director and founder of the Australian Institute for Patient and Family Centred Care chair
and founder of the Hush Foundation.
[00:00:15] A doctor at the Royal Children’s Hospital a Churchill Fellow and an adjunct
professor at the Faculty of Health. School of Psychology at Deakin University. Catherine is
it OK if I call you Catherine.
[00:00:30] Yes go right ahead Phil..
[00:00:32] Catherine I was reading about the Australian Institute for Patient and family
centred care which is something that’s while it was established by you in 2009. You’ve
recently merged. Is that correct. With the Hush. Yes. Foundation. Yeah. I just thought we
might hear a little bit about the institute.
[00:00:54] what you are trying to do there and then maybe we’ll dig in a bit further to your
background around what motivated you to do the things you’ve been doing in this space
so perhaps you just tell us a bit about how the Institute was founded.
[00:01:08] So the Institute came about really out of my work with patients and families at
the Royal Children’s Hospital and I look after children with leukaemia and other cancers.
What I found back nearly 20 years ago now was that the patients and families didn’t have
a lot of voice in the actual system. So they may be experts in their own child and in what’s
going on for their family. But usas health professionals weren’t tapping into that it seemed
to me that we really needed their expertise to help us to understand their child the best as
possible to be able to work more closely with the family to get the best results and back in
the day that was seemed to be quite disruptive way to do things.
[00:01:56] Yeah just. Just on that.
[00:01:59] It sounds very logical. What you’re saying. And yet it’s very unusual. From my
understanding of what’s going on in the health care sector not just in Australia but
elsewhere in the world.
[00:02:12] When you think back on your career when did you have this feeling or
perception that things weren’t right and needed to change.
[00:02:21] Probably when I came back to work after having my own five children. And at
that stage it was quite difficult to have been doing training and have young children. So I’d
stepped back for nearly ten years came back in pretty much fresh to this job doing
procedures on children with cancer and I pretty quickly thought oh my goodness some of
the things we’re doing to these children and families if it was happening to my family I
wouldn’t cope particularly well. And I think with my mother’s view of things I really felt like
for the first time in my life I had to speak up and do something about it. And the families
were so awesome when I did so I sat down with a group of families and I said Tell me
about the journey when you have a sick child. What are some of the parts of that journey
that we as health professionals may not really understand and could be doing better to
make it easier for you. They were just full of great ideas and enthusiasm and feeling really
grateful that at last we were listening to them and that we were going to make changes
based on what they told us.
[00:03:37] Most organisations wouldn’t give people that freedom when you had the initial
real shock and when you came back and you’re looking around What relationships did you
think had to change and whereabouts and how did you have that conversation or did you
have a conversation with you know the more senior administrators in the hospital. How did
you actually get the authority to do that.
[00:04:03] That’s a very interesting question because I think I was somewhat naive at the
time and I just thought This is amazing this information that we’ve got we can go and do
something with it. And I started sort of fiddling with some small parts of the system that I
felt were within my control.
[00:04:21] I had a couple of good mentors at a high level but I also had quite a few people
who I came up against and what real barriers people who you could tell. This has
somehow challenged the status quo. Colleagues who said We’ve done it the same way for
20 years and frankly we don’t like change. No families have ever complained before and
you’re stirring them up now. It actually wasn’t that. It was so constructive and amazing and
what we learned from the families has made incredible change that has been ongoing and
in fact has spread around the world.
[00:04:58] So you’re having these conversations you’re collecting you’re fiddling with the
system. Did you have a model in your head about how you were going to deal with all of
these possible obstructions to making the change and did you actually have a
comprehensive view of the change you wanted or.
[00:05:18] Was it actually incremental and.
[00:05:19] It was incremental definitely incremental. There was no big plan at the start and
it was very much by the seat of our pants and hearing a problem and then looking at that
creatively and thinking how could we do this a little bit differently without it costing a lot
more money or without a lot of redesign and A lot of the wherewithal is actually there in the
system it’s just a different point of view. And what I was finding from the patients and
families was this incredibly different perspective to the one that we as health professionals
have. Here are the families who are sitting in the plastic chair for six hours waiting for
something to happen and saying to me how about you give us a pager and we’ll go to the
park with our child and we’ll come back when you need us. How about you stagger the
admission times into the operating theatre so we don’t have to sit there for five hours.
