Evaluating Children's Hospital
Question 1: Evaluate the key elements of Morath’s efforts to transform Children’s Hospital into a learning organization.
Answer: It was Morath’s leadership abilities and initiatives that helped Children’s Hospital (CH) transform from an organization to a learning organization. We elaborate on the following three building blocks of a learning organization that are evident at Children’s Hospital.
Building Block 1: “A supportive learning environment”
Learning in an organization is inhibited by factors such as tradition, outdated procedures, values, structures, and psychological barriers about getting the work done. At a learning organization, the environment encourages people to bring out the problems / errors …show more content…
in the system, to analyze the problems and to seek solutions to them. This enables an organization to constantly learn and grow. In such a learning environment, new ideas are appreciated, people feel safe in discussing failures, disagreeing with others, asking naive questions, owning up to mistakes and presenting minority viewpoints.
The first block of a Learning Organization encompasses the following features:
• Psychological Safety
• Appreciation of differences
• Openness to new ideas
• Time for reflection
In a healthcare organization, errors are bound to happen and CH was not an exception. In order to create awareness about patient safety, CEO Nelson hired Julie Morath as COO. At CH she faced following Key Challenges.
Patient Safety – Not an easy subject to broach: The primary challenge for Morath was to even suggest launch of a patient safety initiative at CH. The management at most of the hospitals gets defensive whenever the topic of safety is touched upon. It is believed that the Patient safety should be implicit. Speaking about it means ill repute and exposure to legal risks. Morath also found that many employees were reluctant to believe the Medical Accident Data. They were skeptical with the applicability of this data to CH.
Alleviating fears of damaging careers: Transparency is an important parameter for any learning environment. At CH, when an employee commits an error, the first thing that comes to his mind is “Am I responsible for this near-fatal accident?” or “How it will show on my performance?” So he hopes the error does not come to the surface. It was a challenge for Morath to get people talking more openly about errors without damaging people’s careers.
Accusatory Language: The language used during discussions was accusatory in nature and implied finger pointing. Such language added to the environment, which was averse to psychological safety for anyone who commits a mistake. It was a challenge for Morath to change the old ABC model of medicine: Accuse, Blame and Criticize.
To overcome the above mentioned challenges, Morath carried out the following Key Activities to create a supportive learning environment at CH:
Spread awareness about Patient Safety: Morath created forums where staff members could come together to discuss safety issues and to learn more about current research in the field.
Created Blameless Environment: Morath introduced three ground rules for the focused events analysis. These ground rules included “blameless reporting”, confidentiality and anonymity of event details, and creativity to improve processes and systems.
Presented Statistics and Personal Experiences: Morath presented data from reputed studies such as Harvard Medical Practice Study on the frequency and causes of medical errors. This data showed that fatalities due to medical errors are very common among hospitals across the US and CH would be no exception. To allay the employee skepticism of applicability of the study to Children’s, she asked the employees to discuss personal experiences regarding patient safety. The employees found that all had had such experiences.
Conducted Focus Groups: The focus groups provided the hospital employees with a forum to talk about any errors made by them and to explore different possible solutions. The focus groups eventually also included talks with parents about the situation.
Modified Language: To create an environment that encouraged dialogue about medical accidents, Morath emphasized the avoidance of words which implied finger pointing and changed them to neutral phrases.
The above measures implemented by Morath were quite effective in the following ways:
Psychological Safety: The implementation of ground rules and common language made it easy for the employees to talk about errors by providing psychological safety of not being made a scapegoat. Blameless Reporting changed people’s behavior. It helped people to communicate confidentially and anonymously about medical accidents without being punished. This helped people in identifying the shortcomings in their operating system and the changes that should be implemented to prevent similar accidents in the future.
Appreciation of differences and Openness to ideas: The medical data and the personal experiences shared by the employees through focus groups helped them to understand that anyone could make an error. Hence denying such errors is losing an opportunity to learn and improve.
