NSTRUCTIONS:
Develop an Operational Plan as it relates to communication as a safety measure for the Queenan Health Systems.
Be sure that your plan is evidence-based and directly related to the overarching goal of evolving organization into a high reliability organization.
Consider opportunities for rebuilding trust in the aftermath of serious patient-safety events and promoting buy-in and meaningful inclusion of all stakeholders.
The executive team has charged you to rely heavily on the Leadership Domains fromLeading a culture of safety: A blueprint for success,as a foundation on which to evolve the organization into an HRO, or HighReliability Organization.
1.First, provide a brief one-paragraph reminder of the organization (Queenan Health Systems)
issue being addressed (communication as a safety measure), andtheadministrative roleyouhaveassumedfor this project(healthcare administrator).
You will develop the operational plan from the perspective of healthcare administrator.
2.Provide at least6-8clear and measurable objectives. They mustdirectly align with the new vision, thesafety issues (communication as a safety measure) and with the mission and services of the organization.
3.Next,foreachof the objectives,provide aplan(at least 1-2activitiesper objective) for how eachobjective will be actualized.Yourplan mustincorporatethe following: and must adhere to healthcare industry best practices:•Establishment or improvement of safety metrics. •Assurance of compliance with established principles of safety. •Considerations oforganizational, individual, and communitydiversity.•Strategies to instill trust, mutual respect, and inclusion within the organizationand from thecommunity/patient base.4.Lastly for this component of your operational plan,describe how you will design and deliver aneffective training program for workforce and leadership developmentrelated to implementing theseobjectives and planned activities.Your plan should includeintroducing theBlueprint. HSC698 Capstone Project Case Study
High Reliability Organization
Your capstone project will be the design of an operational plan leading to a high reliability organization.
[HRO]. HROs seek to maximize the reliability of organizational operations and services when the
consequences of error can be disastrous. Establishing and maintaining an underlying HRO structure
constitutes an organizational commitment to values and behaviors that increase reliability, improve
responses to surprises and reduce the probability of errors.
Queenan Health System Case Study
The Queenan Health System [QHS] is a multi-facility healthcare system located in the northeastern
United States. QHS has five [5] acute care hospitals, one [1] children’s hospital, one [1] inpatient
rehabilitation hospital, one [1] skilled nursing facility, one [1] home health agency and one [1] large
multi-specialty physician group practice. QHS is fiscally sound but given its location is in a competitive
environment with other similar healthcare systems and freestanding health facilities. The demographics
in the QHS service area include a mix of elderly, adult and young persons.
1. Adult Medicine – Mr. Jones is a previously healthy 55-year-old man, with a recent history of
shortness of breath that is related to exercise. He has been referred by his primary care
physician for a cardiology consultation, at which a stress test is ordered. The results of the stress
test indicate a positive finding for potential heart disease. These results are not communicated
back to his primary care provider, and although they are sent to the referring cardiologist, he is
away at a conference. Mr. Jones receives no communications about the results of his test. One
week later, Mr. Jones presents to the emergency department with chest pain and is diagnosed
with an acute myocardial infarction. Upon further review of his medical records, the care team
reviews his past test results and learns about the positive stress test. Mr. Jones requires
placement of a stent to open his coronary artery, and requires rehabilitation prior to discharge
to his home due to reduced cardiac function. One week after discharge from inpatient
rehabilitation, Mr. Jones returns to his primary care physician, who realizes that Mr. Jones is not
taking one of the new cardiac medications that was ordered by his inpatient team.
2. Obstetrics and Newborn Care – Mrs. Smith is a nineteen year old female who while under the
care of an obstetrician, gave birth by an emergency cesarean section. The baby suffered
permanent injuries at or shortly after her birth. She was diagnosed as having cerebral palsy of
the severest spastic quadriparetic type with microcephaly and mental retardation. Mrs. Smith
instituted a lawsuit on her own behalf, and as guardian, on behalf of her child, against the
physician, and later against an emergency-room pediatrician. Mrs. Smith commenced a second
action against the hospital, members of the operating team, and several hospital administrators.