[00:06:14] So there was sitting there with their child.
[00:06:16] Yes waiting. Yes often. Right. And that’s the way the system works. But the
system doesn’t really examine its stuff itself and say oh it might not be working as
efficiently as it could. And here we had I mean the patients and families come from all
different walks of life. We had business people we had lawyers we had people who were
working in trades who know there’s a different way to do things out in their world. And
sometimes they would say frankly you couldn’t run a business like this. You just can’t leave
people sitting waiting and not tell them what is going to happen next. That raises people’s
anxiety levels makes it harder for the children and families but also harder for the staff.
that of waiting around people can go on to other things. There’s actually a level of
emotional anxiety that there are impacts on staff, tell me a bit more about that.
[00:07:19] Well this in fact then became a really important part of the conversation for me
that it is a very stressful experience to come into hospital. It doesn’t matter if it’s for a sick
child for yourself or another family member you’re feeling vulnerable and you’re feeling
scared and you come into a system you don’t fully understand. So anxiety is already high.
[00:07:41] If we leave you waiting and don’t tell you what’s happening next or what might
be the matter with you or your family member, that makes you actually feel more anxious.
And it builds into the system more possibilities of conflict and upset and even aggression
from people just feeling out of control and that then also affects the staff who are trying to
do the work there.
[00:08:11] So if you’re interacting with patients and families who are highly stressed that
makes everybody tense and I was watching this sort of get more and more out of control
sometimes and in fact I take a different view on things and I thought about how we could
be creative in this environment and actually reduce stress levels for everyone. So I started
to bring musicians and composers and creative people in to have their perspective on
some of these issues. That was fascinating.
[00:08:42] You put a composer in the corner of a room and say what. What’s going on
here how could we have some music that might help us and the composers were just
blown away by the cacophony of noise that you’ll hear in this sort of environment that as
they well know also raises anxiety levels. So composers were able to then think carefully
about where music might sit in a busy stressful hospital environment to calm everybody
down.
[00:09:13] We’ve all heard the sort of the lift music.
[00:09:18] This is a different to that but.
[00:09:21] It’s quite different to that.
[00:09:22] In fact if what we’ve done now. So we formed the Hush Foundation in about the
year 2000 and we’ve produced 17 albums of new Australian music composed for these
sort of environments. And it is quite different to lift music. What we brief the composers
about is that it needs to be music with a sense of optimism. It can be quite fast moving it
can be quite engaging and it’s more about getting people’s mind into a different place not
so much sort of just lullaby dull your senses. It’s actually quite interactive music that we’ve
found is the most successful. Things like jazz and a classical jazz sort of fusion music is
really quite amazing in that environment.
[00:10:09] That’s amazing. I mean I would have said you know based on my own reading if
you like that music is good for you it’s good for your psychology. But knowing what sort of
music to use or how it might have a beneficial effect in a medical or health sense was that
you drawing on your medical practitioner background to make that assessment or we rely
on others around this.
[00:10:38] Bit of both.
musicians. So I could see where in my own life music made a difference but I very much
did rely on the expertise of the composers and musicians and them knowing how to, not
really play with people’s emotions, but sort of modulate people’s emotions with the right
sort of music. It’s been a fascinating journey to work with people like Paul Grabowski and
Joe Chindamo and Tony Gould. Some of the jazz greats of Australian music who are just
so clever at how they can do this and how they can really change the environment in a
room and it’s such a joy to see the impact on the staff in the hospital environment when
you’ve got this music playing. Quite recently we had something go wrong at the hospital
and the staff said to me ..
[00:11:39] This is the Royal Children’s Hospital.
[00:11:41] Yeah. So sometimes things don’t go as well as they possibly can. And we were
all having a debrief afterwards and talking about how can we make this better in the future.
And the nursing staff were actually saying it is so helpful having this music in the
background to help keep us calm while we’re having stressful conversations about how
things are going. It really has helped us to be more respectful of each other in that room
and in that space to try and do the debriefing. So I just love the impact that creative arts
can have in changing the health care environment.
