GHS5850 Nursing Leadership And Management


Part 1

A policy is either a declaration of intent or a course of action.

The Australian Government oversees Australia’s national healthcare policy. Key elements, such as the operation and maintenance of hospitals, are managed by state governments (DHHS 2016, 2016).

The Australian Government is responsible for the community and public health.

This is managed by the Department of Health and Human Services in Victoria.

They aim to make Victorians happy, healthy, and safe.

They “deliver policies and programs that enhance the health, wellbeing, and quality of life for all Victorians” (DHHS 2016, 2016).

The Consultative Council on Obstetric and Paediatric Mortality and Morbidity brought to the attention of Department of Health and Human Services (the Department) a group of perinatal deaths at Djerriwarrh Health Services in 2013 and 2014.

The Australian Commission on Safety and Quality in Health Care conducted an independent review into the actions of the department in relation to these deaths and examined the department’s ability to respond to any new critical issues in public health.

The ACSQHC conducted a post-evaluation and identified significant issues. In Djerriwarrh’s case, it found significant deficiencies in clinical governance that were not being detected. Worse, these deficiencies were not detected by the department’s processes.

The Minister of Health requested that Dr Stephen Duckett review these findings.

Examine the current governance systems of the department for quality assurance and safety in hospitals.

To provide suggestions on how to improve systems where they were found insufficient.

The incidents at Djerriwarrh’s health service are not considered to be a sign of a larger problem.

This comprehensive review will impact all hospitals and health care providers. It is informative, insightful and comprehensive.

There are many recommendations and there is serious need for change.

The department’s oversight over hospitals was not sufficient, it was discovered.

The department also failed to provide the necessary information to ensure that all hospitals were providing high-quality, safe care (DHHS 2016).

These are the major health care deficiencies that were identified and corrected by this review.

1.Failure to report errors or adverse events.

This was evident in the fact that the department did not have a functioning incident management system for hospital staff to report patients’ harm (DHHS, 2016, p13).

Some complains about the system include that the Victorian Health Incident Management System is complex, difficult to use and poorly designed.

The current “incident classification component” of the system currently has over 1400 types of incidents. Users must choose from these different types to make the process of selecting the appropriate classification easy and efficient.

Users may also choose to classify incidents incorrectly or use generic classifications such as “other” in order to save time (DHHS 2016, p107).

All reports regarding the Djerriwarrh tragedies were not submitted on time or accurately.

Nevertheless, it was also discovered that the department did not monitor and analyse the incident database, and therefore would not have detected them (DHHS 2016, p14).

“A dysfunctional incident report system means that potentially valuable information about recurrent safety violations is often not reported, misclassified, or lost before it reaches department” (DHHS 2016, p14).

It was also found that the “departments Performance Monitoring Framework” is not designed to detect catastrophic failures (DHHS 2016, p13).

This major defect is related to NSQHS standard number 1, ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS 2012).

To achieve this particular standard, there are certain criteria.

The management of incidents and complaints, specifically the recognition, reporting and analysis of adverse events, is one of these criteria.

This is evident from the deficiencies identified.

2. The department’s expert committees lack the resources to quickly spot problems and follow up on them (DHHS, 2016).

DHHS (2016) also identified cultural barriers that prevent reporting.

It was discovered that staff complaints were ignored, discouraged, or dismissed.

It was also discovered that neither regulatory oversight nor internal management detected the problems or did not address them (DHHS 2016,).

This NSQHS deficiency is related to standard number 1 ‘Governance for Safety and Quality in Health Service Organisations’.

This particular standard’s criterion has been broken in regard to incident and complaint management.

It is evident that quality and patient safety incidents were not reported properly and analysed, and therefore not used to improve safety systems (NSQHS 2012; Miller 2013).

3. The department relied too heavily on accreditation, even though the evidence does not support it (DHHS 2016, 2016).

Djerriwarrh Health Services, for example, was consistently rated as a high-performing department, earning top scores at the close of 2012-13. However, it was discovered that the department did not have any concerns until 2015, when seven deaths could have been avoided.

