Section 3.2: My pathway to wellbeing
Criterion 3.2.1

Aged care: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.

Home and community: Guidance


Home and community: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Service providers undertake assessment according to best practice.
Service providers have policies that define time frames for completing care or support plans.
Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.

Residential disability: Guidance

Service providers have a documented transition process that:

is developed in partnership with the person entering the service, alongside the people living in the home
demonstrates a partnership approach with the person entering the service and the people currently in the chosen home, including by considering compatibility between people who are living together
enables people moving into a residential home to choose, meet, and engage with the people they will be living with, before they move in
supports the person entering the service to maintain friendships and employment from their previous living situation.


Service providers have implemented processes that support people receiving services to:

use a supported decision-making process in determining their preferred supports
have as much influence over decisions as possible
manage their own conflicts within the home
make decisions about their own health care. This can include contacting the ambulance service or attending an annual GP health check.

Service providers arrange and provide appropriate support when a person is admitted to public hospitals and when discharged back to their home.
Service providers develop an initial care or support plan with the person and their whānau within 48 hours of them entering the home. This initial care or support plan takes account of:

a needs assessment that includes the person’s consent to share results with the provider
other relevant documentation provided.


Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Health pathways are implemented and include procedures to support practice.
Service providers undertake assessment according to best practice.
Service providers have policies that define time frames for completing care or support plans.
Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.

Residential mental health and alcohol and other drug: Guidance


Residential mental health and alcohol and other drug: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Health pathways are implemented and include procedures to support practice.

Public/private hospital: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Health pathways are implemented and include procedures to support practice.

Birthing units: Guidance


Birthing units: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Health pathways are implemented and include procedures to support practice.

Hospice: Guidance

Service providers complete an initial assessment with input from the person receiving services and their whānau.
Service providers develop care or support plans for ongoing care and support of the person receiving services.
The assessment and planning processes align with any contractual requirements and may include goal setting and time frames.
Evidence shows the service provider has asked the person seeking services if they would like whānau involved in developing their care or support plan.
Where whānau are involved, service providers work in partnership with the whānau to develop care and/or support plans.
Health pathways are implemented and include procedures to support practice.

Abortion services: Guidance


Abortion services: Guidance

Service providers undertake assessment according to best practice.
Service providers have policies that define time frames for completing care or support plans.
Evidence shows that service providers develop care or support plans in a timely manner and those plans meet the expectations of, and are agreed with, the people receiving services.
Service providers prioritise development of the care or support plan and base it on the need of the person receiving services and, if service is delayed, on assessed risk.
In some instances, it may be necessary to have support in place before a service provider has developed an in-depth care or support plan with a person receiving services. In these cases, the service provider has a process of review with the person receiving services to provide safe support.


Criterion 3.2.2
Guidance for all providers

Service providers have an implemented policy describing the model of care.
Service providers consider all other demographic information particular to each person receiving services, such as:

culture
religion
disabilities
gender
sexual orientation
relationship status
other social identities or characteristics.

Service providers involve a person’s whānau with that person’s consent.

Additional guidance

Fertility services

Service providers include escalation pathways where appropriate.

Home and community

Service providers include escalation pathways where appropriate.

Residential disability

Service providers include escalation pathways where appropriate.

Residential mental health and alcohol and other drug

Service providers include escalation pathways where appropriate.

Public/private hospital

Service providers follow current guidelines on care or support plan development; for example, the Ministry of Health’s National Maternity Clinical Guidance, specifically Observation of Mother and Baby in the Immediate Postnatal Period: Consensus statements guiding practice (2012) and National Consensus Guideline for Treatment of Postpartum Haemorrhage (2013).
Service providers include escalation pathways where appropriate.

Birthing units

Service providers follow current guidelines on care or support plan development; for example, the Ministry of Health’s National Maternity Clinical Guidance, specifically Observation of Mother and Baby in the Immediate Postnatal Period: Consensus statements guiding practice (2012) and National Consensus Guideline for Treatment of Postpartum Haemorrhage (2013).
Service providers include escalation pathways where appropriate.

Hospice

Service providers include escalation pathways where appropriate.

Abortion services

Service providers include escalation pathways where appropriate.


Criterion 3.2.3

Aged care: Guidance

Service providers demonstrate:

they have an implemented policy relating to intimacy
they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
assessment is clearly linked to the care or support plan
the care or support plan identifies key assessed risks, including medical risks
ongoing assessments and reassessments are completed where required
the care or support plan is goal focused and individualised
the care or support plan meets individualised choices and preferences
interventions describe in detail all support required to address assessed needs
cultural, spiritual, and lifestyle needs are identified and addressed
the care or support plan includes multidisciplinary involvement
service providers meet their contractual requirements
the person using services and, if appropriate, their whānau have input into the development of the care or support plan.

Where service providers provide dementia or psychogeriatric services:

interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
service providers meet their contractual requirements
the person using services and their whānau have input into the development of the care or support plan.

Relevant resources: Physiotherapy New Zealand (2022) New Zealand Physiotherapy Guidelines for Aged Residential Care (ARC)

Fertility services: Guidance

Service providers support people receiving services and their whānau to access counsellors approved by the Australian and New Zealand Infertility Counsellors Association during the consultation, diagnosis, and waiting times.
Point (h) of the criterion does not apply to assisted reproductive technology services.

