Part 3: Leadership of the implementation plan

3.1
In this Part, we examine ACC's leadership in the first year of implementing the Strategy, in 2007. We discuss progress in carrying out actions to meet Objectives 1, 2, and 3 of the Strategy (see paragraphs 3.10, 3.36, and 3.49).

3.2
We do not discuss progress in relation to Objective 4 – Create safer environments to prevent injury from falls, or Objective 5 – Ensure appropriate resource levels for the prevention of injury from falls. We accept ACC's assessment of these objectives as being of less immediate concern, with fewer specific actions and activities that can be achieved in the short term.

3.3
Finally, we discuss ACC's corporate leadership in the implementation of the Strategy, monitoring of progress, and evaluation.

Our expectations

3.4
We expected ACC to have promoted the implementation of the Strategy in keeping with the implementation plan, including:

• establishing effective leadership and direction within ACC and externally;
• gathering and distributing information about falls prevention;
• establishing ongoing communication with, and support from stakeholders;
• promoting delivery of programmes and interventions in alignment with the plan; and
• establishing systems to monitor progress and evaluate results.

Summary of our findings

3.5
Progress against the implementation plan has been uneven. There have been some positive initiatives, but there are also areas where little or no progress has been made.

3.6
ACC has carried out useful work to set up injury prevention agreements with the main injury prevention partners. These offer the potential for a more direct alignment of falls prevention activities among the main partners. ACC has also set up initiatives that extended the reach of existing falls prevention programmes and research. This work has been consistent both with ACC's core injury prevention business and with the Strategy's objectives.

3.7
ACC has a system to monitor progress, and it reports progress against the Strategy's objectives and time frame on its website.¹ However, some of the progress reported to date is only loosely linked to the objectives, and tends to be descriptive. There needs to be more meaningful monitoring that focuses on results, and tighter accountability arrangements for actions under the implementation plan (within ACC and externally).

3.8
ACC identified early the need for a framework to measure the effects and outcomes from implementing the Strategy, and published a high-level approach to such an evaluation. However, this approach did not meet the need to comprehensively measure and evaluate those effects and outcomes. ACC recognised that more work would need to be done.

3.9
Little progress has been made on drawing up a comprehensive evaluation framework to enable ACC and its partners to measure and report meaningfully on results. In our view, this task is a priority for ACC in its leadership in the implementation of the Strategy.

Building effective leadership and co-ordination in the falls prevention sector

3.10
This section discusses progress made on Objective 1 – build effective leadership and co-ordination in the prevention of injury from falls. The first year of the implementation plan focused on establishing the Strategy's support networks. Therefore, meeting Objective 1 has been an important part of work in the early phase of implementing the Strategy.

Making the implementation of the Strategy a corporate priority

3.11
Corporate documents reflect the priority assigned to ACC's leadership of the NZIPS and the Strategy. ACC's Strategic Plan 2007-2012 highlights the NZIPS as a strategic priority, with one focus being on falls prevention. ACC's Business Plan 2007-2008 includes enhancing ACC's leadership of the NZIPS (including falls) as part of its work programme. ACC's Statement of Intent 2007-2012 identifies the NZIPS as a priority, including falls.

3.12
ACC's Injury Prevention Strategy 2007-2008 highlights falls prevention as a priority area for which ACC is the lead agency. It also outlines ACC's approach to meeting its responsibilities through the Strategy. It acknowledges the importance of the Strategy and its links to ACC's own business priorities. ACC's report to its Board on injury prevention activities in 2007 referred to the partnerships, research, and promotional activities involved in implementing the Strategy.

3.13
During 2007, ACC used its own injury prevention activities, its operational teams and programme managers, its stakeholder networks, and corporate strategies to promote collaboration and co-ordination. While focused on injury prevention more generally, these partnerships should have benefits for a joint delivery and funding of falls prevention programmes to different target groups.

Creating forums for collaboration

3.14
ACC has established several forums to encourage collaboration in injury prevention activities (including falls prevention) throughout government agencies and non-government organisations.

3.15
ACC has set up an NZIPS Chief Executives Forum (the forum), which met for the first time in February 2007. This initiative is a deliberate effort to secure the commitment and support of different government agencies. The forum, initially made up of the chief executives of the six NZIPS lead agencies, was a response to the Minister's request to see greater collaboration throughout the agencies.