[00:12:20] It’s very interesting really the effect or the advances perhaps in neuroscience as
well around this sort of thing. In terms of emotional state and what it does to our brain
capacity of our brain to actually perceive new information when it’s under stress. But it has
a different state or in a different state of being these I would imagine also translate directly
into not just different states but perhaps actually medical benefits as well.
[00:12:52] Well you’re actually bringing up something that is very dear to me and that is
when I travelled on my Churchill Fellowship looking specifically at this patient centred care
that we were talking about earlier and I linked it with patient safety. So when you’re talking
about outcomes I was thinking we need to be working out how to make the journey the
safest that it possibly can be for the patients and families. And I arrive in Boston to meet
some of the world experts in Patient safety. Who said the next big challenge really in
patient safety is how staff treat each other. So the idea that how we react to each other in
the workplace has an impact on keeping our patients safe.
[00:13:39] So the idea that we may not be treating each other with respect and kindness
actually can be. You can measure the impact in things going wrong and patients and
families suffering from that.
[00:13:52] When you say patient safety or I come from an industrial environment I think of
safety as you know making sure that electrical cords not in the way of people falling over.
What do you mean. We talk about patient safety.
[00:14:06] It’s a very big area. It’s everything from giving the wrong medication ,doing the
wrong operation. Giving patients the wrong diagnosis. So many intricacies. It can be small
it can be almost insignificant and you get away with it or it can even lead to death of
patients and family patients.
[00:14:29] So patient safety. You are saying that this patient safety concept which is quite
broad but it’s all about in essence the health of the patient while they’re in your care.
[00:14:42] And you are finding in this in while you were doing your Churchill your research
that there was a relationship between the safety and the way in which staff were treating
each other.
[00:14:53] Yes it’s amazing so a lot of work has been done on the actual nuts and bolts
and system problems of patient safety and how we can try and tighten all of that up and
make sure things go wrong. What I was learning was that all of that can fall over if staff are
not in a good space and not treating each other well.
[00:15:14] And in fact what we found around the world is this disrespectful behaviour.
There’s bullying and harassment. There are people feeling not valued and cared for in
their workplaces. Those people are not on the top of their game. They’re not watching as
well as vigilantly as they necessarily could. And they’re not as engaged in their work. So
the evidence is clear on that.
[00:15:40] So this is not about some sort of spite or it is just the fact that you know that
these people are in the wrong place psychologically if you want to be able to perform.
our health care culture and how we were all treating each other. And I’d certainly
experienced it myself at various times as a medical student as during a doctor and then
even in a relatively senior role that the behaviour could make you feel uncomfortable and
make you feel not valued in your team and not cared for. And then it’s so hard to stay
engaged and really switched on and actually joyful in your work ,which I think you need to
be in a in an environment like health care to be really enjoying and you know getting the
best out of your relationship with your colleagues and the patients and families. That’s
where we would all hopefully aim to be.
[00:16:43] This is this I’m so glad you mentioned that word joyful because in my
understanding joyful states or states or happiness if you like that’s probably the wrong
word. But let’s stick with joyful , do lead to greater cognitive function would that be right.
joyful every day. And you can actually watch the efficiency. It is like a well oiled machine.
Every person in the team feels equal in the room. They all feel valued. We have quite a lot
of fun despite the fact that we’re looking after really sick children parents who are worried
but the way the team responds to each other and then responds to the families. We get
feedback from families who say we feel safe and secure when we come. We’ve got a child
with leukaemia who’s really sick we’re uncertain about the future but we feel safe in this
part of the journey that is just so awesome and the team rises to the occasion. And even
on a day where we’re sort of overbooked and we know it’s not all the work is not going to
quite fit in. People focus on each other and kindness amongst the team and looking after
each other. And you’ll see I might have a bit more to do than is actually going to quite fit.
And one of the nurses will come over and say can I do that bit and help you. And then I’ll
help her label some things later on. And it is absolutely seamless. This has been
something we’ve worked on over quite a few years. You need to build this sort of culture.
But once you’ve got it we can actually bring new people in and they’re inducted into this
culture within five minutes. They can feel it. They can see it and they go away with a smile
on their face. [00:18:42] This is very interesting is that because you can take someone from a different
culture a different hospital perhaps maybe one of the more traditional approach and they
would probably be doubtful about anything being much different use of them perhaps to
not have told them about it. But they’ve come in and in five minutes that that sort of
perceptual reconstruction . All of a sudden they relaxed into this new way of working.
