Children’s Hospital and Clinics in Minnesota Essay Example
Children’s Hospital and Clinics in Minnesota Essay Example

Children’s Hospital and Clinics in Minnesota Essay Example

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  • Pages: 10 (2666 words)
  • Published: December 12, 2017
  • Type: Paper
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Inquiring about Morath's efforts in transforming Children's Hospital into a learning organization, the answer highlights Morath's leadership skills and initiatives as the integral elements behind CH's evolution into a learning organization.

At Children’s Hospital, we identify three essential building blocks for a learning organization. The first, known as “A supportive learning environment,” acknowledges that traditional values, structures, outdated procedures and psychological barriers can impede a successful learning process. Therefore, the environment at a learning organization should encourage individuals to raise system issues and explore solutions. This approach promotes continuous growth and development as people feel secure enough to express new ideas, discuss failures and go against the norm. They can ask questions without fear of judgment, take responsibility for mistakes and present alternative viewpoints.

The Learning Organization's initial block i

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ncludes aspects such as Psychological Safety, Appreciation of Differences, Openness to New Ideas, and Time for Reflection. Within a healthcare setting, CH experienced expected errors; consequently, Nelson, the CEO, appointed Julie Morath as COO to foster awareness regarding patient safety. However, at CH, Morath was faced with several key difficulties concerning her patient safety initiative, such as overcoming the challenging nature of engaging the subject matter.

The issue of safety in hospitals is often met with defensiveness from management, who fear reputational damage and legal liability. Patient safety should be a given and discussing it shouldn't be taboo. According to Morath, there is also reluctance from employees to accept Medical Accident Data.

There was doubt about the usefulness of the data for CH. However, transparency is crucial for effective learning environments and to allay fears about career damage. At CH, employees are worried about being responsible fo

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near-fatal accidents or how errors may affect their performance. This makes it difficult for them to admit to mistakes. Morath faced the challenge of encouraging open discussion about errors without harming people's careers. During discussions, accusatory language was used which implied finger-pointing.

Morath faced difficulties in changing the environment at CH as it lacked psychological safety for those making mistakes. The traditional model of medicine at CH was Accuse, Blame and Criticize. However, Morath implemented certain Key Activities to create a supportive learning environment. These included spreading awareness about Patient Safety, creating a Blameless Environment with ground rules such as "blameless reporting", confidentiality and creativity to improve processes, and presenting statistics and personal experiences from reputable studies such as the Harvard Medical Practice Study on the frequency and causes of medical errors.

The information indicated that medical errors resulting in deaths are prevalent in hospitals throughout the United States, including Children's Hospital (CH). To address employee doubts about the study's applicability to their workplace, the author encouraged them to share personal encounters related to patient safety. They found that everyone had experienced such incidents. Focus groups were organized to allow hospital staff to discuss their mistakes and consider potential solutions.

In order to facilitate open discussion about medical accidents, Morath held focus groups with employees and later with parents. One effective strategy he used was to replace accusatory language with neutral phrases to foster a blameless reporting culture. By establishing ground rules and a common language, employees felt comfortable discussing errors without fear of being blamed. This led to a more open and honest reporting of medical accidents that allowed for identification of flaws in the system and

implementation of changes to prevent future incidents, while maintaining confidentiality and anonymity for those reporting.

The use of focus groups, in which medical data and personal experiences were shared by employees, resulted in the appreciation of differences and openness to ideas. It was understood that denying errors can hinder learning and improvement. The study's results not only provided information about patient safety but also allowed for reflection on actions that led to errors, as well as suggestions for enhancing existing processes and systems. This aligns with Building Block 2 of a learning organization, which involves concrete learning processes and practices for generating, collecting, interpreting, and disseminating information. This includes constant employee training for skill upgrades.

The Learning Organization's second building block consists of experimentation, information collection, analysis, education and training, and information transfer. The organization's people experiment with new ideas, which are put into practice through processes. Across the organization, there is a uniform dissipation of information. At CH, Morath encountered a challenge in communicating transparently with patients' families about accidents and sought to change the hospital's communication approach.

Based on the advice of their Lawyer and Risk Manager, CH opted not to disclose information or acknowledge any wrongdoing if an accident occurred. The JCAHO forms primarily focused on documenting the number of accidents, rather than investigating their underlying causes. Due to the implicit nature of patient safety concerns, staff members lacked awareness and proper training regarding safety measures.

The absence of a feedback mechanism among nurses and other employees made it difficult for them to express their opinions regarding any necessary changes in operation procedures. In addition, some staff members were hesitant to point out any

shortcomings. To address this issue, Morath implemented key activities that included the "Complete Disclosure" Policy where families were contacted after a patient incident to explain the incident investigation process and any updates. Furthermore, Patient Safety Dialogues were initiated for Children’s employees and clinical staff to share information about current medical safety research.

