HSC698 Capstone Project Case Study

High Reliability Organization

Your capstone project will be the design of an operational plan leading to a high reliability organization. [HRO]. HROs seek to maximize the reliability of organizational operations and services when the consequences of error can be disastrous. Establishing and maintaining an underlying HRO structure constitutes an organizational commitment to values and behaviors that increase reliability, improve responses to surprises and reduce the probability of errors.

Queenan Health System Case Study

The Queenan Health System [QHS] is a multi-facility healthcare system located in the northeastern United States. QHS has five [5] acute care hospitals, one [1] children’s hospital, one [1] inpatient rehabilitation hospital, one [1] skilled nursing facility, one [1] home health agency and one [1] large multi-specialty physician group practice. QHS is fiscally sound but given its location is in a competitive environment with other similar healthcare systems and freestanding health facilities. The demographics in the QHS service area include a mix of elderly, adult and young persons.

1. Adult Medicine - Mr. Jones is a previously healthy 55-year-old man, with a recent history of shortness of breath that is related to exercise. He has been referred by his primary care physician for a cardiology consultation, at which a stress test is ordered. The results of the stress test indicate a positive finding for potential heart disease. These results are not communicated back to his primary care provider, and although they are sent to the referring cardiologist, he is away at a conference. Mr. Jones receives no communications about the results of his test. One week later, Mr. Jones presents to the emergency department with chest pain and is diagnosed with an acute myocardial infarction. Upon further review of his medical records, the care team reviews his past test results and learns about the positive stress test. Mr. Jones requires placement of a stent to open his coronary artery, and requires rehabilitation prior to discharge to his home due to reduced cardiac function. One week after discharge from inpatient rehabilitation, Mr. Jones returns to his primary care physician, who realizes that Mr. Jones is not taking one of the new cardiac medications that was ordered by his inpatient team.

2. Obstetrics and Newborn Care - Mrs. Smith is a nineteen year old female who while under the care of an obstetrician, gave birth by an emergency cesarean section. The baby suffered permanent injuries at or shortly after her birth. She was diagnosed as having cerebral palsy of the severest spastic quadriparetic type with microcephaly and mental retardation. Mrs. Smith instituted a lawsuit on her own behalf, and as guardian, on behalf of her child, against the physician, and later against an emergency-room pediatrician. Mrs. Smith commenced a second action against the hospital, members of the operating team, and several hospital administrators. In this case, she alleged that the delay in performing the cesarean section, and the infant's resultant injuries, were caused by the negligence of these defendants in assembling the operating team necessary to assist in the delivery. At the time of the birth, Hospital A was under a renovation/construction program that included, among other things, the construction of a new C-section operating room. During this time, those patients in normal labor were treated in Hospital A. Any scheduled C-sections were admitted to Hospital B. Patients such as Mrs. Smith, whose condition changed while in labor were physically transported to Hospital B and an obstetrical operating room team was assembled while the patient was en route. There was a significant delay. 

3. Pediatrics - Newborn twins Jane and John were hospitalized for treatment of a staph infection at Hospital C, the children’s hospital. Their physician prescribed 10 unit/ml of Hep-lock to keep their intravenous lines clear, but hospital personnel made a “medical error” and administered 10,000 unit/ml of Heparin instead. The twins nearly died but recovered. The parents filed a complaint against the drug company alleging strict liability and negligence. The parents alleged that the 10 unit/ml vials of Hep-lock and 10,000 unit/ml vials of Heparin manufactured by the drug company were in an unreasonably dangerous condition because the labels of both vials had a blue background, which made them difficult to distinguish. They alleged that the background colors should have been different and that the vials should have been completely distinguishable in size and shape. The parents have also filed a complaint against Hospital C. They claim that Hospital C failed to act upon an urgent warning about the fatal medication errors to all healthcare providers who could use the product and to require that such providers initiate mandatory education and implement safety measures so that a fatal medication error would not occur.

4. Elderly – Skilled Nursing Facility – On the first day of the July 4^th holiday weekend, Mrs. Wood was a resident in our system’s skilled nursing facility. She was observed sitting on the front porch of the facility with her roommate and the roommate’s adult son in the early evening. Due to a staffing shortage, there was no nursing assistant available to sit with the two residents to monitor them. The adult male asked Mrs. Wood to take a walk with him on the grounds of the facility. He sexually assaulted her behind a grove of trees and threatened to harm her if she said anything to anyone. Several weeks later, the roommate of Mrs. Woods passed away and Mrs. Wood told the story to a nursing supervisor.

5. System-wide Lower Back Injury Rates – QHS was recently inspected by the federal Occupational Safety and Health Administration due to an alarming number of worker compensations cases involving lower back injuries. The System’s overall worker compensation costs for the most recent 12 month period amounted to $25 million, of which 60 percent is due to lower back injuries. The system is an unsafe work environment.

The chairman of the System Board of Trustees has met with the C-Suite Executives regarding these and other quality and safety matters. A review of all root cause analyses was completed. The Chairman is concerned over the quality of care, costs of malpractice settlements, liability insurance coverage, impact on the System’s bond rating and overall public perceptions. He has given the C-Suite Executives a mandate to prevent such incidents from occurring in the future.

Your charge is to advise the C-Suite Executives on the development of an operational plan that evolves QHS into an HRO.  The Chairman has scheduled a meeting with the C-Suite members in two months.