Childrens Hospital and Clinics

Memo
To: From: Date: Re:

Dr. Chailin Cummings Chun Lung Ma 4/28/2012 Individual Written HBR Case Analysis

On 3:00 p.m. January 5, 2001, Matthew, the ten-year old patient was experiencing respiratory arrest due to overdose of morphine. Recognizing that this dose of morphine could be lethal, Dr. Ellington administered a drug that reversed the effect of the morphine. Fortunately, within seconds of receiving this drug, Matthews breathing returned to normal, and he made a full recovery. The next day at 4p.m. Dr. Chris Robison, Associate Director of Medical Affairs, assembled people who directly involved in Matthews overdose event, to identify the causes of this medical accident, and to determine how the hospital could avoid such accidents in the future. Julie Morath became the Chief Operating Officer of Childrens Hospital in May, 1999. She took the roles as a general manager that primary focused an entire organization on safety as a top priority. In order to optimize medical condition and minimize medical errors, Morath has designed and led the transformation of the PSI that reshaped an organizations processes and culture. By analyzing key elements and the strengths and weaknesses of PSI, barriers of organizations changes, leadership of the organization change process, and central challenges Morath faced, we can learn more about different skills required at each stage in organization change process. The team elements of PSI can be observed in taking charge process and implementing process. In the beginning for taking charge of PSI, Morath first presented medical accident data to hospital staff about national research on medical errors. For example, she presented data from the Harvard Medical Practice Study on the frequency and causes of medical errors. Second, she conducted 18 focus groups with doctors, nurses, pharmacists, and may other
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throughout the hospital to learn more about children stagy issues at Childrens. Third, she formulated a detailed strategic plan for the Patient Safety Initiative. This strategic planning aimed to define the organizations goals and objectives for the next five years. In order to implement the PSI, Morath had created the plan with three main components. First, Morath wanted to transform the organizational culture to provide an environment conducive to discussing medical accidents in a constructive manner. She wanted to establish a culture that everyone focused on learning from past mistakes. Patient safety dialogues, blameless reporting, language, and disclosure policy are the primary process that Morath purposely set out to create a culture with welcomed open and frank communication regarding safety issues. Second, she aimed to develop the infrastructure required to implement safety improvements. Also, she established a new process for examining serious accidents such as patient safety steering committee and focused event studies. Third, she launched a project to overhaul the medication administration system with the goal of achieving zero defects. Safety action teams and good catch logs are the ways could be used to prevent medication errors. Finally, In order to moving forward, Mornath recognized the need to tackle some controversial questions about the safety program such as disclosure and legal risk, accountability, measuring results, and leadership. The strengths of PSI can be informed and explained by organization change process. Organization change refers to adoption of a new idea or behavior by an organization. In this case, PSIs change confers to evolutionary change. Their change is gradual, incremental, and narrowly focused on medical safety. One of the strengths of PSI was the creation of blameless environment. An open discussion enabled peers to exchange the experience with each other. So that they could learn from mistakes not only ourselves, but also everyone else. Besides, through professional open discussion in different medical field, people enhanced their knowledge on medical aspect and acquired more expertise on what they are doing. She was able to manage change collaboratively by establishing channels of communication to encourage people to speak up. She had successful reshaped the PSI culture by implementing patient Safety Dialogues. Morath gathered literature on the science of safety into a self-study packet that employees could complete for continuing education credits. Moreover, the blameless reporting asked employees to describe the incident in their own words, and to

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comment on the events that occurred as well as the potential causes of the situation. Last but not least, she was redesigning the hospitals systems and processes by setting up safety actions teams and good catch logs. In this activity, she intentionally increased forces for change in organization change process. She was using a team force to continuously stimulate people to discuss the problems and improvements they hoped to implement. She also used Good Catch Log as a way of capturing information that could be used to prevent medication errors. The weaknesses of PSI are the barriers for its change process. Even though blameless reporting system allow people to communicate confidentially and anonymously about medical accidents without being punished, there are some potential problems occurred to resist organization change process. Several employees expressed concern about the individuals involved in such events. Recognizing that some managers wondered how they could hold people accountable if they were not able to discipline people for making mistake. One the other hand, mangers were fear of loss of power and status. Unit managers and administrators also expressed concern that the blameless reporting system undermined their ability to hold individuals accountable for poor performance. Furthermore, some employees felt failure to perceive benefits of change because they worried about whether the benefits of enhanced disclosure to patients and families exceeded the risk of additional lawsuits. Next, they also have realized the difficulty to measure the effectiveness of the safety initiative. Its members wanted to know whether the benefits outweighed the cost. Indeed the excessive focus on costs associated with change discourages employees incentive to accomplish the goals. So it becomes another barrier for hospital changing process. Some members of the PSSC expressed concern that the organization had not dedicated enough resources to implement improvements to the hospitals processes. Given that apparent weaknesses, they might lack of the tactic to generate capacity for mobilizing resources. Morath faced a several barriers as she tried to encourage people to discuss medical errors more openly. It was difficult to broach the topic of safety because most people get defensive. People were fear of the consequence of mistakes they made or simply recognized talking about safety implies that there is something wrong. To overcome this barrier, Morath present medical accident data to highlight the need for a change in the way that