[00:19:11] Yeah. And we’ve got the music on in the background. We’ve got people who at
the beginning of the day we sort of have a huddle and we all introduce each other make
sure that anyone new to the team knows who’s who in the room and who’s going to be
doing which roles and then what patients we’re looking after so we talk through what we’ve
got to expect what’s coming up in the morning and then we just launch into the work. It’s
fantastic to bring medical students into that as well and make sure that they feel hey we
want to hear from you if you if you notice something that you’re not sure about. You want
to ask some questions. Make sure you feel like you’re part of the team as well. And I think
it’s really good role modelling to that next generation that they can see how well a team
can function.
[00:20:02] That’s a good point. My understanding is that many health care professionals.
And this has been this way for a long time. I believe you’ve got to correct me that. Whether
it’s nurses administrators surgeons there’s a high level of burnout stress perhaps even self
medication and other types of dysfunctional behaviour that go with the traditional model of
health healthcare. And what I understand is that things are getting worse and that sense in
the broader sense of health care in Australia is that is it unfair.
[00:20:47] No I think that’s quite fair. I think while I see it as a crisis something that at least
now we’re talking about. But I think the scale of it is rapidly increasing and we really do
need to all stop and think about it because health care is getting busier the money is
tighter. Everybody’s being told to do more with less and hurry up and get through it. We’re
being measured. I think often by the wrong things.
[00:21:16] You know on time starts for theatre and and measures that yes you can put a
number to it but it may not be about the patient centred care. It may not be about the best
journey that we can have for the patients and families. And I think it sets people against
each other in a way we become more and more competitive. And then instead of feeling
the joy in the room in the work we’re doing we’;re focussing on what what needs to go into
the computer and how quickly can we do it and how quickly can we move everybody
through that is building stress into the system. And I think the burnout and the poor
behaviour is a really sad thing to watch.
[00:22:03] You mentioned the measures and when we look at the bigger picture and we
think back. I mean you mentioned that if if the way in which the. Patients parents are
grateful for the way they experience the care they received. However it’s also true that
there’s quantifiable data around the quality of recovery. The success rate of procedures.
Anything that perhaps we would like to measure in terms of the outcomes for the patient.
This is not some fantasy we’re talking about that there are real hard numbers that go with
this type of intervention.
[00:22:49] Yes there are. And I think we need to be looking more and more at those and
talking more to the patients and families about what actually are the things that matter to
them. So measuring those things that are an important outcome from the treatment. And it
may not be cure of your condition it may actually be helping with the symptoms helping
you plan things from there on in. There’s a lot that can be measured that is different too.
Yes it was a cure or it was not a cure.
[00:23:21] But then at the same time I’m also guessing that costs of interventions cost of
medical support would naturally decline in that environment as well.
[00:23:33] Yes potentially. You can definitely definitely measure the efficiency of a system
where the patients and families are comfortable in the journey and the staff are joyful in
their work in saving money for the health system overall. Absolutely without a doubt.
[00:23:51] So a very big level that occurs on a global level. The numbers are moving in the
right direction. We don’t need to have these as you say competitive you know
inappropriate measures that are focussing on the wrong outcomes .
[00:24:06] With your work you’ve talked about encouraging effective and innovative
partnerships between patients families and healthcare professionals. I imagine the history
of the past of Hospital hierarchy was such that Surgeons nurses administrators they all
had their own status in the hospital and communication would occur at a certain way and
certain people would be like gods if you like in their own domain. This can’t exactly lend
itself to joyful experiences I would have thought. How do the surgeons and others change
the way they communicate between each other to overcome some of these heirarchical or
the status related issues.