Reflection: The results of the study using focus groups not only provided information about patient safety but also allowed the employees opportunities to reflect on their actions which led to the errors. The focus groups also served to surface many suggestions for enhancing existing processes and systems.
Building Block 2: “Concrete Learning Processes and Practices”
A learning organization has processes for generating, collecting, interpreting and disseminating information. At such an organization the employees are constantly trained for upgrading their skills. The people experiment with new ideas. There is a uniform dissipation of information across the organization. The ideas are put into practice by way of processes. Building block two of a Learning Organization includes the following aspects:
• Experimentation
• Information Collection
• Analysis
• Education and Training
• Information and Transfer
At CH, Morath faced the following Key Challenges:
Transparency to patient’s family: Morath wanted to change the way hospital communicated with the families when accidents occurred. As advised by their Lawyer and Risk Manager, CH did not volunteer information and did not admit wrongdoing in the event of an accident.
JCAHO specific forms: Most of the forms used to record accidents were tailored to give JCAHO information about the number of accidents occurring but not the root cause of the accidents.
Lack of awareness: Since the issue of patient safety was considered to be implicit, there was a lack of awareness among the staff as to what steps can be taken to ensure safety. There were no training procedures focused on safety measures.
Absence of feedback: Even if the nurses of any of the other employees felt the need for change in any of the procedures, there was procedure for providing feedback about it. Furthermore, some staff would hesitate to point out any problems.
The Key Activities implemented by Morath to create the required processes were as follows:
Implemented “Complete Disclosure” Policy: Under this policy, CH contacted the family soon after an incident occurred, explained the procedure for examining an accident and described what they learnt more about the causes of the accident. The family was also to be kept informed of any updates.
Patient Safety Dialogues: Morath created a series of sessions for Children’s employees and clinical staff to come together to learn about the current state of research on medical safety. She also invited national speakers to give mini-courses on safety and supplemented these with self-study packets on the science of safety.
Patient Safety Steering Committee: Morath appointed a PSSC to oversee the safety initiative. PSSC conducts a confidential “blameless’ analysis of the incident aimed at documenting the sequence of events as accurately as possible and identifying all contributing systematic failures. PSSC created a Focused Event Analysis process for examining the causes of serious medical accidents. The PSSC also reviewed the findings from the accident inquiries. The focused event studies which used to be conducted only after sentinel serious medical accidents were to be conducted even after less serious incidents. Furthermore, the analysis finding of the logs and studies were to be reported openly. PSSC also developed the new patient safety report.
Safety Action Teams: Each clinical unit manager had to establish a safety action team, a cross-functional team which met regularly to discuss medication safety issues. The team members would inform their co-workers about the problems they discussed and the improvements they hoped to implement.
Good Catch Logs: Good Catch Logs provided the medical staff to report any potential problems anonymously. Such catch logs were a good way of capturing information that could be used to prevent medication errors.
The above measures implemented by Morath were effective in the following ways:
Information Collection and Analysis: The Good Catch Logs and Focused Event Studies provided plenty of information about what sequence of events led to errors. Such information was then analyzed to find the root cause of the errors. By way of good catch logs, the nurses and pharmacy staff could record events in the log anonymously.
Information and Transfer: The patient safety dialogues informed the medical staff the various ways in which errors could occur and hence could be avoided.
Each person gathered ideas and suggestions to share with the Safety action Team.
Education and Training: The literature on science of safety and self-study packets provided by Morath were used by the employees to educate themselves on the subject. This enabled employees to learn about the science of improving safety in complex systems.
Analysis: The focused event analyses develop disciples that then go out into the organization understanding the complexity of medical accidents.
Experimentation: The PSSC started experimenting with new ways such as having two facilitators, one to facilitate and another to observe non-verbal behavior to make sure nothing is missed.
Identification of root causes: The Blameless Reporting system resulted in employees speaking openly about any errors made and identified root causes of the errors.
