Healthcare Deficiencies at Victoria Hospital: A Management Report

This report delves into the healthcare deficiencies identified at Victoria Hospital, focusing on nursing leadership and management practices. The introduction outlines the regulatory framework governing healthcare facilities and sets the stage for an analysis of a review report's impact. The main body examines major deficiencies, including issues like overcrowding, inadequate communication, and lack of functional incident systems, impacting patient safety and care quality. These deficiencies are then linked to specific National Safety and Quality Health Service (NSQHS) Standards, such as Clinical Governance and Partnering with Consumers. The report highlights the importance of addressing these issues through effective management, strategic planning, and the implementation of NSQHS standards to improve the quality and safety of patient care at Victoria Hospital. Finally, the report includes the change management principles and theories of power to overcome the deficiencies.

NURSING LEADERSHIP AND
MANAGEMENT ASSIGNMENT

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
1. a) The major health care deficiencies at Victoria hospital.................................................1
1. b) Which of the National Safety and Quality Health Service Standards do these relate to?4
CONCLUSION................................................................................................................................9
INTRODUCTION.........................................................................................................................10
MAIN BODY.................................................................................................................................10
2. Change management principles and theories of power....................................................10
CONCLUSION..............................................................................................................................16
REFERENCES..............................................................................................................................17

INTRODUCTION
Health care facilities in New Jersey are regulated and licensed by the government. Health
care organisation can also be certified and inspected by numerous private and public agencies at
federal and state levels. The present assignment will explain how a review report will affect all
Victoria hospital and health services. Furthermore, this assignment will also include the major
health care deficiencies that was addressed by review report. In addition to this, National Safety
Standard and Quality Service Standards are related to health care like Clinical Governance
standard, partnering with consumer standard, medication safety standard, comprehensive care
standard, communication for safety, blood management standard, infection standard, etc. This
report will provide in depth knowledge of nursing leadership and management as well.
MAIN BODY
1. a) The major health care deficiencies at Victoria hospital
There are major deficiencies in health care organisations has great impact on the health of
patients and quality of health care. Deficiencies lead to negative impact on the organisation when
there are deficiency in the delivery of quality of services. Deficiencies are the everywhere in the
health care organisation but it is very necessary to overcome as because it leads to negative
impact on the health of people. There are various deficiencies in health care infrastructure like
lack of outreach, overcrowding in hospitals, functional system, lack of finance, lack of facilities
related to health care and many others. In Victoria hospital, there are various deficiencies that
lead to trouble and problem for patients and they face challenges (Murray, 2017).
There are some deficiencies which was identified in Victoria hospital that patients are
avoided to a great extend which in result harm in patient health as well as they suffered a lot. In
Victoria hospital, there is a problem or troubles that cause great problem to the health of people
which is not illness or lack of knowledge about treatment, but it is because of ineffective system
to keep patients safe while receiving care. Variability of care indicates that valuable knowledge
is not shared with patients as well as implemented widely, that results in patients are getting care
that deviate from the best practice. It is recorded by the Australian research that more than one
patient in every 10 patients face complications in care during their stay in hospital. It’s not good
to say that more than half complications are ignored and avoided.
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Complication may be minor which does not have a bad impact on the health of patients
but sometimes, complications are very hard that ends at permanent death and disability. For
patients and family these complications are destructive and significantly rise the care of cost
across the system. As a matter of priority, all the hospitals try to reduce them. There is a very big
challenge for health care organisations to achieve the best practice in quality and safety.
Furthermore, complication are often that result of individual disability. In Victoria Hospital,
there are high pressure working environment as well as it is very complex. By hard or high
pressure working environment where mistakes easily happen and patients are already weak and
at a risk of crumble (Hutchinson, 2018).
In order to control the risk, management of hospitals requires strong and powerful
processes to reduce as well as control the risk. It is also very necessary that management should
ensure what is happening wrong within the organisation and it must be reported to the top level
authorities. In order to reduce the deficiencies which has happened in hospital and that has bad
impact on the health of patients, management need powerful oversight and system of support by
managers such as departments. In order to control the quality and safety systems, it can only be
protected by system managers by monitoring the results of hospitals. Deficiencies in the system
can only be addressed by appropriate action which would be taken by management of hospital in
much effective way so that the strength of hospital in the area of safety and quality of care will
be upgraded.
