Lessons Learned, Says Te Whatu Ora

The basis of the Health and Disability Commissioner system is that clinicians and caregivers learn from their mistakes.

Te Whatu Ora-Southern Quality and Clinical Governance Solutions Executive Director Hywel Lloyd said the organization – formerly the Southern District Health Board – had gone out of its way to accept the damning report of Wendy Fraser’s death and then show demonstrable improvement. .

“We had to think about our shortcomings in this case and we’ve put procedures and processes in place so that the chances of something like this ever happening again are greatly reduced and minimized.”

Senior executives met with Ms. Fraser’s family during the complaint process, apologized regularly and kept the family informed of what the organization was doing to implement the report’s recommendations.

“Events of this level are fortunately rare,” said Dr. Lloyd.

“But if something does go wrong, we have to make sure it doesn’t happen again.”

To that end, it has been critical to assess Korero Mai and implement his philosophy, said Dr. Lloyd.

“It’s been very well recognized with health that there’s a power imbalance, based on knowledge… we’ve done a lot of work with clinicians to see if they recognize that power imbalance and if they’re adjusting their conversation so it’s much more collaborative and that they listen to the patient’s or consumer’s concerns, especially if the person is not well or their condition is deteriorating.”

Korero Mai was now a nationally accepted program, and it fitted in well with improvements the Southern health system had already made, said Dr. Lloyd.

“Korero mai means speak out, and we want people to feel that they can and that they are not hindered in any way from doing so.”

There were some operational hurdles to overcome, such as when Covid-19 restricted visitors to wards, but in general, families should always be welcome to play a role in caring for their loved ones in the ward, said Dr. Lloyd.

“Covid was a difficult time, but in general we encourage family and whanau to come, it is a very important part of someone’s care and the operational problems are not too big.”

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