Safety-Net Hospitals and Healthcare Reform

This assignment delves into the complex world of safety-net hospital systems and their transformation within the context of ongoing healthcare reforms. It examines the unique challenges these hospitals face and explores potential solutions and strategies for improvement. The analysis draws upon a range of academic literature and research on topics such as patient care, resource allocation, and policy implications.

Report
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Table of Contents
Case study........................................................................................................................................3
Analysis..................................................................................................................................3
Improving safety and quality in patient care by clinical governance framework..................5
Consumer participation..........................................................................................................5
Clinical effectiveness..............................................................................................................5
Effective workforce................................................................................................................6
Risk management...................................................................................................................6
Conclusion.......................................................................................................................................6
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Care and safety are important for the patient while providing treatment in order to recover
their health. Without proper safety and care, it becomes difficult to help the patient in improving
their health issues. Present research is based on the case of Mildred Hill death. The present report
will cover possible causes of failure to rescue Mrs. Mildred Hill. Along with this, the way
component of clinical governance can be applied for improving quality of care and to make
patient safety will be discussed.
Case study
The story of Mildred Hill was published on the website of Elderly registrar office. Mrs.
Hill was 70 years old women who was collapsed at her home and she had a mild stroke. Due to a
stroke, she was unable to move her right hand and talk with anyone. Along with this, no family
member is available to look after her and so, she was admitted to elderly registrar’s hospital for
proper care. After few days, her daughter calls in hospital in order to take information regarding
her mother health but nurses have provided wrong information to her on phone call.
In the hospital, treatment was provided to her but no one was there to listen or understand
whatever she was trying to say which makes her depressed. Soon she started to walk with the
help of a stick. One day while walking, she fell on the wet floor due to improper safety of
services provided in hospital and her left leg got fractured. Before fixing her leg, she was brought
to operation theatre without marked. Without drip, she was not in condition of the operations.
After surgery, her health condition was that she suffers from bit cold and pale its already blood
cross match which was not good. Along with this, her blood pressure was low and she was
typically bleeding. At the time of providing treatment nurses known that she is allergic to wheat
and suffer from celiac diseases but she was dispensed with the tablet that is dangerous to her
health. Due to providing the wrong tablet after knowing it was risky for her health become a
reason for her death (Dewing and Dijk, 2016). The entire incident reflects irresponsibility, lack
of proper care provided by of health care professional due to which elder lady suffer.
Analysis
In order to analyse this event, fishbone diagram is used.
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Healthcare professional fails in order to provide proper care to Mrs. Hill because of lack of
communication and irresponsibility towards care. However effective communication helps in
making a proper care plan and improving the health of the patient (Hofmann, Burke and Zohar,
2017). Transferring all the information among healthcare setting help in delivering quality care
and treatment. However, the breakdown of this process leads to fragmented care and also hamper
her medical progress. Along with this, there is some environmental factor that can cause issues
while providing care (Prince and Yusuf, 2015). Some of the environmental factor such as
transferring the patient at operation theatre on inappropriate time, a busy ward, lack of safety
measures etc. were become a barrier to her proper care. Apart from this, lack of following a
special diet which is clearly mentioned in her care plan was the reason for failure. Proper safety
and care are one of the important factors in health and social care service. In healthcare, it is
clearly indicating that leaders throughout the firms have to be responsible for safety, quality and
liable on their particular roles (Ceasar, Chang and Knight, 2016). Further, from the systematic
review of 7 studies, it is clearly examined that there is a significant relationship in between
patient outcome and leadership (Aveyard, 2014).
Improving safety and quality in patient care by clinical governance framework
Consumer participation
To improve the quality of care, it is imperative to listen to voices of patients and their
family members who have a different perspective regarding care of patient and valuable
experience. In case of Mrs. Hill, there was lack of family member’s views and carers while
discussing information of the patient (Agrawal, Cockburn and Zhang, 2015). Information which
was provided by daughter of Mrs Hill on the phone call was avoided by a nurse. It clearly
indicates that right of family member and patient was neglected by healthcare providers. Along
with this, proper treatment was also not provided to the patient and all staff members are busy in
gossips and other activities due to which patient was unable to recover her health.