On the other hand, there are some more deficiencies which are causing serious causes to
heath of patient in receiving care. It was identified that the departments of Victoria hospital are
not performing well and are also not performing their own role. The way that they are
performing is not adequate and appropriate which are causing serious harm to patient’s health as
well as it is not good for the image of Victoria Hospital. The departments of hospital supervision
is not appropriate, it is adequate. They do not have proper information of assuring to public that
they are providing consistently high quality and safer care services. Another deficiency is that
there is lack of management of functional incident system for the staff of hospital to report
patient’s ill health, damage or harm.
In order to provide the best care to patients, it is very essential that Victoria Hospital
should allow or recruit expert team to monitor the roles and performance of each and every
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employee in the hospital, and it is also very necessary that the management of hospital should
delegate the roles and responsibility in an effective way. It should properly communicate. There
is also lack of communication in Victoria hospital which is causing harm to both; patients and
staff because if roles and responsibilities are not properly communicated then it will cause
problem to patients related to care.
Moreover, there are some more deficiencies which are present in Victoria Hospital. The
department of overarching administration is also not up to the mark and it is inadequate. It is
expected from the public sector hospitals that the care services are not adequate in safety and
quality care, but still they are improving to the great extend only because of control of
government. In private sector, the responsibility and roles of departments are also not performing
in delegate way which in result safety and quality is roughly equivalent (de Vries, & Curtis,
2018). They do not conduct any routine round in wards where patients are admitted and they also
do not monitor patient’s health results or serious incidents.
Thus, in both the sectors, there is lack of control on the activities and functions of
departments and the management must ensure safe and quality of care to patients. Beside this,
the support department of hospital in order to discharge their roles and responsibilities related to
the improvement and development in safety and quality is inadequate and not appropriate. The
management of Victoria Hotel do efforts on improvement and development of system of care but
they do not do implement or apply continuous efforts or approaches or any regular investment.
There is lack of innovation to which also result in use of backward and outdated equipment and
tools as well as old style or process of giving treatment to patients.
Lack of approaches in safety and quality of improvement leads to duplication of work
and fluctuation in quality. Another deficiency which was identified by the auditor of Victoria
General office that there is lack of leadership skill in the health of patient’s safety and quality
care which result in ineffective performance of staff. Victoria Hotel is facing huge amount of
loss in its capacity only because of lack of resources and lack of authority. Budget cut and
staffing caps have gutted many departmental functions.
From above all, deficiencies, it is all over summarized that there is lack of strategic
planning in the organisation which in result question on the Australian leading health care
organisation i.e. Victoria Hospital.
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In order to meet all these deficiencies, it is very essential that system should be changed and
management should identify where they are lagging behind and after that they should overcome
all these deficiencies. They should make strategies and plan of action and should be confidential
that they can achieve and afford as well as retain the position in the market (Morsiani,
Bagnasco, & Sasso, 2017).
1. b) Which of the National Safety and Quality Health Service Standards do these relate to?
The National Safety and Quality Health Service (NSQHS) Standards were developed by
the Australian commission on Safety and Quality in Health Care in collaboration with the
Australian Government, states and territories, the private sector, clinical experts, care takers and
patients. The fundamental aims of National Safety and Quality Health Service Standard are to
defend or protect public from damage or harm and to amend the quality of health services
provision. They furnish assurance in quality mechanism that tests whether applicable systems are
in place to make sure that are expected standards of quality and safety are met or not. It is very
important to implement all these standards within organisation for clinical governance, health
care related with infections, partnering with customers and safety of medication, effective
communication, comprehensive care and blood management.
The whole journey of patients is describing in National Safety and Quality Health Service
Standards and are systematically designed to be enforced in a unified manner. Victoria Hotel
also use some standards of NSQHS but still they need some amendments (Kelly, 2017). It is
crucial to determine the connection in between action across all standards of National Safety and
Quality Health Service. By identifying the link in between standards and action, it will become
easy for Victoria Hospital to make sure that their system of safety and quality is unified and in
implementing of standards it will also reduce the duplication of efforts.
