.6.9
access and appraise evidence to identify best
practice
3.6.4
the role of quantitative and qualitative
data for improving system
performance
3.6.10 use valid and reliable measures to evaluate
aspects of service delivery, drive
improvement and inform change and
sustainability
3.6.5
data analysis, interpretation and
presentation to communicate results
3.6.11 use multiple data sources and a broad range
July 2015 Draft Capability Framework
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3.6.6
the requirement for a broad range of
metrics to understand system
performance and reliability
3.6.7
measurement strategies for system
improvement
of metrics to assess system performance and
reliability and to identify areas for
improvement
3.6.12 measure and act on patient/consumer
experience of care and monitor clinical
outcomes
3.7 Quality improvement knowledge and skills
Apply appropriate tools and methods to improve the quality of care
KNOWLEDGE OF
3.7.1
ACTIONS
the history and current context of
health care improvement
3.7.2
the concepts of harm, waste and
variation in health care
3.7.3
improvement methodologies and
tools
3.7.4
measurement strategies for
improvement
3.7.5
implementing and sustaining
improvements
3.7.6
successful improvements in other
organisations nationally and
internationally
3.7.7
identify and define problems especially in
relation to harm, waste and variation
3.7.8
set goals for improvement that are specific,
measurable, achievable, realistic and time
bound (SMART)
3.7.9
work with quality improvement experts to
select appropriate methodology and tools for
improvement
3.7.10 use effective measurements to baseline
current practice and track improvements
3.7.11 identify potential solutions and conduct
sequential tests of change
3.7.12 implement interventions and monitor to
ensure sustainability
3.7.13 support creativity and innovative practice in
system change
3.7.14 coach and mentor others to build capability in
quality improvement
3.8 Patient safety knowledge and skills
Apply appropriate tools and methods to improve the reliability of delivering safe care
KNOWLEDGE OF
ACTIONS
3.8.1
patient safety concepts and
frameworks
3.8.9
3.8.2
the nature and extent of patient harm
3.8.10 use and model appropriate safety practices
to manage risk and increase the reliability of
ensure that an effective clinical governance
structure is in place
July 2015 Draft Capability Framework
Page 23
3.8.3
the principles of ‘human factors’
including human error
3.8.4
approaches to managing safety risks
at the individual and organisational
levels
3.8.5
a systems approach to analyse and
learn from systems failures to
improve patient safety (incident
investigation and analysis)
safe care locally and across the system
3.8.11 is risk aware (clinically and operationally) and
reports safety concerns
3.8.12 is proactive in anticipating future threats and
takes steps to minimise risk
3.8.13 use a systems approach in responding to and
mitigating the consequences of human error
3.8.14 apply human factors knowledge to increase
the safety of system performance
3.8.6
the principles of open disclosure
including understanding the impact on 3.8.15 participate in adverse event reviews to
identify and address system vulnerabilities
others
3.8.7
the role of incident management
systems for organisational reporting
and learning
3.8.16 model openness by sharing learning from
failures and successes and encourage
conversations about safety risks
3.8.8
barriers and enablers for reporting
and learning from system failures
3.8.17 coach and mentor others to build capability in
patient safety
3.8.18 work with senior leaders to ensure that
systems and processes are in place to
support patients, whanau/families and staff
after adverse events
3.9 Managing change
Know and use principles of change management to support effective implementation and
sustainability of quality and safety improvements
KNOWLEDGE OF
ACTIONS
3.9.1
change management theory and
practice
3.9.6
3.9.2
how change can impact on self and
others
communicate the vision for change in
collaboration with the senior executive team
and build a compelling story
3.9.7
help create the imperative for change
3.9.8
assess the readiness for change
3.9.9
lead and support service change processes
3.9.3
facilitation tools and techniques for
leading change
3.9.4
the importance and value of
implementing sustainable quality and
safety improvements
3.9.5
basic understanding of social
movement concepts
3.9.10 build good relationships and networks across
service and organisational boundaries to
influence and engage others for change
3.9.11 empower change within their team and
service areas
3.9.12 actively communicate successful change
July 2015 Draft Capability Framework
Page 24
4
Capabilities of senior organisational leaders
A commitment to improving quality and safety starts with the Board and is operationalised and led
by senior organisational leaders. Together, the Board and senior leaders set the organisational
strategic quality direction and goals, aligned with the national priorities for improvement. They
uphold and model the organisational values for staff and consumers.
The senior organisational leaders need to ensure flexible and responsive governance structures
that enable and support teams and the organisation to adapt to a constantly changing and
challenging health care environment, and ensure that effective clinical governance systems are in
place.