In this case, she alleged that the delay in performing the cesarean section, and the infant’s
resultant injuries, were caused by the negligence of these defendants in assembling the
operating team necessary to assist in the delivery. At the time of the birth, Hospital A was under
a renovation/construction program that included, among other things, the construction of a
new C-section operating room. During this time, those patients in normal labor were treated in
Hospital A. Any scheduled C-sections were admitted to Hospital B. Patients such as Mrs. Smith,
whose condition changed while in labor were physically transported to Hospital B and an
obstetrical operating room team was assembled while the patient was en route. There was a
significant delay.
3. Pediatrics – Newborn twins Jane and John were hospitalized for treatment of a staph infection at
Hospital C, the children’s hospital. Their physician prescribed 10 unit/ml of Hep-lock to keep
their intravenous lines clear, but hospital personnel made a “medical error” and administered
10,000 unit/ml of Heparin instead. The twins nearly died but recovered. The parents filed a
complaint against the drug company alleging strict liability and negligence. The parents alleged
that the 10 unit/ml vials of Hep-lock and 10,000 unit/ml vials of Heparin manufactured by the
drug company were in an unreasonably dangerous condition because the labels of both vials
had a blue background, which made them difficult to distinguish. They alleged that the
background colors should have been different and that the vials should have been completely
distinguishable in size and shape. The parents have also filed a complaint against Hospital C.
They claim that Hospital C failed to act upon an urgent warning about the fatal medication
errors to all healthcare providers who could use the product and to require that such providers
initiate mandatory education and implement safety measures so that a fatal medication error
would not occur.
4. Elderly – Skilled Nursing Facility – On the first day of the July 4th holiday weekend, Mrs. Wood
was a resident in our system’s skilled nursing facility. She was observed sitting on the front
porch of the facility with her roommate and the roommate’s adult son in the early evening. Due
to a staffing shortage, there was no nursing assistant available to sit with the two residents to
monitor them. The adult male asked Mrs. Wood to take a walk with him on the grounds of the
facility. He sexually assaulted her behind a grove of trees and threatened to harm her if she said
anything to anyone. Several weeks later, the roommate of Mrs. Woods passed away and Mrs.
Wood told the story to a nursing supervisor.
5. System-wide Lower Back Injury Rates – QHS was recently inspected by the federal Occupational
Safety and Health Administration due to an alarming number of worker compensations cases
involving lower back injuries. The System’s overall worker compensation costs for the most
recent 12 month period amounted to $25 million, of which 60 percent is due to lower back
injuries. The system is an unsafe work environment.
The chairman of the System Board of Trustees has met with the C-Suite Executives regarding these and
other quality and safety matters. A review of all root cause analyses was completed. The Chairman is
concerned over the quality of care, costs of malpractice settlements, liability insurance coverage, impact
on the System’s bond rating and overall public perceptions. He has given the C-Suite Executives a
mandate to prevent such incidents from occurring in the future.
Your charge is to advise the C-Suite Executives on the development of an operational plan that evolves
QHS into an HRO. The Chairman has scheduled a meeting with the C-Suite members in two months.
Notes: may need a mission statement…
Introduction
Queenan Health Systems is in the northeastern portion of the United States. This
multi-facility healthcare system is responsible for ten facilities that includes acute care hospitals,
nursing homes, and a skilled nursing facility, to name a few. Safety in all areas is a priority
within the Queenan Health Systems, not only for staff but for patients as well. As with any
healthcare organization safety is a huge issue within the industry and continued efforts to reduce
and eliminate safety issues remain ongoing. Communication breakdown between healthcare
providers and patients is one of the major safety issues that affect healthcare organizations. It
involves the inefficient provision of healthcare services to patients. Understanding that
communication breakdown has challenges can contribute to an organization focusing on
strategies to improve communication in the workplace. Communication breakdown in a
healthcare system has negative impacts on the safety of the organization. Implementing a vision
and mission statement can be vital to achieving a better communication channel with clients and
promote a culture of patient safety.
