Health Care, Management & Entrepreneurship

A report submitted to Prof. Ratan Jalan

In partial fulfilment of the requirements of the course HCM 2ND

Year elective

Individual Assignment:2
Case: Children Hospital and Clinic (A)

By:
Deepanshu Singh (1911076)

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 Question to be answers

1. How was the incident involving Matthew’s overdose evaluated by the administration at the
Children’s Hospital?
2. What were the steps taken to get the front line workers involved in the safety initiative?
3. How would you describe Julie’s leadership style? Give examples to support your answer.

Answers
1. How was the incident involving Matthew’s overdose evaluated by the administration at the
Children’s Hospital?

Answer
The medical error kills 44,000 to 98,000 patients annually, as seen in the exhibit, also given that
the error causes more deaths than breast cancer and AIDS per year, the medical study also went
on to state that 72% of them are recurring and predictable and can be avoided.
After a detailed review of the findings, it was concluded that the event referred to above could
have happened in the past but was not successfully resolved to avoid repeating. The
administration recognized the severity of the situation and, instead of naming an error, they
defined the problem as a complicated issue of failure requiring thorough root cause analysis.

Call of events by the administration to evaluate

Created problem solving procedure→Initiated focussed event analysis→directed 9 people for
being connected with the incident→Set the objective of the event→Created the conducive
environment→provided blameless environment→asked for creative solution→documented the
process and insights→ shared the finding with COO→Identified 3 issues→changes to avoid future
mishaps

Dr. Robinson took the lead and, instead of jumping into the blame game, created a conducive
atmosphere for dialogue and uncovered the root cause of the problem, he also established the
four concrete goals to emerge from this meeting and practice. This showed the commitment of
the administration to take care of patient safety as a priority and to make an effort to create a
blameless environment. The Robinson and the moderator Hart discussed the issue with the COO
of the company and find out 3 difficult issues, they discussed the cause of the event and changes
that should be implemented to prevent similar accidents in the future. The strategic method of
including all stakeholders in the review of the case and seeking a solution provided a sense of
control on the front lines, as well as the need to accept such medical mistakes as a result on
complicated problems rather than negligence, and the assessment went on to improve the
implementation plan to prevent potential accidents.
Few criteria set by the admin for the evaluation
1. Involved all those who could make a difference
2. Set the basic rules for discussion
3. Allowed diverse participation of all stakeholders in front

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2. What were the steps taken to get the front line workers involved in the safety initiative?

Answer
There have been several steps taken to get the frontline workers involved to see the extent of the
problem because it has just not been addressed in such detail in the past, and the frontline
workers used to avoid such discussions in order to prevent any repercussion.

1. Convinced the staff of error being a health care org. problem rather than incompetency
Julie Morath persuaded the workers that mistakes were still an issue for all health care
facilities, including children, and that a new approach to safety might reduce accidents.
The administration also sought to persuade the workers to speak more freely about the
mistakes and offered a sense of relief that they would not impact their jobs.

2. Created a safe place to discuss their experiences with the medical errors
Using the focus group as a tool to energize the initiative's front line and think creatively
about how to improve patient health. The workshop has given rise to a great deal of
support for safety measures, with nurses and clinical personnel feeling grateful to have a
secure place to share their experience with medical problems, being more confessional
rather than questioned.

3. Created a culture that welcomed open and frank communication about safety issue
We went on to set up an atmosphere where people could learn from their mistakes rather
than point their fingers when something goes wrong. They set up a forum where people
can come together and address safety issues and learn about new work in the area.

4. Initiated blameless reporting system for medical errors

Allowed people to communicate confidentially and anonymously about medical accidents
without being punished. They created a new patient safety record for the same. This
program allowed the frontline people to come forward without fear.

5. Design of Safety action team.

It provided a vehicle for the front lines to root out unnecessary complexity and to remove
barriers that prevented them from providing effective care of the patients

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3. How would you describe Julie’s leadership style? Give examples to support your answer
Answer
Morath was a strong leader, and she was a visionary leader who had the ability to contribute to
the people and had the experience to deal with the problems and to accomplish long-term goals.
Julie Morath has brought passion and leadership to the topic of patient safety.

Julie Morath showed Visionary, passionate, and transformational leadership style in her approach
of grappling the issue in the Children hospital.

Visionary:
Julie was visionary in the way he approached and labelled the medical errors as a complex error
rather than she treated it as a series of small breakdown in complex systems. Julie Morath’s
program has done some good work and definitely set a foundation for future growth She was
visionary in determining the magnitude of the problem and what harm it can do to the institution
of the Healthcare like Children. She was visionary when she took over and spoke about the value
of communicating medical mistakes for better prevention and the vital importance of patient
health.

Passionate:
In order to resolve this issue, she went on to set up a separate committee and took an active part.
She has demonstrated a caring human being as she leads the hospital on the topic of patient
safety. She was on the road and decided to change the culture of the company from the ground
up. The way she acted, arranged a focus group meeting, workshops, and went on to learn from
other publications to bring about change, described how serious she was about bringing about a
shift in the company about patient error.

Transformative leader:
The Transformative Leader is the person who works with the team to define the change required
to build a vision to drive change through motivation and to achieve change in partnership with
committed members of the community.
She personally approached all stakeholders to address this topic in depth, she came out to bring
about change by openly encouraging them to participate and bring new ideas to the table. She

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offers them a voice to be more confessional than questioned. She generated a sense of
entitlement among frontline staff and made them the driving force behind the shift in her vision.
Morath, on the other hand, confronted several other obstacles that were very serious and
important to resolve. Including blameless coverage, accountability, and legal risk policies. As a
result, it has developed strategies that could not only identify key issues but can also help to
improve the service and develop a collaborative program for hospital staff.

She was visionary in her approach and rather than seeking a short term benefit she was looking
for the long term strategy

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