IMPACT REPORT TO SENIOR LEADERSHIP
Impact Report to Senior Leadership
Impact Report to Senior Leadership
This report examines increased patient safety concerns attributed to medical errors, as a major challenge in a nursing and rehabilitation center located in Florida. Specifically, to provide insight on the role that a new leadership position will play in dealing with the challenge, the report examines the challenge and its implications, its effect/interconnectedness with organization’s practices and conducts a SWOT analysis for the organization. This helps determine the roles and leadership attributes of the new leadership position.
The Nursing Challenge
One of the major nursing challenges that the nursing and rehabilitation center located in Florida has been experiencing relate to patient safety concerns, attributed to an increase in preventable medical errors. As Charney (2012) notes, preventable medical errors highly contribute to sabotaging patient safety to the extent of causing increased hospital mortality. At the nursing and rehabilitation center, medical errors sabotaging patient safety are triggered through numerous ways. Among them include the mistakes related to prescription, administering and dispersing of medication. Nonetheless, medical errors are not just limited to medicines, but extend to errors related to diagnosis, lab reports, equipment, surgery and lab reports among other areas in the hospital. Like in most healthcare organization, medical errors in the nursing and rehabilitation center is attributed to different causes, including miscommunication between those providing care, such as in the case of miscommunication between physicians and nurses. This also goes for poor care plans and leadership among other factors.
Medical errors negatively affect the nursing practice, which seeks to improve care outcomes. in sabotaging patient safety, medical errors may result in increased complications, prolonged hospital stays, deaths, increased costs and lack of patient satisfaction. These outcomes make it difficult for nurses to work effectively to attain the expected outcome. This is because they add unnecessary tasks and complexities to nursing practice, amidst other challenges that nurses face, such as nursing shortage, thus making it difficult for nurses to deliver competent care. The resulting lack of safety, mainly attributed to medical error in the rehabilitation center affects nurses and their performance (Mabry, 2010). As Encinosa and Hellinger (2008) note, medical errors trigger increased levels of sleep loss, anxiety and stress among nurses, physicians and other medical professionals. These emotional effects have the potential of increasing anxiety over errors that may happen in future, reducing job satisfaction, harming nurses’ reputation, leading to litigations and causing difficulties with sleep, thus affecting the performance of nursing. In this case, the impacts that medical errors have on patient safety are massive, thus the need for the nursing and rehabilitation center to find ways to address the problem.
The mission of the nursing and rehabilitation center is providing exceptional experience to patients when delivering care with the aim of promoting recovery and health in compassionate environment. The vision statement is shaping rehabilitative care and its future to facilitate improvement of quality of life of the community that the center serves. In achieving the vision, the center seeks to provide physical rehabilitative services that are superior and sensitive to patients’ financial needs, foster an environment allowing employees to employ their expertise and improve the services delivered continually. Underlying the vision and mission are the center’s core values, which include excellence with the aim of delivering care, as well as, treating others with respect, honesty and in a manner that is humane. This also goes of practicing team playing, being resourceful to facilitate the overcoming of obstacles and being result-oriented to help achieve set objectives.
The center has a hierarchical leadership/organization structure. In specific order, starting with the top to bottom, the structure entail the CEO, the general manager, the medical director, the nursing director and lastly contracted services director. Under each title, from the general manager to contracted services director, are their assistants, unit/department manager, team leaders and other employees. The philosophy of the center is optimizing rehabilitation treatment using interdisciplinary promotion process of a professional and intellectual environment to facilitate the enhancement and maintenance of caregivers’ skills. This also goes for preventing disabling conditions, as well as, hardships improves on society and individual through collaborating with community and healthcare partners. Lastly, the center’s philosophy is also to promote health and wellness awareness in its community to improve working and living conditions of the society and the society.
As Peters (2014) notes, systems thinking examine the interconnectedness of things in the context of how they function as a whole entity. In this case, the analysis and interpretation of problems in healthcare in general and nursing in specific must be viewed in terms of how they are connected to and/or affect the organization’s system in terms of its parts and as a whole. The issue of sabotaging patient safety, which is attributed to medical errors, does not just affect the nurses, but also the organization’s practice and statements. With an increase in medical errors and the resulting lack of patient safety, it would be difficult for the center to attain its vision and mission, in referencing to improving the quality of life, remaining sensitive to patients’ financial needs and providing exceptional experience. This is because the presence of medical errors and its implications, including lack of patient satisfaction, increased costs and increased complications conflict with the aspirations of the center. Notably, leadership and operations would also be challenged, as lack of patient safety due to medical errors, would bring in complexities requiring a change in leadership and operations, if the problem was to be addressed. This suggests a leadership and operations gap already exists. More so, the presence of increased medical errors and sabotaged patient safety conflicts with the philosophy statement, including optimizing rehabilitation treatment using interdisciplinary promotion, preventing disabling conditions and hardships, and promoting health/wellness awareness. It would be common knowledge that an organization with such philosophical basis would be at the forefront of preventing escalation of medical errors and its implications.
