NSG3EPN: Quality and Safety in Healthcare Report - Case Study Analysis

This report examines the failures in quality and safety at Bundaberg Base Hospital, focusing on the case of Dr. Jayant Patel. It analyzes the impact of leadership styles, particularly the lack of transparent leadership, and how this contributed to medical negligence and patient harm. The report highlights the importance of accessible communication and honesty in fostering trust between leaders and employees, which is crucial for patient safety. It also delves into the role of organizational culture, including the failure to address whistleblower complaints and the hierarchical structure that concealed failures. The report emphasizes the need for proper assessment of medical professionals, the impact of financial incentives on safety, and the overall consequences of these systemic issues on patient care and outcomes. References are provided to support the analysis.

Running head: QUALITY AND SAFETY IN HEALTH CARE
QUALITY AND SAFETY IN HEALTH CARE
Name of the student:
Name of the university:
Author note

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Response to module 1: leadership
Transparent leadership is a leadership where leaders foster the culture of trust between
employees and leaders (Jiang & Men, 2017). It allows employees to be more honest about their
perspective and more open about expressing them in a public dialogue. Consequently, it not
only improves the interpersonal skills of the employees but also enhances collaboration, boosts
self-esteem and empowerment that will further assist the achievement of the desired goal (Yi et
al., 2017). Two crucial characteristics of open and transparent leadership include being
approachable or accessible to the employees through honesty and excellent communicators.
Considering the first trait, as a leader, being accessible to the employees and being honest to the
employees of the organizations at every level of employment provide employer the opportunity
to connect with their employees and listen to the concerns (Carasco-Saul, Kim & Kim,
2015). Being accessible to employees foster a culture of trust and respect between employer and
employees. Consequently, the leaders are able to share their vision with employers, motivate
them, and trust them to achieve the desired goal. Considering the second attribute, excellent
commutation with employees, keeping employees informed with the right information at the
right time promotes a positive business environment by breaking the barriers associated with
culture, experience, and personality (Jiang & Men, 2017). Hence, In order to achieve the desired
goal, especially in the health care sector, the adoption of open and transparent leadership is
crucial.
The characteristics were not observed in the key figure of the inquiry. The key figure of
inquiry, Jayant Patel was an Indian-born American surgeon, suspected of negligence at
Bundaberg Base Hospital, Queensland. He was accused of three manslaughter and one case
of serious bodily harm. He lacks the two attributes which are accessible to employees or

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coworkers (Www.qphci.qld.gov.au, 2019). Medical staffs filed more than 20 complaints about
Dr. Patel that he turned up on day-offs, perform surgery on patients that were the responsibility
of him. As discussed above, communicating with medical staffs and being approachable to the
staffs and properly communicating regarding surgeries facilitate the collaboration between
medical staffs and shared decision making (Frich et al., 2015). The staffs complained that
sometimes, he used to perform surgeries that were not required, explaining he did not take the
second opinion of other surgeons and have poor communication and interpersonal skills
(Www.qphci.qld.gov.au, 2019). Majority of the issues regarding patient safety in the Australian
health system could be prevented with proper communication with the staffs and other surgeons
before conducting surgeries and respect and being approachable to other employees
(Www.qphci.qld.gov.au, 2019). He was negligent in showing these two attributes which further
impacted the quality of care.
Proper communication and providing accurate information at the right time influences the
delivery of safe patient care by promoting collaboration between employees and leaders,
facilitate shared decision making before conducting any critical surgery (Frich et al., 2015).
Being approachable to the employees provide employees with the opportunity to communicate
concerns of them which further prevent possible clinical errors as it can be mitigated
immediately (Denier, Dhaene & Gastmans, 2019). Being honest to the patients and coworkers
facilitate the ability to provide persona centered care and, allow career to show trust which is
crucial for providing safe care to the patient.