Building Block 3: “Leadership that Reinforces …show more content…
Learning”
The third building block refers to the leadership within the organization. It reflects the extent to which the leaders of an organization communicate what they value. Leaders build organizations where people grow and develop their capabilities. The leaders in a learning organization demonstrate willingness to entertain alternative viewpoints, emphasize on spending time on problem identification, knowledge transfer and reflection. They engage people in active questioning and listening.
The third building block of a learning organization should have the following features:
• Invite input from others
• Acknowledge limitations
• Ask probing questions
• Listen attentively
• Encourage multiple points of view
• Provide time / resources / venue for identifying problems / reflecting and improving on past performance
• Criticize views different from their own
Morath faced the following Key Challenges in reinforcing learning:
Limited Understanding: In many cases, administrative and support staff did not fully comprehend how seemingly simple policy changes complicated the way doctors and nurses performed their daily work.
Disconnect between upper management and front-line workers: There was a disconnect between the administrators and the people working hard to provide patient care.
Seeking approval to hold a focus group with a set of parents: The most controversial aspect of the effort of patient safety was getting an approval for holding a focus group with a set of parents. It was feared that involving parents and disclosing information about medical accidents at CH may bring ill repute to CH and may expose it to legal risks.
Lack of motivation for implementing safety measures: Since the issue of patient safety was meant to be implicit, the employees had to be motivated to put in efforts to make the initiatives successful.
The Key Activities implemented by Morath to create the required processes were as follows:
Focused Vision: Morath accepted the role of the COO of CH with focused vision of having explicit patient safety measures. She recognized that health care is very complex system and risk-prone. Everyone must work together to understand safety, identify risks and report them without fear of blame. She launched a strategic planning process to define the organization’s goals and objectives for next five years.
Invited inputs from others: Morath involved doctors, nurses, pharmacists and many other people from different areas of the organization. She energized them about the initiative and thinking creatively about ways to enhance patient safety. There were several ways of inviting input from employees and parents including the catch logs, steering committees and action teams.
Creation of empowered teams and committees: Morath appointed the PSSC to oversee the safety initiative. She served as the chairman of the committee. It also included physicians, representatives from nurses union, parents and a member from the board.
Approval from Board: Morath successfully obtained an approval from the CH board to hold a focus group with parents.
Management Efforts: Morath recruited Mark Thomas, Pharmacy Director, to take charge of the project to improve medication administration system. She wanted him to focus not only on the internal processes but also on the entire flow associated with medications.
Dedicated Chairperson for PSSC: When Morath realized that she would not be able to give her full attention to the PSSC, she appointed Dr. Eric Knox on a full-time basis as the Chair of the PSSC.
Stretch Goals: Morath set the goal of achieving zero defects and a 100% reliable medication system. Such goals required revamping the hospital’s systems and processes and motivated the employees to change the way they thought about patient safety.
The above mentioned measures implemented by Morath were effective in the following ways:
Created Vision: The strategic planning process initiated by Morath was instrumental in aligning the organization behind a clear set of objectives, particularly with respect to Patient safety. As they share same goals, the upper management and the front-line workers easily aligned with each other on patient safety agenda.
Generating enthusiasm for the safety effort: Morath was successful in creating enthusiasm amongst the employees about the safety effort. People at CH became confessional. The employees and the clinical staff felt relieved to have a place to discuss their experiences with medical errors.
Encourage multiple points of view: The focus group provided an opportunity to parents to speak openly about their experiences and to offer suggestions. This additional point of view provided a wealth of information about the current state of patient safety, identified underlying causes of medical errors at CH and surfaced many suggestions for how to enhance existing processes and systems.
Collective Responsibility: Major effect of forming PSSC was the collective responsibility for setting goals for the safety initiative, for revising hospital policies and procedures. Such collective responsibility begets accountability.
Probing questions, listening attentively and Criticizing: The entries from the catch logs were to be reviewed, summarized and presented by the Safety Action Team at meetings. The conclusions from the reviews were then translated to concrete actions.
