As most baybuzz readers know, back in February of last year, co-author Mark Sweet and I wrote a sharply critical account of the internal turmoil then at Cranford.

That article, Dying in Hawke’s Bay, and further updates that followed, evoked strong reactions from all sides. On the one hand, I was reprimanded for “setting off a bomb under a beloved institution … that’s not the way it’s done in Hawke’s Bay”. And on the other hand, strangers approached me when I was out and about town, thanking BayBuzz for giving voice to significant concerns about the quality of care given by the Hospice.

In any case, a series of events ensued – executive departures, a staff ‘re-structuring’ that magically caused all ‘complaining’ nurses to disappear, temporary suspension of in-patient care at the Hospice, creation of a new Governance Board – that have changed the faces now managing and providing palliative care to Hawke’s Bay’s most ill.

Some would regard the Cranford story as over last November, when a new general manager, Helen Blaxland, took over and in-patient care was restored. Others saw it end in March when mediation resolved the employment dispute between former nurses and Presbyterian Support, with the latter issuing an apology and financial compensation. And still others see the story as not over yet, as they await more evidence of performance by the new team and the culture it is creating.

New team

The immediate trigger for this article was an interview offer from Ken Gilligan, chair of the new Cranford Governing Board, and GM Helen Blaxland. It’s fair to say that the new Governing Board, broadly representative of the community, has kept a fairly low profile to date. Appointed last July, the board meets monthly, but has yet to engage the public that it represents. Plenty of public appearances to accept fundraising proceeds, but not substantive interaction.

Ken Gilligan, Chairman and Helen Blaxland, General Manager.

Chairman Gilligan, with strong corporate governance credentials, notes that the board has been focused internally on matters like recruitment, re-structuring services and building upgrades. “We’re pleased with the way it’s going,” he says. But he agrees that the board should now take steps to engage its public constituency, other than by newsletter. Says Gilligan: “We can put together an afternoon or evening once we have a year completed and ask people to come along and we’ll give you a presentation from the board and from Helen and her team and talk about what is going on.” Adds Blaxland: “That seems necessary and appropriate.” Mrs Blaxland seems quiet and confident … and professes an open door policy, including to critics. “Things were broken down and there’s still a lot of rebuilding work to be done.” She cites her style of leadership as a key point of difference from the recent past.

Gilligan and Blaxland are diligent in distancing themselves from Cranford’s recent past. Gilligan says: “The shots were called … we come into it later” … noting that the new team, including the Governance Board, came in after the original set of criticisms were tabled and acted upon. And whatever one thinks of that process, “we are now charged with getting Cranford doing what it is supposed to be doing for the good of the people of Hawke’s Bay. We’re trying to get it right … but we realise there might still be hard feelings out there.” Adds Blaxland: “… we don’t want to downplay those individuals.”

“… we are now charged with getting Cranford doing what it is supposed to be doing for the good of the people of Hawke’s Bay. We’re trying to get it right … but we realise there might still be hard feelings out there.” ken gilligan

Presently, the functioning capacity within the Hospice is six beds, six patients. While there is physical capacity for eight beds, Blaxland says “over the past weeks we haven’t any ongoing need to go to more beds, at times having only two or three patients requiring in-patient care”. Gilligan argues that while eight beds reflects the norm in terms of patient/population ratio throughout NZ, Cranford’s experience since in-patient care resumed has shown that six beds are adequate for now. That number will increase as needed in the months ahead.

Blaxland says that Cranford has no trouble providing the medical and nursing staff to operate at six bed capacity; however, more patients would be problematic at present. Of course treatment within the Hospice accounts for a small fraction of the palliative care Cranford provides throughout the community … a point I will return to.

Recruitment issues

Many differing perceptions swirl around Cranford’s ability – since regime change – to in fact recruit sufficient qualified staff. For example, while GM Blaxland managed North Haven Hospice in Whangarei for 12 years, and has extensive public hospital and NGO health sector management experience, her formal qualifications are in the area of general nursing, with a certificate in infection control. Some critics point to individuals on the present roster and compare them unfavourably position-by-position to predecessors, more experienced  in palliative care, who formerly held essentially the same positions. That said, I have yet to hear anyone propose exchanging Mrs Blaxland for her predecessor.

Chairman Gilligan argues that, first, Cranford is well-staffed; and second, that while recruiting palliative care personnel is challenging, this is a sector-wide issue not limited to Hawke’s Bay … or even New Zealand … “it’s an issue all over the world”. Mrs Blaxland is comfortable with the new team that has been assembled. “We’ve put a lot of time into looking at staff needs and competencies … people could say we have some new staff here who are not fully palliative care trained, but they are engaged in education to become palliative care trained people.” She also maintains that a broader range of staff experiences will benefit the care Cranford gives throughout the community, and observes: “The ethos of caring for people doesn’t change … we’re getting back to the foundations of what has been here before.”

