This site has not been optimised for Internet Explorer due to Microsoft no longer providing support for the browser. Please view this site using another browser such as Google Chrome or Microsoft Edge.

On this page:

System infrastructure
Continuous quality improvement

Below are the activities and processes to be considered in the first couple of years of implementation, such as building a guiding team, creating a platform and desire for change, going where people are willing, trying/piloting and sharing the small wins to build momentum.

The ‘foundation’ actions listed below for different parts of the sector relate to each of the four quadrants. 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:

  • Approach local community groups, eg, service groups, church groups, etc, and offer an ACP presentation.
  • Offer consumers opportunities to attend local ACP presentations at community venues, local groups, aged residential care facilities, etc.

Health workforce management actions: 

  • Support management to value ACP and release staff to attend ACP training and participate in ACP initiatives/processes.
  • Present at Grand Round/DHB board meetings etc, to garner support.

Health workforce actions:

  • Develop an activity plan for participation in Advance Care Planning Day. Help to organise local activities, ideas and share print resources, such as posters, postcards, etc.
Downloadable resources and case studies:


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

Community actions:

  • Create generic consumer presentations tailored to recognise the diverse needs of the community.
  • Promote the use of online ACP information and resources.
  • Work alongside the national ACP team to develop community capacity for the national community training model.
    • Recruit a team of volunteers for training.

Health workforce management actions:

  • Work alongside the national ACP team to develop local capacity for the national training model.
  • Recruit skilled staff for facilitation training by developing processes for: 
    • advertising the training
    • recruiting appropriate participants for training
    • reviewing applications for training
    • supporting trained staff.
  • Create a generic presentation for the health workforce outlining local processes (such as where to find a plan, how to recognise when to use the plan to support care, etc), which can be adapted to meet the needs of different parts of the workforce (eg, specialty, professions, etc).
  • Promote use of online ACP information and resources (eg, advance care plan and guide, brochures, level 1 modules, etc).
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.


  • Consider how advance care plans and ACP conversations will be identified in your DHB.
  • Clarify who needs to have access to an advance care plan and how this might be supported. 
    • Consider are there new or existing networks or IT systems that can be tapped into or used? 
    • Or will you create paper-based processes?
  • Consider having a dedicated ACP budget for training, presentations and printing.
  • Identify key/priority areas to target ACP local and national training initiatives.
  • Appoint a DHB ACP coordinator (this may not be a full-time role in smaller DHBs).
  • Identify where the national ACP resources (guide, brochures, etc) are received in your area, where they are kept and how they are distributed.
  • Evaluate how local processes will link with national policies and processes.
  • Identify who the target audience is for ACP in your DHB. There may be a different focus at different times (eg, chronic conditions, palliative care, the ‘surprise question’, etc).
  • Establish a local steering group and appoint a clinical lead.
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.


  • Define your DHB’s parameters regarding quality. Does it have a baseline for quality of advance care plans and processes?
  • Define measures:
    • What data is your DHB going to collect?
    • How will you collect it?
    • Who are you sharing this data with? Eg, DHB annual plan, regional service plan, quality accounts, etc.
    • What format will it be shared in? Eg, raw data, graphs, etc. 
    • How will these link with national measures?
  • Develop a baseline of ACP preparedness.
  • If issues are identified with advance care plans or processes within your DHB:
    • who should be made aware?
    • who is responsible for following up?
    • who will be advised when the issue is resolved and/or further follow-up is identified as being needed?
Downloadable resources and case studies:


Last updated: 2nd December, 2021