Evaluating Children's Hospital

Question 1: Evaluate the key elements of Morath’s efforts to transform Children’s Hospital into a learning organization.

Answer: It was Morath’s leadership abilities and initiatives that helped Children’s Hospital (CH) transform from an organization to a learning organization. We elaborate on the following three building blocks of a learning organization that are evident at Children’s Hospital.

Building Block 1: “A supportive learning environment”

Learning in an organization is inhibited by factors such as tradition, outdated procedures, values, structures, and psychological barriers about getting the work done. At a learning organization, the environment encourages people to bring out the problems / errors
Each person gathered ideas and suggestions to share with the Safety action Team.

 Education and Training: The literature on science of safety and self-study packets provided by Morath were used by the employees to educate themselves on the subject. This enabled employees to learn about the science of improving safety in complex systems.

 Analysis: The focused event analyses develop disciples that then go out into the organization understanding the complexity of medical accidents.

 Experimentation: The PSSC started experimenting with new ways such as having two facilitators, one to facilitate and another to observe non-verbal behavior to make sure nothing is missed.

 Identification of root causes: The Blameless Reporting system resulted in employees speaking openly about any errors made and identified root causes of the errors.

Building Block 3: “Leadership that Reinforces
Both CH managers and families complained about “Blameless Reporting”. There was no penalty for people who were responsible for the accidents. In some cases, errors could have been caused by poor performance of a particular person rather than a system failure. The reporting method was focused on identifying the problems in the system. CH management including Morath was finding it difficult to respond to Family’s demand for the name of people accountable for accidents.

3. The focused event studies encouraged employees to share their experience about medical errors but due to lack of time, staff or resources to follow up on each issue it was difficult for managers to analyze the problems that emerged during a focused event analyses. With their current job and responsibilities, they did not have time to follow up the outcome from the session. As the solutions could not be implemented, the errors are bound to happen again. Thus, such event studies will become redundant and eventually vanish.

4. CH might face legal problems in the future caused by complete disclosure policy. It is possible that disappointed families may sue the hospital for carrying out accidents. Now as the CH was disclosing a lot more information to families through focused event studies, the effect on CH’s legal exposure could not be determined. CH may revert to tight-lip stand on disclosing information to the