Introduction Children? s Hospital and Clinics was formed in 1994 because of the merger between Minneapolis Children? s Medical Center and Children? s Hospital St. Paul. The hospital medical services went from very basic care to very complex treatments. In 1999, Brock Nelson the CEO of the hospital named Julie Morath as the new COO of Children’s Hospital and Clinics. Julie had a lot of experience on patient care administration and put all her efforts on a strategy to make safety the top priority in the hospital. While they were implementing the strategy, an accident with a kid happened and had to be resolved.
Problems Problem #1: The implementation of the patient safety strategy has not been fully successful. There is no clear way to measure effectiveness of these programs. Not everybody on the hospital agree that the strategy will work. Change of leadership in the implementation. Problem #2: The accident with Mathew is going to make the parents ask questions and the hospital has to define how to act; and there isn’t any clear decisions they yet. Facts Problem #1 Doctors and nurses used to get defensive when they were broached on the topic of safety.
To them, talking about safety implied that that they were doing something wrong. Julie developed a detailed strategic plan for the Patient Safety Initiative. A patient safety steering committee that included board members, doctors, nursing and parents, was implemented. Several employees expressed concern about the implementation of the strategy. Responsibilities in employee? s job make difficult to focus on the effectiveness of changes. Some people believed that the hospital has not moved boldly enough with respect to parental involvement.
One surgeon expressed that talking openly about accidents was an invitation to trouble. The PSSC thinks it? s difficult to measure the effectiveness of the safety initiative People are concern about how they are going to move from theory to a real change. Julie hired Dr. Erick Knox to fill her role in the patient safe strategy. Problem #2 The procedures of medical administration fail in Mathew’s case. The label in the medicine was not clear. At first Julie saw the accident as an opportunity to improve patient care. The family may want to know the responsible of the accident.
People attending the sequence events of the accident are not sure about the causes of the accident Julie doesn’t know how much information she should tell Mathew? s parents. The hospital made a commitment to patients and their families to involve them in the decisions that the clinical staff made about health care. In the patient safety strategy was established the “Blameless report system”. The disclosure policy talked about the way the hospital should communicated with families when accidents occurred. Before, lawyers advised to don’t give information to parents when accidents occurred.
The legal exposure could not be determined. Solutions Problem #1 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. The implementation of the initiative has been very fast, trying to put many things together at once. The Hospital should implement the strategy slowly, starting with one area that doesn’t represent much risk. Once the initiative is implemented in one department, this strategy could be replied in the other areas.
Changing the culture in an organization is a hard thing to do, implementing the strategy gradually will help to change the culture all the employees because they will see the result in other departments and will help to see where the hospital can measure the effectiveness of the program. Have “zero errors/accidents” in a hospital is something that has to be achieve in the long them, and the hospital should be aware of that and act in consequence. The hospital is implementing most of the strategy to have information, but haven’t make anything about how are they going to compensate the people who suffered an accident.
Julie has been a good leader in the patient safety initiative and she shouldn’t delegate the leadership yet. She has to do important things and has to coach Dr. Knox to make him understand where she wants to go with the strategy. Problem #2 Mathew? s parents will ask questions, and they may want the responsible of the accident. The hospital’s policy is to tell everything to the relatives and family of the patient, but the “Blameless reporting” says that one person is blamed for an error”. Julie Morath has to say that no particular individual was responsible for the accident and was the system that failed.
She can say as well that the case has been examined by the PSSC. A modified system will be in place ASAP so as in the future no such issues arise. The responsibility doesn’t lie on an individual but it lies on the whole organization and the process which was followed, and the hospital has to assume all the legal responsibility in case it would be necessary. For future accidents the hospital has to act the same way, accepting responsibility and talking clear to the parents, otherwise all the initiative can be in danger because people will see a disparity between “paper” and reality.