According to Marquis and Huston (2012), medical errors and other patient safety issues are triggered by factors inherent from the organization, such as poor nurse-physician collaboration, and lack of protocol to facilitate through crosschecking prior to administering any medication to patients. In this case, Charney (2012) suggest that it would be obvious that the solutions can also be found within the organization, by maximizing of elements that could facilitate medical error prevention. In this case, a SWOT analysis is critical for identifying organizational weakness and threats in patient safety, as well as, opportunities/strengths to help identify strategies to help deal with the problem.
State –of-the-art equipment, which could help avoid medical errors, by eliminating malfunctioning and care sabotage
A culture of continually focusing in improvement, which could be employed to focus of on dealing with weaknesses and maximizing improvement opportunities to reduce medical errors
Considerable investments in healthcare informatics/technology, which could help chart care to eradicate errors
Highly trained healthcare professions who can deliver top-notch services, thus having the capacity to detect possible errors in advance and prevent them.
Poor communication across leadership hierarchy, and between nurses and physicians, thus chances of providing conflicting care;
Poor use of technology, such as absence of system integration and poor technology adoption. This complicates decision-making across departments and different areas of care, increasing chances of medical error;
Lacking financial resources to facilitate necessary improvements to prevent medical errors, such as nursing informatics training and hiring consultants
Collaboration with other rehabilitation centers, which have succeeded in reducing medical errors;
The use of expertise within the center to create lasting solutions
The increase pressure in reducing healthcare costs, which contradicts with high demand for expensive state-of-art facilities and technologies; this creates challenges in balancing these two in a manner ensuring that services offered are free from medical errors.
Drawing from the SWOT analysis the new nursing leadership position with focus of improving areas of leadership oriented towards reducing medical errors. These include helping cultivate a culture of continual improvement, focusing on reducing medical errors as well as, educating nurses to make them understand how they can use their expertise to reduce the errors. As Marquis and Huston (2012) note, simple measures, such as being thorough in cross checking medications, communicating clearly when exchanging shifts and other care elements helps eliminate chances of errors. In the leadership position, focus will also be on facilitating effective communication along the hierarchy, as well as, between physicians-nurses-patients. As Sherman and Pross (2010) note, effective communication capable of nurturing collaboration is needed to eliminate medical errors. This is because parties crucial in delivering standard care can communicate the care process, changes that occur and consult each other, thus eliminating chances of delivering care characterized by errors.
Such a leadership position will affect organization changes in different ways. One of them is requiring a shift from the top-down approach to communication or decision-making in the leadership hierarchy to a bottom-up or collaborative communication/decision-making. This will enable the top management understand issues that nurses and other staff members go through in preventing medical error, as well as, allow them to create their own solutions, thus ensuring effectiveness in reducing medical errors. In addition, the healthcare providers within the organization, including nurses will be required to understand how their collaboration and expertise may prevent medical errors. This implies that training will be needed, thus the need to restructure organization activities, including allowing rotations to ensure all people receive the training needed (Marquis & Huston, 2012).
Leadership knowledge, skills and abilities required include the art to lead people and this implies, having human resource leadership skills, shared decision making, influencing behavior and relationship management skills, as well as, a sense of diversity. Leaders lead best through exemplification meaning that the nurse in the position must have the capacity to lead herself/himself. In this case, professional and personal accountability, discipline and passion in reducing medical errors are expected (Curtis, Vries & Sheerin, 2011).
In brief, the issue of medical error will be approaches with a systems perspective, since organization-wide factors contribute to medical errors. In this case, building collaboration among relevant parties and changing hierarchical decision-making will be prioritized. The leadership position must have the art to leader people and lead by example to help create the needed culture and execute other roles. These efforts will lead to a reduction in medical error and associated complications to improve on patient safety.
Charney, W. (2012). Epidemic of medical errors and hospital-acquired infections: Systemic and social causes. London, LND: CRC Press.
Curtis, E. A., Vries, J., & Sheerin, F. K. (2011). Developing leadership in nursing: Exploring core factors. British Journal of Nursing, 20(5), 306-309.
Encinosa, W. E., & Hellinger, F. J. (2008). The impact of medical errors on ninety-day costs and outcomes: An examination of surgical patients. Health Serv Res, 43(6), 2067–2085. doi: 10.1111/j.1475-6773.2008.00882.x
Mabry, R. L. (2010). Medical error: Medical suspense with heart. New York, NY: Thorndike Press.
Marquis, B., & Huston C.J. (2012). Leadership roles and management functions in nursing (7th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Peters, D. H. (2014). The application of systems thinking in health: Why use systems thinking? Health Research Policy and Systems, 12, 51. Doi: 10.1186/1478-4505-12-51
Sherman, R., & Pross, E. (2010). Growing future nurse leaders to build and sustain healthy work environments at the unit level. The Online Journal of Issues in Nursing 15(1), Manuscript 1