Question 2: Which one of the following do you think will happen to the changes that are started at Children’s?
1. They will all disappear in 5 years.
2. Some will disappear but some will remain. Which will remain? Which will disappear? Why?
3. All will continue to prevail.
Provide 4 reasons to support your answer.
Answer
Changes / Actions Prevail / Disappear in 5 Years? Reasons
Safety Action Teams Prevail 1. These changes became an integral part of culture at CH. All employees found these tools useful to identify possible medical errors.
2. Employees found it comfortable to point out concerns anonymously via the Good Catch Logs.
3. Sharing personal experiences with safety action teams about errors helped employees to reduce emotional burden.
4. The patient safety dialogues served to enhance awareness about safety issues.
Good Catch Log
Patient Safety Dialogue
Blameless Reporting Disappear 1. The patient’s parents as well as many managers were concerned about the accountability taken away by Blameless reporting.
2. The progress made by carrying out changes was not measurable.
3. Employees did not have time to follow up issues discussed.
4. Complete disclosure policy to parents could lead to legal problems for the hospital.
Focused Event Studies
Disclosure Policy In the next five years, the leadership role in the patient safety program will be handled by a different person. The new leader might have different approach towards patient safety. Aside from that, we think that some of the changes initiated by Morath will continue at CH but some will disappear.
Programs that will prevail are Safety Action Teams, Good Catch Log, and Patient Safety Dialogue. The reasons for these are:
1. Safety Action Teams, Safety Dialogues and the Good Catch Logs were imbibed in the culture at CH. These activities did not take any extra effort on part of the employees and simultaneously enhanced their learning. Hence, the benefits certainly outweigh the efforts of implementing these initiatives.
2. The Good Catch Logs provided a way for the employees to voice their opinion anonymously and contribute to patient safety. The employees also found that the concerns put forth in Good Catch Logs were being implemented. Hence, we believe that Good Catch Logs will continue to prevail.
3. Many people felt guilty when they committed a medical error. People wanted to speak to someone about it to reduce their emotional burden. The safety action team provided employees a chance to share any medical errors committed by them. As the disclosure was confidential and anonymous, they could release this burden by sharing their experience. As this change was helping employees, it appears to prevail in the long run. This activity also encouraged team work.
4. Employees became aware of the safety aspects through the safety action dialogues. It is observed that the number of people attending the dialogues was less initially but subsequently, the attendance increased substantially. The dialogues were supplemented with mini-courses, which the staff found very informative. The new in-charge of the safety initiative, Dr. Eric Knox, is a nationally regarded expert on medical safety. He would maintain people’s interest in safety by inviting many more speakers for the talks. On the other hand, the changes that are likely to disappear in five year are “blameless reporting”, Focused Event Studies, and Complete Disclosure Policy due to the following reasons:
1. There is no definite tool to assess the outcome of focused event studies. PSSC did not have a systematic way to ensure that recommended procedural changes were implemented or to measure the effectiveness of changes.
2.
Both CH managers and families complained about “Blameless Reporting”. There was no penalty for people who were responsible for the accidents. In some cases, errors could have been caused by poor performance of a particular person rather than a system failure. The reporting method was focused on identifying the problems in the system. CH management including Morath was finding it difficult to respond to Family’s demand for the name of people accountable for accidents.
3. The focused event studies encouraged employees to share their experience about medical errors but due to lack of time, staff or resources to follow up on each issue it was difficult for managers to analyze the problems that emerged during a focused event analyses. With their current job and responsibilities, they did not have time to follow up the outcome from the session. As the solutions could not be implemented, the errors are bound to happen again. Thus, such event studies will become redundant and eventually vanish.
4. CH might face legal problems in the future caused by complete disclosure policy. It is possible that disappointed families may sue the hospital for carrying out accidents. Now as the CH was disclosing a lot more information to families through focused event studies, the effect on CH’s legal exposure could not be determined. CH may revert to tight-lip stand on disclosing information to the
parents.
