Earlier this year, writer and consultant, Lea McInerney reported for Croakey on an event held in Victoria for healthcare professionals, called The Gathering of Kindness.
The purpose of the Gathering was simple: participants were invited to “re-imagine a healthcare system that has kindness, trust and respect as core components.”
One of the organisers was Dr Catherine Crock AM, a Melbourne-based doctor who leads a team that has successfully implemented these components, in the award-winning redesign of a paediatric oncology day surgery service. They did this by partnering with patients and families to make major improvements in the quality and efficiency that would not have been possible with a top-down approach.
In the post below, Lea McInerney asks Catherine Crock about her work in the hospital, and with the Hush Foundation, an arts in health program using music and theatre and to transform healthcare culture. For those with a musical bent, Hush is launching its 16th album in the coming days. See the end of this post for details.
Lea McInerney writes:
What if you could improve hospital efficiency by 400 per cent and at the same time reduce stress for families and increase job satisfaction for staff?
That’s what a healthcare team in an operating theatre of a children’s hospital managed to do by applying principles of patient-centred care to their work. They went on to win the 2007 Australian Council for Healthcare Standards National Award for Clinical Excellence and Patient Safety.
The head of that team, Dr Catherine Crock, is an Australian physician and an internationally-recognised leader in patient-centred care. She’s also becoming increasingly well-known for her work on promoting staff wellbeing.
I recently had the opportunity to ask her some questions about her work.
Was there a specific catalyst for your shift to more patient-centred care?
In 1998 I began working in a hospital in charge of lumbar punctures and other procedures for children with leukaemia and was concerned to see children who were distressed and upset when they came to hospital.
At the time, it was pretty much unheard of for staff to ask families what being in hospital was like for them. My team and I began asking families what they thought about the care they were receiving. From this small thing, big things began to grow.
It was life-changing for me to speak to the children’s parents and find that they had many suggestions for improvements – but to realise at the same time that there was no mechanism to feed these into the hospital system.
In 2009, I helped set up the Australian Institute for Patient and Family Centred Care and the following year visited centres of excellence in patient-centred care in the UK and USA on a Churchill Fellowship. What I found was that patient-centred care, patient safety and staff wellbeing are all intrinsically linked.
What does the term ‘patient-centred care’ mean?
Patient-centred care describes care that involves patients, families and staff as partners in providing the right care for that individual and their family at that time. It means we collaborate at every level – at the bedside, in hospital meetings and planning, and at policy and government levels too.
How did the shift to patient-centred care play out where you worked?
We began by sitting down with parents and asking them what they thought we were doing well and what we could do better. It changed the course of the way I practised medicine. Families can tell us where the gaps are in real time, and where things can go wrong. We found out that sometimes children and their families were waiting up to six hours for a procedure. I began to realise that the systems work for health professionals and management, and not necessarily for the children and families.
We got into a bit of trouble with some of the managers who saw it as encouraging families to complain. Their view was, ‘Patients and families haven’t been complaining, therefore everything is going fine and dandy.’ Once we started asking the families, we realised it wasn’t fine and dandy.
‘We’re stressed,’ they’d tell us. About pain, long waits, not having much say in how things were run. We found they had some great ideas for improving things. They’re sitting there, observing a lot, and experiencing a lot. In partnership with them, we knew we could make it a lot better and safer.
We were also hearing from them that they were often aware of when staff weren’t getting on with each other and it made them feel unsafe. That was an eye-opener.
In what ways?
Staff think that poor behaviour is just among them, behind the scenes, that it’s hidden from the families. But it’s not. Families quickly work out when staff aren’t working together as a cohesive team and they twig that it isn’t going to be good for their child or themselves. It makes them feel unsafe and that’s not fair. They’re already vulnerable.
Patient safety experts around the world say the next big challenge for healthcare globally is how staff treat each other. People like Don Berwick, previous President of the Institute for Healthcare Improvement in the USA, now talk about how important it is to have joy and meaning in your work, to get on with your colleagues, treat each other with respect and kindness, be part of a well-functioning team.
Bullying amongst staff in healthcare has been rife for many years and is now recognised as unsafe for patients, costly to hospitals and leading to loss of good people from the system. It’s urgent that we talk about this more and work on addressing poor behaviour and culture.
The idea of talking about kindness, respect and trust in healthcare seems the positive way to approach the problem. What would a kind health system look like? For those working in it and for the patients and families?
What does that look like in practice?
It’s where executive team members are on the floor talking to their staff regularly. That creates a much better culture. A lot of organisations espouse values and have them up on the walls in the workplace, but staff usually haven’t been involved in developing them, nor do they see their managers ‘walking the talk’, so they become disengaged and cynical.
In the same way that we have to involve patients more, seeking their views, so we have to involve staff. The next healthcare shift has to be about looking after your staff, engaging them, making them feel valued and cared for.
What about your own team? Who’s in it and how do you look out for each other?