3.16
Other objectives of the forum were to enable better monitoring of progress on the implementation of the NZIPS, promote joint outcomes and evaluation, and create a mandate for better integration and collaboration on injury prevention objectives. Importantly, the forum has considered how well current injury prevention programmes are aligned to the NZIPS – and highlighted population groups or settings under-represented by existing targeted interventions. The forum now also includes a local government representative.

3.17
The forum has identified three areas of injury prevention for particular attention – falls prevention, child safety, and safety culture. The NZIPS Secretariat carried out a “stocktake” between March 2007 and May 2007. The stocktake identified the safety-related and injury prevention programmes being delivered in these three areas, considering possible areas of collaboration and alignment. This stocktake provided information and guidance to the forum.

3.18
An Injury Prevention Ministerial Committee was formed in 2005 and the Strategy is one of its areas of interest. One of the functions of the forum is to guide the Injury Prevention Ministerial Committee's agenda.

3.19
ACC has separately met their main partner agencies to promote the implementation of the Strategy. ACC also has agreements with the Ministry of Health, the Department of Labour, and the Ministry of Social Development in the area of injury prevention.

3.20
A Government Inter-Agency Steering Group functions as a co-ordinating forum for injury prevention work throughout government agencies that have a strong interest or involvement in injury prevention policy or related responsibilities.

Strengthening co-ordination to implement the Strategy

3.21
The Working Group, established to draw up the implementation plan, is still in place. The Working Group makes use of the expertise and resources of stakeholders and ensures a national perspective on implementing the Strategy. However, as explained in paragraphs 3.66 to 3.69, various factors – including staffing pressures – were responsible for some loss of contact with stakeholders in 2007, and for the limited focus on monitoring progress. As a result, the Working Group did not meet between March 2007 and January 2008. ACC advises us that it is reviewing the composition of the Working Group, so that members can more actively guide the implementation of specific actions in the plan.

3.22
ACC has carefully considered the need for channels and forums through which to work with its injury prevention partners. However, the support of those agencies, and their commitment to a joint implementation of the Strategy, depends heavily on relationships with specific individuals. It relies on persuasion, and depends on other agencies' assessment of their own priorities. Therefore, ACC's capacity to hold other parties (principally government agencies) to account and to ensure that they meet their commitments to implementing the Strategy may be limited. We found some evidence of variable commitment to implementing the Strategy. In the longer term, this is a risk to achieving the Strategy's goals.

3.23
Accountability arrangements may need to be strengthened and formalised to bring about cross-agency change in injury prevention policy and practice. Existing collaborative forums promote the sharing of information. However, such forums may not be enough to ensure cross-agency commitment to implementing the Strategy. An ACC-commissioned analysis of injury prevention activities and programmes throughout the six NZIPS lead agencies in 2007 reached a similar view. The analysis showed the need to consolidate the commitment of chief executives and their senior managers in partner agencies and to strengthen operational working relationships with those agencies.

3.24
Our own discussions with ACC's managers, staff, and stakeholders, pointed to the limitations of the current collaborative arrangements in getting commitment. We were told that the quality of commitment from stakeholders has varied. Such limitations put the Strategy at risk.

3.25
We have published a range of reports about the implementation of strategies and cross-agency collaboration. This work has highlighted the need for agencies responsible for cross-agency activities to consider a variety of mechanisms to promote accountability and shared implementation. A mix of arrangements is likely to be more effective in getting agencies' full commitment.

3.26
ACC should make full use of existing accountability relationships between ACC and other government agencies in the area of injury prevention. To strengthen ACC's leadership mandate and make progress on the implementation of the Strategy, ACC should also consider having a protocol in place with the agencies identified in the implementation plan as responsible for leading the actions. This protocol should:

• refer closely to the implementation plan and be based on a statement of shared outcomes;
• require consultation on planning, information sharing, and funding;
• define explicitly the nature and extent of accountabilities; and
• specify objectives and targets.

3.27
Ideally, the relevant Ministers, chief executives and boards should endorse this protocol.

Injury prevention partnerships with district health boards and local government

District health boards

3.28
The emphasis in the first year of implementing the Strategy has been on establishing injury prevention partnerships with district health boards. This work has included promoting a closer joint focus on falls prevention activities. ACC recognised that district health boards were important stakeholders for ACC and that it needed to increase their capacity and participation in falls prevention.

3.29
As noted in paragraph 2.27, 18 of the 21 district health boards have formally endorsed the implementation plan. At May 2007, ACC had partnerships with 11 district health boards on falls prevention for older adults. ACC also advised us that it was actively working with two-thirds of district health boards in falls prevention.