As part of her safety initiative, Morath invited national speakers to give safety mini-courses and provided self-study packets on safety science. She also appointed a Patient Safety Steering Committee (PSSC) to oversee the initiative. The PSSC conducts confidential "blameless" analyses of incidents, documenting the sequence of events and identifying all contributing systematic failures. They developed a Focused Event Analysis process for investigating serious medical accidents and reviewed the findings from accident inquiries.

PSSC has expanded the scope of focused event studies from solely investigating sentinel serious medical accidents to including less serious incidents as well. Additionally, the analysis findings of these studies and the logs are required to be disclosed publicly. PSSC has also introduced a new patient safety report. Each clinical unit manager is responsible for forming a safety action team, comprised of cross-functional members who meet regularly to discuss medication safety concerns and share progress on improvements they intend to implement. Medical staff can anonymously report any potential problems using the Good Catch Logs.

Recording catch logs was a beneficial method for obtaining data that could aid in the prevention of medication errors. The measures implemented by Morath were successful in the following capacities: gathering and examining information, with the assistance of Good Catch Logs and Focused Event Studies, pertaining to the sequence of events that led to errors, and then analyzing

that information to identify the root cause of the errors. Through good catch logs, nurses and pharmacy staff were able to document incidents anonymously. Additionally, patient safety dialogues informed medical staff about potential errors so that they could be avoided.

Individuals contributed suggestions and ideas to the Safety Action Team. Employees utilized Morath's self-study packets and scientific safety literature for education and training, allowing them to comprehend the intricacies of enhancing safety in intricate systems. Focused event analyses create adept professionals who understand the complexities of medical accidents and disseminate this knowledge throughout the organization.

The PSSC conducted experimentation by incorporating two facilitators - one to facilitate and another to observe non-verbal behavior. This was done to ensure that nothing was missed during the process. Furthermore, the implementation of Blameless Reporting system resulted in employees speaking openly about any errors made, which led to the identification of root causes of the errors. Building Block 3, which is called "Leadership that Reinforces Learning", emphasizes the importance of leadership within the organization. It denotes the extent to which leaders of an organization communicate their values and build organizations where people can grow and develop their capabilities.

The leaders of a learning organization exhibit a willingness to consider alternative perspectives, prioritize problem identification, knowledge transfer, and reflection, and involve others in active questioning and listening. The third pillar of a learning organization should entail inviting input from others, recognizing limitations, asking probing questions, attentively listening, encouraging multiple points of view, providing resources and time for problem identification and reflection, as well as criticizing differing views. Morath experienced challenges in reinforcing learning due to limited understanding among administrative and support

staff regarding how simple policy changes could complicate doctors' and nurses' daily work. There was also a disconnect between upper management and front-line workers who were responsible for providing patient care.

Approval was sought to hold a focus group with parents as part of efforts to improve patient safety. However, there was concern that involving parents and sharing information about medical accidents could harm the reputation of CH and result in legal risks. In addition, employees needed motivation to implement safety measures as these were not previously emphasized. COO Morath introduced a Focused Vision approach to create explicit patient safety measures, recognizing the complexity and risks of healthcare systems.

Collaboration is crucial in comprehending safety measures, recognizing potential hazards, and reporting them without apprehension. A five-year strategic plan was initiated by her to establish the organization's objectives and aspirations. Various personnel, including medical staff, pharmacists, and others from different departments of the organization, were encouraged to provide their valuable insights. Morath inspired the employees and urged them to be inventive in elevating patient safety levels. Multiple channels such as catch logs, steering committees, and action teams were used for employees and parents to contribute their suggestions.

The creation of empowered teams and committees was a priority for Morath in overseeing the safety initiative. Leading the way, she served as chairman of the PSSC which also included physicians, representatives from nurses unions and parents, as well as a board member. Morath sought and obtained approval from the CH board to hold a focus group with parents. In terms of project management, Morath brought on board Mark Thomas, Pharmacy Director, to take charge of the task of improving the

medication administration system.

The Chairperson of PSSC, Morath, appointed Dr. Eric Knox as a full-time Chair to ensure attention to both internal processes and the entire flow of medications. Additionally, Morath set stretch goals for a 100% reliable medication system with zero defects.

