Analysis of Queens Healthcare System (QHS) Capstone Project

This capstone project analyzes the Queens Healthcare System (QHS), a multi-facility healthcare organization facing significant safety challenges stemming from poor communication, medication errors, and staff shortages. The project applies leadership domains from "Leading a Culture of Safety: A ...Read More

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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

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(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

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assurance to enhance the safety of the patients. However, this seems not to be the case resulting
in process and system failures in the organization. For instance, inefficient process and systems
in the facility resulted in the delay in providing emergency services resulting in a child being
born with severe medical conditions including cerebral palsy. Also, a lack of communication
between staffs resulted in the health of a patient worsening, and inadequate training of staff
regarding medical administration lead to overdosing. All these factors contribute to legal and
ethical issues in the organization including the issue of negligence.
Medication administration errors are unavoidable. However, disclosing these errors to
family members and patients act as a basis for litigation. Sorrell (2017) substantiates this claim
by pointing out that the catalyst for litigation in nursing practice is professional negligence,
malpractice, and negligence (National Commission on Correctional Health Care, 2011; Guillod,
2013). For instance, the nurse who administered 10,000 unit/ml vials of Heparin instead of
10unit/Ml to the newborn twins can be sued for professional negligence. QHS healthcare staffs,
arguably, violated the ethical principles of beneficence and nonmaleficence which mandates
them to avoid harm and do that which benefits the patients (Kangasniemi, Vaismoradi, Jasper,
&Turunen, 2013). Therefore, avoiding medication errors and other malpractices requires the
design of a training program to help staffs on the significance of reporting errors. Additionally,
they should be though on effective strategies to enhance the safety of the patients in addition to
implementing appropriate ethical and moral standards to remedy the safety issues in the facility.
QHS Mission
QHS is dedicated to providing all residents of Hawaii with quality healthcare services
with the sole purpose of improving their well-being. However, the mission statement should also
include the safety of patients rather than just focusing on healthcare quality. Patient safety is a

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global initiative aiming at preventing injury and harm to patients. It is, thus, the responsibility of
QHS to devise ways to minimize errors, improve care, and exceed its expectations. It should also
focus on the satisfaction of patients through the coordination of various units.
Compelling Vision that Helps QHS Develop a Culture of Safety
Patient safety is founded on legal and ethical dimensions. For this reason, a new vision
for QHS must take into consideration the legal and ethical challenges that the organization faces
due to its inability to enhance the safety of its patients. Therefore the new vision of the
organization is “to demonstrate leadership in enhancing patient’s access to excellent and high-
value service, patient safety, clinical quality, and healthcare. The organizations will also boost
and attract relationships with competent staffs, healthcare professionals, nurses, scientists, and
physicians with the sole purpose of promoting organizational commitment to value, quality, and
leadership.
Budget
Training of Staff $54,0000
Recruiting new staffs $35,000
Purchasing technical Equipment $ 1milion
Providing Refresher Courses $42,000
Continuous monitoring and quality
Improvement
$ 500,0000
Total $1,593,200
References

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Bonny, W. (2014). Medical errors: Moral and ethical considerations. Journal of Hospital
Administration, 3(2), 80-88.
Guillod, O.(2013). Medical error disclosure and patient safety: Legal aspects. Journal of Public
Health Research, 2(3), 31-35. doi: 10.4081/jphr.2013.e31
Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A.(2017). Ethical
and legal aspects of patient’s safety: A clinical case report. Journal of Medical Ethics and
History of Medicine, 10(2), 15-25.
Kangasniemi, M., Vaismoradi, M., Jasper, M., &Turunen, H.(2013). Ethical issues in patient
safety: Implications for nursing management. Nursing Ethics, 2(3),1-13.
National Commission on Correctional Health Care.(2011).Ethical and Legal issues. Retrieved
from, https://www.ncchc.org/cnp-ethical-legal
Rathert, C., & Phillips, W. (2010). Medical error disclosure training: Evidence for values-based
ethical environments. Journal of Business Ethics. 97(3): 491-503.
http://dx.doi.org/10.1007/s10551-010-0520-3
Sorrell, J.M. (2017). Ethics: Ethical issues with medical errors: Shaping a culture of safety in
healthcare. The Online Journal of Issues in Nursing, 22(2), 1-6. doi:
10.3912/OJIN.Vol22No02EthCol01
The Institute for Healthcare Improvement. (2017). Leading a culture of safety: A blueprint for
success. Retrieved from, http://www.ihi.org/resources/Pages/Publications/Leading-a-
Culture-of-Safety-A-Blueprint-for-Success.aspx
Whitcher, D.M., Kass, N.E., Audera-Lopez, C., Butt, M., Jauregui, I.L., Harris, K., Knoche, J.,
& Saxena, A.(2014). Ethical issues in patient safety research: A systematic review of the
literature. Journal of Patient Safety, 00(00), 1-11.

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