Correcting Error Reporting Systems

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Correcting Error Reporting Systems

HA 255-01
April 5, 2011

A sophisticated continuous quality improvement process should involve the clinical employees as well as the senior medical staff. “Leading an organization refers to an individual’s ability to galvanize resources and motivate employees to work collectively to further organizational goals, which goes beyond simply controlling day-to-day operations.” (O'Connor, 2009) Continuous quality improvement cannot function properly without effective leadership and managers who have a dual role in managing staff as well being a part of the leadership of the organization as a whole. By definition, continuous quality improvement involves employee empowerment and interdisciplinary teams. By only utilizing the senior nurse manager in monthly CQI meetings, clinical staff, which are a very integral part of the overall process, were undermined in the improvement and organizational forward motion of the facility. While the managers were satisfied with the formal changes and the decrease in medical error reporting, the clinical staff was not satisfied as they were not included or informed nor did they have any input regarding the feasibility of medical error reporting. CQI has become a pivotal tool at use in health care organizations. Engaging and empowering all staff in a health care facility lends to growth both personally and organizationally within a health care system. Job performance and satisfaction in the work place environment are impacted positively as a result of employee’s being able to participate in the structured monthly meetings of the organization. The segregation of clinical staff and management does not lend to the prosperity of a health care facility. When implementing a CQI process to reduce medical errors, I would involve the clinical staff as well as they do have practical experience and the knowledge of what is feasible in a real life situation. 3

When including a CQI process to reduce medical errors, the entire clinical staff would be involved in conceiving and implementing of the disciplinary action assigned to reported errors. Involvement at every level of the facility would create an atmosphere of teamwork and inclusion. In the case study scenario, the senior management and leadership had set themselves apart from the clinical staff. Since the clinical staff was not consulted regarding discipline and the discipline was punitive, the senior leadership succeeded in creating a barrier and ostracizing themselves rather than creating an atmosphere of continuity. As more health care organizations are implementing a CQI process along with a non- punitive reporting system, management systems must also be adjusted to avoid such scenarios in their respective work place. A great management team relies on the employees to be effective. They cannot lead if they do not have anyone that follows. Employees must have some empowerment and some level of inclusion. When a new human resource consultant was hired to investigate the problem in the case scenario, the work ethic the clinical staff was forced to adopt as a result of the punitive reporting system was discovered and corrected. What appealed to the senior management early on regarding the systematic and formal process that medical error reporting would be conducted was not actually effective at all since staff were not always filling out incident reports to avoid the punitive reporting system. “A punitive, person-centered approach therefore, severely hampers effective improvements in safety.” (Webster, 2001) The senior management had a false sense of success which I feel could have been avoided if the clinical staff would have been consulted regarding the quality of care and safety in the nursing home. Often it is relatively simply to address these issues by empowering the very individuals who rules apply to. The clinical staff knows what works and what will not be...
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