David Galler’s Blog: A recent address to the HVDHB

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Tena kotou

Ka mihi ki nga tangata katoua

I korero nei

Tena kotou

Tena kotou katoa

I te taha o toku matua

Ko Tatra oku maunga

Ko Vistula toku awa

Ko Lipa Galler

te rangitira

Ko Aron Galler

Toku papa

He tangata ia no hurae

Ko Galler hapu

Ko Galler toku whanau

Ko David Galler toku ingoa

Ko Ema toku hoa rangatira

He kaimahi ahau i te hohipera

nunui rawa atu Tamaki makaura

Ko Middlemore te ra

Hei rata i roto i te ICU

Ka nui tena mo tene wa

Tena koutou

Tena koutou

Tena koutou katoa

Greetings and thank you for the honour to speak with you today.

This is an evening of celebration – Foremost it’s an opportunity for the DHB and others to acknowledge and honour you. To thank you for the fine work you have been doing and celebrate your place in the engine of this place, to improve the lives of the people we are here to help.

The QI movement in NZ is still in its adolescence but together we have come a long way in a relatively short time…it doesn’t seem that long ago when I sat in international forums elsewhere, listening to the work of others engaged in improvement with my heart racing from embarrassment at what little value we in NZ placed on that kind of an approach.

By way of context, in the late 90s and early 2000s that began to change with the establishment of the Epiqual Committee sadly without Putea, a ministerial committee with good people but no resources; then we set up the better resourced National Quality Improvement Committee which began a series of national programmes to reduce harm. Following the review of health services led by the former Treasury Secretary Murray Horn in 2010, we set the scene for the establishment of the Health Quality and Safety Commission as a Crown Entity outside of the Ministry of Health.

At the same time, my own organisation, Ko Awatea was formed – we said to accelerate our ability to help our staff and communities help themselves. Across the country too, DHBs began to invest in their own improvement, perhaps led by the pioneering work of the good folk in Canterbury.

Thanks to people like you, healthcare improvement in NZ is becoming a strong bottom up movement and now has a life of its own.

Despite being a Wellington boy, it’s still somewhat poignant for me to be here in the Hutt, not so far from Mitchell Park where I played so much tennis when I was younger , and of course very close to Chilton Grove where my mother spent her last few decades of life surrounded by a remarkable group of friends.

My mother Zosia was an impressive woman who, in her tumultuous life, had seen and experienced things no human being ever should. Despite the horrors of a childhood spent in Auschwitz, against all odds she became a wife, mother, grandmother and a loyal friend to many. Fiercely independent, politically savvy, generous and liberal-minded, to those who knew her, she remains a symbol of resilience and strength.

She died not in hospital but at home and during those final weeks, was looked after by a small group of us, my brother Les, my partner Ema, the staff of the Te Omanga Hospice and me.

Because of my longstanding role as an Intensive Care Specialist and perhaps because of some of the other roles I have had over the years, people think I am an expert in matters health and perhaps in some areas I might be, but when it comes to being on the other side, that of experiencing care, I am not. Up to that point in my life before my mother became so ill, I‘d had no real personal experience as a patient, and of being at the mercy of well-meaning people like yourselves. For me, it had been an annual visit to my GP and on the receiving end of the occasional scope slipped into one of my orifices – little more.

Over the years though I helped broker care and translate the foreign language of medicine for friends and acquaintances. For those angry with the way they were treated – stories that sometimes upset and embarrassed me – I would always encourage them to complain and on some occasions I would even help them draft those letters. Perhaps like you, my beliefs about what to expect by way of care is entirely based on my perception of how I provide care to others.

So back then when my mother deteriorated so dramatically and we needed help, YOU came through for us and during that time I know my mother was deeply grateful for the care she received and I want to thank you for that. I especially want to acknowledge Atul Dhabuwalla, a surgeon at this place who was gracious and kind in his dealings with my mother when we turned up at his clinic not having done the staging CT scan or had the blood tests he had requested. A little put out at first, I could see the relief come over him when he realised that he didn’t need to pretend that doing those tests would change my mother’s fate.

That was several years ago now so I’ve had plenty of time to reflect on what happened then – what we did and what we could have done better – of course, at the time it was a complete whirr, an immersive fog.

I have thought a lot about why things worked so well and about the lessons there to improve care in other areas. What I saw was a set of principles and practice seldom seen, apart from in modern day Palliative Care and Geriatric Medicine. I see these specialities as unique examples of co-design and patient-centred care.

Sadly, in most other branches of medicine we still seem to be more interested in what we do to people than we are in the people themselves. In my mind that position effectively changes us from doctors to technicians.

However, having a genuine interest in people and what matters to them is just the first step – reliably delivering care in a timely manner, safely, efficiently and effectively is another challenge. That’s the one we are becoming expert at eh!

In my mother’s case, the people and the services that helped us, understood and respected her wishes – to stay at home; to be pain free and for her family to be with her.

The hospice staff were kind and worldly – interestingly they were mainly women – but gender aside, what stood out most was how they operated.

