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System infrastructure
Continuous quality improvement

Below are the activities and processes relating to the period when we are moving from creating change to sustaining change. ACP becomes business as usual, an expected activity, and there is entrenched clinical leadership.

The actions listed below relate to ‘embedding’ activities in each of the four quadrants for different parts of the sector. Links to downloadable associated resources and case studies are included.

Note that teams, departments and DHBs may be at different stages within and between the various quadrants.





Focuses on promoting ACP to the general public and health care sector; normalising future care planning.

Community actions:

Consumers are:

  • aware of the need to plan for future care and the importance of sharing what matters to them so it can underpin the planning of their health care
  • thinking and talking to whānau and family in the community about ACP
  • expecting to have ACP conversations as part of the whole system of care
  • acknowledging that death is a natural process that happens to everyone
  • receiving care in the place they prefer
  • referred to another provider when their needs are more specialised.

Health workforce management actions: 

  • Management provide appropriate funding to support ACP services and encourage an increase of ACP activity.

Health workforce actions:

  • Staff are supported to be ACP ambassadors.
  • The health workforce follows advance directives when the situation is relevant. If there are enduring powers of attorney and/or advance care plans, they are enacted and utilised appropriately. 
  • Staff have the required skills to support conversations and advance care plan development.
  • ACP success stories are routinely shared and published across networks. 
  • ACP promotion and advocacy or patient voice are included in job descriptions. 
Downloadable resources and case studies: 


Focuses on increasing the skills and knowledge of the health workforce and consumers.

Community actions:

Consumers are:

  • using website and tools
  • participating in ACP community meetings
  • volunteering to become ACP communicators and trainers
  • being empowered through training to co-lead an ACP programme.

Health workforce actions:

  • Staff are confident and competent and have integrated ACP into everyday practice. They:
    • know how and when to use ACP
    • can initiate early conversations
    • document all ACP conversations
    • participate in team training for support and sustainability, eg, mentoring
    • role-model ACP methods and communicate effectively.
  • Level 1 e-learning is business as usual and there is an expectation all staff will have completed it.
Downloadable resources and case studies:

System infrastructure

Focuses on the systems and processes required to maximise the investment in ACP and training so what is important to consumers is recorded, shared and valued.


  • Update ACP clinical pathways as and when systems are refined, ie, there is one point of communication with the health workforce.
  • ACP is an accepted and expected part of performance appraisal processes.
  • Local and national ACP training is advertised through established networks with high demand for training positions within targeted parts of the health workforce.
  • Regional networks are established and effective in supporting communication and distribution of information, resources and ideas across DHBs.
  • A regional ACP priority workstream is developed.
  • Continue working with IT leadership and providers to improve the IT platform.
Downloadable resources and case studies:

Continuous quality improvement

Focuses on developing an ACP culture that uses measurement and evaluation tools to determine quality processes and applies them practically for quality improvement.


  • Maintain quality cycles and monitor outcome measures (eg, annual evaluation of ACP projects and processes).
  • Use collected data and measures to:
    • inform ongoing development
    • generate reports and presentations for DHB boards, Ministry of Health, Health Quality & Safety Commission, etc.
    • inform business cases for further funding approval.
  • Use collected data and measures for research purposes, such as:
    • research articles
    • audits.
  • Continue to adopt co-design processes to inform the development of ACP resources, processes and services.
Downloadable resources and case studies:
Last updated: 2nd December, 2021