Clear expectations and a compelling story need to be communicated by senior leaders in a way that
supports an organisational culture for learning, and helps create the imperative and leverage for
changes that make care safer and more effective. This group doesn’t necessarily need to have an
in-depth knowledge of quality and safety methodologies, but they do need at least foundation level
knowledge. Understanding the concept of variation and being able to interpret data means they will
know what questions to ask to keep the organisation on track to meet its objectives for
improvement.
Working with quality improvement experts, they will select and prioritise portfolios that align with the
organisational quality and safety objectives, to ensure a cohesive and systematic approach to
quality and safety improvement work.
4.1 Partnership with patients/consumers and their whānau/family
Establish meaningful engagement and partnership with patient/consumer and their whānau/family
as the central participant of the health care team
KNOWLEDGE OF
ACTIONS
4.1.1
the core values associated with
patient centred care
4.1.5
4.1.2
the concept of patient engagement
and patient partnership across the
spectrum of health care as a key
strategy for improving health
outcomes
ensure and enable consumer participation in
decision-making about health and disability
services at every level including governance,
planning, policy, setting priorities, and
highlighting quality improvement
opportunities
4.1.6
the principles of health literacy and
cultural competency
facilitate the co-design of care across all
levels of health care
4.1.7
apply patient centred care principles to
organisational decision-making
4.1.8
ensure that staff are enabled to apply the
principles of patient centred care and
facilitate patient empowerment as part of
their everyday practice
4.1.3
4.1.4
the concept of co-design in health
care as a way of involving patients
in co-producing health at the
individual, organisational, and policy
levels to improve the experience of
care for patients
July 2015 Draft Capability Framework
Page 25
4.2 Quality and safety culture
Contribute to and model a culture that values and promotes quality and safety as top priorities
KNOWLEDGE OF
ACTIONS
4.2.1
what an ideal quality and safety
culture is and the links with better
patient outcomes
4.2.5
champion an ideal quality and safety culture
within their own work environment
4.2.6
4.2.2
the value of openness and
transparency in health care and the
implications for quality and safety
ensure their words and actions model and
uphold the values of openness and
transparency
4.2.7
4.2.3
how to measure the safety culture
4.2.4
balancing system versus individual
accountabilities and approaches to
improving the safety and consistent
quality of health care
ensure safety culture measurement is
undertaken and the results used to inform
improvement
4.2.8
receive and act on quality and safety
concerns raised and escalate where
appropriate
4.2.9
takes a lead in ensuring clinical and
operational risk management systems are
current, effective and given equal
consideration
4.3 Leadership
Doing what is right and setting an example so that others follow. In the context of a defined
leadership role, leadership carries the responsibility of setting the direction for improving quality and
safety consistent with organisational and national goals
KNOWLEDGE OF
ACTIONS
4.3.1
transformational leadership theory
and practice
4.3.5
4.3.2
the application of organisational
theory and management in health
care (including strategic planning)
set and lead the organisational strategic
direction for quality improvement in
collaboration with the board
4.3.6
ensure that each member of the team
sponsors, chairs or participates in
organisational committees that have a key
influence on quality and safety within the
organisation
4.3.7
ensure continuous quality improvement with
key stakeholders and across boundaries, to
create effective strategies for organisational
change to reduce waste, improve capacity
and flow, streamline processes and enhance
the patient experience of care
4.3.8
motivate and support organisational and
clinical leaders in the design of patient
centred health care
4.3.9
ensure organisational implementation and
4.3.3
methods and tools for clinical and
operational risk assessment and
management
4.3.4
the value of giving and receiving
constructive feedback
July 2015 Draft Capability Framework
Page 26
spread of effective quality and safety
initiatives
4.3.10 ensure structures and processes are in place
to support emerging leaders
4.3.11 coach and mentor to improve capability in
quality and safety leadership
4.3.12 acknowledge and celebrate successful
quality improvements
4.4 Systems and process thinking
Optimise system performance by being aware that a system is an interdependent group of items,
people or processes with a common purpose and work with others to avoid unintended
consequences
KNOWLEDGE OF
ACTIONS
4.4.1
the New Zealand health care
context including the structure and
function of national, regional and
local organisations
4.4.7
4.4.2
the New Zealand Triple Aim and
managing resources appropriately