Poor clinical governance was the main reason for this failure. The department also over-relied upon accreditation.

This clinical governance failure at Djerriwarrh was a troubling sign and could easily happen at any hospital or other health service (DHHS 2016, 2016).

This deficiency is related to NSQHS standard number 1, ‘Governance for Safety and Quality in Health Service Organisations’.

To achieve this particular standard, there are certain criteria.

One of these criteria is the need to implement a governance system that conducts regular clinical audits. (NSQHS 2012).

It has not been as effective as it should have been. If regular, effective audits had been conducted, then clinical governance problems would have been detected.

4. The department lacks routine data to monitor hospitals’ complication rate (DHHS, 2016).

Hospitals and clinics cannot access vital information because essential data isn’t collected or made available in a practical format.

It was also found that a lot of routine data is being collected but not enough time is given to the department to be able monitor patient outcomes or investigate red flags.

The department has not been able to access and use the detailed information about hospital-acquired complications, which means that cases of underperformance are being missed.

This deficiency is related to NSQHS standard number 1, ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS 2012).

This standard requires that quality improvement and governance systems be in place to ensure patient safety and quality.

This is evident as the department failed to recognize red flags and cases that were not performing well, which in turn put patients at risk.

5. In the public sector, the department relies too heavily upon hospital boards to ensure that care is safe and continually improving (DHHS 2016).

The department does not do enough to ensure that all boards have the necessary tools to perform this function (DHHS 2016, 2016).

This is an indication that the department’s overall governance of hospitals is not adequate.

The department did not give patient safety enough importance.

Although the review highlights the differences between large and small hospitals in hospital boards, as well as the differing opinions of CEOs, financial teams and other leaders, this is not the focus of the essay.

Bottom line: The department wasn’t doing enough to understand, be involved in, and pick up on these disparities at the cost of patient safety, continuous improvement in healthcare, and patient safety.

This deficiency is related to NSQHS standard number 1, ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS 2012).

This standard requires that you meet two criteria.

The first is governance and quality improvement systems.

This clearly shows that integrated systems of governance have been compromised to manage quality and patient safety.

The criterion for incident and complaint management was also breached. Patient safety incidents are not reported, analysed, and acknowledged at all levels within the healthcare system.

6. Similar to six, the department in the private sector rely more heavily on local governance (i.e.

hospital boards) to ensure safe and continuous improvement (DHHS, 2016).

In the private sector, it was also discovered that the department does not conduct routine monitoring of patient outcomes and serious incidents (DHHS 2016,).

Private hospitals do not have to report the same requirements as public hospitals. In fact, almost no data about safety performance is collected, monitored, or fed back to private hospital.

This deficiency is related to NSQHS standard number 1, ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS 2012).

Similar to the sixth point, two criteria to meet this standard were broken.

The first is governance and quality improvement systems, while the second is incident and complaint management (NSQHS 2012).

Both sectors could use more departmental support to make sure hospitals don’t provide care that is beyond their capabilities (DHHS, 2016).

7. The department has not provided enough support to hospitals and has shown insufficient leadership in quality improvement and safety (DHHS, 2016).

The department did not provide the necessary support and sustained investment to ensure that hospitals have the resources they need.

Hospitals are often left to develop their own safety and quality improvement strategies, which can lead to duplication, variation in quality, and inefficiency (DHHS 2016).

High quality information was not shared or developed, so hospitals cannot learn from one another.

The department does not offer a strong system, and it is not providing the right information, incentives, and resources for hospital executives and clinicians to provide the best care.

It was also found that the department is not communicating with external experts regarding information sharing and, more importantly, the identification and removal of unqualified practitioners (DHHS 2016).

This standard requires that two criteria have been met.

The first is clinical practice.

