handadverse eventshuman failuresystems failureprocess failureorganizational culturecomplacencyunforgiving environment H e a l t h M e d i c a l

handadverse eventshuman failuresystems failureprocess failureorganizational culturecomplacencyunforgiving environment H e a l t h M e d i c a l

The case study “Dana-Farber Cancer Institute”. Dana-Farber is a world-class cancer research and treatment facility. A patient’s death led to the discovery of major systems issues.

You will be exploring this case through the lens of Systems Thinking. As you read the case study, keep in mind that organizations have multiple internal and external stakeholders and customers. Every functional area in a healthcare organization supports other areas/departments of the organization. Inputs into one area go through a process and become outputs that are handed off to other areas/departments in the organization.

As such, each and every functional area in an organization is both a customer of and a supplier to other areas.

The dynamics of the Dana-Farber case demonstrate the complexity of healthcare organizations and what can happen when the right-hand does not know what the left hand is doing.

You will need to reread lectures 1-­1, 2-­1, 3-­1 and 4­-1. Begin to analyze this case by creating two lists. One will be labeled, What’s Working and the other will be What’s Not Working. Think deeply and come up with everything you can think of to include on each of these lists. Please be in detail.

You might want to consider the following as you delve into the case:

  • Organizational structure
  • Drug administration protocols
  • The design and performance of the care delivery system.
  • Patient safety
  • Boston Globe story of March 23, 1995
  • Risk reduction
  • Medication errors
  • Immediate response to the issue at hand
  • Adverse events
  • Human failure
  • Systems failure
  • Process failure
  • Organizational culture
  • Complacency
  • Unforgiving environment for mistakes
  • Complex research protocols
  • Access to needed information
  • Communications, verbal and written
  • Non­standard language
  • Patient handoffs between different providers
  • Error tracking and reporting
  • Denial of fallibility
  • Oversight
  • Psychological safety of the team
  • Automation
  • Team composition
  • Staffing levels

The above points might seem exhaustive, but they are just a place to begin. After you create what is working and then what’s not working lists, set aside the what’s working list.

For each item on the what’s not working list, respond to the following 6 – Questions:

  • Do you think personal mastery and/or mental models contributed to the death that occurred? Why or why not? Please be in detail.
  • Consider each one of the 11 laws of systems and select the one that you feel best applies to each item on the What’s Not Working List. Spell out the law. For example, “Today’s problems come from yesterday’s solutions.
  • Write a Shared Vision statement that you feel would embody the values, desires, and aspirations of the staff at the Dana-Farber Cancer Institute. Incorporate any of the items from the what’s working list, that you feel would be appropriate. The vision statement should be no longer than one page in length.
  • What’s Working List
  • What’s not Working List, with the two points listed above for each item, spelled out.
  • Conclusion with complete assessment of the case – minimum 2 pages for this.
  • References

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