Answer: It was Morath’s leadership abilities and initiatives that helped Children’s Hospital (CH) transform from an organization to a learning organization. We elaborate on the following three building blocks of a learning organization that are evident at Children’s Hospital.
Building Block 1: “A supportive learning environment”
Learning in an organization is inhibited by factors such as tradition, outdated procedures, values, structures, and psychological barriers about getting the work done. At a learning organization, the environment encourages people to bring out the problems / errors …show more content…
in the system, to analyze the problems and to seek solutions to them. This enables an organization to constantly learn and grow. In such a learning environment, new ideas are appreciated, people feel safe in discussing failures, disagreeing with others, asking naive questions, owning up to mistakes and presenting minority viewpoints.
The first block of a Learning Organization encompasses the following features:
• Psychological Safety
• Appreciation of differences
• Openness to new ideas
• Time for reflection
In a healthcare organization, errors are bound to happen and CH was not an exception. In order to create awareness about patient safety, CEO Nelson hired Julie Morath as COO. At CH she faced following Key Challenges.
Patient Safety – Not an easy subject to broach: The primary challenge for Morath was to even suggest launch of a patient safety initiative at CH. The management at most of the hospitals gets defensive whenever the topic of safety is touched upon. It is believed that the Patient safety should be implicit. Speaking about it means ill repute and exposure to legal risks. Morath also found that many employees were reluctant to believe the Medical Accident Data. They were skeptical with the applicability of this data to CH.
Alleviating fears of damaging careers: Transparency is an important parameter for any learning environment. At CH, when an employee commits an error, the first thing that comes to his mind is “Am I responsible for this near-fatal accident?” or “How it will show on my performance?” So he hopes the error does not come to the surface. It was a challenge for Morath to get people talking more openly about errors without damaging people’s careers.
Accusatory Language: The language used during discussions was accusatory in nature and implied finger pointing. Such language added to the environment, which was averse to psychological safety for anyone who commits a mistake. It was a challenge for Morath to change the old ABC model of medicine: Accuse, Blame and Criticize.
To overcome the above mentioned challenges, Morath carried out the following Key Activities to create a supportive learning environment at CH:
Spread awareness about Patient Safety: Morath created forums where staff members could come together to discuss safety issues and to learn more about current research in the field.
Created Blameless Environment: Morath introduced three ground rules for the focused events analysis. These ground rules included “blameless reporting”, confidentiality and anonymity of event details, and creativity to improve processes and systems.
Presented Statistics and Personal Experiences: Morath presented data from reputed studies such as Harvard Medical Practice Study on the frequency and causes of medical errors. This data showed that fatalities due to medical errors are very common among hospitals across the US and CH would be no exception. To allay the employee skepticism of applicability of the study to Children’s, she asked the employees to discuss personal experiences regarding patient safety. The employees found that all had had such experiences.
Conducted Focus Groups: The focus groups provided the hospital employees with a forum to talk about any errors made by them and to explore different possible solutions. The focus groups eventually also included talks with parents about the situation.
Modified Language: To create an environment that encouraged dialogue about medical accidents, Morath emphasized the avoidance of words which implied finger pointing and changed them to neutral phrases.
The above measures implemented by Morath were quite effective in the following ways:
Psychological Safety: The implementation of ground rules and common language made it easy for the employees to talk about errors by providing psychological safety of not being made a scapegoat. Blameless Reporting changed people’s behavior. It helped people to communicate confidentially and anonymously about medical accidents without being punished. This helped people in identifying the shortcomings in their operating system and the changes that should be implemented to prevent similar accidents in the future.
Appreciation of differences and Openness to ideas: The medical data and the personal experiences shared by the employees through focus groups helped them to understand that anyone could make an error. Hence denying such errors is losing an opportunity to learn and improve.