What they offered was this: their expertise as palliative care specialists and nurses; a range of equipment both simple and specialised including flash beds and la-z-boy chairs; nebulisers (my mother was a smoker and, as a result of a stroke, had fallen down her stairs and broken her ribs); a walking frame which we used till she could no longer walk – the sight of them still send a chill down my spine; community resources through their links with the local pharmacies and NGOs who could access a wide range of home care options – someone to come in everyday to shower my mother was a godsend; and good working relationships with local GPs and, critically for us as it turned out, with the Wellington Free Ambulance service, to ensure that everyone knew what really mattered to my mother.

This group of people from very different services listened and they cared. They were a good team – there were no obvious hierarchies – and they worked well together towards the same goal. They stayed in touch with us and each other and adjusted what they did on a daily basis to my mother’s ever-changing needs.

They were impressive. In fact their care was an example of transformation in action.

Thinking about all of that later I couldn’t help but wonder why we spend so much time analysing the bejesus out of the rare things that go wrong instead of systematically learning from the multitude of things that go right?

Well, in fact we are beginning to do that – using simulation, small groups of enlightened people – staff in my own ICU in fact – are recognising the complexity of what we are dealing with on a day-to-day basis and use this technology to invest in people by fostering teamwork and communication skills and in how to create a safe environment to encourage all members to contribute to solving the problem at hand. Some have called this approach Safety 2 – reducing unwarranted variation in our approach to everyday tasks but at the same time fostering easy adaptation to changing circumstances, especially in emergency situations, e.g. a failed intubation or dealing with a cardiac arrest.

This approach, Safety 2, is just one example where we are increasingly recognising that the solutions to the problems we face lie in the heads of our people and the skills we wish them to have. That same thinking applies here in the Hutt as it does more generically to the challenges we face as a nation.

When I refer to our people, I am of course talking about you and me. That is the entire raison d’etre for tonight; that is why my group established Ko Awatea and I know it’s the same for the Health Quality Safety Commission.

I am now in the late afternoon of my career so I feel I’ve seen most of the issues we are now grappling with several times before! To me they are a manifestation of a repetitive churn of past problems treated with sticking plasters. The recent scandal of people losing their sight because of the unintended consequences of targets is but one example. So too is our perpetual unwillingness to deal with the root causes of the problems that drive so many people to the doors of our health and justice systems.

“The definition of insanity is doing the same thing over and over again and expecting different results.”  Who said this one?   Albert Einstein.

And this: “Every system is perfectly designed to get the results it gets”  Paul Batalden

And this: “We have two jobs: to do our jobs and to improve our jobs”, I dunno who said that but whoever did was pretty smart!

How do we do get beyond this churn – who can do this – well the answer is in the room … it’s us, it’s YOU and ME and it’s US TOGETHER.

Wouldn’t it be great if this government would see the success and wellbeing of all New Zealanders as an investment rather than a cost?

Would it make a difference if we had a Minster FOR Health not simply of it.

Maybe we could even create the position of a Minister FOR Wellness, and a vision of health contributing to an even higher purpose for this little country at the end of the world. I am talking about a Vision but also about a Plan, in effect a Driver Diagram for the nation!

The Vision might be something like this:

To ensure that our people, families and communities are well, happy, self reliant and productive; so they can start their own businesses and staff their own businesses; and ensure that all New Zealanders can truly reach their potential.

He aha te mea nui o te ao

What is the most important thing in the world?

He tangata, he tangata, he tangata

People, people, people.

Imagine if we really believed that – and we had a unifying vision, maybe instead of one step forward, two steps sideways and several steps back, we might approach all those things outside health that impact on it in a smarter and more strategic way?

Maybe too a new flag might emerge!

If we all worked FOR health and wellness and that unifying vision would we still be facing the same terrible costs from the plague of Obesity and Diabetes that we do now and will in the future?

Would our people have more money in their pocket and not have to sleep in cars and garages?

Might we have already eliminated the scourge of child poverty and Rheumatic Fever from our midst?

It’s been a hell of a year – the chaos of the Middle East and the ongoing human tragedy that is Aleppo; David Bowie, Leonard Cohen, Leon Russell all dead; many of us with our own personal battles; TRUMP; and now earthquakes!!!

Where is our place in all of this – what impact might we have on the national and international chaos the world chooses to perpetuate? What does this mean for the work we do? Is there a better way? Well isn’t that what we improvers do – constantly be on the look-out and find a better way?

We have plenty of wonderful examples all around us:

The Epuni school near here

The Gardens for Health project in Auckland

The virtuous cycle at the Wiri men’s prison where they grow 40% of all their vegetables and all their food waste is recycled in worm farms creating compost for the gardens that feed them.

The Manaiakalani Trust – breaking a cycle of deprivation and failure by propelling students from deprived areas to success in life, through the use of innovative approaches to e-learning at school and at home.

And there are many, many more – All achieving much, but usually quite isolated and swimming against the tide of the status quo– a bit like we were in improvement 15 years ago.

We owe it to ourselves to raise our expectations, to apply the rigor of improvement more broadly because all of us deserve better.

Not just here in the hospital, but out there in our communities.

You are the people who have the skills and the approach to make that happen.

Let’s do this.

No reira

Nga mihi nui

Ki a koutou

Tena koutou

Tena koutou

Tena tatou kaatoa

– David Galler