Here are some standards of National Safety and Quality Health Service which are as follows-
 Clinical Governance
 Partnering with Consumers
 Preventing and Controlling Healthcare Associated Infection
 Medication Safety
 Comprehensive Care
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 Communicating for Safety
 Blood Management
 Recognising and Responding to Acute Deterioration
Clinical Governance Standard- Clinical Governance is the standard in health safety that
describes clinical control, system of safety and quality that are needed to develop and maintain
the safety and quality and reliability. Beside all these, this standard has actual focus on
improvement in the result of health of patients. Health service industry leaders have
responsibility to the community for regular improvement and development of the safety and
quality of service. This is the best standard that should also be used in the management, function
and operations of Victoria Hospital that help patients and customers acquire safe and high-
quality health care. The reason behind the implementation of standards are to make sure that
leaders or managers at all levels use clinical governance system in order to improve the quality
and safety of the patient's health, safety of patients quality systems as well as safe environment in
Victoria hospital for care delivery (Nzinga, McGivern, & English, 2018).
Partnering with Consumers Standard- It is standard of National Safety and Quality
Health Service that describes the system and plan of action to create a person- centred system of
health by considering patients in decision making to make sure that patients are partners in their
own care. Addition to this, customers should also involve in the development and design of
quality healthcare. In order to achieve the goals and objectives of giving quality and safety
healthcare to patients, it is very important for Victoria to develop, maintain and implement
systems to partner with patients and customers. Planning design, measurement, design, delivery
and evaluation of care is directly affiliated with these partnerships. This standard is very
important for Victoria Hospital to achieve and retain the best position in healthcare sector. By
implementation of this standard with the organisation, it will make happy and healthy
relationship between customers and company as well as in between patients and organisation but
it can only be achieved if partnership in between them is existed when people are treated with
respect and dignity (National Safety and Quality Health Service Standard, 2017).
Preventing and Controlling Healthcare Associated Infection Standard- It is also the
standard of National Safety and Quality Health Service which describes the system and strategies
to prevent infection effectively as well as to manage when they occur. Furthermore, this will also
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help Victoria to limit the development of antimicrobial resistance by judicious use of
antimicrobial. These standards assist health care organisations to implement and monitor systems
to manage, control or prevent infections associated with healthcare. Victoria Hospital is using
this standard but it is inadequate as they are not monitoring the staff of infectious department
which results in harm in the health of patients (Frankel, & PGCMS, 2018). In order to follow this
standard, it is very essential that system are place to support and encourage prevention and
control of healthcare associated infection as well as improve antimicrobial stewardship. Further,
it is also very essential to reprocess of reusable medical devices like tool, equipments.
Medication Safety Standard- Medicines are one of the most common treatment used in
health care. It is also one of the most important standard in National Safety and Quality Health
Service that describes the system and strategies to assure that practitioner risk free or safely
prescribe, dispense and manage proper medicines to informed patients and monitor use of the
medicines. In health care organisation, it is very essential that the management of Victoria
Hospital should implement and monitor systems to minimize the happening of incidents related
to medications. The practitioners of Victoria Hospital are well qualifies and educated, so their
patients and customers are aware of their medicines. Clinicians of Victoria Hospital inform each
and every aspects of medicines like needs of medicines as well as risk associated with it. It is
crucial that medicines are utilized in a systematic order in order to make improvement in the
health of patient. Administration broad methods are utilized to influence and encourage safety
for securing, storing, supplying, manufacturing, compounding, prescribing, administering and
observing the result of medicines.
Comprehensive Care Standard- It is one of the most essential standards in the health
care as because it describes the unified screening, assessment and identification of the procedure
of risk for developing a care plan individually in order to prevent and reduce the risk of damage
or harm in predetermined areas (Elliott, 2017). In healthcare organisation, it is essential that
managers or leaders should maintain and control the system and procedures in order to support
practitioners to render comprehensive care. In addition to this, they should also maintain and
manage system and strategies to control the particular risk. In Victoria Hospital, there is lack or
regular monitor on patient's health which cause serious complication to them, they avoid this
standard within their operations and functions. Thus, in order to provide comprehensive care to
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the patients, it is very crucial that practitioners should deliver or render a systematic treatment
which is requested by patients. The care or treatments which are provided to patients should be
justified with the patient's goal and objectives as well as according to their needs. Beside this, it
is also the duty of practitioner that risk of harm should be screened and also use the process to
assess the risk. Therefore, it is very essential that proper system of support practitioners to
provide comprehensive care. Further, management of Victoria Hospital also develop plan of
comprehensive care like unified screening procedures should be used by practitioners and that
should be implemented with patients, family and cares collaboration in order to develop the best
and goal directed comprehensive care, safe and secure care should be provided by clinicians
(Giddens, 2018).