Home and community: Guidance


Home and community: Guidance

The care or support plan for the person receiving services clearly articulates agreed variability and flexibility, plus any identified associated risk to the support received.
In developing a care or support plan, people are offered choice in terms of the number and type of support workers engaged for different tasks (for example, reading mail or home support).
The care or support plan effectively integrates cultural beliefs, values, and practices. Cultural aspects of a care or support plan may be identified over a period of time.
Adequate time is available to develop a person’s care or support plan.

Residential disability: Guidance

Service providers follow a supported decision-making process when developing a care or support plan.
The care or support plan should:

demonstrate how the person receiving services is being supported to self-determine
support people to develop and maintain relationships outside of the service that extend beyond whānau
be in a format accessible to the person
integrate the person’s identities, cultural needs, values, and beliefs
demonstrate that a proactive approach is taken to make people aware of options, entitlements, and community activities available to them
be agreed to and signed by the person, where possible.

The person owns the care or support plan.
The care or support plan can include:

information about how the person wants to be supported and what outcome they want to receive from the service provider. This includes essential information such as personal care and risks
evidence that the person receiving services is offered the opportunity to identify and document their personal aspirations and goals and ways to achieve these. The plan presents the person’s aspirations in a format they prefer. The person has the option to decline this aspect of the care or support plan.


Service providers document the person’s choice to participate in and have an aspirational plan.
Service providers demonstrate that people receiving services are informed of other services available to them.
Service providers have an implemented policy relating to intimacy.

Residential mental health and alcohol and other drug: Guidance

Service providers demonstrate:

they have an implemented policy relating to intimacy
they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
assessment is clearly linked to the care or support plan
the care or support plan identifies key assessed risks, including medical risks
ongoing assessments and reassessments are completed where required
the care or support plan is goal focused and individualised
the care or support plan meets individualised choices and preferences
interventions describe in detail all support required to address assessed needs
cultural, spiritual, and lifestyle needs are identified and addressed
the care or support plan includes multidisciplinary involvement
service providers meet their contractual requirements
the person using services and, if appropriate, their whānau have input into the development of the care or support plan.

Where service providers provide dementia or psychogeriatric services:

interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
service providers meet their contractual requirements
the person using services and their whānau have input into the development of the care or support plan.


Service providers follow a supported decision-making process when developing a care or support plan.
The care or support plan should:

demonstrate how the person receiving services is being supported to self-determine
support people to develop and maintain relationships outside of the service that extend beyond whānau
be in a format accessible to the person
integrate the person’s identities, cultural needs, values, and beliefs
demonstrate that a proactive approach is taken to make people aware of options, entitlements, and community activities available to them
be agreed to and signed by the person, where possible.

The person owns the care or support plan.
The care or support plan can include:

information about how the person wants to be supported and what outcome they want to receive from the service provider. This includes essential information such as personal care and risks
evidence that the person receiving services is offered the opportunity to identify and document their personal aspirations and goals and ways to achieve these. The plan presents the person’s aspirations in a format they prefer. The person has the option to decline this aspect of the care or support plan.

Service providers document the person’s choice to participate in and have an aspirational plan.
Service providers demonstrate that people receiving services are informed of other services available to them.
Service providers have an implemented policy relating to intimacy.

Hospice: Guidance


Hospice: Guidance

Service providers demonstrate:

they have an implemented policy relating to intimacy
they have a sexual safety policy that also includes the importance of risk assessment and management and actions taken in response to a complaint involving sexual safety
assessment is clearly linked to the care or support plan
the care or support plan identifies key assessed risks, including medical risks
ongoing assessments and reassessments are completed where required
the care or support plan is goal focused and individualised
the care or support plan meets individualised choices and preferences
interventions describe in detail all support required to address assessed needs
cultural, spiritual, and lifestyle needs are identified and addressed
the care or support plan includes multidisciplinary involvement
service providers meet their contractual requirements
the person using services and, if appropriate, their whānau have input into the development of the care or support plan.

Where service providers provide dementia or psychogeriatric services:

interventions take into account habits, routine, and specific communication support strategies to reduce distressed behaviour across a 24/7 period
service providers meet their contractual requirements
the person using services and their whānau have input into the development of the care or support plan.


Abortion services: Guidance

Service providers offer people receiving services and their whānau access to appropriate counselling services, which are provided by a workforce holding relevant qualifications or equivalent training in abortion counselling. People can access these services at all stages before, during, and after treatment.

Criterion 3.2.4
Guidance for all providers

Service providers follow a supported decision-making process where appropriate.

Additional guidance

Aged care

Implementation of intervention where appropriate includes:

monitoring charts and escalation as required
continence management
wound care management
pressure injury prevention and management
nutrition
weight management
falls prevention strategies
maintaining and supporting independence and meeting individualised goals
documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.

Where services provide dementia or psychogeriatric services:

behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
the person’s whānau are involved in the process where relevant.


Home and community

Where possible, service providers offer people choice over the accessible format of the care or support plan and where it is located.
Relevant information about a person receiving services is available and accessible by support workers before they enter the person’s home. This may include the full care or support plan.

Residential disability

Implementation of intervention where appropriate includes:

monitoring charts and escalation as required
continence management
wound care management
pressure injury prevention and management
nutrition
weight management
falls prevention strategies
maintaining and supporting independence and meeting individualised goals
documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.

Where services provide dementia or psychogeriatric services:

behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
the person’s whānau are involved in the process where relevant.

Where possible, service providers offer people choice over the accessible format of the care or support plan and where it is located.
Relevant information about a person receiving services is available and accessible by support workers before they enter the person’s home. This may include the full care or support plan.