Everyone within the healthcare home is responsible for the care and safety of the patient.
Cultures safety need to be promoted within the workplace as it has 3 important elements that are
safety promoting attitude, environmental structures and process and safety-related behaviour
(Carpenter, Webb and Coomber, 2017). All the risky hazard need to be kept far from the patients
and floor should be properly cleaned and left dry so that no patient get fall. After operations her
allergy related issues was avoided by a nurse and even after resisting of older lady she was
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dispensed with a tablet that makes her unconscious. Lack of providing proper remedy she was
death.
Clinical effectiveness
In the entire case it can be clearly noticed a clinical ineffectiveness. There was lack of
effective clinical screening tools and guideline to support clinicians and understand they are high
risk or not. Doctors were not providing treatment to Mrs. Hill on time and she was ignored
health care professional need to also look other patients (Healy, 2016. ). Hence, in the health care
home there are large number of elderly patient and staff members are in less number due to
which proper care and treatment was not provided to the patients on specified time. Delay in
treatment lead to impact the entire health of an patient. It can be stated that patient care approach
should be followed at the health care firm while providing treatment to Mrs. Hill. Patient and
family centered care is known as improving health care through the eyes of the patient. In the
health care home all patients are deserved to receive high quality care. The patient centered
approach includes following principles such as effective treatment delivered by the nurses and
other staff member
(Andrulis and Cooper, 2015). Involvement of family members and patient in decision making
process. Along with this it is important to provide emotional and empathy support to the patients.
Effective workforce
In respect to building an effective workforce it is important for health care professionals
to have appropriate knowledge and skills related to the collaborative work, From the fishbone
diagram it can be clearly stated that if there is any incompetency within the workforce or lack of
team work then it lead to affect the practices (Faillie and Hillaire‐Buys, 2016). It is essential for
health and social care organizations to formulate strategies focusing on these areas. Along with
this, there are various recommendation which can be used for improving team work and for
effective delivering services.
Risk management
At the health and social care organization it is essential to manage risk so that patient and
employees both can work in the safe working environment. As per the given case, it is being
clearly shown that there is a large number of patients and lack of staff members due to which
treatment was not provided on time (Inzucchi, and Bergenstal, 2015). Due to lack of patient
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transfer notes clearly, reflect that nurses and doctors are too busy that they are not a ready way
for few minutes if the patient was changing her dress. Along with this evidence clearly, reflect
that patient safety was clearly avoided. They are not provided any type of respect for emotion
feeling which makes them depressed. For nurses, it is important to be available with patient 24
hours a day but in the case of Mrs. Hill most of the time she was left alone which increase the
chances of risk and she fell on the wet floor (Nyström, and Andersson-Bäck, 2015). Result of
this was that her left leg got fractured and again she was left
Conclusion
From the provided case it is was clearly concluded that nurses and other healthcare
professional irresponsibility lead to becoming a reason for death for Mrs. Hill. The patient died
unexpectedly while it can be prevented. It is a role and responsibility of health care professionals
to take proper care of the patient and provide services according to their needs and requirements.
There are many environmental and situational factors which can lead to clinical tragedy. For
healthcare professional, it is important to understand the causes of incidents and formulate
strategies in order to overcome them so that quality services can be provided to patients
(Aveyard, 2014). At last, it can be stated that clinical risk management strategies can be
implemented for making sure technology support are designed for keeping the record and
important information of patients
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Reference
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Aveyard, H., 2014. Doing a literature review in health and social care: A practical guide.
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Prince, M.J., and Yusuf, S., 2015. The burden of disease in older people and implications for
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