Reflection: The results of the study using focus groups not only provided information about patient safety but also allowed the employees opportunities to reflect on their actions which led to the errors. The focus groups also served to surface many suggestions for enhancing existing processes and systems.
Building Block 2: “Concrete Learning Processes and Practices”
A learning organization has processes for generating, collecting, interpreting and disseminating information. At such an organization the employees are constantly trained for upgrading their skills. The people experiment with new ideas. There is a uniform dissipation of information across the organization. The ideas are put into practice by way of processes. Building block two of a Learning Organization includes the following aspects:
• Experimentation
• Information Collection
• Analysis
• Education and Training
• Information and Transfer
At CH, Morath faced the following Key Challenges:
Transparency to patient’s family: Morath wanted to change the way hospital communicated with the families when accidents occurred. As advised by their Lawyer and Risk Manager, CH did not volunteer information and did not admit wrongdoing in the event of an accident.
JCAHO specific forms: Most of the forms used to record accidents were tailored to give JCAHO information about the number of accidents occurring but not the root cause of the accidents.
Lack of awareness: Since the issue of patient safety was considered to be implicit, there was a lack of awareness among the staff as to what steps can be taken to ensure safety. There were no training procedures focused on safety measures.
Absence of feedback: Even if the nurses of any of the other employees felt the need for change in any of the procedures, there was procedure for providing feedback about it. Furthermore, some staff would hesitate to point out any problems.
The Key Activities implemented by Morath to create the required processes were as follows:
Implemented “Complete Disclosure” Policy: Under this policy, CH contacted the family soon after an incident occurred, explained the procedure for examining an accident and described what they learnt more about the causes of the accident. The family was also to be kept informed of any updates.
Patient Safety Dialogues: Morath created a series of sessions for Children’s employees and clinical staff to come together to learn about the current state of research on medical safety. She also invited national speakers to give mini-courses on safety and supplemented these with self-study packets on the science of safety.
Patient Safety Steering Committee: Morath appointed a PSSC to oversee the safety initiative. PSSC conducts a confidential “blameless’ analysis of the incident aimed at documenting the sequence of events as accurately as possible and identifying all contributing systematic failures. PSSC created a Focused Event Analysis process for examining the causes of serious medical accidents. The PSSC also reviewed the findings from the accident inquiries. The focused event studies which used to be conducted only after sentinel serious medical accidents were to be conducted even after less serious incidents. Furthermore, the analysis finding of the logs and studies were to be reported openly. PSSC also developed the new patient safety report.
Safety Action Teams: Each clinical unit manager had to establish a safety action team, a cross-functional team which met regularly to discuss medication safety issues. The team members would inform their co-workers about the problems they discussed and the improvements they hoped to implement.
Good Catch Logs: Good Catch Logs provided the medical staff to report any potential problems anonymously. Such catch logs were a good way of capturing information that could be used to prevent medication errors.
The above measures implemented by Morath were effective in the following ways:
Information Collection and Analysis: The Good Catch Logs and Focused Event Studies provided plenty of information about what sequence of events led to errors. Such information was then analyzed to find the root cause of the errors. By way of good catch logs, the nurses and pharmacy staff could record events in the log anonymously.
Information and Transfer: The patient safety dialogues informed the medical staff the various ways in which errors could occur and hence could be avoided.
Each person gathered ideas and suggestions to share with the Safety action Team.
Education and Training: The literature on science of safety and self-study packets provided by Morath were used by the employees to educate themselves on the subject. This enabled employees to learn about the science of improving safety in complex systems.
Analysis: The focused event analyses develop disciples that then go out into the organization understanding the complexity of medical accidents.
Experimentation: The PSSC started experimenting with new ways such as having two facilitators, one to facilitate and another to observe non-verbal behavior to make sure nothing is missed.
Identification of root causes: The Blameless Reporting system resulted in employees speaking openly about any errors made and identified root causes of the errors.