[00:25:02] I think it’s something that is now being looked at and thought about and talked
about a lot more so the College of Surgeons. A lot of the medical colleges and certainly
the College of Medical administrators are now thinking about a different type of leadership
in our healthcare system a more equal and collaborative and more partnerships between
the different craft groups. We’ve worked in silos a lot and those silos have often not
communicated particularly well and been competitive. We can all feel that this hasn’t been
working particularly well. So it’s I’m really pleased to see that now people are trying to
change some of this. And certainly our medical students and our next generation are
thinking differently about the interrelationships between themselves their colleagues their
nursing colleagues. Basically everyone in the system. What the Hush Foundation has
been working on for the last three or four years is actually changing the conversation about
this hierarchy and about the bad behaviour and the bullying and the lack of respect
amongst people and talking about what’s a kind health system and how can everybody
who is in it start working towards this aspiration.
[00:26:25] And that actually has been a very joyful conversation so people I think are a
little bit. It runs you down a bit if you keep talking about the negative.
and joy and. There’s a guy called Professor Cooper David Cooperrider I don’t never heard
of him. He has a thing called Appreciative Inquiry. [00:26:58] Right. Yes. [00:26:59] So inquiry into the system but finding what the good things are that are going on
in the system and then trying to amplify those and it sounds like that’s what you’re doing.
Sounds like what you’re doing is saying well where’s the happiness where is the joy. How
can we create more of that which is a far more uplifting ,this is my interpretation of it, a
more uplifting discussion of conversation than one about Ive got all these problems, How
do we do root cause analysis and try to get rid of it.
[00:27:29] Exactly. And I think our methods really are a type of appreciative inquiry that we
know there’s some really good things happening. We know there’s some nuggets of really
amazing good culture. Let’s have a look at those. Let’s examine those and go how’s,
How’s that working and how can we build it outwards. And I certainly do that in my own
small way in my operating theatre and then other people come in and they come from
other theatres or they come from other hospitals and they go, ah not too hard actually to
have done a huddle and got to know everybody and then treat each at each other person
with kindness and respect. And look what happens you can see the good results.
training on good behaviours. But when you when you’re actually in an area like that that’s
working so well you can see it you can feel it. You can take something away from that. It’s
very empowering for individuals to know that you yourself can make a difference. So there
are places where I’ve been to talk about this kindness initiative and people will say well
you know how can we be doing that when we’re so busy when there are so many barriers
in the way when we don’t have the right CEO at the moment or the hospital makes more
money. Actually let’s just pare it right down and say if this was all the money and you know
all the leadership that we were going to get for now how could you make a difference in
your own sphere and you can do that with your own acts of kindness that actually change
your brain may change the other person’s brain. And it’s like a contagious thing. It’s just so
positive.
[00:29:19] A contagion in the hospital. Oh no but it’s good!
[00:29:22] It’s a good one.
[00:29:24] With your experience of other. And I’m assuming through your Churchill
fellowship you would have had the opportunity to see other hospitals to hear from them.
You mentioned you know changing people’s brains. I think it was Marcel Proust who said
something like to see with new eyes is the challenge. And I think that sounds to me that’s
what you you’re doing. How do you think or if you were to think about the challenges that
you’ve seen in the system of healthcare in the bigger picture what what do you see as
being the fundamental things that you’d want to see shift in Australia’s healthcare system.
relationships and I think for me that’s the key. There’s a lot of clever people doing all the
systems things and the some amazing science. But I think if we could come back to the
simple. And think about how we treat every single person that we interact with. And we
might not get it right every time. You may think you’re being kind to someone when in
actual fact you haven’t checked in with them. But that’s really what matters to them. So I
think there’s a lot of work we can do in this space. But to me it’s the absolute core of how
we can have the most robust healthcare system in Australia. It’s interpersonal relationships
it’s kindness respect and dignity. And that would be my take home message.
[00:31:09] Fantastic figuring out what it takes to be human at work.
[00:31:13] Yes.
[00:31:14] And joyful a little into the into the bargain.
[00:31:20] Fantastic with your work at the Hush foundation do you only work with health
care.
[00:31:32] Mm hmm. That’s interesting we’re finding that a lot of what we do applies across
society. And people are coming to us and well so Hush has got 17 albums of beautiful
music which are in hospitals all around Australia and internationally. But that music is also
being used by orchestras around the world so they can take out sheet music and they can
use it and play it publicly or wherever. We know the music’s in lots of homes and in
schools. In prisons.
[00:32:06] Yeah I was thinking about schools. I wasn’t thinking about prisons but yes I can
imagine that as well.