3.30
A Charter of Collaboration, ratified between ACC and district health boards in March 2007, promotes ACC involvement in the district health boards' annual planning process and identifies falls prevention as one output under the communities' injury prevention work stream.

Local government

3.31
In 2005, ACC embarked on a local government partnership programme, with a focus on community safety, promoting best practice, gaining support for ACC programmes, and reducing accident rates. ACC's local government initiatives are aligned to the principles of the NZIPS, including falls prevention. They provide a strategic context for ACC's actions at a local level, and they indirectly support the objectives of the Strategy. In 2006/07, ACC established injury prevention agreements and action plans with 23 local authorities to promote an increased involvement in communities' injury prevention work.

Other partnership initiatives

3.32
ACC has explored options for closer collaboration with the primary health care sector. In April 2007, ACC approached primary health organisations and district health boards, seeking opportunities to collaboratively pilot primary care projects – including the potential for joint delivery of injury prevention services. Closer collaboration with primary care providers also offers the potential for higher levels of referral to ACC-funded programmes and ACC resources.

3.33
ACC received 43 responses to its invitation for expressions of interest in becoming a collaborative partner. ACC analysed and evaluated these responses and chose three entities as collaborative partners in July 2007. ACC has also begun using its contracting process with non-government organisations to further promote injury prevention in the community.

3.34
In 2007, ACC used its contracting process to increase the reach of the falls prevention programmes for older adults: the Otago Exercise Programme² and modified Tai Chi³ classes. Both programmes support the implementation of the Strategy, and Objective 3 in particular.

Area of focus for ACC

3.35
We consider ongoing communication with the injury prevention sector is important in ensuring broad commitment to achieving all of the Strategy's objectives. We encourage ACC to take this into account as the implementation of the Strategy progresses.

Knowledge about falls prevention

3.36
This section discusses progress made on Objective 2 – improve the gathering and dissemination of knowledge about the prevention of injury from falls. ACC's research programme will play an important part in meeting this objective, and underpins a number of activities and objectives elsewhere in the plan.

3.37
Research supports ACC's funding of falls prevention programmes and identifies factors contributing to falls among different groups and in various settings. Research also provides an evidence base for best practice. Therefore, it is crucial to the implementation the Strategy.

3.38
We asked ACC staff whether the Strategy was having an influence on planning for ACC's research programme, and looked at relevant documentation. We also spoke to researchers who carry out work on contract to ACC.

Alignment of ACC's research programme to the Strategy

3.39
The Strategy has provided a useful context for ACC's research programme by supporting the continuing funding of ongoing falls prevention activities, particularly for older adults. An ACC report prepared in July 2007 on alignment of current interventions with the Strategy noted the risk that weak links between the Strategy and ACC's own planning of future research might compromise the achievement of the Strategy's goals.

3.40
The report noted 14 research interventions that were in progress at the time. However, it found no evidence that these interventions were aligned with the Strategy, with the exception of a project to compare the benefits of different programmes for older adults.

3.41
Our own examinations and discussions with ACC staff and stakeholders indicate that ACC's falls prevention research programme needs to be more explicitly aligned with the Strategy. This is necessary to confirm the value of ongoing research, broaden the scope of exploratory and primary research, and address gaps in the current programme in target populations and settings identified in the Strategy.

3.42
ACC has reviewed falls prevention research that was commissioned between 2003 and 2007, and made recommendations for areas of future research. ACC has noted that the Working Group would review this information and consider the direction of future research in June 2008.

3.43
To date, the Strategy has had a limited effect on research priorities, and is not yet serving as a clear reference point for the consideration of proposals for future research. For example, ACC's research and development strategy makes no explicit reference to the Strategy. As a consequence, ACC's research programme risks continuing to support existing ACC programmes without recognising the need to respond to the directions identified in the Strategy's implementation plan.

3.44
ACC has begun extending the scope of its falls prevention research. Objective 2 includes an action to encourage proposals to investigate the social and economic costs of falls and injuries from falls. Some exploratory work has been done to identify factors leading to poor outcomes for people injured from falls. However, this research work needs to be extended to provide a comprehensive picture of the different effects of falls for different population groups.