Building Block 3: “Leadership that Reinforces …show more content…
Learning”
The third building block refers to the leadership within the organization. It reflects the extent to which the leaders of an organization communicate what they value. Leaders build organizations where people grow and develop their capabilities. The leaders in a learning organization demonstrate willingness to entertain alternative viewpoints, emphasize on spending time on problem identification, knowledge transfer and reflection. They engage people in active questioning and listening.
The third building block of a learning organization should have the following features:
• Invite input from others
• Acknowledge limitations
• Ask probing questions
• Listen attentively
• Encourage multiple points of view
• Provide time / resources / venue for identifying problems / reflecting and improving on past performance
• Criticize views different from their own
Morath faced the following Key Challenges in reinforcing learning:
Limited Understanding: In many cases, administrative and support staff did not fully comprehend how seemingly simple policy changes complicated the way doctors and nurses performed their daily work.
Disconnect between upper management and front-line workers: There was a disconnect between the administrators and the people working hard to provide patient care.
Seeking approval to hold a focus group with a set of parents: The most controversial aspect of the effort of patient safety was getting an approval for holding a focus group with a set of parents. It was feared that involving parents and disclosing information about medical accidents at CH may bring ill repute to CH and may expose it to legal risks.
Lack of motivation for implementing safety measures: Since the issue of patient safety was meant to be implicit, the employees had to be motivated to put in efforts to make the initiatives successful.
The Key Activities implemented by Morath to create the required processes were as follows:
Focused Vision: Morath accepted the role of the COO of CH with focused vision of having explicit patient safety measures. She recognized that health care is very complex system and risk-prone. Everyone must work together to understand safety, identify risks and report them without fear of blame. She launched a strategic planning process to define the organization’s goals and objectives for next five years.
Invited inputs from others: Morath involved doctors, nurses, pharmacists and many other people from different areas of the organization. She energized them about the initiative and thinking creatively about ways to enhance patient safety. There were several ways of inviting input from employees and parents including the catch logs, steering committees and action teams.
Creation of empowered teams and committees: Morath appointed the PSSC to oversee the safety initiative. She served as the chairman of the committee. It also included physicians, representatives from nurses union, parents and a member from the board.
Approval from Board: Morath successfully obtained an approval from the CH board to hold a focus group with parents.
Management Efforts: Morath recruited Mark Thomas, Pharmacy Director, to take charge of the project to improve medication administration system. She wanted him to focus not only on the internal processes but also on the entire flow associated with medications.
Dedicated Chairperson for PSSC: When Morath realized that she would not be able to give her full attention to the PSSC, she appointed Dr. Eric Knox on a full-time basis as the Chair of the PSSC.
Stretch Goals: Morath set the goal of achieving zero defects and a 100% reliable medication system. Such goals required revamping the hospital’s systems and processes and motivated the employees to change the way they thought about patient safety.
The above mentioned measures implemented by Morath were effective in the following ways:
Created Vision: The strategic planning process initiated by Morath was instrumental in aligning the organization behind a clear set of objectives, particularly with respect to Patient safety. As they share same goals, the upper management and the front-line workers easily aligned with each other on patient safety agenda.
Generating enthusiasm for the safety effort: Morath was successful in creating enthusiasm amongst the employees about the safety effort. People at CH became confessional. The employees and the clinical staff felt relieved to have a place to discuss their experiences with medical errors.
Encourage multiple points of view: The focus group provided an opportunity to parents to speak openly about their experiences and to offer suggestions. This additional point of view provided a wealth of information about the current state of patient safety, identified underlying causes of medical errors at CH and surfaced many suggestions for how to enhance existing processes and systems.
Collective Responsibility: Major effect of forming PSSC was the collective responsibility for setting goals for the safety initiative, for revising hospital policies and procedures. Such collective responsibility begets accountability.
Probing questions, listening attentively and Criticizing: The entries from the catch logs were to be reviewed, summarized and presented by the Safety Action Team at meetings. The conclusions from the reviews were then translated to concrete actions.
