Four excerpts from 'The Point of Care' book...
Carol pointed to the slide. "Good managers are critical to this because they can point everyone in the same direction and build teams that work to their strengths to create Great Care. These managers - and the and quality teams that support them - must be equipped with the skills they need to play their role in providing great care. At the very least they should have a working knowledge of complexity, change, resilience and measurement. They should know how to get the best out of people in a challenging environment and understand how to work with consumers to create positive experiences and outcomes. People aren't born with this knowledge, nor do they necessarily acquire it on their rise through the ranks. Basically, if we want great care, we have to develop great managers."
Carol paused as she clicked to her final slide, emblazoned with the KVHS Great Care logo, and many photos of KVHS consumers, staff and committee members.
“And where has all this left us? Just before this session I received a text containing our state DHHS results.” A hush descended over the audience. All that work and commitment.
Did it make a difference?...
Pari’s face was creased with indignation. She glanced around the table. Kristen looked too surprised for words. Anton was slumped in his chair reading the article on his tablet, while Jeff sat bolt upright, ready for action. Elena was grim-faced, giving nothing away. Carol’s face was flat and expressionless. She put the paper down and clasped her hands in front of her knuckles white.
“How dare they portray Carol as a bad manager trying to cover up problems with a fad, when in fact she’s doing the exact opposite!” Pari exclaimed, crossing her arms defiantly.
Kristen recovered her powers of speech. “WHO is giving them the information? It’s time to get it stopped, once and for all. Not only is it untrue, but if it continues it’s going to kill any hope of embedding GC. I know some people who are already using the bad press as an excuse not to participate, and this is just a boost to their cause. And we’ll never win back the community… oh, no!” She slapped her forehead dramatically. Our next Great Care community workshop is next week. It won’t be a happy crowd!”
“It’ll be OK,” Jeff reassured her. “It gives us an opportunity to counter the ‘Leader’s’ rubbish, at least. As for who is doing the leaking, they may just have slipped up by providing so much detail.”
“What do you mean?” Pari uncrossed her arms and leaned forward, intrigued.
“Well, by my reckoning, it’s got to be someone who’s actually attended a GC workshop,” replied Jeff. “There are details about Great Care in that article that could only have been gleaned from being there in person.”
“That’s around 150 people across 10 workshops now,” said Pari, quietly.
“That’s not too many.” Jeff shuffled impatiently in his chair. “Pari, can you get us the workshops lists? There can’t be too many people there who are disaffected enough to take this risk. We should be able to narrow it down without too much trouble.” Pari nodded. “I know your strategy has been to address this quietly and not give it much oxygen, Carol,” he continued, glancing at his silent CEO. “And at first I agreed with you. But it hasn’t worked. Someone is playing with us and it’s time to confront it head-on.”
“And we have social media!” Anton announced, fingers flying over his tablet. “Don’t worry, just the usual haters who are happy that today’s ‘Leader’ has given them something else to attack. Nothing worth our attention.”
“You haven’t said much Elena,” continued Jeff, who was on a roll, responding to the crisis with typical ED physician vigour. “There must be some dissatisfied nurses. There usually are.”
“Well, seeing as they make up the biggest slice of the staff, you should expect that there will be more unhappy nurses than other staff,” responded Elena testily, lips pursed. “And what about allied health and non-clinical staff?”
Pari gazed at her thoughtfully. She wasn’t sure that Elena’s heart was really in what she was saying, whereas the other Executive Team members were stirred up and ready for action.
Carol completed her analysis of the KVHS results in the Department of Health’s performance report and sat down.
“How did we get into this situation?” Chris Bowman-West, the Quality Committee chair, and nurse-turned-lawyer, was struggling to conceal his frustration.
The other Board members on the Quality Committee looked at the Executive Team, who looked down at the table. Nancy sat in silence. This was Chris and Carols’ show – for now.
“It’s not just the consumer and staff satisfaction we need to worry about is it?” Andy Bidwell, chair of the Consumer and Community Partnerships Committee, pointed at the screen showing the KVHS performance results summary. There are problems with clinical care there as well.”
“I meant the ‘whole’ situation,” said Chris. ‘Consumers, staff, care, everything. KVHS has always prided itself on providing excellent care; it’s been a strategic objective as long as I can remember. And the Board was always led to believe that it was an operational reality.”
“We do provide excellent care.” Elena looked up defiantly. “Every health service has its up and downs. No-one can expect us to be perfect. But we have very good, hard-working staff, and no-one at KVHS comes to work to do a bad job.”
Carol regarded her CNMO thoughtfully, wondering why she would make such potentially career-limiting statements in this situation. With a shock she realised that this was no evasive smokescreen. Elena really believed what she was saying. Carol winced inwardly. So much work still to do to get everyone on the same page, she thought, knowing that Elena was not going to enjoy the next slide in her presentation.
“Well,” continued Chris, ‘whilst I’d like to believe that, Elena, I think we’ve avoided the hard facts for too long. At least now we know where we are. As Carol has now had enough time in her role to get a good feel for the issues, I’ve asked her to put together her thoughts on how we got here. I believe we need to understand where you are and why, before we work out how to get where we want to go. Our plans must be based on the reality of how we got here in the first place, or we could make the same mistakes. Carol?”
