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

These are the next steps building on foundation activities, either through broadening applicatio

n or deepening understanding. Activities include increasing the quantity and quality of ACP, building on wins, sharing successes, widening advocacy and building clinical leadership.

The actions below relate to ‘progressing’ 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 supported and encouraged to raise ACP with health care providers and relevant others.
  • Presentations are given to relevant consumer groups (eg, service groups, church groups, community groups, etc).

Social sector actions: 

  • Develop opportunities for collaboration across health, social and other sectors.

Health workforce management actions:

  • Create an expectation that what matters to consumers informs health care planning.
  • Promote the benefits of ACP and future health care planning within DHBs to providers, non-governmental organisations, aged residential care facilities, primary health organisations, general practice and community groups.
  • Socialise ACP at orientation and inductions across the health workforce.

Health workforce actions:

  • Collect ACP stories and share successes.
  • Workforce staff are approached and supported to organise and participate in ACP promotions.
  • Plan for regular ACP articles and patient stories to feature in publications (eg, chief executive updates, quality accounts, local publications, etc).
Downloadable resources and case studies:


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

Community actions:

  • Support volunteers to work with the community and consumers.

Health workforce actions:

  • Establish infrastructure, processes and policies to support locally trained ACP facilitators to deliver ACP in your DHB and maximise the value of the training, ie, tracking conversations.
  • Engage and educate the health workforce and give them the tools to initiate, participate and facilitate ACP. 
  • Incorporate level 1 e-learning modules into continuous education processes.
  • Existing level 2 practitioners mentor and support other staff with ACP activities and conversations.
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.


  • Incorporate ACP into established systems and processes (eg, annual performance appraisals for health workforce staff).
  • Develop and implement processes to support the strategic advertisement and selection of staff to attend ACP training at both a local and national level.
  • Develop a regional ACP network linking with representatives from each DHB in your region to:
    • network
    • share ideas and activities
    • distribute ACP communications, information and updates.
  • Cultivate conversations with IT providers/DHB IT leadership regarding electronic ACP.
  • Appoint a regional ACP coordinator to support regional ACP deployment in line with the national ACP policies and the work of the team.
  • Negotiate an ongoing budget to support the ACP coordinator/facilitator role.
  • Consider how your DHB might support ACP initiatives and the creation of advance care plans (eg, ACP subsidy for primary care).
  • Develop clinical pathways to communicate and share processes at a local and regional level (eg, HealthPathways, Map of Medicine, etc).
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.


  • Collect ACP data.
  • Identify local opportunities for ACP improvement and innovation.
  • Provide DHB data to the Health Quality & Safety Commission for national measures.
    • Contribute to national knowledge on the process and impact of ACP.
  • Develop pilot projects to implement aspects of ACP, and evaluate using feedback loop processes.
  • Use co-design to inform ACP processes and services, and the development of ACP resources.
Downloadable resources and case studies: 
Last updated: 2nd December, 2021