to achieve best value outcomes for
individuals and the population
demonstrate awareness about the complex
interplay between patients, health care
workers and the work environment, and can
explain the implications for the quality and
safety of care
4.4.8
draw on multidisciplinary input and use
quality improvement advisors to analyse
system quality and safety gaps and prioritise
strategies for action
4.4.9
ensure that quality and safety improvement is
coordinated locally and across organisational
boundaries
4.4.3
4.4.4
the systems and processes in key
organisations, and agencies they
interact with
health care as a complex adaptive
system
4.4.5
quality as a systems feature
4.4.6
the application of systems theory
and operational management in
health care
4.4.10 build organisational quality and safety
capability and capacity to improve system
resilience
4.5 Teamwork and communication
Work with others across professional, organisational and cultural boundaries to facilitate achieving
shared quality and safety goals
KNOWLEDGE OF
ACTIONS
the basic principles of:
4.5.7
foster a team culture that supports quality
and safety
4.5.8
model communications that are clear,
respectful and logical
4.5.1
4.5.2
effective team work and impact on
patient outcomes
team building skills including
July 2015 Draft Capability Framework
Page 27
individual member traits and how
they contribute to team functioning
4.5.9
model trust and respect for others in the
workplace
4.5.3
effective communication skills
including active listening
4.5.4
conflict management and resolution
4.5.10 demonstrates understanding of their roles,
strengths and responsibilities as well as that
of each team member clarifying their roles in
quality and safety
4.5.5
negotiation skills
4.5.6
giving and receiving constructive
feedback
4.5.11 build organisational team capability by
providing adequate resources including time,
to ensure teams are effective in supporting
quality and safety
4.5.12 adapt and adjust own behaviour and
strategies to meet executive team objectives
4.5.13 model effective strategies for conflict
management and negotiation to enhance
quality and safety
4.5.14 give and receive constructive feedback in the
context of an open team culture
4.6 Improvement is evidence-based and data-driven
Decisions are made on evidence rather than on beliefs and perceptions
KNOWLEDGE OF
ACTIONS
4.6.1
evidence-based practice methods
and tools
4.6.7
4.6.2
the requirement for a broad range of
metrics to understand system
performance and reliability
use evidence and industry benchmarks to set
organisational performance standards and
take decisions to get the best value for health
care resources at population and individual
levels
4.6.3
measurement strategies for system
improvement
4.6.8
4.6.4
types of data, sampling
methodologies, data collection and
management
use valid and reliable measures to evaluate
aspects of service delivery, drive
improvement and inform change and
sustainability
4.6.9
ensure services use evidence-based practice
4.6.5
the reliability, validity and limitations
of metrics for measurement
4.6.6
data analysis, interpretation and
presentation to communicate results
4.6.10 receive and act on information from multiple
sources to drive organisational quality and
safety improvement
4.6.11 measure and act on patient/consumer
experience of care and monitor clinical
outcomes
July 2015 Draft Capability Framework
Page 28
4.7 Quality improvement knowledge and skills
Apply appropriate tools and methods to improve the quality of care
KNOWLEDGE OF
ACTIONS
4.7.1
the history and current context of
health care improvement
4.7.7
4.7.2
the concepts of harm, waste and
variation in health care
use an effective set of measures to monitor
quality performance of services and foster
openness and transparency with the results
4.7.8
improvement methodologies and
tools
ensure resources are appropriately allocated
to achieve quality and patient safety goals
4.7.9
ensure patient participation in quality
improvement
4.7.3
4.7.4
measurement strategies for
improvement
4.7.5
implementing and sustaining
improvements
4.7.6
successful improvements in other
organisations nationally and
internationally
4.7.10 ensure and resource adequate quality
improvement expertise to meet current and
future demand and build capability in quality
improvement
4.7.11 encourage creativity and innovative practice
in system change
4.7.12 encourage the sharing of learning through
coaching, mentoring, and presentations to
enable cross pollination of ideas and lessons
4.8 Patient safety knowledge and skills
Apply appropriate tools and methods to improve the reliability of delivering safe care
KNOWLEDGE OF
ACTIONS
4.8.1
patient safety concepts and
frameworks
4.8.9
4.8.2
the nature and extent of patient
harm
4.8.3
4.8.4
4.8.5
4.8.6
the principles of ‘human factors’
including human error
approaches to managing safety
risks at the individual and
organisational levels
a systems approach to analyse and
learn from systems failures to
improve patient safety (Incident
investigation and analysis)
the principles of open disclosure
including understanding the impact
on others
