Business Capstone Project

Running head: BUSINESS CAPSTONE PROJECT 1
Business Capstone Project
Name:
Institutional Affiliation:

BUSINESS CAPSTONE PROJECT 2
Business Capstone Project
Description of Queens Healthcare System (QHS)
Queens Healthcare System is situated in the northeastern part of the United States. As a
multi-facility healthcare system, it is characterized by one children’s hospital, five acute care
hospitals, one skilled nursing facility, one inpatient rehabilitation hospital, one large multi-
specialty physician, and one home health agency. The facility faces fierce competition from
freestanding health organizations and similar healthcare facilities. QHS provides health care
services to a diverse population including the young, the adult, and the elderly. However, the
facility faces a wide range of safety issues that are attributable to poor communication between
staffs as well as between staffs and patients; delay in the provision of emergency services;
medication errors, lack of collaboration, and staff shortage. For all these reasons, it is imperative
for the facility quality analyst to reward and lead a just culture in addition to establishing
organizational behavior expectations. These strategies will help address the safety issues in the
organization.
Needs Assessment
According to the case study, it is evident that a lack of behavior expectations and just
culture in QHC is undermining patient safety. Leaders must have a thorough comprehension of
the behaviors and principles of a just culture. Conversely, they must be dedicated to modeling
and teaching these behaviors and principles to their staffs (The Institute for Healthcare
Improvement, 2017). The focus, in a just culture is on tackling system issues that result in harm
and errors. The Institute for Healthcare Improvement notes that in a just culture, the staff and
clinicians are held responsible for disregarding procedures and protocols. However, they are
encouraged to report adverse events, near-misses, lapses, and errors whenever they occur

BUSINESS CAPSTONE PROJECT 3
(Bonny, 2014). Therefore, a just culture ensures that both non-clinical and clinical staffs are
confident and empowered to address issues that threaten the safety of both workers and patients.
Also, establishing behavior expectations is the role of the quality analyst to enhance the safety of
patients in QHS.
Senior leaders are obliged to promote self-mindfulness behaviors among staffs. These
behaviors include active communication, excellent collaboration, transparency, prompt feedback,
and civility among hospital staffs regardless of their unit or rank (The Institute for Healthcare
Improvement, 2017). However, a lack of behavior expectations and just culture resulted in safety
issues being experienced at QHS. For instance, an unsafe working environment increased the
rate of lower back injuries. Inadequate staffing resulted in Mrs. Wood being sexually assaulted
resulting in her death several weeks later. Newborns administered in the hospital were given a
wrong dose, and health professionals failed to share important information about Mr. Jones,
which exacerbated his condition further. Delays in providing c- section resulted in the child
being born with fatal injuries including cerebral palsy. These safety issues might jeopardize the
reputation and financial health of the company if the quality analyst manager does not implement
a just culture and behavior expectations amongst staff.
Ethical and Legal Considerations
As noted earlier, it is apparent that lack of a just culture and behavior expectations is the
reason behind the safety issues ailing Queens Healthcare System. According to Kadivar et al.
(2017), patient safety is a public health problem globally. They not only result in preventable
harm, but also suffering, pain, and the death of the client as evidenced in QHS (Whitcher et al.,
2014; Rathert & Phillips, 2010). It is the responsibility of the quality analyst to ensure that
Queens Healthcare System regularly engages in audits, quality improvement, and quality