Public/private hospital

Implementation of intervention where appropriate includes:

monitoring charts and escalation as required
continence management
wound care management
pressure injury prevention and management
nutrition
weight management
falls prevention strategies
maintaining and supporting independence and meeting individualised goals
documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.


Where services provide dementia or psychogeriatric services:

behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
the person’s whānau are involved in the process where relevant.


Hospice

Implementation of intervention where appropriate includes:

monitoring charts and escalation as required
continence management
wound care management
pressure injury prevention and management
nutrition
weight management
falls prevention strategies
maintaining and supporting independence and meeting individualised goals
documenting acute changes in health status on short-term care or support plans or updating long-term care or support plans.

Where services provide dementia or psychogeriatric services:

behaviour monitoring charts are established as a short-term strategy to identify triggers that threaten the person’s wellbeing
the charts are reviewed after a prescribed period of time and changes are linked into the care or support plan
the person’s whānau are involved in the process where relevant.

Criterion 3.2.5

Aged care: Guidance

Service providers meet evaluation time frames according to aged residential care contracts and other contracts held.
Service providers seek multidisciplinary input as appropriate to the needs of a person receiving services.
Care or support plan evaluations identify progress to meeting goals.
Acute changes in health status are documented on short-term care or support plans or updated on long-term care or support plans.
When a person’s needs change, the service provider completes a reassessment.
Where service providers provide dementia or psychogeriatric services, they:

seek a reassessment when a person’s needs change to consider if the person continues to require secure care as the least restrictive option
involve the person’s whānau in the process where relevant.


Home and community: Guidance

Service providers meet evaluation time frames according to aged residential care contracts and other contracts held.
Service providers seek multidisciplinary input as appropriate to the needs of a person receiving services.
Care or support plan evaluations identify progress to meeting goals.
Acute changes in health status are documented on short-term care or support plans or updated on long-term care or support plans.
When a person’s needs change, the service provider completes a reassessment.
Where service providers provide dementia or psychogeriatric services, they:

seek a reassessment when a person’s needs change to consider if the person continues to require secure care as the least restrictive option
involve the person’s whānau in the process where relevant.


Residential disability: Guidance

When reviewing a person’s care or support plan, service providers always follow a supported decision-making process.
Service providers conduct a review of a person’s:

care or support plan at least annually or as the person’s support needs change, or when requested by the person
aspiration-based plan within the agreed time frame with the person, and then determine further aspirations in consultation with the person.

Where whānau are engaged:

as much as possible the person being supported should determine the level of whānau engagement
the whānau should be actively involved to the highest degree possible
in situations where the person requires a higher level of substitute decision-making, the service provider demonstrates a high level of engagement with whānau wherever possible.

In situations where a person does not have whānau support or external advocacy support (for example, through Auckland Disability Law or the Personal Advocacy and Safeguarding Adults Trust), service providers do everything possible to engage another way of supporting the person using their services to make decisions.
Outcome measurements may include:

a certificate of achievement
a photograph
a person’s personal agreement
a hui
a daily diary
a visual chart in the person’s room.


Criterion 3.2.6
Guidance has not been developed for this criterion.
Criterion 3.2.7
Guidance has not been developed for this criterion.
Section 3.3: Individualised activities
Criterion 3.3.1

Aged care: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.
Align visiting and social activity policies with the Six Principles for Safe Visiting and Social Activities in Aged Residential Care.

Home and community: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.

Residential disability: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.
Service providers consider:

that people receiving services may want time at home alone
more solutions provided by residential disability providers when obstacles are making it difficult to facilitate what the person using services wants to do.

Residential mental health and alcohol and other drug: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.
Service providers consider:

that people receiving services may want time at home alone
more solutions provided by residential disability providers when obstacles are making it difficult to facilitate what the person using services wants to do.


Public: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.

Hospice: Guidance

People receiving services have input into and provide feedback on what their activity preferences are.
Activity assessments and plans identify individual interests and consider the person’s identity.
People have access to both group and individual activities. Service providers support this access as needed.

Criterion 3.3.2

Aged care: Guidance

Service providers:

have implemented procedures for managing community activities or outings, including in terms of transportation safety and medication management
consider activities suitable to the identity of the person receiving services
encourage members of the person’s chosen community and community groups (for example, from local schools or religious institutions) to visit people’s homes.

Where service providers provide dementia or psychogeriatric services, they:

take a holistic 24/7 approach to activities and take into account aspects of the person’s life and past routines
offer appropriate activities that provide diversion at appropriate times during the day in line with the needs identified in the person’s care or support plan
provide appropriate access and support to community and external activities.


Home and community: Guidance

Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
Activities are mainstream first.
People have full access to indoor and outdoor activities.
Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
Service providers use wheelchair safety belts whenever people are travelling in a van.
Service providers support people to be in contact with family and friends.
Service providers support people to have groups of friends and to interact with them.

Residential disability: Guidance

Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
Activities are mainstream first.
People have full access to indoor and outdoor activities.
Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
Service providers use wheelchair safety belts whenever people are travelling in a van.
Service providers support people to be in contact with family and friends.
Service providers support people to have groups of friends and to interact with them.

Residential mental health and alcohol and other drug: Guidance


Residential mental health and alcohol and other drug: Guidance

Service providers:

have implemented procedures for managing community activities or outings, including in terms of transportation safety and medication management
consider activities suitable to the identity of the person receiving services
encourage members of the person’s chosen community and community groups (for example, from local schools or religious institutions) to visit people’s homes.

