Cranford Hospice – Dying in Hawke’s Bay, Part 2

Yesterday we posted Part 1 of Dying in Hawke’s Bay, our investigation into the state of affairs at Cranford House. Below is Part 2. The entire article can be downloaded here.

Dying in Hawke’s Bay – Part 2
By Mark Sweet and Tom Belford

The Management
In January 2008 Shaun Robinson, CEO of PSEC, announced the recruitment of a new leadership team at Cranford.

Barry Keane, Executive Director, Dr Mike Harris, Medical Director, and Sandra Sanderson, Nursing Director. Keane and Harris worked together at Arohanui Hospice in Palmerston North. Dr Harris was relatively inexperienced in palliative care, and yet to qualify as a Palliative Care Specialist.

Barry Keane comes from a nursing background, and is currently Chair of the Palliative Care Advisory Group, which signals his pre-eminence in current palliative care trends. His enthusiasm for the Liverpool Care of the Dying Clinical Pathways was recognised at the outset. Sandra Sanderson was recruited from Scotland, where she worked as a palliative care co-ordinator with a background in nursing leadership, education, and facilitation, all within palliative care.

Our interviews indicated that another major player in the restructuring of Cranford was Diane Keip. Keip comes from a hospice nursing background in the South Island and was employed by Cranford, when Kerryn Lum was Medical Director, to help implement the HB Palliative Care Strategy, which Lum and her colleagues had developed.

Keip developed a close working relationship with Shaun Robinson, giving her access to confidential information, which caused distress to those involved. She now holds the position of Palliative Care Planning and Funding Manager with HBDHB, and is the primary day-to-day monitor of Cranford’s performance … relied upon by senior management to reassure that “all is well.”

With Shaun Robinson micromanaging, the new leadership team soon changed the culture of care that had characterized Cranford. Many people BayBuzz spoke to pointed to Robinson and Keane as the protagonists most responsible for creating a culture of distrust and fear.

Numerous incidents were related where staff have been treated with disrespect and intimidation. Many are convinced there was an orchestrated campaign of ‘constructive dismissal’ where abusive behaviour was employed as a weapon to move along old time employees. Only in past weeks has an employment action brought by three Cranford nurses been settled by mediation.

And in a 29 November 2009 letter written to HB Today (but rejected), Richard Grey, husband of Sue Grey, until recently a nurse at Cranford, with decades of experience, said:

“If the reorganisation is not going smoothly, management often react with an increase in discipline to assert their management role. The staff then believe that they are not respected, are being threatened, intimidated and can feel very insecure. This leads on to a down turn in morale, increase in sickness, more involvement in disputes and unions, along with a loss of employees. As well as increased costs and possible reduction in the services offered.

Much of the above was already beginning to occur whilst my wife was in employment at Cranford, so I strongly advised her to leave soonest. On reflection, the correct decision, even though she, as are the remaining Cranford nurses, felt torn by the strong bond of loyalty, commitment and allegiance first and foremost to their patients and then to their fellow colleagues.”

The clash of cultures, between the old Cranford and the new, is not just a matter of management styles, but also of systems and philosophy.

In a presentation entitled Rethinking Palliative Care Provision, Barry Keane asks, “But where have we come from? Reactionary movement – Cottage hospice – Charity base – Culture of ‘specialness.’” He then asks, “Has the nature of Hospice development been one of the barriers to progress?”

He obviously thinks so. Indeed, nurses at Cranford have been admonished not to refer to Cranford as “a Hospice … it is a Palliative Care Unit.”

Palliative care provision with a diminished hospice role would appear the direction Cranford is being steered, with an emphasis of spreading care for the dying more broadly by providing training to Health Providers in palliative care, including the Liverpool Care of the Dying Pathway (LCP).

”Over the last 12 months, 1100 staff in resthomes and hospitals have received specific training in the care of the dying through the Liverpool Care of the Dying Pathway project,” states Ron Hall in his open letter. Barry Keane describes LCP as “a tool designed to be used in settings other than a hospice, which enhances the skill and confidence of practitioners, and the quality of care.”

Listening to Barry Keane speak passionately about, “ensuring best practice in palliative care for the dying being available to all in need,” is hard to reconcile with the allegations of his insensitive management style. It’s unfortunate his tenure at Cranford has been mired in so much controversy, but from what Baybuzz has heard from the parties dealing with Keane, he has brought it on himself.