ensure and operationalise an effective
organisational patient safety framework to
manage current and future safety risks
4.8.10 ensure and resource an effective clinical
governance structure
4.8.11 ensure and resource adequate patient safety
expertise to meet current and future demand,
and build capability and capacity
4.8.12 use an effective set of measures to
understand and monitor system safety and
reliability
4.8.13 demonstrate openness and transparency,
and share learnings by communicating the
results about system successes and failures,
escalating as appropriate
4.8.14 ensure staff use appropriate safety practices
to manage risk and increase the reliability of
July 2015 Draft Capability Framework
Page 29
4.8.7
4.8.8
the role of incident management
systems for organisational reporting
and learning
the barriers and enablers for
reporting and learning from system
failures
safe care across the system
4.8.15 ensure all staff and patients are encouraged
to report operational and clinical safety
concerns
4.8.16 champion and take part in safety walkarounds
4.8.17 ensure a systems approach and human
factor knowledge is used in adverse event
reviews
4.8.18 ensure and resource systems to support
patients, whanau/families and staff after
adverse events
4.9 Managing change
Know and use principles of change to support effective implementation and sustainability of quality
and safety improvements
KNOWLEDGE OF
ACTIONS
4.9.1
change management theory and
practice
4.9.6
communicate the organisational vision for
change and build a compelling story
4.9.2
how change can impact on self and
others
4.9.7
help create the imperative for change
4.9.8
4.9.3
facilitation tools and techniques for
leading change
assess the readiness for organisational
change
4.9.9
champion and support organisational change
processes
4.9.4
4.9.5
the importance and value of
implementing sustainable quality
and safety improvements
basic understanding of social
movement concepts
4.9.10 build good relationships and networks across
organisational and agency boundaries to
influence and engage others for change
4.9.11 empower collaborative change within their
organisation
4.9.12 actively communicate successful change
July 2015 Draft Capability Framework
Page 30
5
Capabilities of quality and safety experts
Experts are those who have advanced expertise in the application of quality and safety
methodologies and tools, and operate within organisations in a high level advisory capacity, working
both in dedicated quality improvement roles and in other capacities. This means they need to have
an overview of the system’s capabilities and the ability to critically analyse, design, manage and
facilitate quality and safety improvement projects. Their roles may vary depending on the size of
organisation they are working in and the other staff working in this area.
Experts work closely with the executive leadership team to influence strategy and policy. For this
they need to ensure the appropriate metrics are in place to provide the information needed to inform
and monitor the system.
Experts also work closely with the middle managers to enable the translation of organisational goals
into actions at the frontline. For this, they need a sophisticated level of knowledge about the use of
data to monitor the reliability of processes and the safety of systems to identify gaps. An ability to
interpret and communicate results at the appropriate level is essential.
Expertise here is often referred to as ‘deep’ knowledge in the fields of improvement and safety
science – but they also need the skills to mentor and coach others across all levels in the
organisation. Experts need to be able to have relationships across the spectrum from consumers to
boards, and be able to communicate effectively at all levels to effect change.
Coming from diverse backgrounds experts often bring a very strong system perspective and a focus
on process that challenges health care thinking and guides it towards new paradigms.
5.1 Partnerships with patients/consumers and their whānau/families
Establish meaningful engagement and partnership with patient/consumer and their whānau/family
as the central participant of the health care team
KNOWLEDGE OF
ACTIONS
5.1.1.
the core values associated with
patient centred care
5.1.5
5.1.2.
the concepts of patient
engagement and patient
partnership across the spectrum of
health care as key strategies for
improving health outcomes
promote, provide guidance and collaborate to
ensure consumer participation and decisionmaking about health and disability services
occurs at every level – including governance,
planning, policy, setting priorities, and
highlighting quality improvement opportunities
5.1.6
model and support staff in applying the
principles of patient centred care as part of
their everyday practice
5.1.7
work with teams/organisations to facilitate
consumer participation in the design of care
across all levels of health care
5.1.8
collaborate with consumers to provide
guidance to ensure patient centred care
principles are applied in organisational
decision-making
5.1.3.
the principles of health literacy and
cultural competency
5.1.4.