3.45
We found some evidence of new research to explore factors contributing to falls in populations or settings that ACC's past research programmes did not target. One example of such research is a project examining risk factors for non-fatal injuries from falls at home among adults 25-60 years of age. Another example is a recently commissioned project into home safety, designed to examine the roles of alcohol, recreational drug use, and fatigue in unintentional injuries at home among people of working age. Research is also being carried out into the design of healthy homes, with falls prevention one of a number of environmental design considerations.

3.46
We encourage ACC to build on this early work to address specific population groups and settings. This will require – among other work – ongoing collaboration with the Ministry of Health on child safety (including falls), a continuing focus on people of working age, and additional research into options to improve safety in the home. It will also involve ongoing examination of causal factors to support the piloting of falls prevention programmes, provide an evidence base for existing programmes, and identify factors contributing to the risk of injury from falls.

3.47
One important action identified under Objective 3 is the preparation of a research action plan. The Stakeholder Reference Group discussed a proposal for a dedicated research fund and the research action plan at its meeting in March 2007, noting the need to consider funding and effective alignment of implementing the Strategy with research priorities. However, the plan has not been prepared.

3.48
ACC is aware of the gaps in research. In responding to the review of alignment between its injury prevention activities and the Strategy, ACC has recognised the need to direct research at a wider range of target groups. ACC has also recognised the need to explore risk factors associated with settings such as the home and residential care environments, and consider opportunities for a more cohesive and joint approach to research.

Programmes and interventions

3.49
This section discusses progress made on Objective 3 – Develop and implement programmes and interventions that focus on the prevention of injury from falls, based on best practice. As part of this discussion we comment on alignment between ACC injury prevention activities and the Strategy.

Collating and publishing information about falls prevention

3.50
ACC has collated and published a wide range of advice and information about falls prevention. ACC's website provides an easily accessible source of information about falls prevention. This information includes:

• copies of the Strategy and the implementation plan;
• links to New Zealand and overseas sites and resources related to falls prevention, grouped by target population groups and settings;
• research reports;
• falls-related statistics;
• sources of injury-related data; and
• links to partners and stakeholders.

3.51
The process of implementing the Strategy is designed to produce valuable best practice tools and guidance, such as the planning and evaluation guide that has been written by ACC staff in collaboration with members of the Working Group. The guide provides examples, templates, and references to useful sources to help community partners decide how to plan local injury prevention projects and evaluate the results.

Alignment between ACC's injury prevention programmes and the Strategy

3.52
The ACC-commissioned Falls Intervention Alignment Project reported on the alignment between current injury prevention interventions and the implementation plan.⁴ The report identified 41 interventions of which 20 targeted falls prevention directly. The report noted that ACC was the lead agency for 71% of falls-related interventions. However, no interventions focused on reducing the social, psychological, and economic effects of injuries from falls.

3.53
The report recommended that ACC ensure that it integrated the Strategy's goals and objectives in its internal planning and reporting. We too found little evidence of links between the Strategy and ACC's operational injury prevention business planning in the early phase of implementing the Strategy. For example, the 2007/08 operational plans for ACC's falls prevention programmes do not refer to, or reflect, the priorities of the Strategy. This was confirmed in our discussions with ACC staff who told us that injury prevention activities had remained largely unchanged until late 2007, 12 months after publishing the implementation plan.

3.54
While ACC was slow to use the Strategy to review its own injury prevention programmes, business planning at an operational level has now begun to focus on the need to align injury prevention activities with the Strategy. This has been reflected in the focus of operational planning for 2008/09, with background papers identifying the Strategy as a crucial issue for discussion at the business plan workshop of ACC's injury prevention group.

3.55
To align its work effectively with the Strategy, ACC will need to modify or extend its falls prevention programmes, or pilot fresh initiatives, consistent with the Strategy's objectives. ACC could consider establishing accountability requirements for relevant managers and groups within ACC that explicitly reflect the relationships between falls prevention-related activities (such as research, contract management, programme delivery, and community involvement) and implementing the Strategy.

Focus area for ACC

3.56
We consider that close alignment (where appropriate) with business planning for ACC's own injury prevention activities (including design of the research programme) will be important in promoting the implementation of the Strategy. We encourage ACC to take this into account as the implementation of the Strategy progresses.

Monitoring progress against the implementation plan

3.57
The NZIPS Secretariat reports on the implementation of the Strategy as part of its overall reporting responsibilities. It has prepared a quarterly reporting framework and template that all NZIPS lead agencies use to report on their respective areas of responsibility (ACC for the Strategy). The Secretariat uses these to report periodically to the ACC Board and half-yearly to the Minister. The Minister reports annually to Parliament.