Question 2: Which one of the following do you think will happen to the changes that are started at Children’s?
1. They will all disappear in 5 years.
2. Some will disappear but some will remain. Which will remain? Which will disappear? Why?
3. All will continue to prevail.
Provide 4 reasons to support your answer.
Answer
Changes / Actions Prevail / Disappear in 5 Years? Reasons
Safety Action Teams Prevail 1. These changes became an integral part of culture at CH. All employees found these tools useful to identify possible medical errors.
2. Employees found it comfortable to point out concerns anonymously via the Good Catch Logs.
3. Sharing personal experiences with safety action teams about errors helped employees to reduce emotional burden.
4. The patient safety dialogues served to enhance awareness about safety issues.
Good Catch Log
Patient Safety Dialogue
Blameless Reporting Disappear 1. The patient’s parents as well as many managers were concerned about the accountability taken away by Blameless reporting.
2. The progress made by carrying out changes was not measurable.
3. Employees did not have time to follow up issues discussed.
4. Complete disclosure policy to parents could lead to legal problems for the hospital.
Focused Event Studies
Disclosure Policy In the next five years, the leadership role in the patient safety program will be handled by a different person. The new leader might have different approach towards patient safety. Aside from that, we think that some of the changes initiated by Morath will continue at CH but some will disappear.
Programs that will prevail are Safety Action Teams, Good Catch Log, and Patient Safety Dialogue. The reasons for these are:
1. Safety Action Teams, Safety Dialogues and the Good Catch Logs were imbibed in the culture at CH. These activities did not take any extra effort on part of the employees and simultaneously enhanced their learning. Hence, the benefits certainly outweigh the efforts of implementing these initiatives.
2. The Good Catch Logs provided a way for the employees to voice their opinion anonymously and contribute to patient safety. The employees also found that the concerns put forth in Good Catch Logs were being implemented. Hence, we believe that Good Catch Logs will continue to prevail.
3. Many people felt guilty when they committed a medical error. People wanted to speak to someone about it to reduce their emotional burden. The safety action team provided employees a chance to share any medical errors committed by them. As the disclosure was confidential and anonymous, they could release this burden by sharing their experience. As this change was helping employees, it appears to prevail in the long run. This activity also encouraged team work.
4. Employees became aware of the safety aspects through the safety action dialogues. It is observed that the number of people attending the dialogues was less initially but subsequently, the attendance increased substantially. The dialogues were supplemented with mini-courses, which the staff found very informative. The new in-charge of the safety initiative, Dr. Eric Knox, is a nationally regarded expert on medical safety. He would maintain people’s interest in safety by inviting many more speakers for the talks. On the other hand, the changes that are likely to disappear in five year are “blameless reporting”, Focused Event Studies, and Complete Disclosure Policy due to the following reasons:
1. There is no definite tool to assess the outcome of focused event studies. PSSC did not have a systematic way to ensure that recommended procedural changes were implemented or to measure the effectiveness of changes.
2.
Both CH managers and families complained about “Blameless Reporting”. There was no penalty for people who were responsible for the accidents. In some cases, errors could have been caused by poor performance of a particular person rather than a system failure. The reporting method was focused on identifying the problems in the system. CH management including Morath was finding it difficult to respond to Family’s demand for the name of people accountable for accidents.
3. The focused event studies encouraged employees to share their experience about medical errors but due to lack of time, staff or resources to follow up on each issue it was difficult for managers to analyze the problems that emerged during a focused event analyses. With their current job and responsibilities, they did not have time to follow up the outcome from the session. As the solutions could not be implemented, the errors are bound to happen again. Thus, such event studies will become redundant and eventually vanish.
4. CH might face legal problems in the future caused by complete disclosure policy. It is possible that disappointed families may sue the hospital for carrying out accidents. Now as the CH was disclosing a lot more information to families through focused event studies, the effect on CH’s legal exposure could not be determined. CH may revert to tight-lip stand on disclosing information to the
parents.