the concept of co-design in health
care as a way of involving patients
in co-producing health at the
individual, organisational and policy
levels, to improve the experience of
care for patients
July 2015 Draft Capability Framework
Page 31
5.2 Quality and safety culture
Contribute to and role model a culture that values and promotes quality and safety as top priorities
KNOWLEDGE OF
ACTIONS
5.2.1
what an ideal quality and safety
culture is and the links with better
patient outcomes
5.2.5
champion an ideal quality and safety culture
within their own work environment and across
the organisation
5.2.2
how to analyse safety culture
measurements and use for
improvement
5.2.6
ensure their words and actions model
openness and transparency
5.2.7
5.2.3
the value of openness and
transparency in health care and the
implications for quality and safety
provide guidance and support with measuring
the safety culture and using the results for
improvement
5.2.8
5.2.4
system versus individual approaches
to improving the safety and reliability
of health care
assist senior leaders with identifying and
prioritising and addressing quality and safety
concerns
5.3 Leadership
Doing what is right and setting an example so that others follow. In the context of a defined
leadership role, leadership carries the responsibility of setting the direction for improving quality and
safety consistent with organisational and national goals
KNOWLEDGE OF
ACTIONS
5.3.1
transformational leadership theory
and practice
5.3.2
5.3.3
5.3.4
5.3.5
5.3.6
the application of organisational
theory and management in health
care (including strategic planning)
work with senior leaders to set and lead the
organisational strategic direction for quality
improvement
5.3.7
methods and tools for clinical and
operational risk assessment and
management
support the senior leadership team in bringing
a quality and safety focus to organisational
meetings
5.3.8
chair or participate in organisational
committees that have a key influence on
quality and safety within the organisation
5.3.9
provide expertise to facilitate continuous
quality improvement with key stakeholders
and across boundaries
principles of sustainability and
spread
the value of giving and receiving
constructive feedback
5.3.10 motivate and support organisational and
clinical leaders in the design of patient
centred health care
5.3.11 support and provide guidance to ensure
organisational implementation and spread of
effective quality and safety initiatives
July 2015 Draft Capability Framework
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5.4 Systems and process thinking
Optimise system performance by being aware that a system is an interdependent group of items,
people or processes with a common purpose and work with others to avoid unintended
consequences
KNOWLEDGE OF
ACTIONS
5.4.1
the New Zealand health care context
including the structure and function
of national, regional and local
organisations
5.4.6
teach about the complex interplay between
patients, health care workers and the work
environment and the implications for the
quality and safety of care
5.4.2
New Zealand Triple Aim and
managing resources appropriately to
achieve best value outcomes for
individuals and the population
5.4.7
ensure human factors knowledge is applied in
detecting and ameliorating deficiencies in the
processes of care
5.4.8
5.4.3
health care as a complex adaptive
system
work with multidisciplinary teams to analyse
system quality and safety gaps and prioritise
strategies for action
5.4.4
systems and processes in key
organisations and agencies they
interact with
5.4.9
facilitate the coordination of quality and safety
improvement initiatives locally and across
organisational boundaries
5.4.5
tools available to analyse the
organisation and its processes
5.4.10 lead organisational quality and safety
leadership and capability building to improve
system resilience
5.4.11 challenge the status quo by asking the right
questions
5.5 Teamwork and communication
Work with others across professional, organisational and cultural boundaries to facilitate achieving
shared quality and safety goals
KNOWLEDGE OF
ACTIONS
the basic principles of:
5.5.7
foster a team culture that supports quality and
safety
5.5.8
model communications that are clear,
respectful and logical
5.5.9
model trust and respect for others in the
workplace
5.5.1
5.5.2
effective team work and impact on
patient outcomes
team building skills including
individual member traits and how
they contribute to team functioning
5.5.3
effective communication skills
including active listening
5.5.4
conflict management and resolution
5.5.10 work with senior leadership and middle
managers to help clarify and support roles
and responsibilities in quality and safety
July 2015 Draft Capability Framework
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5.5.5
negotiation skills
across the organisation, including their own
5.5.6
giving and receiving constructive
feedback
5.5.11 adapt and adjust their own behaviour and
strategies to meet service and organisational
objectives
5.5.12 model effective strategies for conflict
management and negotiation to enhance
quality and safety
5.5.13 give and receive constructive feedback in the
context of an open team culture
5.6 Improvement is evidence-based and data-driven
Decisions are made on evidence rather than on beliefs and perceptions
KNOWLEDGE OF
ACTIONS
5.6.1
5.6.7
provide guidance on identifying and using
evidence and industry benchmarks to set
organisational performance standards
5.6.8
the requirement for a broad range of
metrics to understand system
performance and reliability
take decision to get the best value for health
care resources at population and individual
levels
5.6.9
the role of quantitative and
qualitative data for improving system
performance
promote the use of evidence-based practice