We work in the operating theatre, sometimes with very sick children. We have two anaesthetists, two theatre nurses, an oncology nurse, a technician, and one or two students. There can be eight to ten people, not always the same ones.
We’ve put a lot of work into allowing ourselves to be vulnerable in front of each other. At the start of each day we’ll tell each other how we’re going. Someone might say something like, ‘I’m feeling a bit unsettled today, something’s happened at home.’ The things we were taught not to say as health professionals. You were meant to put on your uniform and walk in there and nothing’s going to faze you.
When I started sharing how I was feeling – not in any ‘psychobabble’ way, just something like ‘I’ve had a really rough couple of days, I’m not concentrating as well as usual,’ others would say, ‘That’s okay because we’re all here as a team and we’ll help keep an eye on you when you’re checking the chemo.’ It’s very matter-of-fact.
It also helps to know if one of the anaesthetists has been on a shift the night before and didn’t get home until three or four in the morning. That’s a safety thing and to share that with the team is more than helpful, it’s vital.
We all help to make sure everything is safe and good and efficient. It’s built trust between the team members and it’s flattened out the structure. The whole room understands the way we treat each other in there. I know people talk about what we’ve got in our theatre because it doesn’t happen everywhere, and people enjoy coming and working there.
When we’re all pulling together, teams are way more efficient and they save money. And it’s also safer for patients and families as well as for staff. I’ve seen this shift and it gives me great hope that if we talk about it more it can happen much more widely.
How do you avoid it happening in a needy self-serving way?
I might be recognised as the leader in the room, but I don’t have to act like the boss. We’re sharing the load and appreciating the part that each person is playing in the room and the particular expertise they bring. There’s this really good sharing of responsibilities. It seems egalitarian.
And the kindness is genuine. We care about each other, about getting to know each other. When someone who’s new arrives we get to know them quickly. We’ve developed this way of everyone taking an interest in each other. We’ll ask a new person where they’ve come from and what they’re interested in. Then we let them know how we’re going to work together today.
And the patients and families are part of that team too. It’s made the staff more willing to include the families.
What do you do to include them?
When we meet a new family, my first chat is about them being part of the team and part of the safety of everything that’s going on. I say to them that we want them to feel comfortable to speak up if they have concerns about anything.
The family will say, ‘Thanks for letting us know, we hadn’t realised you’re wanting us to be so active in this.’ But we need them to be. Healthcare is so complex that we can’t have our eye on every single ball.
Sometimes in hospitals people end up feeling like they’re being a ‘difficult patient’ and we don’t want them to ever feel that. We’ve found that it’s great for them to feel they’re part of the team and that their input is critical to what’s going on. They know their loved one better than we ever can. If they tell us something doesn’t seem right, we need to be listening.
Does it take up more resources than the old way of working?
We haven’t done anything that has taken any more money, time or effort. And we’re one of the most efficient theatres in the hospital. The hospital management is delighted. We have great turnaround times, because we spend that little bit of time getting the families comfortable as part of the team, and letting us know what’s going to work best for their child.
We improved our efficiency for patients having medical procedures when we changed a whole series of hospital systems based on what they and their families told us. They were able to identity inefficient things that were happening in their journey. To begin with it could take up to an hour per procedure. With the improvements we brought in based on their feedback we reduced stress and anxiety, and were able to do 4 cases per hour.
When you include patients and families in the team, and have built trust with the families, you move much more rapidly and more safely through the work.
Finally, can you tell us about the work you’re doing in arts in health?
I set up the Hush Foundation in 2000, initially to produce music composed specifically to reduce stress and anxiety felt by patients and families in hospitals. Sixteen CDs later, many musicians – people like Slava and Leonard Grigoryan, Paul Grabowsky, members of the Tasmanian Symphony Orchestra – have volunteered their time and talent to compose and play music for the recordings. They’re now played in healthcare settings around the world.
Our latest one, Hush 16, was inspired by stories of young cancer patients and other children. We asked them questions about their lives and their responses were full of humour, wonder and surprising wisdom. The music that resulted – written and performed by Lior, The Idea of North and Elena Kats Chernin – conveys the children’s feelings, hopes and dreams beautifully.
We’ve also collaborated with well-known playwright Alan Hopgood on two plays – ‘Hear Me’ and ‘Do You Know Me?’ We stage them for healthcare staff and then involve them in discussion about the issues they raise, like communication with patients and between staff, and bullying and safety.
For Sydney and Melbourne readers: Hush will be launching its 16th album at concerts featuring Lior, The Idea of North and Elena Kats Chernin.
Dates: Sydney on 15 November and Melbourne 24 November.
More information at www.hush.org.au
Lea McInerney is an organisation development consultant with a background in healthcare and community services. She also writes essays and poetry, and her work has been published in Griffith Review, Cordite, Meanjin, Southerly and Westerly. She lives in Melbourne. Follow her on Twitter – @leamcinerney