[00:32:11] So we’ve had teachers write to us and say we’ve been putting the music on for
the Grade Two Class and the kids have actually written some of their thoughts about what
the music does how it helps them to focus when they’re sitting doing their workout makes
them feel less stressed how they interact better with their classmates when they’ve had the
music on in the background.
[00:32:33] So we get some amazing feedback about what the music does. The other thing
that Hush has done is we’ve written three plays so we’ve used actors and playwrights to
portray some of these issues in health care. It’s another way of getting messages out there
in a more creative way. And those plays we put on in hospitals and for the general public
so that we’re getting the community involved in thinking about some of these issues in
health care and where they fit into it as well.
[00:33:06] So the play is just a general reflection to the community or is it something that
can be used to stimulate dialogue and change within the institution.
[00:33:19] That was the original idea to raise awareness of issues and start dialogue. So
the first play is about medication errors and the behaviour issues that I was talking about
out of my church. So bullying and things that go on behind the scenes and how that has
led to some pretty bad outcomes all based on true stories that have been sent to us. And
we’ve used them in the plays our second play is called Do You Know Me.
[00:33:46] And it’s little scenarios from aged care which is so very relevant at the moment
to all of us and really we were a little bit ahead of the game with the Royal Commission. So
we’ve got The Good The Bad and the Ugly of what can go on in aged care. The third play
is about kindness. Which of course. Is a pretty big issue for me. Acts of kindness that you
can see making a difference or you’re watching some scenes where obviously the
kindness is lacking and things aren’t going quite so well. We use the play to really spark
conversations and some of them can be quite difficult conversations. But I think the use of
drama and theatre opens up an audience and they do start then to explore what’s going on
in our organization or in our aged care sector or even in our community.
[00:34:44] I think that’s brilliant. I mean I’ve heard of people using theatre not so much
music but certainly theatre as a way of helping organizations and leaders to communicate
more effectively so on.
transformation really about the relationship between each other and about the relationship
with the client the patient. I think that’s brilliant and gives it a very straightforward focus of
outcome orientation.
[00:35:16] This is how you can improve things almost from day one with the right heart.
[00:35:24] That’s fantastic Catherine is there anything else you’d like to say about your
Hush foundation or your work at the Australian Institute for Patient and Family Centred
Care.
[00:35:32] Well I guess the final thing would be that we now have this movement called the
gathering of kindness that is definitely making its own way through health care and we’ve
got organisations running their own events around kindness and actually focussing on staff
talking about these interrelationships. I’d love that to go as far and wide as it possibly can.
Certainly Deakin University and Rotary are really interested in helping scale this up and
getting it out there.
[00:36:06] Because everybody’s now realizing this is not only health care. This is our
education sector as well. We can talk about stamping out bullying in the schoolyard but
what’s a kind school and what are the elements that can make a kind school. If you think
about families that are under stress and families that have got some issues with domestic
violence. What’s a kind family. So let’s give people the tools to know what some of those
things are. What are the building blocks. Of kindness. And how can we be more
aspirational about that. So I would love people to get involved in the gathering of kindness.
We’ve got a Web site you can use our resources on the Web site got videos that you can
use in staff meetings and things to just start conversations.
[00:36:56] I think that’s brilliant with the idea of kindness in families seems a bit odd. So
that is sort of what you talk about of course you know. But yes it’s true. And we know that
many families don’t actually know how to care for children at a very simple level to display
as you say kindness or some people will have very unusual ideas about the development
of children and think that talking to children is a waste of time because they don’t
understand it. Of course this is not the case. So your opportunities to extend this work are
you looking for partners.
[00:37:37] We would love partners. Yes. That’s really why we’ve been talking to Deakin
University and Rotary amazing partners who’ve got connections everywhere that can help
to scale things up but other partners please come and talk to us.
[00:37:52] Fantastic. Catherine thank you so much today for this chat has been brilliant.
And it’s great to see your transformational work that you were doing. And it sounds like it’s
got a head of steam.
[00:38:03] And obviously anybody out there who’d like to support the work of Catherine
Crock and the Institute please go to the Web site to tell us more. Thank you very much.
[00:38:16] Thank you. Phil.