across the organisation
5.6.10 ensure data is used as evidence to support
any quality and safety initiative
the application of appropriate
statistical techniques, evidencebased practice methods and tools
Expertise in:
5.6.2
5.6.3
5.6.4
types of data, sampling
methodologies, data collection and
management
5.6.5
the reliability validity and limitations
of metrics for measurement
5.6.6
data analysis, interpretation and
presentation to communicate results
5.6.11 set up and use a broad range of metrics to
measure and monitor system performance
and reliability to identify improvement
opportunities
5.6.12 undertake robust data analyses and
communicate the results effectively and
timely
5.6.13 teach measurement methods and tools to
build organisational capability in using
appropriate measurement strategies to drive
improvement
5.6.14 apply relevant statistical methods to support
improvement
July 2015 Draft Capability Framework
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5.7 Quality improvement knowledge and skills
Apply appropriate tools and methods to improve the quality of care
KNOWLEDGE
ACTIONS
Expertise in
5.7.7
ensure the use of effective sets of measures
to monitor quality performance of services
and support openness and transparency with
communicating the results
5.7.1
the history and current context of
health care improvement
5.7.2
the concepts of harm, waste and
variation in health care
5.7.8
lead creativity and innovative practice in
patient centred system change
5.7.3
improvement methodologies and
tools
5.7.9
5.7.4
measurement strategies for
improvement
teach quality improvement concepts,
theories, skills and tools to build quality
improvement capability and expertise in the
organisation to meet future demand
5.7.5
effective implementation strategies
and how to sustain improvements
5.7.6
how other organisations, nationally
and internationally, have
successfully improved aspects of
care
5.7.10 share learning through coaching, mentoring,
and presentations to enable cross pollination
of ideas and lessons
5.7.11 help organisations in the use of appropriate
tools and techniques
5.7.12 provide expertise and feedback to quality
improvement initiatives
5.7.13 facilitate the implementation and
sustainability of quality improvement
initiatives
5.8 Patient safety knowledge and skills
Apply appropriate tools and methods to enhance the delivering of safe care
KNOWLEDGE
ACTIONS
Expertise in
5.8.7
work with senior leaders and middle
managers to guide and support the
application of appropriate safety practices to
manage risk and increase the reliability of
safe care locally and across the system
5.8.8
work with senior leaders and middle
managers to ensure an effective clinical
governance structure
model clinical and operational risk awareness
and support reporting of safety concerns by
staff and patients
5.8.1
patient safety concepts
5.8.2
the psychology of human error
5.8.3
concepts of harm and the role of
human factors and its application in
health care to improve quality and
safety
5.8.4
approaches to manage safety risks
at the individual and organisational
levels
5.8.9
5.8.5
incident investigation and analysis
process
5.8.6
the principles of open disclosure
5.8.10 are proactive in anticipating future threats and
work with staff at all levels to identify and take
steps to minimise risk
July 2015 Draft Capability Framework
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including understanding the impact
on others
5.8.11 uphold and teach a systems approach in
responding to and mitigating the
consequences of human error
5.8.12 teach human factors knowledge to increase
the safety of system performance
5.8.13 lead adverse event reviews to address
system vulnerabilities
5.8.14 set up and support a system for sharing
learning from failures and successes to
improve system performance
5.8.15 teach, coach, mentor, and support others to
build capability and expertise in patient safety
to meet future demands
5.8.16 work with senior leaders to ensure that
systems and processes are in place to
support patients, whanau/families and staff
after adverse events
5.9 Managing change
Know and use principles of change to support effective implementation and sustainability of quality
and safety improvements
KNOWLEDGE OF
ACTIONS
Expertise in
5.9.5
communicate and support the organisational
vision for change with senior executives,
boards and operational and clinical leads
5.9.6
assess and communicate the readiness for
organisational change
5.9.7
champion and support organisational change
processes
5.9.8
build good relationships and networks across
organisational and agency boundaries to
influence and engage others for change
5.9.9
facilitate and lead a collaborative change
process
5.9.1
change management theory and
practice
5.9.2
facilitation tools and techniques for
leading change
5.9.3
the importance and value of
implementing sustainable quality and
safety improvements
5.9.4
basic understanding of social
movement concepts
5.9.10 actively communicate successful change and
encourage participants to share their stories
July 2015 Draft Capability Framework
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6
Capabilities of governance/boards
A commitment to improving quality and safety starts with the Board and is operationalised and led
by senior organisational leaders. The Board with the senior leadership team set the organisational
strategic quality direction and goals aligned with national priorities for improvement. These leaders
uphold and model the organisational values for staff and consumers and have ultimate responsibility
for the governance of compassionate, patient centered, quality clinical care within their health
organisation. They are instrumental in setting, championing and ensuring a quality and safety
culture within their organisations.