This means that the care provided by clinicians must adhere to current best practices.

If hospitals have high-quality information but it is not shared among hospitals, then it is unlikely that all clinicians follow current best practices.

The second criterion has been broken is ‘governance & quality improvement systems’ (NSQHS 2012).

This criterion requires that there must be an integrated system of governance in order to manage quality and patient safety.

Inefficient departments have been responsible for providing the necessary resources to clinicians and hospitals.

It is possible that all the current NSQHS standards are being violated by the department.

These include preventing and controlling infections in healthcare, medication safety, clinical blood and products, preventing pressure injuries, managing blood and bleeding, recognizing and responding to acute clinical deterioration, and preventing falls.

They all boil down to a serious lack of clinical governance.

According to the review, clinical governance is defined as “systems and processes required for health services to be accountable to the community to ensure that care is safe and effective, patient-centred, and continually improving.” (DHHS, 2016 p3)

The review revealed that both Djerriwarrh and all hospitals’ processes were incapable of detecting serious deficiencies in clinical governance.

These issues and deficiencies in clinical governance are not unique to Victoria.

An extensive literature review revealed many articles that highlighted similar issues in health care systems regarding clinical governance, quality and safety of patient care (Atsalos, O’Brien, & Jackson, 2007, Robinson, Travaglia, & Bradithwaite, 2008, Tuan, 2015).

It has been suggested in Victoria that there is no need for major reforms to the health system (Duckett 2008).

However, it is recognized that major reforms are needed at both the macro and micro levels of Commonwealth and state governments, as well as among health care providers.

Part 2 – Change management

The review by Stephen Duckett clearly shows that significant change within the department, with a focus on health care concerns immediately, is essential.

Health care requires change.

External and internal factors influence change and it is necessary to adapt the organization to new realities (Kumar Kumar, Deshmukh and Adhish 2015).

Technological advances, the need for quality assurance, epidemiology and reemergence of diseases, eras of evidence-based policy, health care and medical care, privatisation, commercial interests, and health as a human rights (Kumar and al., 2015).

In summary, an organisation must be able to adapt to changing circumstances in order to survive.

It is difficult to implement and sustain change, particularly in a long-term manner.

Organizational change requires personal change within an organizational setting (Carlopio and Andrewartha 2008, p.496).

Many people resist personal change.

It takes time, effort, persistence, and patience.

There can be a loss when old methods of doing things are no longer relevant. However, with change, we adapt, learn, and grow.

Research shows that healthcare sector often faces challenges in implementing change (Allen 2016, 2016).

These difficulties include difficult to motivate employees to change, communicate the need for change effectively, and maintaining any improvements made over time (Martin Weaver & Currie 2012).

It is well-known that change can be difficult due to the complexity of the healthcare system (Allen 2016,).

Macro change can be referred to as micro change.

Macro change refers to the overall transformation of the Victorian health system and health care system.

Microchange can be applied to specific work units or departments.

Macro change is required at the system-level, beginning with the department, in the Victorian health system.

This will create ripple effects that can be reflected in micro changes to service delivery and bedside care.

However, all of these changes require change management (Currie & Loftus–Hills 2002; Kumar et. al. 2015).

Change process

It is important that nurses and other healthcare professionals are familiar with theories and models of change in order to increase the chances of organisational change being successful (Mitchell and Price, 2013; 2008).

This applies especially to health care leaders and managers, as they will be most likely to initiate and implement the change.

There are many theories that can be used for organisational change (Allen and Freshwater, 2016).

Two models are most useful for implementing health care reform.

Many modern theories and models are adaptations of Kurt Lewin’s classic three-stage change model.

John Kotter (1996) created an eight-step change model that was based on Lewin’s three-step process. This model has been proven to be successful (Kumar and al., 2015).

The two models are summarized below. However, Kotter’s (1996) model will be the guide for the reader to help them understand how to implement a plan to improve safety-related reporting culture in a ward.



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