3.58
The Strategy's implementation plan establishes who is responsible for the actions specified in the plan. ACC teams and stakeholders provide feedback on their activities to the Strategy's project team, which uses the information to report to the NZIPS Secretariat.

3.59
However, the reporting to date has been mainly descriptive, focusing on activities and lacking a results-based approach. ACC has told us that it is reviewing the nature and format of its reporting.

3.60
ACC's website allows transparent monitoring and reporting on the implementation of the Strategy. ACC has posted material periodically on the website to show evidence of the progress.

Evaluation of effects and outcomes

3.61
In 2004, ACC commissioned work on outcome indicators for serious injuries, including falls, using morbidity and hospitalisation data. This was an important early initiative, and the indicators have been published and recently updated. The indicators will form a vital tool to measure and evaluate the results from implementing the Strategy.

3.62
The need for a framework by which to measure the results was identified as a critical task early in developing the Strategy (June 2004), with a draft evaluation framework prepared in April 2005. However, it was recognised that this framework needed further work, including indicators to measure the effects of less serious injuries. In November 2006, a sub-group of the Strategy's Working Group was formed to draw up a more comprehensive evaluation framework. The Stakeholder Reference Group discussed the framework in March 2007, but no further progress was made.

3.63
The Strategy's Working Group agreed in January 2008 to make further work on the monitoring and evaluation framework a priority.

3.64
An evaluation framework and methodology is important to measure effects and outcomes and monitor progress. We agree that priority should be given to preparing a methodology and framework for an evaluation in the future. Because of the many factors contributing to falls, it may be difficult to isolate the effects of the Strategy on the incidence and severity of falls. ACC needs to define clearly the extent to which results can be attributed to the Strategy.

3.65
This framework could then be applied by ACC and other agencies to assess whether intended results have been achieved, to assess the effects and outcomes of specific actions and activities, and to report on progress in implementing the Strategy.

The Accident Compensation Corporation's corporate leadership

3.66
Limited staffing capacity led to a loss of continuity and focus on the plan during part of 2007. In July 2007, not long after the launch of the implementation plan, the ACC project manager resigned. The following months saw other gaps in resources because of staff turnover. These difficulties were compounded by changes in senior management in ACC's injury prevention division in 2007.

3.67
Concerns about staffing changes and shortages were raised with ACC management. However, the response was neither prompt nor fully effective. We found no contingency planning to address the risks of unexpected staff changes or to maintain focus on the plan and ensure ongoing communication with stakeholders. Without sufficient permanent staff assigned to the Strategy's project team, and only seconded staff to support the work, progress depended to a large extent on the personal commitment of individuals.

3.68
ACC's Falls Intervention Alignment Project recognised the need for ACC to take a stronger leadership role to involve the falls prevention sector. The Falls Intervention Alignment Project noted the risks of not having a dedicated team with a comprehensive oversight of accountabilities and budget for achieving the Strategy. In response, ACC's public safety team took over responsibility for implementing the Strategy. A new relationship manager position was set up to lead the implementation of the Strategy, and it was filled in January 2008.

3.69
Adequate planning should be in place to provide enough resources for the project, to provide support for the relationship manager role, and to ensure effective leadership in the implementation of the Strategy. This planning should consider the scope of the relationships manager and supporting roles, the demands of the implementation's tasks and time frames, and the need for succession planning to address staffing contingencies. If this does not happen, there is still the risk that staffing changes, or limited staffing capacity, could mean a loss of momentum in implementing the plan and a loss of focus on the Strategy.

Area of focus for ACC

3.70
In our view, it will be important to provide sustainable resourcing to support ACC's leadership role. We encourage ACC to focus on this to ensure continuity in implementing the Strategy.

1: See the injury prevention section on ACC's website (www.acc.co.nz).

2: The Otago Exercise Programme is an individually tailored exercise programme delivered to people in their home by a trained health professional. It consists of a series of leg strengthening and balance retraining exercises and a walking plan.

3: Tai Chi involves a series of slowly performed gentle movements designed to improve mobility, flexibility, and balance. Modified Tai Chi is a style of Tai Chi that has been adapted for older adults. It focuses on preventing falls by improving lower limb strength and balance.

4: The ACC-commissioned report of the Falls Intervention Alignment Project was published internally in July 2007.