The Board, along with the senior organisational leaders, needs to ensure flexible and responsive
governance structures are used that enable and support teams and the organisation to adapt to
constantly changing and challenging health care environments and ensure that effective clinical
governance systems are in place. They are responsible for putting in place the structures and
systems to support patient engagement and partnership.
The Board and senior leaders need to set clear expectations of staff and communicate a compelling
story in a way that supports an organisational culture for learning, and helps create the imperative
for change, to make care safer and more effective.
The Board or governance team needs to ensure and enable training programmes for building
capability and leadership within the organisation, to ensure all staff have the necessary knowledge,
skills and behaviours to meet the quality and safety requirements appropriate to their role.
All board members need a base ‘foundation’ level understanding about the importance of improving
quality and safety in health care by reducing harm, waste and variation.
6.1 Partnership with patients/consumers and their whānau/family
Establish meaningful engagement and partnerships with patients/consumers and their
whānau/families as the central participant of the health care team
KNOWLEDGE OF
ACTIONS
6.1.1
the core values associated with
patient centred care
6.1.2
the concepts of patient
engagement and patient
partnership across the spectrum of
health care as key strategies for
improving health outcomes
6.1.3
6.1.4
the principles of health literacy and
cultural competency
the concept of co-design in health
care as a way of involving patients
in co-producing health at the
6.1.5 ensure and enable consumer participation
and decision-making about health and
disability services at every level – including
governance, planning, policy, setting
priorities, and highlighting quality
improvement opportunities
6.1.6 ensure that staff apply the principles of
patient centred care as part of their
everyday practice
6.1.7 facilitate participation by consumers in the
co-design of care across all levels of health
care
July 2015 Draft Capability Framework
Page 37
individual, organisational and policy
levels, to improve the experience of
care for patients
6.1.8 apply patient centred principles to board
decision-making
6.2 Quality and safety culture
Contribute to and model a culture that values and promotes quality and safety as top priorities
KNOWLEDGE OF
ACTIONS
6.2.1
what an ideal quality and safety
culture is and the links with better
patient outcomes
6.2.4
champion and ensure a quality and safety
culture within their organisation
6.2.5
6.2.2
safety culture and measurements to
inform improvement
ensure that each Board agenda has quality
and safety as the first item, and includes
patient stories, feedback and qualitative
reports and measures
6.2.3
the value of openness and
transparency in health care and the
implications for quality and safety
6.2.6
uphold the values of openness and
transparency culture
6.2.7
ensure that the organisational strategic plan
clearly articulates the quality and safety vision
for the organisation
6.2.8
review safety culture measurements and
ensure senior executive team act on
outcomes
6.2.9
ensure clinical and operational risk
management systems are current, effective
and given equal consideration.
6.2.10 ensure that quality accounts are published
annually and used to inform strategic quality
plans and agenda
6.3 Leadership
Leadership is about doing what is right and setting an example so that others follow. In the context
of a defined role, it is also that, but carries the responsibility of setting the direction for improving the
quality and safety of care consistent with organisational and national goals
KNOWLEDGE OF
ACTIONS
6.3.1
6.3.4
transformational leadership theory
and practice
set and lead the organisational strategic
direction for quality and safety in collaboration
with the executive team consistent with
July 2015 Draft Capability Framework
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6.3.2
6.3.3
organisational theory and
management in health care
(including strategic planning)
clinical and operational risk
management
national priorities
6.3.5
with senior management set specific goals to
reduce harm each year
6.3.6
ensure structures and processes are in place
to support the strategic vision and direction
for quality improvement and safety
6.3.7
ensure structures and processes are in place
to support organisational leadership and
emerging leaders
6.4 Systems and process thinking
Optimise system performance by being aware that a system is an interdependent group of items,
people or processes with a common purpose and work with others to avoid unintended
consequences
KNOWLEDGE OF
ACTIONS
6.4.1
6.4.4
ensure and support management in building
quality and safety capability and capacity
6.4.5
ensure that quality and safety is coordinated
across organisational boundaries
6.4.6
ensure the organisation meets the national
agenda for quality and safety
6.4.7
draw on multidisciplinary input and use
quality improvement advisors to explore and
advise on system quality and safety gaps and
to prioritise strategies for action
6.4.2
6.4.3
the New Zealand health care context
including the structure and function
of national, regional and local
organisations
the New Zealand Triple Aim and
managing resources appropriately to
achieve best value outcomes for
individuals and the population
