Children’s Hospital and Clinics Essays

Children’s Hospital and Clinics Essays Children’s Hospital and Clinics Essay Children’s Hospital and Clinics Essay Due to a patient near fatal accident, the children’s hospital and clinics were looking for any effort to provide a safety patient culture. Julie Morath was hired in 1999 to improve hospital operations; she wanted to make Safety the top priority of the hospital. Julie Morath directed and begun setting up the Patient Safety Initiative at Children’s Hospital and Clinics by making employees obtain the mindset of safety and building a culture. The key steps to her patient safety initiative were the blameless patient safety reporting system, making focus groups, and setting up a committee of patient safety practice. During each process of the patient safety initiative at Children’s Hospital and Clinics there were many positive and negative effects of each step. The key elements of Patient Safety Initiative were followed by three steps, the first step was presentations that she conducted to the hospital staff about the national research and medical errors. The second step was focus groups that focused on the patient safety issues at Children’s Hospitals and Clinics. The third step was to make the initiative more strategic by developing it. Morath wanted to create a culture where she had the concept of â€Å"do not harm† was clearly developed rather than expressly stated. She wanted to focus her culture based on collaboration among others and operations around the science and sense of safety. When she came into Children’s and clinic, her main objective was making safety the top priority. According to exhibit 10, you can see that the safety reports have been steady improving since she got hired. One of the key elements of Patient Safety Initiative was to transform the organizational culture in order to provide an environment that would be able to discuss medical accidents in a proper manner. She wanted to embrace a culture that welcoms communication about safety issues. She enforces the idea of learning from past mistakes rather then pointing fingers whenever there was a mistake. There was the patient safety dialogues which created a sessions which all of the employees come together to talk and discuss the research of medical safety. Blameless reporting was also part of building the culture and this was a system designed to report medical accidents without the fear of being punished. According to exhibit 7, the blameless report help make the line workers to find out how to eliminate breakdowns. One of the weaknesses of the building culture was everyone was not happy about this approach. Many employees believed itwould be more of the employee lack of ability instead of the failed system. Many were worried that it was hard to actually find out who the poor workers were because of the blameless reports. The second element was to develop the infrastructure that was required to direct safety improvements. This was a reporting system that examines serious accidents and it was responsible for approving all of the major policy changes. Patient safety steering committee was formed and they would set the goals for the safety initiative. Exhibit 9 below shows all of the members that were in the committee. When developing the infrastructure, this allowed focus event studies which they would be able to conduct investigations after any serious medical accidents. The focused event studies helped identified the sequences of events accurately as possible, and this helps tell all of the system failures. The weakness in the process of developing the infrastructure was that many employees had the concern that they didn’t have enough time, staff, or resources to follow up on the issues. There was another issue about the recommended changes that was forced and to meet the effectiveness of the change. The last concern about developing the infrastructure was if this approach actually changed the hospitals legal risk profile. The third element was to launch a project to examine the medication administration system at the hospital. This approach was to achieve the goal of having zero defects in the administration system. The purpose of the medication administration system was to improve the safety of the patient by moderating the system and processes. Safety action teams were formed and it was eight employees that came together to discuss the problems and they way it could be improved. The strength of this was that it could provide a powerful vehicle for workers to get out the unnecessary complexity and remove barriers. The barriers that Morath faced as she tried to encourage people to discuss medical errors more openly is one thing she did was she presented data from the Harvard Medical practice study on the frequency and the causes of medical errors. The staff then came to mind that the events that occur at children’s happen along with other colleagues. She convinced everyone that errors were a problem and that it happens to all care organizations. She then tried to persuade Children’s hospital staff about talking openly about errors because open discussion will eventually improve patient care. She then conducted focus groups, sheinvolved staff from other areas and she did get people more focus about coming up with ways to improve the patient safety. Overall, she conducted 18 groups that included many of the staff through the hospital and this created more awareness and many felt free to talk about their experiences with medical errors. According to exhibit 10, there issue was also the parents who were concerned so a parent group was formed to keep them updated on the information. When she conducted the strategic plan, she summarizes the components of the strategic plan by calling it SAFE. The acronym stand for safety, access, financial, and experience, each of the categories had a clear goal and what to do to accomplish them. My assessment of Morath’s leadership of the organization change process at Children’s hospital and Clinics was that she was really impassionate about safety. It stated in the article that her leadership was going to be hard to replace and all the effort she put into the hospital can go to a fad. The central challenge that she faced was that to change people mindsets towards accident in the medical field. She wanted to change it from a penalty environment to a learning experience environment. Another challenge she faced was getting employees to own to a mistake without the fear of getting in trouble. The key activities that she initiated was the learning from past mistakes environment instead of blaming. In stage 1 of the changing process, her system was very encouraging and more employees were more willing to share their mistakes. In stage 2 and 3, the system believed that mistakes occurred because of drawbacks in the processes rather then the ability of the staff. Judith Morath had the right mindset when it came to making safety the top priority at Children’s Hospital and Clinics. There were many issues such that dealt with disclosure and legal risk, accountability, measuring results, and leadership. When it came to disclosure and legal risk, she worried about the benefits of enhancing disclosure to patients and families exceeded the risk of additional lawsuits. There was a belief that the respect with the parents involvement in the safety improvement effort. She also had the challenge of accountability, many of the unit managers and administrators were concern over the blameless reporting and that staff should be responsible for the accident. They believed that there should be consequences and accountability for the poor performance. Also the measuring results didn’t match up well. According to exhibit 10, she wasn’t able tojustify the financial results and the benefits outweighed the costs.