Organization’s Mission
The Queenan Health System’s mission will be to facilitate efficient communication
with patients and to provide quality care and excellent health services. The major aim of the
organization in implementing the mission is to ensure that it continues to achieve the objectives
of quality health. The mission supports the communication and interaction of healthcare
practitioners and patients. More so, it advocates for connection between the healthcare providers
and the clients in the facility. Having an efficient mission statement guides healthcare
Running Head: Vision for Safety.
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practitioners toward the strategy to implement for efficient results (Alam, 2015). If the
organization adheres to the mission statement, there is a high possibility of achieving adequate
results and reducing the different challenges that it is currently facing.
Communication breakdown is associated with a range of hazards that affect the safety of an
organization. According to Tiwary et al. (2019), communication failures in the healthcare sector
account for 27% of medical malpractice. The challenges, associated with the lack of adequate
communication, therefore, revolve around the inability to deliver quality healthcare services to
patients. Examples of the identified impacts of communication breakdown are dissatisfied
patients, incorrect treatment processes, and waste of resources in the facility (Tiwary, 2019). The
Queenan Health System faced distinct issues due to communication breakdown including the
lack of delivery of results to patients, incorrect medicine administration, and dissatisfied patients
who instated lawsuits. These issues occurred since the healthcare practitioner groups in the
health system lacked efficient communication with the patients.
Ethical and Legal Considerations
The ethical and legal considerations related to the problem of communication on patient
safety are significant in evaluating overall patient outcomes. The distinct ethical issues to
consider include the privacy and disclosure of information. Patients need to receive adequate
information regarding their health status to ensure that they take the necessary precautions. Mr.
Jones did not receive the test results from the cardiologists and hence did not take further steps
toward improving their condition. As a result, his status worsened. The legal considerations to
consider are justice, beneficence, and patient autonomy. Adhering to distinct ethical and legal
Running Head: Vision for Safety
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considerations about communication is significant for promoting patients (Kadivar et al., 2017).
This occurs through facilitating the prevention of mistakes and errors in the system.
Vision
The Queenan Health System’s vision will be to develop and sustain the enhanced
provision of healthcare services by focusing on efficient communication and collaboration with
patients. This vision statement recognizes the fact that challenges occurring in the organization
are due to the lack of an adequate communication channel. More so, the vision statement focuses
on creating a better connection with patients to ensure that their needs are met and the services
provided to them are adequate and efficient. Quality care and patient safety is the top-most
priority identified in the vision statement. Developing the vision statement will be significant in
creating a better future for the organization and developing practices that recognize the
importance of providing patients with adequate information about their health (Alam, 2015).
Patients are likely to trust an organization with a well-outlined vision of their future and how
they intend to continue enhancing patient safety. As a result of the trust, the health organization
will have developed a high-reliability organization that aims at enhancing and maintaining a
culture of patient safety and quality service delivery. Through this vision statement, Queenan
Health System will have the chance to deliver the care services that patients visiting the different
hospitals intend to receive.
Running Head: Vision for Safety
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Conclusion
The Queenan Health System is facing diverse challenges due to the existing
communication problems and breakdown. Healthcare practitioners are expected to facilitate
efficient communication and patient safety to maintain client satisfaction. A strategic approach
towards developing a culture of safety and HRO is possible through the recognition of the role
that patients play in the success of the organization. Satisfied clients seek future services from
the healthcare facility they trust while dissatisfied clients are likely to engage in lawsuits with the
organization. The identified mission statement will be important in guiding the care providers on
how they should interact with the patients. The vision statement outlines where the health facility
intends to be and develop in the future. Thus, the short-term and long-term objectives of the
organization are to promote patient safety in the different organization, by prioritizing efficient
communication with patients.
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References
Alam, A. Y. (2015). Hospital vision and mission strategic planning and departmental
performance. Journal of the Pakistan Medical Association, 65(4), 345-346.
Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical
and legal aspects of patient’s safety: A clinical case report. Journal of Medical Ethics and
History of Medicine, 10,15.
Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by
health care professionals may lead to life-threatening complications: Examples from two
case reports. Wellcome Open Research, 4, 7.
https://doi.org/10.12688/wellcomeopenres.15042.1