Where service providers provide dementia or psychogeriatric services, they:

take a holistic 24/7 approach to activities and take into account aspects of the person’s life and past routines
offer appropriate activities that provide diversion at appropriate times during the day in line with the needs identified in the person’s care or support plan
provide appropriate access and support to community and external activities.

Service providers adopt a rights-based approach when planning activities, in which they support people receiving services to be contributing and involved members of their communities.
Activities are mainstream first.
People have full access to indoor and outdoor activities.
Service providers support health care and support workers to take a problem-solving approach, so that people can meet their commitments in instances where the usual solutions are not available (for example, in terms of people’s employment or appointments).
Where people no longer wish to attend certain activities, service providers support them to attend alternatives.
Service providers take a proactive approach to inform people of the options, entitlements, and community activities available to them.
Service providers use wheelchair safety belts whenever people are travelling in a van.
Service providers support people to be in contact with family and friends.
Service providers support people to have groups of friends and to interact with them.


Criterion 3.3.3

Service providers should enable Māori using their service to participate in community initiatives and provide opportunities for cultural exploration, participation, and connection. This may require service providers to encourage and enable their workforce to facilitate these linkages through dedicated time.

	For example, if there is a Matariki festival happening in the community and Māori residents are interested in celebrating Matariki, enable them to participate by either bringing your residents to the community event, or bringing the community event to your facility.

	Or, if you know a person belongs to an Iwi, service providers offer resources and support for residents who wish to connect with their Iwi. Different avenues, such as te reo Māori classes, kapa haka should also be available and encouraged for cultural exploration.

In order to know what options people have to connect with their Iwi, look up their Iwi and marae via these two resources:

Te Kāhui Māngai (Directory of Iwi and Māori Organisations). Overseen by Te Puni Kokiri the Ministry of Māori Development. This directory of Iwi and Māori organisations may be searched alphabetically, by map, or by listed-region.
Māori Maps  -  Overseen by Te Potiki National Trust gathers the information for Māori Maps from public sources and marae community engagement. This resource helps to connect Māori descendants with their marae, and enable visitors to make appropriate contact with these centres of culture - in particular, linking Māori youth with their ancestral identity.


Criterion 3.3.4

Aged care: Guidance

Opportunities for Māori to participate in te ao Māori include:

activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
local Matariki, kapa haka, and sport events, such as waka ama competitions
leadership training, te reo Māori, and ngā tikanga Māori courses
national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.


Residential disability: Guidance

Opportunities for Māori to participate in te ao Māori include:

activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
local Matariki, kapa haka, and sport events, such as waka ama competitions
leadership training, te reo Māori, and ngā tikanga Māori courses
national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.

Residential mental health and alcohol and other drug: Guidance

Opportunities for Māori to participate in te ao Māori include:

activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
local Matariki, kapa haka, and sport events, such as waka ama competitions
leadership training, te reo Māori, and ngā tikanga Māori courses
national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.


Public/private hospital: Guidance

Opportunities for Māori to participate in te ao Māori include:

activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
local Matariki, kapa haka, and sport events, such as waka ama competitions
leadership training, te reo Māori, and ngā tikanga Māori courses
national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.

Birthing units: Guidance

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.

Hospice: Guidance

Opportunities for Māori to participate in te ao Māori include:

activities that promote whanaungatanga, such as whānau reunions, whānau events, and tangihanga
local Matariki, kapa haka, and sport events, such as waka ama competitions
leadership training, te reo Māori, and ngā tikanga Māori courses
national iwi-specific events such as Te Matatini, poukai, koroneihana, and iwi sports.


Abortion services: Guidance

Opportunities for Māori to participate in te ao Māori include following tikanga such as:

kawa
blessing of rooms
rākau rongoā
mirimiri
karakia.


Section 3.4: My medication
Criterion 3.4.1
Guidelines for all providers

Service providers are aware of, and may take up, an electronic medication management system.
Service providers are aware of national programmes of work in medication management relevant to their service type. This may include:

New Zealand Nurses Organisation (2018) Guidelines for Nurses on the Administration of Medicines (PDF, 809 KB)
Ministry of Health ‘Advice to DHBs on prescribing controlled drugs’
Ministry of Health (2016) Standing Order Guidelines.


Additional guidance

Aged care

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.

Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
To support their medication management system, service providers can consult the Ministry of Health’s (2011) Medicines Care Guides for Residential Aged Care.

Fertility services

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.

Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.

Home and community

The guiding document to support medication management is Ministry of Health (2019) Medication Guidelines for the Home and Community Support Services Sector.

Residential disability


Residential disability

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.

Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Where a person cannot manage their own medication, a competent health care or support worker administers it.
Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.

Residential mental health and alcohol and other drug

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.


Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Where a person cannot manage their own medication, a competent health care or support worker administers it.
Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.

Public/private hospital

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.

Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.

Birthing units

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.


Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Where a person cannot manage their own medication, a competent health care or support worker administers it.
Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.

Hospice

Service providers’ medication management systems reflect an end-to-end process.
Service providers have implemented policies that describe the medication management system, covering:

prescribing
administration (including use and management of as needed (PRN) medicines, remote (including telephone) orders, standing orders)
review
monitoring
adverse reactions
reconciliation on admission and on transfers of care
clinical decision support
procurement
supply
dispensing
safe storage
disposal
management and use of people’s own medication.