Care in the community

Although the image most people have of Cranford Hospice is a lovely facility in Hastings, by far the greatest amount of palliative care given by Cranford occurs out in the community – about half in private homes and half in some other group setting – rest homes, private hospitals and managed care facilities. At any one time, Cranford might have a ‘case load’ of 130 or so patients receiving various levels of support. Very few will spend their last days in the Hospice. Since patients will naturally be in frequent contact with their GPs, Mrs Blaxland indicates that a great deal of effort is being devoted to “rebuilding the trust and confidence” in Cranford’s relationships with GPs in the community, which the tensions of a year ago disrupted.

She also notes: “The role of our nurses will change. Yes, they will provide care in the Hospice and in patients’ own homes, but they will spend an increasing amount of time supporting and educating other health care providers out in the community.” Supporting palliative care out in the community will be a new online patient record system that by the end of the year will give all care providers in the system direct access to complete, continually updated patient information. Among other benefits, this capability will enhance the existing specialist advice via telephone that is available 24/7 for Cranford patients and their GPs, whether inside or outside the Hospice.

Providing palliative care – physically and psychological – out in the community is consistent with a much broader emphasis, as seen in the DHB’s new strategy for care of older people, of distributing care outside of core facilities … like the hospital itself or the Hospice. The senior population in Hawke’s Bay is swelling. In 15 years, Hawke’s Bay will be home to approximately 36,000 people aged 65+, and nearly 5,000 people aged 85+ … or a 67% increase in 85+ residents by 2026.

So the number of patients requiring palliative care will increase steeply, posing significant resource issues – including major recruitment challenges – for Cranford moving forward. Against that daunting challenge, Ken Gilligan says that all Cranford can prudently do is plan for a rolling three-year window, ratcheting up services incrementally in line with demand. Reflecting on this scenario, one might think the Cranford imperative would be ‘let’s get all qualified hands on deck’ … including interested former employees!

Future accountability

While there are observers who are legitimately skeptical of how the new team is proceeding at Cranford, surely everyone wants the institution to succeed going forward. No one disputes that a higher standard of accountability must be met, with ample opportunity for the community to voice any concerns. It is important to recall that the situation turned toxic when those raising informed concerns, including staff on the inside, were ignored – or worse … rebuffed and retaliated against.

New governance is of course a key element … assuming it is transparent and responsive to the community. Chairman Gilligan promises that the board will issue its own ‘Annual Review’ of Cranford’s performance – in terms of both care-giving and financials – in September, marking its first year of stewardship.  He notes that financial support from the community has rebounded since a year ago when “with the tensions, it had plummeted … it was way down”. Now, “it’s come way back and we want to thank the community for that.” I for one would hope that the Cranford Board does sponsor a public forum where that review can be discussed, together with a new strategic plan that has been developed for Cranford, and any community concerns can be ventilated.

Then there’s the new general manager, who should be granted time to make her mark and demonstrate her accessibility to the community. Meantime, Cranford is participating in a quarterly bench-marking process, a nationwide self-evaluation process for assessing progress against service goals and standards. While that’s currently a process outside of public scrutiny, it is monitored by the Board, and both Blaxland and Gilligan indicated they would be willing to make these performance results available to the public.

More formally, the hospice ‘sector’ is in the process of developing uniform standards, key performance indicators (KPIs) and assessment tools for hospice and palliative care throughout New Zealand. Mrs Blaxland is a member of the national governance group for that exercise, with work to be completed at the end of 2012. While many might shudder at the mention of KPIs in the context of care for the dying, with the enormous growth of demand ahead for palliative care services – and a context of more demanding patients and families – it seems prudent that some systematic framework for evaluating the care provided, and setting agreed standards, is necessary. Perhaps that will avert the need for special crisis audits, as was required to break the log jam at Cranford last year.

KPIs aside, at the frontline, it is first and foremost the patients and their families who must be satisfied with the care given by Cranford, whether at the Hospice or out in the community. That satisfaction is actively assessed through an extensive survey completed by each family upon the death of their loved one. These surveys too are now monitored monthly by the Governance Board. A copy of the survey will be published on the BayBuzz website.

In summary, it appears that appropriate measures are in place, or being implemented, to enable Cranford Hospice to provide the services our community expects. So long as Cranford’s leadership team indeed is open – to critics and donors alike – and pays attention to the signals delivered by the community, they should be given their opportunity to succeed.  “What more can we do?” asks Chairman Gilligan. He is clearly mindful of the public trust Cranford must earn and the increased degree of transparency required to do so. He concludes: “We must do this … 35% of our support comes directly from the confidence and generosity of the community, from a dollar in the cup to the biggies, as well as the support of our volunteers. The Cranford team is enormously grateful to the people in the community for all the ways they support us.”

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