Inquiry into a Health System Failure

Running Head: INQUIRY INTO A HEALTH SYSTEM FAILURE
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Inquiry into a Health System Failure
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INQUIRY INTO A HEALTH SYSTEM FAILURE
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Introduction
For most governments of developed nations, improving the performance of health care
systems is the key priority that defines the agenda of health policies. Majority of the healthcare
systems have considered clinical governance as a major component of attaining this health
agenda through improvements in patient safety and healthcare quality. Gottwald & Lansdown
(2014) define clinical governance as a systematic approach in the maintenance and improvement
of care given to patients through a culture that emphasizes patient safety and high-quality care.
According to the Australian Council on Healthcare Standards, clinical governance and a
safety organizational culture should be demonstrated through shared responsibilities,
transparency, and accountability between clinicians and managers. Besides, collaboration should
foster continuous improvements, minimization of risks and an environment of care excellence
for patients. This paper discusses the issues in Organizational Culture, Leadership and
Management that were associated with the health system failure of Djerriwarrh Health Services,
Bacchus Marsh, Victoria, Australia hence high perinatal mortality rates. Clinical governance and
a safety organizational culture have been associated with high-quality care, job satisfaction, and
improved patient outcomes.
4) Organizational culture
i) Whistleblower Definition
An individual who possesses and voluntarily reports insider knowledge of unethical and
illegal events that happen in an organization to the public or a person in an authority position is a
whistleblower. In the healthcare setting, a whistleblower may be employees, patients, contractors
or any person who is aware of unethical professional practices (Schein & Dawsonera, 2010). In
Australia, whistleblowers are protected under various programs that were created in the

INQUIRY INTO A HEALTH SYSTEM FAILURE
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constitution. For instance, in the case of Bacchus Marsh, it was necessary to have a
whistleblower so that the cycle of under-reporting was broken. This would have helped in the
early identification of gaps that existed and contributed to high perinatal mortality rates before
instituting appropriate measures.
ii) Influence of the Organizational Culture on the Quality of Care in Bacchus Marsh
Organizational culture refers to a common system of shared philosophies, beliefs,
assumptions, values, and socialization which govern people’s behavior within an organization.
Organizational culture has a strong influence on employees and it determines how they act,
dress, interact and execute their roles and responsibilities (Schein & Dawsonera, 2010).
A culture of fear and intimidation contributed to the lack of social lines of
communication and acknowledgment of the authority. Besides, it contributed to a
communication breakdown and a bad relationship between staff and the management. The end
result was poor attitudes and reduced morale from staff who instituted less effort to provide
quality care hence high perinatal mortality rates (Shelton, 2015).
An unsafety culture in Bacchus Marsh’s contributed to medical negligence, lack of
accountability and resignations. The management of Bacchus Marsh failed to act on reports that
questioned the competency of specific health care providers whose practice did not reflect the
professional and legal standards of respective professional bodies that regulate the clinical
practice. This sent wrong signals to staff and contributed to resignations that further
compromised the availability of skills (Shelton, 2015). As a result, most healthcare staff missed
opportunities to learn from mistakes and similar mistakes/issues are repeated over and over
which negatively influenced the quality of care.
iii) How The Culture Of Bacchus Marsh Healthcare Service Helped To Hide The Failure