Service providers demonstrate a holistic approach to understanding a person’s needs without making assumptions, such as for gender and sex characteristics.
Where a person cannot manage their own medication, a competent health care or support worker administers it.
Service providers use the appropriate medication guidelines to support medication management. See Ministry of Health (2013) Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.
Service providers use other available resources to support medication; for example, the Health Quality & Safety Commission’s guidelines on medication safety.


Criterion 3.4.2
Guidance for all providers

Service providers demonstrate an understanding of:

the role of the health professional for each aspect of care supporting safe practice
the differences between prescribing and dispensing as defined in legislation (Medicines Act 1981 and Misuse of Drugs Regulations 1977)
reconciliation and review.

Service providers use available resources to support medication. This includes the Health Quality & Safety Commission’s medication reconciliation guidance tools and training resources.
Service providers prescribe and use all medications for valid therapeutic indications. They never use medications to force compliance or render a person incapable of resistance; use of medications in this way could be classed as chemical restraint and is in breach of this standard.

Additional guidance

Fertility services

Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide.

Public/private hospital

Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide.

Birthing units

Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide.

Hospice

Service providers have implemented policies and procedures on prescribing oxygen and nitrous oxide.


Criterion 3.4.3
Guidance for all providers

Health care and support worker competency includes understanding and considering cultural and identity-specific needs; for example, needs related to religious beliefs.
Service providers adhere to relevant legislation, such as the Misuse of Drugs Act 1975 and the Medicines Act 1981.

Additional guidance

Aged care

The responsible registered nurse undertakes annual training and competency assessments of health care and support workers in regard to managing medication.
Service providers clearly state the role of support workers in medication management.
Training and annual competency assessments determine the breadth of health care and support workers’ role, which may include:

administering pre-packed regular medication
high-risk medication (as outlined in the Ministry of Health (2011) Medicines Care Guides for Residential Aged Care).

Service providers have an implemented process for using registered nurse-initiated medication such as that classified as over-the-counter or ‘pharmacy-only’ medication.
Service providers orientate agency staff to the facility or home and medication processes.
Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.

Fertility services

Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.


Residential disability

The responsible registered nurse undertakes annual training and competency assessments of health care and support workers in regard to managing medication.
Service providers clearly state the role of support workers in medication management.
Training and annual competency assessments determine the breadth of health care and support workers’ role, which may include:

administering pre-packed regular medication
high-risk medication (as outlined in the Ministry of Health (2011) Medicines Care Guides for Residential Aged Care).

Service providers have an implemented process for using registered nurse-initiated medication such as that classified as over-the-counter or ‘pharmacy-only’ medication.
Service providers orientate agency staff to the facility or home and medication processes.
Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.

Residential mental health and alcohol and other drug

Service providers orientate agency staff to the facility or home and medication processes.
Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.


Public/private hospital

Service providers orientate agency staff to the facility or home and medication processes.
Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.

Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Birthing units

Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.

Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Hospice

Service providers orientate agency staff to the facility or home and medication processes.
Service providers adopt a risk-based approach to the use of PRN medication that is evidenced in policy and practice.
Service providers have implemented policies and procedures that include the management of:

controlled drugs, including register checking and six-monthly reconciliation, where applicable
medication storage and disposal
medication when a person receiving services is on an incremental dosing regimen.

Where applicable, immunisation providers managing vaccinations meet national standards. See Ministry of Health (2019) National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).


Criterion 3.4.4
Guidance for all providers

Service providers demonstrate medication adverse events are linked to the quality and risk system in their investigation and corrective action implementation.
Service providers identify allergies and adverse drug reactions before prescribing medication, or at least before administering it.

Additional guidance

Fertility services

Evidence for this process may include the assessment of allergies and sensitivities and consideration of components in culture media used for insemination or embryo transfer.


Criterion 3.4.5
Guidance for all providers

Service providers consider the health literacy of people receiving services.
Information is available to help people to understand their medications and their side effects.
Service providers inform people receiving services and their whānau of medication changes, including changes involving adding, removing, or substituting medication.
Service providers provide accessible information to facilitate use of medication that includes:

how and when to take the medication
dose
side effects
when people should get back in touch with the prescriber
supplements and foods to avoid
additional information and resource sheets
name of the medicine
purposes of the medicine.

Service providers communicate effectively with the person and their whānau about prescribed medication.
Service providers have mechanisms in place to support people with a disability to understand their medication. This may include use of technology, Braille, or tactile labelling.

Additional guidance

Aged care

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Residential disability

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Residential mental health and alcohol and other drug

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Public/private hospital

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Birthing units

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Hospice

Service providers consider using a pharmacist to support people’s understanding of medications and how they interact.

Abortion services

Service providers inform people about who to contact after hours for medical-abortion-specific advice.
Service providers make available contraceptive supplies and any prescriptions given on the day of prescribing.


Criterion 3.4.6

Guidance for all providers (except home and community)

Service providers have implemented policy and procedures to support practice. These include:

assessment of the person who is to self-administer medication to determine their competence
training and supervision of the person
security of the medication.

Service providers verify that people who experience difficulties at the time of administration have an emergency contact.

Criterion 3.4.7

Guidance for all providers (except home and community)

Service providers manage Standing Orders according to the Ministry of Health’s (2016) current Standing Order Guidelines, Medicines Act 1981 and Medicines Regulations 1984, and the  Misuse of Drugs Act 1975 and Misuse of Drugs Regulations 1977.

Criterion 3.4.8

Aged care: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.


Fertility services: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.

Residential disability: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.