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Response to module 2: organization culture
The term Whistle-blower is referred to a person who exposes the activity that is
unethical or wrong within the organization. The illegal activity can be categorized in many ways
such as violation of the company, law and regulations or threats to the public interest. Some laws
protect whistleblowers from being fired or mistreated for reporting misconduct (Call et al.,
2018).
The culture of the workplace regulates the way employees behave amongst themselves
and with people outside the organization which further decide the success of the organizations
(Buys et al., 2016). Considering the quality of care in the inquiry, while staffs were a
whistleblower, in this case, the organization showed no evidence of investigating the
complaints. Many patients and staffs filed complained against him which varied in their
seriousness and the formality, some of them were extremely crucial. Mr. Leck and Dr. Keating
persistently ignored the seriousness of the complaint and Dr. Keat opinioned that these
complaints are solely based s ‘personality conflicts’ which further affected the quality of care as
Dr. Patel continued to continue to do misconduct that affected lives (Www.qphci.qld.gov.au,
2019). McPhail et al. (2015), highlighted that a person is appointed in a higher position, it is the
responsibility of the management to assess the skills of the professionals as it will facilitate the
quality of care that would be provided to the patients. The reason behind negligence of
assessment was that considering the size of the Hospital, no coworker with the same
qualification was present at the Hospital who could evaluate his clinical ability as well as
competence in the course of their work (Www.qphci.qld.gov.au, 2019) . Consequently, he was
continued conducts his illegal deeds. Consequently, sometimes the actions of Dr. Keating and
Mr. Leck antagonist the complaints filed against Patel.

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Moreover, the hierarchical system culture of the organization further hide the failures
of providing quality care to the patients. Dr. Patel’s anticipation of inspection of his clinical
behavior was solely contributed to by the position to which he was appointed, Director of
Surgery (Www.qphci.qld.gov.au, 2019). Hence, the organizational culture itself hides the
failures which affected the quality of care and questioned patient safety (Www.qphci.qld.gov.au,
2019). In the first place, both of the doctors at the hierarchical position saw themselves as people
running successful a business of providing hospital services.
Health care system in queen’s land is under the pressure of supply chain and position
competition which further affected the quality of care (Feng, Cummings & Tweedie, 2017).
Dr. Keating and Mr. Leck received strong incentives for maintaining the budget even if any
misconduct happens in the clinical premises (Www.qphci.qld.gov.au, 2019). Consequently,
while some of the surgeries did not even require for the patients, doctor Patel conducted surgery
without the second opinion which further caused serious injuries or death to the patient,
compromising the quality of care. Mr. Leck’s and Dr. Keating showed greater concern with
sustaining surgery target than safety which further reflected in many surgeries conducted by dr.
Patel (Www.qphci.qld.gov.au, 2019). Due to careless surgeries, they are able to meet their
surgical target.

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References:
Buys, N., Wagner, S., Randall, C., Harder, H., Geisen, T., Yu, I., ... & Fraess-Phillips, A.
(2017). Disability management and organizational culture in Australia and
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Call, A. C., Martin, G. S., Sharp, N. Y., & Wilde, J. H. (2018). Whistleblowers and outcomes of
financial misrepresentation enforcement actions. Journal of Accounting Research, 56(1),
123-171.
Carasco-Saul, M., Kim, W., & Kim, T. (2015). Leadership and employee engagement:
Proposing research agendas through a review of literature. Human Resource
Development Review, 14(1), 38-63.
Denier, Y., Dhaene, L., & Gastmans, C. (2019). ‘You can give them wings to fly’: a qualitative
study on values-based leadership in health care. BMC medical ethics, 20(1), 35.
Feng, T., Cummings, L., & Tweedie, D. (2017). Exploring integrated thinking in integrated
reporting–an exploratory study in Australia. Journal of Intellectual Capital, 18(2), 330-
353.
Frich, J. C., Brewster, A. L., Cherlin, E. J., & Bradley, E. H. (2015). Leadership development
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medicine, 30(5), 656-674.
Jiang, H., & Men, R. L. (2017). Creating an engaged workforce: The impact of authentic
leadership, transparent organizational communication, and work-life
enrichment. Communication research, 44(2), 225-243.

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Jiang, H., & Men, R. L. (2017). Creating an engaged workforce: The impact of authentic
leadership, transparent organizational communication, and work-life
enrichment. Communication research, 44(2), 225-243.
McPhail, R., Patiar, A., Herington, C., Creed, P., & Davidson, M. (2015). Development and
initial validation of a hospitality employees’ job satisfaction index: Evidence from
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Www.qphci.qld.gov.au (2019). Chapter One – Report summary: Queensland Public Hospitals
Commission of Inquiry Report [online] Qphci.qld.gov.au. Available at:
http://www.qphci.qld.gov.au/final_report/Chapter-01.pdf [Accessed 27 Aug. 2019].
Yi, H., Hao, P., Yang, B., & Liu, W. (2017). How leaders’ transparent behavior influences
employee creativity: The mediating roles of psychological safety and ability to focus
attention. Journal of Leadership & Organizational Studies, 24(3), 335-344.