The key issues identified in the Children's Hospital case are leadership, accountability, and communication. As COO, Morath aims to improve patient safety but lacks a detailed plan and ability to implement changes. The hospital has short-term problems with communication and priorities, and long-term problems with structure and accountability for reporting errors. Alternative solutions include implementing best practices through leadership training, communication, and continuing education. The recommended solution is for Morath to conduct a focus group using participatory action research to gather staff input and promote cultural change from the bottom-up.

1. Running head: CHILDREN'S HOSPITAL 1
Dr. Obumneke Amadi-Onuoha_Scripts_ 13
CML-Case Analysis
Children's Hospital

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Introduction
The purpose of the essay is to write a summary of Children’s Hospital case analysis
report and present an analysis of what I have identified as the three key issues or problems in the
case and why I believe these are key issues and theories to support that supports the
observations.
Statement of the Problem
With the issues surrounding the case of Matthew a patient in the intensive care unit_
medical-surgical flood, whom experienced over dose of Morphine due to drug labeling errors
(medical error), there lies the problems identified in the organization management and operations
that needs to be “focused and align teamwork and operations around the principles of patient
safety’ for effective and efficient performances’ (Edmondson, Robert, and Tucker, 2007, p.3).
The chief operating officer (COO) of the Children’s Hospital and Clinics (Children’s) is faced
with the problem of ‘How to address adverse events or medical errors” in the organization by
addressing these key issues: 1). Leadership: protocol and training, 2). Accountability: error
disclosure, and 3). Communication: parents and providers.
As the COO of the Children’s Hospital and Clinics (Children’s) Morath has fixed her
attention on patient safety as her uttermost goal. Morath created diverse patient safety initiative,
in the order to support her goals. Although, Morath brings along a transformational and
visionary leadership styles, she has no detailed plan, and problem with time e.g. on exhibit 4 of
the case literature, gives evident of the timeline of events that are rather to quick and not properly
planed (Edmondson, Robert, and Tucker, 2007, p. 18) and ability needed by providers to
effectively e.g. Morath explained she “had many other duties and responsibilities that required

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her attention and needed to hire someone to assist her” (Edmondson, Robert, and Tucker, 2007,
p. 14).
The company have short term problems on organizational culture that include:
communication, and priority management e.g. “O’Reilly was not familiar with this type of
electronic infusion pump, and none of the nurses on the floor were accustomed to using these
pumps (Edmondson, Robert, and Tucker, 2007, p. 1). Whereas, the long-term problems, lies on
the organizational structure, their incapability to be responsibly accountable to inform events
surrounding patient safety and implementation e.g. after the board approved the new complete
disclosure, Nelson met with the family the second time and fully showed transparency in
describing issues around their son’s case (Edmondson, Robert, and Tucker, 2007, pp. 8-9).
Causes of the Problem
The COO is faced with the decision to conduct a change in management, because of
identified issues surround patient safety accountability and disclosure involving providers,
patients and their families. The case study revealed that being accountable and disclosing errors
evets was a major priority to be addressed e.g. “Morath tried to convince the staff that errors
were indeed a problem for all health care organizations including children’s and that a new
approach to safety could reduce accidents” (Edmondson, Robert, and Tucker, 2007, p.5), based
on this, applying communication, social cognitive theories and ecological models(EM)
incorporating intrapersonal factors may help the COO to improve leadership and management
operations to prevent and report error events that are identified through cause and effect in this
organization. “The EM provides a basic structure for ascertaining reasons for public health
problems as well as for planning interventions, the base of the model recognizes that public

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health problems are not caused only by human error but by a combination of factors on different
levels that include intrapersonal factors and environmental factors” (Amadi -nwada,2017, p.5).
Decision Criteria and Alternative Solutions
Systems improvement in all organization operations requires, a great communication,
accountability, training, policies, and organizational culture. The key issues identified in this
case are negatively impacting the proper functional ability of this organization despite already
implemented solutions regarding other identified problems (Edmondson, Robert and Tucker,
2007, pp 158-167). According to Longenecker et al. (2014), “healthcare systems are amid
revolutionary change virtually in every area that include talent shortages, human resource issues,
and others (p.148), such that is for this case analysis. As the COO of this organization, my
alternative solution to this problem would be to apply an organizational management change
approach towards the hospital operations, including a leadership communication and
performance theories surrounding the several aspects of the hospital operation services to
conduct reform were necessary to advance integrity, accountability, professionalism, and
promote effectiveness towards service operations. However, because the COO, needs to conduct
a change in management intervention for the hospital, this will be a major undertaking,
“organizational change takes place over time; to increase the probability of success, it is
important to plan for change, setting a clear timeframe and addressing the critical factors that
affect change success” (Al-Haddad & Kotnour, 2015, p.243), to support successful
implementation of the required change, based on this, my alternative solution as a short step
forward would be to conduct a “ Focus group” participatory action research (PAR)
collaborations.
“PAR examines issues systematically from the perspectives and lived experiences
of the people involved and affected by the resulting actions of change. Planned