Residential mental health and alcohol and other drug: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.

Public/private hospital: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.


Birthing units: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.

Hospice: Guidance

Service providers have implemented policies and procedures to describe processes for the use and safe storage of complementary and alternative medicines (for example, rongoā).
The prescriber considers, as part of the person’s medication, medications and supplements purchased over the counter and given, or prescribed, by alternative health practitioners.
Providers consider alternatives in consultation with the person receiving services, pharmacy, and members of the multidisciplinary team as required, and taking account of the prescriber’s scope of practice. Holistic considerations may include:

dosing
interactions
content
side effects
the person’s health condition
pregnancy and breastfeeding.


Criterion 3.4.9
Guidance for all providers

Ensure Māori and whānau in your service have the understanding and support to navigate the health system. The identification of health literacy, care of dependents, transport/access, and financial means is extremely important in terms of achieving health equity for Māori and whānau in accessing medication. Have resources and key contacts available who can support Māori to access medication.
Provide advice on how to have a conversation with their pharmacist to see if they are eligible for the New Zealand Government’s Prescription Payment Subsidy scheme. More information available on the Ministry of Health website .
There are some instances where work and income may cover prescription costs, for more information see: Work and Income website - Prescriptions and health practitioner costs .
Ensure staff are familiar with resources on the follow consumer support sites, including Health Navigator on Prescription Charges.

Criterion 3.4.10
Guidance for all providers

Service providers work in partnership with Māori to verify that:

the appropriate support is in place
advice is timely and easily accessed
treatment is prioritised to achieve better health outcomes.


Ensure Māori in your service are supported to access the required medication and blood products. This includes supporting them to know what their medication is for, how to use it, side effects, and may extend to supporting them to take it at the appropriate times.
The following resources are accessible to support Māori in their medical appointments: 5 questions to ask about your medications – consumer safety poster (available in te reo Māori and English). Ideally, staff should understand these guidelines and proactively answer  these questions where possible.
For some Māori, receiving or donating blood products may have cultural, religious, or spiritual significance. Be sensitive to these possibilities and demonstrate empathy when having conversations about these topics. Work with the person to adjust their care and support pathway that make the process safer for them.
The New Zealand Blood Service provides information relevant to Māori about blood donation and products, which may be useful to share with Māori who are interested in this ahead of relevant specialist appointment.

Criterion 3.4.11

Fertility services: Guidance

The principles and requirements of medication management apply.
Service providers have implemented policies and procedures that describe blood transfusion and blood management, including:

prescribing
gaining informed consent for administration
receiving, collecting, and labelling blood samples for pre-transfusion testing
administering the transfusion
managing and reporting adverse reactions
ensuring traceability through accurately recording all cases of administration
receiving, storing, handling, and returning blood.


Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements.
The service provider provides access to the following resources to support blood management:

clinical information about blood transfusion from the New Zealand Blood Service
for DHB hospitals, the hospital’s blood resource folder on its intranet
information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
information about adverse reaction reporting from the New Zealand Blood Service
information for patients from the New Zealand Blood Service.


Public/private hospital: Guidance

The principles and requirements of medication management apply.
Service providers have implemented policies and procedures that describe blood transfusion and blood management, including:

prescribing
gaining informed consent for administration
receiving, collecting, and labelling blood samples for pre-transfusion testing
administering the transfusion
managing and reporting adverse reactions
ensuring traceability through accurately recording all cases of administration
receiving, storing, handling, and returning blood.

Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements.
The service provider provides access to the following resources to support blood management:

clinical information about blood transfusion from the New Zealand Blood Service
for DHB hospitals, the hospital’s blood resource folder on its intranet
information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
information about adverse reaction reporting from the New Zealand Blood Service
information for patients from the New Zealand Blood Service.


Birthing units: Guidance

The principles and requirements of medication management apply.
Service providers have implemented policies and procedures that describe blood transfusion and blood management, including:

prescribing
gaining informed consent for administration
receiving, collecting, and labelling blood samples for pre-transfusion testing
administering the transfusion
managing and reporting adverse reactions
ensuring traceability through accurately recording all cases of administration
receiving, storing, handling, and returning blood.

Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements.
The service provider provides access to the following resources to support blood management:

clinical information about blood transfusion from the New Zealand Blood Service
for DHB hospitals, the hospital’s blood resource folder on its intranet
information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
information about adverse reaction reporting from the New Zealand Blood Service
information for patients from the New Zealand Blood Service.


Hospice: Guidance

The principles and requirements of medication management apply.
Service providers have implemented policies and procedures that describe blood transfusion and blood management, including:

prescribing
gaining informed consent for administration
receiving, collecting, and labelling blood samples for pre-transfusion testing
administering the transfusion
managing and reporting adverse reactions
ensuring traceability through accurately recording all cases of administration
receiving, storing, handling, and returning blood.

Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements.
The service provider provides access to the following resources to support blood management:

clinical information about blood transfusion from the New Zealand Blood Service
for DHB hospitals, the hospital’s blood resource folder on its intranet
information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
information about adverse reaction reporting from the New Zealand Blood Service
information for patients from the New Zealand Blood Service.


Abortion services: Guidance

The principles and requirements of medication management apply.
Service providers have implemented policies and procedures that describe blood transfusion and blood management, including:

prescribing
gaining informed consent for administration
receiving, collecting, and labelling blood samples for pre-transfusion testing
administering the transfusion
managing and reporting adverse reactions
ensuring traceability through accurately recording all cases of administration
receiving, storing, handling, and returning blood.