Communicating for Safety Standard- This is one of the most essential and common
standard in each and every sectors as well as in health care too. Communication is the essence of
all businesses. This standard of NSQHS describes that it is necessary that unified and systematic
system and strategies to build effective communication in between patients, care takers and
families as well as across the entire health care organisation. In healthcare organisation,
managers and leaders should maintain and manage effective system and procedure to build
effective communication. Effective communication plays a vital role in ensuring safety of
patients. In addition to this, proper knowledge of treatment should be communicated to patients,
which Victoria Hospital is lagging behind. Thus, Victoria Hospital should set up a system plan
for effective communication as well as coordinated communication.
Blood Management Standard- This is the critical and crucial standard in NSQHS as
because it is related with patients own blood. This standard describes that strategies and system
for the risk-free, safe, efficient, appropriate and effective care of patients own blood and other
supplies of blood and blood products. According to this standard, it is essential that proper and
systematic system of monitoring should be implemented within organization. This standard is
very useful as because it identifies the risk and put in place schemes to make sure that blood of
patients is conserved and optimised. Victoria Hospital is following this standard in there
functions and operations as they guaranteed there patients that they receive appropriate and safe
blood and blood product (Murray, Sundin, & Cope, 2018).
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Recognising and Responding to Acute Deterioration Standard- This is the standard of
NSQHS that describes the system and procedures to give response effectively to patients when
their physical, mental or cognitive condition deteriorates. It is essential that leaders or managers
in health care organisation should set up or manage effective system for recognising and
responding to acute impairment. This standard is followed by Victoria Hospital as they
guaranteed that patients acute impairment is recognized promptly and suitable action should also
be taken as fast as possible. Early determination of impairment may amend outcomes and
diminish the intervention needed to steady patients whose condition devolve in hospital.
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Illustration 1: National Safety and Quality Health Service Standard
(Source: National Safety and Quality Health Service Standard, 2017)

CONCLUSION
From the above essay, it was concluded that the major health care deficiencies at Victoria
hospital. This essay presented various deficiencies at Victoria hospital. Addition to this, National
Safety and Quality Health Service Standards are also discussed in the above essay.
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INTRODUCTION
In healthcare organisation, safety is most essential concern for patient’s health. Under
section 2(3) of the Health & Safety at Work Act 1974, health and safety policy is must have
required in each and every health care organisation. In this present report, principle of change
management, theories of power and models of effective change management will also be
discussing. Kurt Lewin Theory will also be included in this assignment.
MAIN BODY
2. Change management principles and theories of power
In healthcare organisation, safety is most essential concern for patient’s health. Under
section 2(3) of the Health & Safety at Work Act 1974, health and safety policy is must have
required in each and every health care organisation. In order to boost positive culture of health
and safety, it plays a vital role. Organisation normally underestimate the scale of change that is
necessary when there is implementation of new corporate technology or when changing the type
of goods or services, or any other change. Implementing changes is not an easy task because
employees resist changes (Ha, & Pepin, 2018). In Victoria Hospital, there are many deficiencies
in the functions and operations of organisation which in result causing serious health harm to
patients. So, in Victoria Hospital, there are some areas where changes are needed like in the
areas of communication, medication, comprehensive care, blood management etc. Producing the
changes is tough especially at the initial step. Victoria Hospital do some efforts to accept and
carry out changes, they follow some model and theories as well as they implement changes by
taking some steps, so that the culture of ward and other departments will be improved and
developed.
Here are some steps that are followed by management of Hospitals to implement the
changes are as follows-
Training- Training is the most important techniques to boost the changes within
organisation. In order to implement the changes, organisation should provide training and
development programmes, so that changes can be carry out easily and systematically. If
company wants to implement changes in effective manner, then it is very important that
management of hospital should provide effective training to employee’s can know what is to be
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