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action research can be a very successful method for change as it gathers input
from the people undergoing change, making them feel more involved. And when
employees feel that change belongs to them, this holds them more responsible to
ensure change succeeds. The involvement of people in processes, products and in
problem solving eventually leads to cultural change” (Al-Haddad & Kotnour,
2015, p. 245-247.).
Alternative Solutions:
The organization may need to implementing change for ‘best practices’ by their staffs,
this can be attained through organizing leadership training to communicate “what", "how" and
"why" surrounding treatment protocols’ and continuing educations to refresh staffs of their
professional skills. Proper communication remains a challenge in large organizations, especially
in periods of rapid change” (Longenecker et al., 2014, p.152), therefore, “conducting a two –
way communication between those responsible for leading the change and those responsible for
making the change to happen should be executed.
Recommended Solution, Implementation, and Justification
According to Gretzky,2010” concluded in their study that, “real change and
transformation takes place when leaders manage the human dimensions of the change process
with great care, and effective change requires teamwork, understandable meaningful and realistic
plan, effective two-way communication, and strong vision with sense of urgency” (Longenecker
et al., 2014, p. 155). Conducting a focus group collaboration approach by COO for the
organizations change in management would be my recommended plan to support the COO in her
other endeavors towards patient safety in the hospital. “Focus group approach “with target
populations of interventions have been an effective qualitative method to develop new
intervention” (Moore et al., 2017, p.2). It is a small-group discussion guided by a trained leader.

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It is used to learn about opinions on a designated topic, and to guide future action (community
tool box, 2018. Para.1). Also, “A focus group is basically a way to reach out to your potential
users for feedback and comment. Organizations use it in planning, evaluation, either to improve
some specific product or service” (Blank, 2018).
The COO of the organization would need to conduct a focus group meeting as the first
step of this intervention, the rationale behind my recommended plan of action is based on,
“organizational culture as a key factor in both patient and staff experience of the healthcare
services. Patient satisfaction, staff engagement and performance are related to this experience”
(Mash, De Sa, & Christodoulou, 2016, p.1), and would greatly promote better organizational
management change. Also using theoretical models e.g. social cognitive theory may be a solid
foundation that would help address those key issues surrounding the case problem that needs to
be addressed. SCT “theorizes that learning occurs in a social context with a dynamic and
reciprocal interaction of the person, environment, and behavior, and emphasis on social influence
and its emphasis on external and internal social reinforcement” (BUSPH, 2016, para.1).
Statement of Bias
My bias for the case is for the blameless culture, my rational is based on my experience
from working as a patient care technician in a designated nursing home people with disability
people, that got me to realize that patient safety is not only the issue of provider and their care
givers’. I began to wonder what and how other agencies that foresee these similar facilities do to
make sure that everyone is made to be responsibly accountable to be cognitive and give reports
of adverse events(medical errors) that may or are at risk to patient safety on the course of care.
This is most important, in some group disability homes were the patients are dependent and
neurologically impaired that they are not able to inform any event, are their ethical assurance of

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transparency by care givers to report wrong doings? However, in the group home that I worked,
they have in place an incident reporting software that is programed to accommodate nurses start
of care for patients on relieve from another end of shift that requires nurses to document patients
care every 30mins. This technology approach greatly supported the case manager to monitor
patient safety and care, and to address at once any report of adverse event with the facility
supervisor. Because of the technology approach, nurses are very careful towards patients’
because they read care logs that informs them duly of the next procedures on patient care and
seeks for clarity on activities that are questionable. It is important to acknowledge that adverse
events occur by both providers and patients and good approach is needed to handle them in all
healthcare facilities.

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Reference
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