Service providers verify that training and competency assessments are completed for all the activities listed above so that health care workers can manage transfusion of blood components.
Service providers have, if relevant, blood storage equipment that complies with, and is maintained in accordance with, AS 3864 Medical Refrigeration Equipment for the Storage of Blood and Blood Products, and New Zealand Blood Service requirements.
The service provider provides access to the following resources to support blood management:

clinical information about blood transfusion from the New Zealand Blood Service
for DHB hospitals, the hospital’s blood resource folder on its intranet
information about blood and blood products in the New Zealand Blood Service’s (2016) Transfusion Medicine Handbook
information about adverse reaction reporting from the New Zealand Blood Service
information for patients from the New Zealand Blood Service.

Criterion 3.4.12

Fertility services: Guidance

Service providers follow the principles and requirements for medication management.
Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe:

gaining informed consent for administration
managing and reporting adverse reactions.

Public/private hospital: Guidance

Service providers follow the principles and requirements for medication management.
Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe:

gaining informed consent for administration
managing and reporting adverse reactions.


Birthing units: Guidance

Service providers follow the principles and requirements for medication management.
Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe:

gaining informed consent for administration
managing and reporting adverse reactions.

Hospice: Guidance

Service providers follow the principles and requirements for medication management.
Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe:

gaining informed consent for administration
managing and reporting adverse reactions.

Abortion services: Guidance

Service providers follow the principles and requirements for medication management.
Service providers implement policies and procedures specific to fractionated plasma (this includes Anti-D) that describe:

gaining informed consent for administration
managing and reporting adverse reactions.


Section 3.5: Nutrition to support wellbeing
Criterion 3.5.1

Aged care: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.

Home and community: Guidance

Service providers offer people choice in the meals available.
Service providers monitor people for signs and symptoms of dehydration and malnutrition, and implement interventions as needed.
Where people require special or modified diets, service providers support them to meet these needs.
Service providers with specific training and demonstrated competencies meet the needs of people with enteral feeding tubes.
Service providers provide food that has been stored and prepared safely so that people are at no risk of disease caused by unsafe storage and preparation practices, and support workers are oriented to safe food-handling practices.
Service providers have a mechanism to consult with health professionals when needed to support the needs of people receiving services.

Residential disability: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers use supported decision making as an integral part of menu planning.
Menu planning is individualised, takes likes and dislikes into consideration, and makes alternatives available.
Nutritional information of food is available for people receiving services.

Residential mental health and alcohol and other drug: Guidance


Residential mental health and alcohol and other drug: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
Service providers have implemented policies and procedures covering:

accessibility, such as to hot drinks
menu development and consultation with people receiving services
strategies to keep food at an appropriate temperature
consideration of environmentally friendly practices for waste management.

Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
Audit of food services is part of the annual internal audit programme.
Service providers can accommodate dietary requirements at short notice.

Public/private hospital: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
Service providers have implemented policies and procedures covering:

accessibility, such as to hot drinks
menu development and consultation with people receiving services
strategies to keep food at an appropriate temperature
consideration of environmentally friendly practices for waste management.

Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
Audit of food services is part of the annual internal audit programme.
Service providers can accommodate dietary requirements at short notice.

Birthing units: Guidance


Birthing units: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers have implemented policies and procedures covering:

accessibility, such as to hot drinks
menu development and consultation with people receiving services
strategies to keep food at an appropriate temperature
consideration of environmentally friendly practices for waste management.

Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
Audit of food services is part of the annual internal audit programme.
Service providers can accommodate dietary requirements at short notice.

Hospice: Guidance

Service providers:

demonstrate menu planning that takes into account likes and dislikes and makes alternatives available
adopt the International Dysphagia Diet Standardization Initiative in menu development and food service provision
consider survey feedback during menu development.

Service providers have implemented policies and procedures covering:

accessibility, such as to hot drinks
menu development and consultation with people receiving services
strategies to keep food at an appropriate temperature
consideration of environmentally friendly practices for waste management.

Service providers undertake engagement surveys to seek feedback on the menu and food services. Based on the results, they develop and implement corrective actions plans.
Audit of food services is part of the annual internal audit programme.
Service providers can accommodate dietary requirements at short notice.


Criterion 3.5.2

Aged care: Guidance

Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:

baking or similar activities
setting tables before meals
preparing a hāngi or equivalent
supporting people to have culturally appropriate food
growing and preparing vegetables
pre-cooking preparation
preparing for celebrations.


Home and community: Guidance

Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:

baking or similar activities
setting tables before meals
preparing a hāngi or equivalent
supporting people to have culturally appropriate food
growing and preparing vegetables
pre-cooking preparation
preparing for celebrations.

Where applicable, service providers encourage people receiving services to manage the preparation of food independently or with the support of whānau.
If a person is dependent on food preparation, the service provider offers solutions that may include:

Meals on Wheels options
people being involved in meal planning
pre-cooking preparation
cooking simple nutritious meals
working alongside each person to meet cultural food preferences and preparation practices
giving people access to food and drink if they wish at any time unless clinically contraindicated
working alongside the person to prepare food.


Residential disability: Guidance

Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:

baking or similar activities
setting tables before meals
preparing a hāngi or equivalent
supporting people to have culturally appropriate food
growing and preparing vegetables
pre-cooking preparation
preparing for celebrations.