Carol clicked to the next slide which was headed up ‘Clinical Governance Warning Bells’. “I’ve got a mental list of clinical governance ‘warning bells’, that I’ve developed over many years in the healthcare game. Some of them are also discussed in the relevant literature. When I hear a bell ring, my antennae go up, because I know there’s a fair chance that there’s a poor care issue lurking. Maybe not across the whole organisation, but generally one or more of these warning bells indicates that consumers may be getting a raw deal somewhere in the service. These bells have been ringing in my ears ever since I got here, so I thought they’d provide a good framework to look at the organisational issues that either have been or currently are likely contributing to our poor results.”
The group studied the list silently. Every item had a red tick next to it.
- Hierarchical culture with little point of care staff power or recognition, which can manifest as a culture of fear and staff reluctance to speak up
- Institutional, isolated and inward looking culture, unwilling to learn from elsewhere (long standing Board/exec members with little role evolution)
- Board and Executive unwilling to hear bad news
- Lack of specific clinical leadership at each level of the organisation, and deliberate and ongoing teamwork development, for the provision of safe, quality care
- Weak S&Q reporting format and content, and lack of active response to data and feedback
- Lack of robust review of clinical practice; and assumptions by clinicians that monitoring, performance management or intervention is the responsibility of someone else
- Tolerance of sub-standard care: problems are long standing and known by many stakeholders but not acted on
- Lack of consumer participation in their care and little interest shown in consumers’ interests; with decisions made to meet the needs of the organisation and staff over care safety and quality
- Quality system based on compliance with standards with limited service and care improvement beyond standards’ requirements and reaction to things that go wrong
- Building works, budget issues, major restructure, rapid demand growth
- CEO lacks requisite S&Q improvement knowledge to lead point of care excellence
- CEO and Board chair are at loggerheads or collude to withhold information from the rest of the Board and Executive.
Chris broke the heavy quiet around the table. “This Board has been content for far too long to accept the good news stories and not probe too far into the murky stuff. Well, it’s time to dive into the murk. OK, Carol, give it to us straight, and don’t pull any punches.”
On the Monday morning after the Executive Team planning session, Rosie bustled in and set a pile of ‘non-urgent’ messages in Carol’s in-box. “How did it all go?” she asked. As usual, she didn’t stop while Carol replied, but busied herself with changing the flowers.
“Surprisingly well, thanks Rosie.” Carol stopped to admire Rosie’s deft flower arranging. “We’ve got a ways to go but there’s definite progress. We learned some useful skills and committed to some good decisions. Now the hard work continues.” She picked up the message on top of the pile and read it. “What’s this one from the National Rural Health Association?”
“Oh!” Rosie actually stopped what she was doing. “That’s good news. Just after you left for the executive planning workshop, the Association called and – wait for it – asked if you’d be willing to be the closing speaker for the annual conference, to talk about how you’ve turned KVHS around. No-one from Kinsley Valley has ever been asked to give a keynote address at the conference, so it’s a real honour!”
Carol opened her mouth to respond, but Rosie continued hurriedly. “Of course I said I’d check with you but that I was sure you’d say ‘yes’. You’re going to have so many good stories about KVHS to tell with everything that’s going on. We haven’t seen this much action for years!” She stopped and peered at Carol. “You don’t look as pleased as I thought you would. Is something wrong? I thought I was doing the right thing.”
Carol immediately assembled a smile and slipped it on.
“I am pleased - that you are so proud of Kinsley Valley, Rosie. And of all the hard work everyone is doing. I’m just not sure that there will be enough good news stories by the time the conference is on. Isn’t it just before the state election?”
“Yes, in about four months. And you will have lots of good stories to tell, I’m sure of it.” Suddenly Rosie noticed she had stopped moving and went back to continue with the flowers. The staff will be so proud that the whole country will hear about Kinsley Valley. Lots of them will be able to attend as this year it’s being held at the Woodside conference centre, only three hours away: just down the road! Year after year we’ve had to hear CEOs from other rural health services blow their trumpets. The ‘Mountain Health Care’ CEO has done that closing address three times in the past seven years. Their care may be average but their self-promotion is outstanding.”
Carol regarded the normally positive Rosie with interest, surprised at her intensity.
“The staff really need something to brighten them up,” Rosie said. “This past year has been such a grind. If you can’t do it, no-one can.”
Carol rolled the idea around her mind and felt the familiar lead in the pit of her stomach. She did not entirely share Rosie’s optimism. As nice as it was to be asked, and to hear Rosie’s enthusiastic endorsement, Carol knew that concrete improvements might not have emerged by then. After everything the health service had been through, they didn’t need to add public embarrassment at a conference to their list. It was too big a reputational risk.
She shook her head. “Sorry Rosie,” she said as she sat down and picked up her phone.
“Carol. We need this.” To Carol’s surprise, Rosie’s normally cheery voice wavered.