Revamping the hospital's systems and processes and changing the mindset of employees towards patient safety were necessary for achieving set goals. As led by Morath, these measures had successful outcomes in several ways. Firstly, the strategic planning process implemented by Morath was crucial in creating a clear vision for the organization, especially concerning patient safety. This vision brought together upper management and front-line workers, who shared the same objectives. Secondly, Morath's efforts generated enthusiasm amongst CH employees for the safety agenda, resulting in individuals becoming more committed to the safety effort.

Both employees and clinical staff were relieved that they could utilize a space to converse about their experiences with medical errors. The focus group opened up opportunities for parents to share their experiences and suggestions, providing a multitude of perspectives about current patient safety. This helped unveil the underlying causes of medical errors at CH and surfaced several recommendations to improve the existing processes and systems. The formation of PSSC resulted in collective responsibility, giving way to setting safety initiative goals, revising hospital policies and procedures, and accountability.

During Safety Action Team meetings, the catch logs were examined, summarized, and presented for discussion. The resulting conclusions were then translated into actionable steps. Question 2 poses the scenario of the changes initiated at Children's: will they fade away within five years?

2. Certain things will endure while others will vanish. What will endure

and what will disappear? Why? 3. Everything will persist. Give four justifications for your response. Answer: Will Certain Actions Persist or Vanish in Five Years? Reasons: Safety Action Teams will Persist.

These changes were adopted as a cultural norm at CH, finding them helpful for identifying potential medical errors. The use of Good Catch Logs enabled employees to anonymously express concerns, which was a comfortable approach. Additionally, sharing personal experiences with safety action teams helped to reduce the emotional burden on employees.

4. The Patient Safety Dialogues helped to increase knowledge regarding safety concerns, including the Good Catch Log and Patient Safety Dialogue. However, there were concerns from both parents and managers about the lack of accountability with Blameless Reporting. Unfortunately, the impact of implementing changes could not be measured.

Within the realm of Focused Event Studies Disclosure Policy, concerns arise regarding employees' ability to address discussed issues and the potential legal complications that may arise from disclosing information to parents. Additionally, the patient safety program will see a change in leadership within the next five years, bringing a new perspective and approach to the forefront.

Despite some changes at CH being eliminated, we anticipate that certain initiatives initiated by Morath will continue. Safety Action Teams, Good Catch Log, and Patient Safety Dialogue programs are expected to persist for several reasons. These activities were ingrained in the culture at CH, did not require additional effort from employees, and simultaneously improved their learning.

Therefore, despite the effort required to implement these initiatives, their benefits are significant. The Good Catch Logs enable employees to anonymously share their opinions and contribute to patient safety. Moreover, employees have seen that the issues

raised in Good Catch Logs are being addressed, reinforcing our confidence in their continued effectiveness.

There was a sense of guilt experienced by many individuals who had made a medical mistake. They wished to relieve this emotional weight by speaking to someone about it. The Safety Action Team offered them the opportunity to discuss any errors they had made without fear of repercussions, as the disclosure was both confidential and anonymous. This was discovered to be a successful long-term solution that not only assisted employees in releasing their burden but also promoted teamwork within the organization.

During the safety action dialogues, employees were able to learn about safety aspects which led to an increase in attendance. Initially, few people attended the dialogues but eventually, more people showed interest. Additionally, mini-courses were provided to supplement the dialogues, which employees found informative. The safety initiative is now led by Dr. Eric Knox, who is a nationally recognized expert on medical safety.

With regards to safety, the individual plans to increase engagement by inviting numerous speakers for talks. However, certain practices such as "blameless reporting", focused event studies, and complete disclosure policy are expected to vanish within five years. This is due to various reasons which include the absence of a conclusive tool for evaluating the outcomes of focused event studies. The PSSC did not have a structured approach for ensuring that recommended procedural changes were adopted or measuring their effectiveness. Additionally, both families and CH managers had grievances about "Blameless Reporting".

The absence of penalties for those accountable for accidents made it challenging for CH management, including Morath, to satisfy the Family's request for the names of those responsible. While the

reporting method aimed to detect system flaws, some errors may have resulted from individual shortcomings. Despite the focused event reviews prompting employees to share their insights on medical mistakes, analyzing every problem that arose during such analyses proved difficult for managers due to time, staffing, or resource constraints.

Due to their current job and responsibilities, they were unable to follow up on the session's outcome. Consequently, the solutions remain unimplemented, and it is likely that the identified errors will resurface. Eventually, such event studies may become obsolete and fade away. Moreover, CH may encounter legal issues in the future due to their complete disclosure policy.

There is a chance that families who are unhappy may take legal action against the hospital due to incidents that occur. Although CH is releasing more data to families via targeted incident investigations, it is unclear how this will impact their legal liability. As a result, CH may choose to withhold information from parents.

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