People who live in the house are involved in all aspects of food purchase, meal preparation, and planning.
People who live in the house choose what they eat.
Health care and support workers help choose healthy food options.
People have access to food and drink when they wish and at any time, unless clinically contraindicated.
Service providers offer choices in the person’s preferred communication method. This may include pictures.

Residential mental health and alcohol and other drug: Guidance

Service providers encourage people receiving services and, where appropriate, their whānau to be involved in food preparation. This may include:

baking or similar activities
setting tables before meals
preparing a hāngi or equivalent
supporting people to have culturally appropriate food
growing and preparing vegetables
pre-cooking preparation
preparing for celebrations.

People who live in the house are involved in all aspects of food purchase, meal preparation, and planning.
People who live in the house choose what they eat.
Health care and support workers help choose healthy food options.
People have access to food and drink when they wish and at any time, unless clinically contraindicated.
Service providers offer choices in the person’s preferred communication method. This may include pictures.


Criterion 3.5.3

Aged care: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.
In relation to the dining experience of people receiving services, service providers should consider:

providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
supplying appropriate equipment to support independence
using respectful processes around assisted feeding
respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
making the menu visible to the people
maintaining a good standard of meal presentation for various food models
making soft or pureed food visually appealing
providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs.


Home and community: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.

Residential disability: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.
In relation to the dining experience of people receiving services, service providers should consider:

providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
supplying appropriate equipment to support independence
using respectful processes around assisted feeding
respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
making the menu visible to the people
maintaining a good standard of meal presentation for various food models
making soft or pureed food visually appealing
providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs.

Residential mental health and alcohol and other drug: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.
In relation to the dining experience of people receiving services, service providers should consider:

providing a meal that is aesthetically pleasing and seen as consistent with meals eaten outside of the service
supplying appropriate equipment to support independence
using respectful processes around assisted feeding
respecting a person’s choice (for example, if they do not want to go to the dining room or want clothing protectors)
making the menu visible to the people
maintaining a good standard of meal presentation for various food models
making soft or pureed food visually appealing
providing a suitable space for dining; this may include access to a table that is suited to the individual’s needs.


Public/private hospital: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.

Birthing units: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.

Hospice: Guidance

Service providers are aware of and have mechanisms to monitor nutritional intake and address insufficiency.
Service providers consider the kind of support people need when they eat.

Criterion 3.5.4

Aged care: Guidance

Two different levels of nutritional value are considered by service providers:

the overall menu for the facility
specialised dietary requirements for individuals.


Residential mental health and alcohol and other drug: Guidance

Two different levels of nutritional value are considered by service providers:

the overall menu for the facility
specialised dietary requirements for individuals.

Service providers have implemented a healthy eating policy.
Service providers follow relevant guidelines, such as the Ministry of Health’s (2020) Eating and Activity Guidelines for New Zealand Adults. Updated 2020.
Service providers consult with appropriately qualified personnel if required.
Service providers have a policy that defines the period of review required.
An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.

Public/private hospital: Guidance

Service providers have a policy that defines the period of review required.
An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.

Birthing units: Guidance

Service providers have a policy that defines the period of review required.
An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.

Hospice: Guidance

Service providers have a policy that defines the period of review required.
An appropriate dietitian, for example, a paediatric dietitian for child health services, reviews the nutritional value of meals.

Criterion 3.5.5

Aged care: Guidance

For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.

Public/private hospital: Guidance

For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.

Birthing units: Guidance

For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.

Hospice: Guidance

For guidance and applicability, see New Zealand Food Safety’s ‘Food safety rules’.


Criterion 3.5.6

Residential disability: Guidance

Dishwashers are available in the home.
Food is stored properly and use-by dates noted.
Fridge and freezer temperatures are checked at defined intervals.

Residential mental health and alcohol and other drug: Guidance

Dishwashers are available in the home.
Food is stored properly and use-by dates noted.
Fridge and freezer temperatures are checked at defined intervals.

Criterion 3.5.7

Aged care: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Home and community: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Residential disability: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Residential mental health and alcohol and other drug: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Public/private hospital: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Birthing units: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Hospice: Guidance

Menu development may cover:

sharing of drink and food after formal activities
choices of food available.

The following basic Māori practices rely on an understanding of tapu and noa – key concepts that underpin many practices. Tapu and noa are entirely consistent with a logical Māori view of hygiene and align with good health and safety practices.

Never pass food over the head.
Use tea towels only for the purpose of drying dishes and wash them separately from all other soiled linen.
For microwaves that are used for food, do not use them for heating anything that has come into contact with the body.
Keep anything that comes into contact with the body or body fluids separate from food and do not place it on surfaces where food is placed.
Use receptacles for drinking water only for that purpose.
Health care and support workers should not sit on tables or workbenches and particularly on surfaces used for food or medication.
Never take food or drink into a room containing a tūpāpaku (deceased person).
			For more information, see Glover M, Wong SF, Taylor RW, et al (2019) ‘The complexity of food provisioning decisions by Māori caregivers to ensure the happiness and health of their children’. Nutrients 11(5): 994.


Section 3.6: Transition, transfer, and discharge
Criterion 3.6.1
Guidance for all providers

Service providers have a policy and procedures for transitioning, transferring, and discharging people using their services.
The process includes medication reconciliation and transfer of specialist care if required.

Additional guidance

Aged care

Where applicable, discharge planning starts when a person enters a service.

Fertility services

Service providers have processes to:

transition people between public and private services (and vice versa) to support them through the change
provide continuous care following a procedure. This process can include people who choose to self-discharge.