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medical professionals thought about accidents. She repeatedly described her philosophy and vision on patient safety. She tried to convince the staff that errors were indeed a problem for all health care organizations including Childrens and that a new approach to safety could reduce accidents. She also attempted to persuade the staff that talking more openly about errors would improve patient care without damaging peoples careers exposing the hospital to new legal risks. To foster candid dialogue about medical accidents, Morath tried to change the way that people discussed safety issues. Since people have frustrated on what words to say and what words not say. Morath began to emphasize the avoidance of several words that were indicative of culture where people dissatisfy at others, rather than trying to learn from mistakes and failures. For example, they tried to talk about medical accidents rather than errors because, to nurses and others, it feels very punitive. So, she overcame this barrier by creating a complete list of Words to Work By at Childrens to remind people what words to say and what words not say. Another barrier Morath encountered was conducting focus group. Morath gathered data on the current state of patient safety, and to dismantle the barriers that prevented people from discussing medical accidents. Morath wanted to involve many people from different areas of the creatively about initiative and thinking creatively about ways to enhance patient safety. Malone laso conducted 18 focus groups with doctors, nurses, pharmacists, and many other throughout the hospital. People, who had been involved in accidents, even at a time and place distant from here, carried that experience with them in a vivid way. The most controversial aspect of this effort involved getting approval to hold a focus group with a set of parents. Hospital employees feared that starting a discussion about medical accidents would alarm families, and possibly might imply that the hospital was not sage. Eventually, she did obtain the Boards approval to conduct a focus group with parents. During the discussions, families indicated that they were well aware of many medical errors and misses. Rather than increasing anxiety, the focus group offered an opportunity for parents to speak openly about their own experiences, and to offer suggestions for improving patient care. Morath significantly provided an effectual leadership of the organization change process at Childrens hospital and Clinics. According the ways she exerted in organization change process, she was adapting Kurt Lewins Change Process Model. At the early stage of

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the change process, she focused on unfreezing the organization from its present state. Through presentation of medical accident data, she was able to convince people to believe that a new approach to safety could reduce accidents. Thus, she was introducing her vision by proving medical fact. Also, she fostered people interaction and communication by conducting focus groups. The open discussion without punishment enabled people to start building the culture that pushing employees to learn from mistakes. In the second stage of change process, she made the desired type of change. She coined the acronym SAFE to summarize the four components of hospitals strategic plan SAFE stood for Safety, Access, Financial, and experience. In the other word, she tried to optimize desirable type of change in these aspects. For example, she created a series of session for Childrens employees, and clinical staff to come together to learn about the current state of research on medical safety, as well as to discuss other safety-related topics. This effort can be highlighted as continuous learning process for their employees. Second, she orchestrated a new system for reporting medical accidents which she called blameless reporting to motivate people to further accept the idea of open discussion. This system enhanced the experience flow between different departments, so hospital can increase overall efficiency and avoid the same accident in the future. This system actually changed organization culture through altering employees mind-set and behavior. By organizing Patient Safety Steering Committee and conducting focused even studies, she created a clear infrastructure that facilitated learning. In the last stage, she refreezed the organization in a new, desired state. Be recognized that she could not devote all of her time to the safety effort. She eventually concluded that hospital needed to hire someone else to lead the effort on a full-time basis, and become the new Chair of the PSSC. In conclusion, organization change process has involved many skills and strategies. Through examining the activities and challenges Morath faces in each phase of change process, we can learn about different tactics required at each organization change stage.

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