Shaun Robinson declined to speak to BayBuzz about “issues” at Cranford, quoting Ron Hall’s letter as PSEC’s “final word on the matter.” He did however reply to a written question: Has the CEO of PSEC any comment to make about the management structure ‘bedding in’ process?

”Given the stable and close knit culture within a traditional hospice like Cranford, organizational development and change can be difficult for staff, volunteers, leadership and the community… As a result of this situation, communication between some key clinical staff was adversely affected leading to some negative impacts on staff morale. Since that time additional effort has gone into communications and team development; workshops and meetings have been held with staff and volunteers to address their concerns about change and to work together on the way forward – this is an ongoing process. While change is always hard, the reality in February 2010 is a growing sense of positiveness within Cranford and a desire to keep progressing palliative care for the people of the Hawke’s Bay.”

Also the “reality” in February 2010: The situation remains sufficiently “negative” that a mediator has been brought in to help rebuild morale. So, while Robinson speaks of “growing sense of positiveness” and Mr Hall proclaims all is well, employment actions and mediator involvement suggest otherwise.

The DHB
The complaints are too numerous, too widely-known, too widely-shared, and too credible to be dismissed. Certainly the ‘open letter’ from Presbyterian Support is an inadequate response to widespread public apprehension.

In view of this, one might think that the Hawke’s Bay DHB, provider of 70% of Cranford’s funds and the contractor (through PSEC) of its services, might inquire vigorously and independently into the matter. Not so.

BayBuzz interviewed a member of DHB’s senior executive team, Ken Foote, General Manager of Planning, Funding & Performance. Mr Foote expressed nothing but confidence in PSEC, who he repeatedly discussed as a “contractor” satisfactorily delivering “outputs.” When issues were raised publicly last November, Foote said he and his team made inquiries of PSEC management and came away reassured that “there were no concerns in terms of quality of care affecting patients.” This is the message he passed to the DHB Board.

Said Mr Foote: “We have expressed our support for Cranford … We remain confident in the level of care … We have no cause for concern about the delivery of the contract and the quality of care.”

He noted that DHB’s contract is with PSEC and how they deliver their services is up to them … “unless we felt there was some threat to the organization that could make that contract difficult to deliver.” Clearly, DHB, through Mr Foote, sees no such threat. Why? Because PSEC has assured them there is none!

A routine “audit” of Cranford’s performance begins this month as part of a normal three-year cycle of evaluation of service contracts.

Recommendations
BayBuzz suggests several significant steps are required.

1. First and foremost, as 70% funder and possessor of requisite expertise, HBDHB, with active oversight by Board members, must investigate the situation fully and issue a public report indicating findings and any recommended actions.

The aforementioned “audit” can feed into this (as should the McLeod report), but cannot substitute. We believe the review team should include appropriate management & clinical senior officials (including some not in the cozy loop between DHB and PSEC), plus some elected Board members. The latter are necessary to signal a high level of concern by those directly accountable to the community and to reinforce the credibility of findings. The report should be discussed with the interested public in an open forum sponsored by DHB.

2. In this process, the management role of Presbyterian Support should be re-considered. Clearly the dysfunction at Cranford is linked to the management approach imposed by PSEC. As a community asset, Cranford is funded by our taxes and donations, and deserves to be run directly by a Board with one mission and with requisite experience coming from the community.

3. An evaluation program should be instituted to systematically ascertain the views of families whose loved ones have been treated at Cranford. If it can be done for hospital patients, it can be done as a sign of respect and concern for the families of those who die after hospice care. And of course to improve practices where necessary for the benefit of future patients.

4. The HBDHB must also take a more proactive role is educating the public about the HB Palliative Care Strategy, and specifically on how and where this care will be provided. In 2009, 499 patients were referred to Cranford. But clearly not all the terminally ill are or will be cared for at Cranford Hospice, whatever the public perception … both because the numbers will skyrocket, and because this is not the preference of all patients. So what does the future scenario look like? The public should be clear about this.

5. Finally, the Hawke’s Bay community needs to place its present funding relationship with Cranford “in escrow” until these issues are dealt with fully and publicly. The community has been tremendously generous to Cranford Hospice over the years. But unquestioning generosity would now be irresponsible until some substantially greater accountability and public responsiveness is brought into play.

You can find supporting documents at www.baybuzz.co.nz/issues/health/cranford