health care as a complex adaptive
system
6.5 Teamwork and communication
Work with others across professional, organisational and cultural boundaries to facilitate achieving
shared quality and safety goals
KNOWLEDGE OF
ACTIONS
the basic principles of:
6.5.7
clarify roles and responsibilities in quality and
safety for the board
6.5.8
team building skills including
individual member traits and how
they contribute to team functioning
build board capability by undertaking training
and education in quality and safety
6.5.9
model communications that are clear,
respectful and logical
effective communication skills
6.5.10 adapt and adjust behaviours and strategies to
6.5.1
6.5.2
6.5.3
effective team work and impact on
patient outcomes
July 2015 Draft Capability Framework
Page 39
including active listening
meet board and organisational objectives
6.5.4
conflict management and resolution
6.5.5
negotiation skills
6.5.6
giving and receiving constructive
feedback
6.5.11 model trust and respect for others in the
board and organisation
6.5.12 model effective strategies for conflict
management and negotiation to enhance
quality and safety
6.5.13 give and receive constructive feedback in the
context of an open team culture
6.6 Improvement is evidence-based and data-driven
Decisions are made on evidence rather than on beliefs and perceptions
KNOWLEDGE OF
ACTIONS
6.6.1
the principles of evidence-based
practice methods and tools
6.6.7
6.6.2
a broad range of metrics as part of
the requirement for a broad range of
metrics to understand system
performance and reliability
use evidence and industry benchmarks to
evaluate organisational performance and take
decisions to get the best value for health care
resources at population and individual levels
6.6.8
receive and act on information from multiple
sources to drive organisational quality and
safety improvement
6.6.9
apply evidence for best practice to their own
board activities for improving board
performance
6.6.3
measurement strategies for system
improvement
6.6.4
types of data, sampling
methodologies, data collection and
management
6.6.5
the reliability, validity and limitations
of metrics for measurement
6.6.6
data analysis, interpretation and
presentation to communicate results
6.7 Quality improvement knowledge and skills
Apply appropriate tools and methods to improve the quality of care
KNOWLEDGE
ACTIONS
Have a basic understanding of
6.7.6
use an effective set of measures to monitor
quality performance of the organisational and
its services and foster openness and
transparency with the results
6.7.7
ensure resources and expertise are
appropriately allocated to achieve quality and
patient safety goals to meet current and
future demand
6.7.8
ensure and resource consumer participation
and partnership in quality improvement
6.7.1
the history and current context of
health care improvement
6.7.2
the concepts of harm, waste and
variation in health care
6.7.3
the basic principles of improvement
methodologies and tools
6.7.4
the basic principles of measurement
strategies for improvement
July 2015 Draft Capability Framework
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6.7.5
implementing and sustaining
improvements
6.7.9
encourage creativity and innovative practice
in system redesign
6.7.10 ensure management is undertaking
continuous quality improvement
6.8 Patient safety knowledge and skills
Apply appropriate tools and methods to improve the reliability of delivering safe care
KNOWLEDGE OF
ACTIONS
6.8.1
patient safety concepts and
frameworks
6.8.7
6.8.2
the nature and extent of patient harm
ensure the organisation has a coherent and
effective safety framework to manage current
and future safety risks
6.8.3
human factors including human error
6.8.8
ensure and resource an effective clinical
governance structure
6.8.4
managing safety risks at the
individual and organisational levels
6.8.9
6.8.5
incident management systems for
organisational reporting and learning
receive an effective set of measures to
monitor safety performance of the
organisation and its services and foster
openness and transparency with the results
6.8.6
the barriers and enablers for
reporting on and learning from
system failures
6.8.10 ensure staff use appropriate safety practices
to manage risk and increase the reliability of
safe care across the system
6.8.11 ensure all staff report operational and clinical
safety concerns
6.8.12 champion and take part in safety walkarounds with the senior executive team
6.8.13 ensure openness and transparency in
learnings about system successes and
failures
6.8.14 ensure and resource adequate patient safety
expertise to operationalise the safety
framework and build organisational capability
6.9 Managing change
Know and use principles of change to support effective implementation and sustainability of quality
and safety improvements
KNOWLEDGE OF
ACTIONS
6.9.1
change management theory and
practice
6.9.4
6.9.2
how change can impact on the
organisation
assess the readiness for organisational
change that addresses quality and safety
improvements
6.9.5
champion and support organisational change
processes that target quality and safety
improvements
6.9.3
facilitation tools and techniques for
leading change
July 2015 Draft Capability Framework
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6.9.6
actively communicate successful change that
improves patient safety and health care
delivery
6.9.7
empower change within their organisation
July 2015 Draft Capability Framework
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